rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
3310,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-02-14,550,G,1,0,QB4N11,"> Based on review of facility files and interview, the facility failed to ensure each resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside the facility. Resident #1 was held down and his/her fingernails cut when s/he resisted care. LPN (Licensed Practical Nurse) #1 removed the resident from the unit dining room into the hallway outside the dining room and proceeded to cut the resident's nails even though s/he resisted. One of three resident's reviewed for dignity. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA (Certified Nursing Aide) #1, and CNA #2. The facility's details of the reportable incident indicated the DON (Director of Nursing) was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area herself/himself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said s/he would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. Review of the facility's Refusal of Treatment policy statement revealed the facility shall honor a resident's request not to receive medical treatment as prescribed by his or her physician, as well as care routines outlined on the resident's assessment and plan of care. Review of the facility's Resident Rights Guidelines for All Nursing Procedures revealed the purpose was to provide general guidelines for resident rights while caring for the resident. The procedures indicated that staff must have appropriate in-service training on resident rights, including resident right of refusal (medications and treatments). The general guidelines included if a resident refuses, notify your supervisor.",2020-09-01
3311,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-02-14,600,G,1,0,QB4N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident remained free from abuse and neglect. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. LPN #1 was attempting to cut Resident #1's finger nails and the resident resisted. CNA #1 and CNA #2 held the resident down while LPN #1 cut the resident's finger nails. The tips of the resident's fingers were nicked and the resident's arms and hands were bruised during the incident. One of three residents reviewed for incidents. The findings included: The facility reported alleged abuse for Resident #1. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area herself/himself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said h/she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son /daughter on 1/10/18 and told her/him it had been reported to law enforcement. S/he asked if it had been reported to DHEC and they said yes. Review of CNA #1's Status Change Form dated 1/10/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #1's Time Card revealed s/he worked 6:45 AM to 3:09 PM on 1/8/18 and 6:46 AM to 1:18 PM on 1/10/18. Review of CNA #2's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #2's Time Card revealed s/he worked 6:43 AM to 2:38 PM on 1/8/18 and 6:59 PM to 3:13 PM on 1/9/18. Review of LPN #1's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of LPN #1's Employee Time Card revealed s/he worked 6:40 AM to 7:22 PM on 1/8/18. Review of the facility's Abuse Investigations Policy revealed all reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by facility management. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. Review of the facility's Abuse Prevention Program revealed residents have the right to be free from abuse and neglect. Policy Interpretation and Implementation included the protection of residents during abuse investigations.",2020-09-01
3312,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-02-14,607,G,1,0,QB4N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. LPN #1 was attempting to cut Resident #1's finger nails and the resident resisted. CNA #1 and CNA #2 held the resident down while LPN #1 cut the resident's finger nails. The tips of the resident's fingers were nicked and the resident's arms and hands were bruised during the incident. CNA #1 and CNA #2 continued to work at the facility during the investigation into the incident. One of three residents reviewed for incidents. The findings included: The facility reported alleged abuse for Resident #1. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area him/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come in assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said she/he would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told her it had been reported to law enforcement. S/he asked if it had been reported to DHEC and they said yes. Review of CNA #1's Status Change Form dated 1/10/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #1's Time Card revealed s/he worked 6:45 AM to 3:09 PM on 1/8/18 and 6:46 AM to 1:18 PM on 1/10/18. Review of CNA #2's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #2's Time Card revealed s/he worked 6:43 AM to 2:38 PM on 1/8/18 and 6:59 PM to 3:13 PM on 1/9/18. Review of LPN #1's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of LPN #1's Employee Time Card revealed s/he worked 6:40 AM to 7:22 PM on 1/8/18. Review of the facility's Abuse Investigations Policy revealed all reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by facility management. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. Review of the facility's Abuse Prevention Program revealed residents have the right to be free from abuse and neglect. Policy Interpretation and Implementation included the protection of residents during abuse investigations.",2020-09-01
3313,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-02-14,608,G,1,0,QB4N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to develop and implement written policies and procedures that ensure each individual reported immediately, but not later than 2 hours after forming the suspicion, for events that cause the suspicion result in serious bodily injury to the State Agency and law enforcement. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. The resident was held down by CNA #1 and CNA #2 so that LPN #1 could cut the resident's finger nails. The resident's fingers were nicked during the incident and the resident sustained [REDACTED]. One of two reportable incidents reviewed. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed the incident involving Resident #1 occurred on 1/8/18 at 1:30 PM. Review of the facility's investigation revealed the police were notified on 1/10/18 The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area him/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come in assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told him/her it had been reported to law enforcement. H/She asked if it had been reported to DHEC and they said yes.",2020-09-01
3314,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-02-14,609,D,1,0,QB4N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure all alleged violations involving abuse, neglect, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the State Agency. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. The incident was not reported within 2 hours to the State Agency. One of two reportable incidents. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area himself/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come in assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told him/her it had been reported to law enforcement. H/She asked if it had been reported to DHEC and they said yes. Review of CNA #1's Status Change Form dated 1/10/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #1's Time Card revealed s/he worked 6:45 AM to 3:09 PM on 1/8/18 and 6:46 AM to 1:18 PM on 1/10/18. Review of CNA #2's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #2's Time Card revealed s/he worked 6:43 AM to 2:38 PM on 1/8/18 and 6:59 PM to 3:13 PM on 1/9/18. Review of LPN #1's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of LPN #1's Employee Time Card revealed s/he worked 6:40 AM to 7:22 PM on 1/8/18. Review of the facility's policy on Abuse Investigations revealed the administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within 5 working days of the reported incident. The policy was last revised on April 2014. Review of the facility's policy on Reporting Abuse to Facility Management revealed it is the responsibility of employees to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. The definitions of abuse included abuse, neglect, and injury of unknown source. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect was defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injury of unknown source was defined as an injury that meets both of the following conditions: 1) the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and 2) the injury is suspicious because of: the extent of the injury, or the location of the injury (the injury is located in an area not generally vulnerable to trauma), the number of injuries observed at one particular point in time, or the incidence of injuries over time. Further review of the facility's policy on Reporting Abuse to Facility Management revealed employee and facility consultants must immediately report any suspected abuse or incidents of abuse to the Director of Nursing Services. In the absence of the Director of Nursing Services such reports may be made to the Nurse Supervisor on duty. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, DON, or Charge Nurse.",2020-09-01
3315,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-02-14,610,G,1,0,QB4N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to prevent further potential abuse and neglect while investigations were in progress and when an alleged violation was verified failed to take appropriate corrective action. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. LPN #1 was attempting to cut Resident #1's finger nails and the resident resisted. CNA #1 and CNA #2 held the resident down while LPN #1 cut the resident's finger nails. The tips of the resident's fingers were nicked and the resident's arms and hands were bruised during the incident. CNA #1 and CNA #2 continued to work at the facility during the investigation into the incident. One of three residents reviewed for incidents. The findings included: Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area him/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come in assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said h/she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told her it had been reported to law enforcement. She asked if it had been reported to DHEC and they said yes. Review of CNA #1's Status Change Form dated 1/10/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #1's Time Card revealed s/he worked 6:45 AM to 3:09 PM on 1/8/18 and 6:46 AM to 1:18 PM on 1/10/18. Review of CNA #2's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of CNA #2's Time Card revealed s/he worked 6:43 AM to 2:38 PM on 1/8/18 and 6:59 PM to 3:13 PM on 1/9/18. Review of LPN #1's Status Change Form dated 1/11/18 revealed s/he was terminated on 1/10/18 for substantiated abuse. Review of LPN #1's Employee Time Card revealed s/he worked 6:40 AM to 7:22 PM on 1/8/18. Review of the facility's Abuse Investigations Policy revealed all reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and promptly investigated by facility management. Employees of this facility who have been accused of resident abuse will be suspended immediately pending the outcome of the investigation. Review of the facility's Abuse Prevention Program revealed residents have the right to be free from abuse and neglect. Policy Interpretation and Implementation included the protection of residents during abuse investigations.",2020-09-01
3316,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-02-14,656,G,1,0,QB4N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident. Resident #1 was noted to be abused by LPN (Licensed Practical Nurse) #1 and CNA (Certified Nursing Aide) #1 and CNA #2. The resident was noted to have the behavior of refusing care. Resident #1's care plan was not followed related to how staff should respond to the resident's behavior. Resident #2's care plan was not followed by CNA #3. Resident #2 was noted to require 2 staff for ADL care and CNA #3 provided care to the resident without additional staff and heard a pop sound while providing care to the resident. Two of three residents reviewed for care. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #2. Review of the facility's Five-Day Follow-Up Report dated 10/11/17 indicated Resident #2's fracture was identified on 10/6/17 at approximately 10:00 PM. The DON (Director of Nursing) was notified of the fracture at 10:15 PM. A complete body audit was performed. The left shoulder was pink and swollen with no other injury identified at that time. Statements revealed that on 10/4/17 the CNA taking care of the resident reported to the nurse that the resident had a popping sound. Interview with the CNA revealed that while performing incontinent care, when s/he went to position Resident #2 over on his/her side using the pad the CNA heard the resident's left arm pop. The CNA alerted the nurse. The nurse confirmed that on 10/4/17 between 8:00 PM-8:30 PM s/he was told about the popping sound when the CNA moved the resident. The nurse assessed the resident's arm and at that time there was no evidence of an abnormality or injury. Further statements revealed that on 10/5/17 the resident did have pain in the left arm and the nurse was notified by the CNA. The nurse assessed the resident and medicated him/her for pain. On 10/6/17 the resident complained of pain in the left arm when touched. This is when the nurse practitioner was asked to see the resident and s/he ordered an x-ray. After consulting with the medical director, it was felt that with the resident's history and frailty ([CONDITION] and [MEDICAL CONDITION] with allergies [REDACTED]. Routine incontinent care was being delivered on 10/4/17 when the CNA, providing care alone, heard a pop. The resident is care planned for the assistance of 2 with bed mobility and toileting. The CNA was counseled for not following the plan of care. Review of the Nurses' Progress Notes revealed there was no entry on 10/4/17 related to the CNA reporting the popping sound and the nurse assessing the resident. Further review of Resident #2's Nurses' Notes dated as a late entry on 10/10/17 for 10/5/17 indicated LPN #2 was notified by CNA that was assisting another CNA while doing a brief change on resident. Resident was complaining of much pain with any movement of left arm or touching arm. Checked resident's left arm and did not see anything. Left arm warm to touch, left arm up on pillow. Resident history of unable to move arm his/herself. Resident was given a pain pill at that time. The Progress Note documented by the Nurse Practitioner dated 10/6/17 at 1:37 PM revealed Resident #2 complained of left arm pain when touched or arm moved. States that it is his/her entire arm. Unable to tell where it is coming from. S/he yells and says don't move it with any amount of movement. No obvious deformity, no redness or [MEDICAL CONDITION]. Plan was for an x-ray of the left shoulder. A late entry on 10/7/17 for 10/6/17 by LPN #2 indicated the physician was notified about the x-ray report. New order to check pulse in left arm and medicate as needed for pain. Apply sling to left arm and position arm for comfort. If pulse changes or hand cold or increase in pain send to ER for evaluation of fracture. Review of the Radiology Report dated 10/6/17 revealed Resident #2 had a humeral fracture with slight displacement. Review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #2 as having a Brief Interview for Mental Status score of 10. The Quarterly MDS coded the resident as having verbal behavior 1-3 days during the assessment period. Review of Resident #2's care plan revealed ADL deficit related to dementia and impaired mobility was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included staff to provide assistance as needed with bed mobility x 2 assist and hygiene x 2 assist. Review of Resident #2's Resident Profile revealed the resident was coded as requiring 2 staff for bed mobility and hygiene with a start date of 1/14/16. LPN #3's facility-obtained statement indicated CNA #3 reported s/he heard some popping sounds when s/he moved Resident #2. LPN #3 went and looked at the resident. There was no swelling or discoloration. Resident #2 said it didn't hurt. CNA #4's facility-obtained statement dated 10/9/17 indicated on 10/5/17 s/he helped another CNA change Resident #2's brief one time. Resident #2 was screaming and complaining of pain in his/her arm like I have never heard him/her do before. CNA #4 was not assigned to the resident that night but Resident #2's behavior alarmed him/her so much that s/he immediately went to the nurse, LPN #2 and told him/her how Resident #2 was acting. CNA #4 expressed to LPN #2 how serious s/he thought it may have been. CNA #3's facility-obtained statement indicated s/he had Resident #2 on 10/4/17 and reported that the resident had a popping sound. Review of the Education Counseling form for CNA #3 dated 10/11/17 revealed the subject was following plan of care using appropriate assistance with bed mobility. Comments included to always use appropriate assistance with bed mobility. This information can be found in the kiosk under resident profile. Use your need to know books. In an interview with the surveyor on 2/14/18 at approximately 2:30 PM, the Healthcare Manager stated that s/he was told they heard a pop while giving care to the resident. The CNA reported it. The Healthcare Manager stated s/he did not know anything about what happened with the CNA being suspended. In an interview with the surveyor on 2/14/18 at approximately 2:40 PM, the unit 1 manager stated Resident #2 had been complaining about mouth soreness for a while. The resident was transported to the dentist on 10/3/17. All of a sudden, the resident started complaining about left shoulder pain out of nowhere. Resident #2 was moved to Unit 3 on 9/30/17 to accommodate an infection control issue, moved to Unit 2 on 10/2/17, and returned to his/her original room on Unit 1 on 10/4/17. The unit 1 manager did not hear about the resident's complaints of pain until the weekend. The unit 1 manager stated s/he did not know about the CNA hearing a pop until the investigation began. The unit 1 manager stated the pop was not documented by the nurse when it happened, it should have been. The unit 1 manager received a call about the x-ray report and s/he called the DON. The x-ray revealed a fracture. The unit 1 manager called the DON the night of 10/6/17. During the investigation they learned about CNA #3 hearing a pop while providing care. CNA #3 was providing care by him/herself and the resident is supposed to have 2 people for bed mobility. Resident #2 can't move one side, s/he is bedbound, and s/he refuses to get up. That information is on the resident profile on the kiosk. The DON educated CNA #3 that the resident required 2 people and the profile had that information. CNA #3 worked with Resident #2 a good bit. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area himself/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come in assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said h/she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told him/her it had been reported to law enforcement. S/he asked if it had been reported to DHEC and they said yes.",2020-09-01
3317,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-02-14,658,G,1,0,QB4N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to provide services that meet professional standards of quality. CNA (Certified Nursing Aide) #3 heard a pop sound from Resident #2 while providing ADL care. The CNA reported the incident to the resident's nurse. The nurse failed to document the incident in the resident's medical record. Resident #1 was held down by LPN #1 and CNA #1 and #2 and his/her fingernails cut when s/he resisted care. Two of three residents reviewed for professional standards. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #2. Review of the facility's Five-Day Follow-Up Report dated 10/11/17 indicated Resident #2's fracture was identified on 10/6/17 at approximately 10:00 PM. The DON (Director of Nursing) was notified of the fracture at 10:15 PM. A complete body audit was performed. The left shoulder was pink and swollen with no other injury identified at that time. Statements revealed that on 10/4/17 the CNA taking care of the resident reported to the nurse that the resident had a popping sound. Interview with the CNA revealed that while performing incontinent care, when s/he went to position Resident #2 over on his/her side using the pad the CNA heard the resident's left arm pop. The CNA alerted the nurse. The nurse confirmed that on 10/4/17 between 8:00 PM-8:30 PM s/he was told about the popping sound when the CNA moved the resident. The nurse assessed the resident's arm and at that time there was no evidence of an abnormality or injury. Further statements revealed that on 10/5/17 the resident did have pain in the left arm and the nurse was notified by the CNA. The nurse assessed the resident and medicated him/her for pain. On 10/6/17 the resident complained of pain in the left arm when touched. This is when the nurse practitioner was asked to see the resident and s/he ordered an x-ray. After consulting with the medical director, it was felt that with the resident's history and frailty ([CONDITION] and [MEDICAL CONDITION] with allergies [REDACTED]. Routine incontinent care was being delivered on 10/4/17 when the CNA providing care alone, heard a pop. The resident is care planned for the assistance of 2 with bed mobility and toileting. The CNA was counseled for not following the plan of care. Review of the Nurses' Progress Notes revealed there was no entry on 10/4/17 related to the CNA reporting the popping sound and the nurse assessing the resident. Further review of Resident #2's Nurses' Notes dated as a late entry on 10/10/17 for 10/5/17 indicated LPN #2 was notified by CNA that was assisting another CNA while doing a brief change on resident. Resident was complaining of much pain with any movement of left arm or touching arm. Checked resident's left arm and did not see anything. Left arm warm to touch, left arm up on pillow. Resident history of unable to move arm his/herself. Resident was given a pain pill at that time. The Progress Note documented by the Nurse Practitioner dated 10/6/17 at 1:37 PM revealed Resident #2 complained of left arm pain when touched or arm moved. States that it is his/her entire arm. Unable to tell where it is coming from. S/he yells and says don't move it with any amount of movement. No obvious deformity, no redness or [MEDICAL CONDITION]. Plan was for an x-ray of the left shoulder. A late entry on 10/7/17 for 10/6/17 by LPN #2 indicated the physician was notified about the x-ray report. New order to check pulse in left arm and medicate as needed for pain. Apply sling to left arm and position arm for comfort. If pulse changes or hand cold or increase in pain send to ER for evaluation of fracture. Review of the Nurses' Progress Notes revealed there was no entry on 10/4/17 related to the CNA reporting the popping sound and the nurse assessing the resident. Review of the Radiology Report dated 10/6/17 revealed Resident #2 had a humeral fracture with slight displacement. Review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #2 as having a Brief Interview for Mental Status score of 10. The Quarterly MDS coded the resident as having verbal behavior 1-3 days during the assessment period. Review of Resident #2's care plan revealed ADL deficit related to dementia and impaired mobility was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included staff to provide assistance as needed with bed mobility x 2 assist and hygiene x 2 assist. Review of Resident #2's Resident Profile revealed the resident was coded as requiring 2 staff for bed mobility and hygiene with a start date of 1/14/16. LPN #3's facility-obtained statement indicated CNA #3 reported s/he heard some popping sounds when s/he moved Resident #2. LPN #3 went and looked at the resident. There was no swelling or discoloration. Resident #2 said it didn't hurt. CNA #4's facility-obtained statement dated 10/9/17 indicated on 10/5/17 s/he helped another CNA change Resident #2's brief one time. Resident #2 was screaming and complaining of pain in his/her arm like I have never heard him/her do before. CNA #4 was not assigned to the resident that night but Resident #2's behavior alarmed him/her so much that s/he immediately went to the nurse, LPN #2 and told him/her how Resident #2 was acting. CNA #4 expressed to LPN #2 how serious s/he thought it may have been. CNA #3's facility-obtained statement indicated s/he had Resident #2 on 10/4/17 and reported that the resident had a popping sound. Review of the Education Counseling form for CNA #3 dated 10/11/17 revealed the subject was following plan of care using appropriate assistance with bed mobility. Comments included to always use appropriate assistance with bed mobility. This information can be found in the kiosk under resident profile. Use your need to know books. In an interview with the surveyor on 2/14/18 at approximately 2:40 PM, the unit 1 manager stated Resident #2 had been complaining about mouth soreness for a while. The resident was transported to the dentist on 10/3/17. All of a sudden, the resident started complaining about left shoulder pain out of nowhere. Resident #2 was moved to Unit 3 on 9/30/17 to accommodate an infection control issue, moved to Unit 2 on 10/2/17, and returned to his/her original room on Unit 1 on 10/4/17. The unit 1 manager did not hear about the resident's complaints of pain until the weekend. The unit 1 manager stated s/he did not know about the CNA hearing a pop until the investigation began. The unit 1 manager stated the pop was not documented by the nurse when it happened, it should have been. The unit 1 manager received a call about the x-ray report and s/he called the DON. The x-ray revealed a fracture. The unit 1 manager called the DON the night of 10/6/17. During the investigation they learned about CNA #3 hearing a pop while providing care. CNA #3 was providing care by him/herself and the resident is supposed to have 2 people for bed mobility. Resident #2 can't move one side, s/he is bedbound, and s/he refuses to get up. That information is on the resident profile on the kiosk. The DON educated CNA #3 that the resident required 2 people and the profile had that information. CNA #3 worked with Resident #2 a good bit. The facility reported alleged abuse for Resident #1. Review of the facility's Five-Day Follow-Up Report dated 1/12/18 revealed employees were terminated due to substantiated abuse of Resident #1. The allegation of physical abuse was substantiated for LPN #1, CNA #1, and CNA #2. The facility's details of reportable incident indicated the DON was notified at 12:18 AM on 1/9/18 by the House Supervisor RN (registered nurse) #1 about the bandages on Resident #1's fingers from reported nicks while the resident's fingernails were being cut on day shift. The DON was unaware of the information. The House Supervisor had been called to assess the resident because the bandages were saturated with blood. At 5:33 AM on 1/9/18 the DON called LPN #1 to ask about what happened to the resident's fingers. LPN #1 stated s/he was trying to cut the resident's fingernails because the resident was trying to scratch him/herself and staff during feeding. LPN #1 stated s/he did not realize that s/he had nicked the resident's fingers until s/he was done. LPN #1 stated that s/he nicked more than one finger. S/he was asked if anyone saw this and s/he stated CNA #2. At this point, the DON informed LPN #1 that s/he was being suspended pending investigation. The DON arrived at the building at approximately 7:20 AM and went to observe Resident #1, who was sitting in a wheelchair near the nurses' station. The resident had his/her hands in a fist and refused to open them. The DON noticed bruises on his/her left hand and arm. RN #2 had assessed the resident at approximately 7:00 AM while still in bed and reported that the resident was noted to have a bandage to the left pinky finger, and bandages to all fingers on the right hand. The resident refused to allow RN #2 to remove the bandages to assess his/her fingers. RN #2 also noted bruising to the right hand and forearm. The DON asked CNA #2 about the incident. CNA #2 stated that Resident #1 was in a mood and that s/he had told LPN #1 that when the resident acts like that s/he should leave him/her alone. The DON asked CNA #2 if s/he held the resident down and s/he said who me. CNA #2 stated s/he had no involvement and that s/he and CNA #1 were feeding other residents in the dining room at the time. The DON called DHEC certification at 8:25 AM. Review of the Nurses' Notes dated 1/8/18 at 1:30 PM by LPN #1 indicated resident was being fed by staff and started fighting and trying to scratch staff and self. This nurse went to cut resident's finger nails. Resident continued fighting while performing nail care and tips of fingers were cut. Applied band aids and pressure to area to stop bleeding. Resident left in recliner to calm down after incident. Later observed skin tear to left forearm had been reopened due to resident pinching area himself/herself. On 1/9/18 at 12:44 AM LPN #4 indicated at approximately 10:00 PM s/he was called to residents room by CNA related to resident was noted to have moderate amounts of blood on bandage to his/her left hand, ring finger. This LPN immediately went in to assess resident and observed moderate amount of dried blood to the resident's dressing on his/her left hand, ring finger and also on his/her top blanket and top sheet and also on his/her fingers on bilateral hands. Bright red moist blood in scant amount was noted on the tip of his/her gauze dressing to his/her ring finger. This writer notified house supervisor on Unit 1. House supervisor instructed LPN #4 to use wound cleanser to moisten bandage to remove and reapply dressing. Upon assessment of resident at that time noted resident to have multiple dark purple discolorations to the top of his/her left hand and wrist area and to his/her ring finger and upwards towards arm where there is a left forearm dressing. Also noted dark purple discolorations on fingers. RN #3 completed a body audit on Resident #1 on 1/9/18. The findings noted bruises to the right upper posterior aspect of the arm and mid-upper right arm. Dark bruising covering right forearm and right hand. Left forearm skin tear with dressing in place. Dark bruising covering left wrist and hand. Left wrist appears swollen. Bandages noted to right thumb, first, second, and fourth fingertips. 3rd fingertip has a nick on the tip. Nicks noted to the left thumb, second and fourth fingertips. 3rd finger has red area on top of finger above nail. 4th fingertip black with bruising and bandage applied. Purple bruises to left outer and inner aspect of ankle. Scratch noted to top of left foot. Several bruises noted to bilateral legs from hips down and varying colors of yellow, green, and purple. Further review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 2. The Quarterly MDS coded Resident #1 as rejecting care and having physical behaviors toward others 1-3 days during the assessment period. Review of the care plan revealed resident exhibits negative behaviors as evidenced by hitting, punching, kicking, and scratching at staff; resident can be resistant towards staff and care was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included if resident refuses care or becomes agitated, make sure that resident is safe and leave resident, attempt the task again at a later time. During continued investigation both CNAs #1 and #2 were interviewed and stated they did not have any involvement in the cutting of Resident #1's fingernails. Both CNAs stated they were in the dining room while LPN #1 cut the resident's nails in the hallway in front of the dining room. They both stated that LPN #1 placed the resident in a recliner in the day room and were advised to let him/her rest. On 1/10/18 at 12:45 PM Speech Therapist #1 told RN #2 that s/he was on the unit the day of the incident. Speech Therapist #1 stated that s/he was walking through the unit dining room looking for a resident. Out of the corner of his/her eye s/he noticed an agitated resident being tended to by the nurse (LPN #1). Two CNAs were present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and holding a bloody tissue. Speech Therapist #1's facility-obtained statement indicated s/he was walking through the Unit 3 dining room looking for a resident. Out of the corner of his/her eye, s/he noticed an agitated resident being tended to by the nurse. Two were CNAs present on either side of the resident holding him/her down due to agitation. The nurse appeared to be tending to the resident's left hand and was holding a bloody tissue. The nurse appeared frustrated. The Human Resource Director's facility-obtained statement indicated in a telephone interview with LPN #1 on 1/10/18 s/he stated Resident #1 was scratching his/her arm during lunch because his/her nails were long. LPN #1 pulled Resident #1 out of the dining area in his/her wheel chair and attempted to cut the resident's nails. Resident #1 was fighting against them being cut so s/he asked 2 aides (CNA #1 and CNA #2) to help hold Resident #1 while s/he cut. They held the resident's arms down while s/he cut all 10 of Resident #1's fingernails. LPN #1 admitted that Resident #1 was fighting against being bandaged up and that s/he had to hold the resident's arms and legs to bandage him/her. In an interview with the surveyor on 2/14/18 at approximately 12:10 PM, Staff Development Director RN #2 stated s/he arrived at the facility before the DON the morning after the incident. The DON had called RN #2 and asked him/her if s/he would come assess Resident #1. Staff had called the DON and told him/her the resident's fingertips had been cut. RN #2 went and looked at Resident #1 that morning. At that time, the resident was in the bed, it was approximately 7:15 AM when s/he arrived. The resident's fingertips at that time were wrapped and s/he could see blood coming through some of the bandages. RN #2 could see blood on three bandages on the right hand. RN #2 tried to hold Resident #1's hand, but the resident jerked back from him/her. RN #2 left the resident alone. RN #2 stated s/he could see deep purple-blue bruising on both the resident's arms from the knuckle to the elbow. Resident #1 had a bandage on his/her left arm, it was a previous skin tear that had reopened. RN #2 called the DON and told him/her s/he needed to come in. The DON asked CNA #2 what happened, s/he was the only one of the three working that day. The DON came out and said CNA #2 said LPN #1 cut Resident #1's nails, and s/he did it by him/herself. The next day RN #2 and the Human Resources director both talked to CNA #1. CNA #1 told them that LPN #1 was feeding the resident in the dining room and the resident was combative. CNA #1 and CNA #2 had told LPN #1 that when Resident #1 is combative you just have to leave him/her alone. They were in the dining room on Unit 3. LPN #1 was on one side of the dining room with Resident #1 and CNA #1 and CNA #2 were on the other side. LPN #1 was trying to feed the resident and Resident #1 was scratching him/her. At that point, CNA #1 said LPN #1 pushed the resident out into the hallway and was cutting his/her fingernails. CNA #1 said s/he and CNA #2 remained in the dining room feeding. LPN #1 transferred the resident from his/her wheelchair into a recliner in the dayroom and continued to cut his/her nails. RN #2 asked how LPN #1 was cutting the resident's nails with the resident being combative. CNA #1 said LPN #1 was sitting on the side of the resident and had the arm s/he was cutting the fingernails with holding down the other arm. CNA #1 said the resident kicked, so LPN #1 crossed the resident's leg and LPN #1 used his/her body to hold the resident's legs together so s/he couldn't kick. They asked CNA #1 if they thought that was the incorrect thing to do and s/he said yes. They asked CNA #1 why s/he did not report it and CNA #1 said s/he didn't know. CNA #1 denied helping LPN #1 cut the resident's nails. LPN #1 gave CNA #1 the keys to get bandages out of the treatment cart. CNA #1 said s/he was assigned to Resident #1 that day. LPN #1 covered up Resident #1 with a blanket and told CNA #1 to let him/her rest when s/he finished cutting his/her nails and bandaging them. RN #2 asked if CNA #1 did any care for the rest of the shift and s/he said no because LPN #1 said to leave the resident alone. They told CNA #1 that was considered abuse and s/he should have reported it immediately. Later that day, the therapy director came and brought over Speech Therapist #1. Speech Therapist #1 said s/he walked through the day room the day of the incident, and out of the corner of his/her eye saw LPN #1 putting a dressing on Resident #1's hand. In an interview with the surveyor on 2/14/18 at approximately 12:45 PM, interim DON RN #1 stated s/he was the night supervisor at the time of the incident. S/he was working a cart on Unit 1 and s/he got a call from the nurse on Unit 3. The nurse said s/he had a situation, s/he wanted RN #1 to come look at a patient with him/her. The nurse called around 10:00-10:30 PM. RN #1 went to Unit 3 and the nurse told him/her in report they had told him/her Resident #1 had become combative and was trying to scratch so they had to trim his/her nails. The nurse said the resident had dressings on his/her fingers, one of the aides said s/he needed to have the dressing changed because it was bleeding through. When the nurse went in to change the dressing, s/he saw that the resident had several fingers bandaged. RN #1 went in and looked at the resident and saw one finger that was bleeding through. They tried to look at the resident's fingers and the resident resisted so they backed off. RN #1 called the DON and told him/her they had a situation. RN #1 told the DON that the resident had bruising on both arms, and bandages on his/her fingers where they had been nicked while cutting his/her nails. RN #1 actually talked with the DON and s/he said h/she would be in shortly to look. RN #1 called the DON around 11:30 PM. The DON did not come in that night, but the next morning. RN #1 told the nurse to monitor the resident closely that night. RN #1 had concerns when s/he saw the resident, s/he asked the nurse about report and checked the note from that day. RN #1 told the DON about what s/he saw and about his/her concerns. RN #1 was concerned with the extent of the bruising without the resident being on an anti-coagulant, and the bandaging on the fingers. In an interview with the surveyor on 2/14/18 at approximately 2:10 PM, the Healthcare Manager stated s/he found out about the incident the next morning. S/he was on the way to a conference out of town and the DON informed him/her about the incident. The DON was riding with the Healthcare Manager on the way to the meeting. The DON told him/her the nurse the day before had clipped Resident #1's fingernails and cut the tips of his/her fingers. The DON said there was an old skin tear that had reopened and a lot of bruising to that arm. The DON stated s/he was going to have to investigate and report the incident. It was about 7:00 AM when the DON told him/her about the incident. The DON had not reported it at that point. The DON called the number to report the incident and left a message, sometime between 7:00-7:30 AM. The DON started his/her investigation when they got back that afternoon. The Healthcare Manager saw the resident's fingers the next day when the nurse manager had unbandaged the fingers and was redressing them. The pinky fingers had a good bit nipped off the end of the fingers. All 5 fingers on one hand and the pinky of the other all had clipped areas on the cuticles. The pinky was still bleeding on one hand. There was bruising on one arm and was the same that had the most of the clips on it. It was bruised all the way up to the elbow, dark purple. The Healthcare Manager talked with the resident's son/ daughter on 1/10/18 and told her it had been reported to law enforcement. H/She asked if it had been reported to DHEC and they said yes.",2020-09-01
3318,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2017-02-23,332,D,0,1,BE5V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of the manufactures recommendations, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 25 opportunities for error, resulting in a medication error rate of 8%. The findings included: Error#1 On 2/22/17 at 9:17 AM, during observation of Resident #122's medication administration, Registered Nurse #2 was observed to administer 1 spray of [MEDICATION NAME] 50 microgram (mcg.) nasal spray to the resident in each nostril. Following the observation a review of Resident #122 physician's orders [REDACTED]. RN #2 verified s/he only gave 1 spray and the order was for 2 sprays into each nostril. Error #2 On 2/22/17 at 1:07 PM, during observation of Resident #3's medication administration, Licensed Practical Nurse (LPN) #1 administered 1 drop of Artificial Tears 1.4 % eye drops into each of the residents' eyes. On 2/23/17 at 8 :45 AM, reconciliation review of Resident #3's medication administration revealed the physician order [REDACTED]. to Adm: 2 Drops; ophthalmic Spec. Inst: Instill 2 drops in both eyes TID. For dry eyes TID- three times A Day 06:00 AM, 01:00 PM, 08:00 PM. On 2/23/17 at 9:00 AM, LPN #2 verified the physicians order for Resident #3 to receive 2 drops of Artificial Tears 1.4% Solution into both eyes. LPN #1 further stated, We only give one drop per eye on all eye drops.",2020-09-01
3319,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2017-02-23,425,D,0,1,BE5V11,"Based on observations, interview, and review of the facility policy, the facility failed to follow a procedure to ensure biologicals and pharmaceutical services met the needs of the residents for 1 of 5 carts reviewed for medication labeling. Eye drops were being used and not labeled properly. The findings included: On 2/23/17 at 9:00 AM, an observation of the 300 unit medication cart with Licensed Practical Nurse #2 revealed Resident #3's Artificial Tears Solution with stamped pharmacy box instructions stating, Artifi Tears Sol 1.4% OP Instill 1 Drop into Both Eyes Three Times Daily for Dry Eyes. Also, review of Resident #3's physicians orders revealed an order stating, Artificial Tears (polyvinyl alcohol) (OTC) drops; 1.4% Amt. to Adm: 2 Drops; ophthalmic Spec. Inst: Instill 2 drops in both eyes TID. For dry eyes TID- three times A Day 06:00 AM, 01:00 PM, 08:00 PM. Following the review of the pharmacy box instructions and the physicians' orders with LPN #2, s/he verified there was a discrepancy in the physicians order for the Resident #3 to receive 2 drops of Artificial Tears Solution into both eyes and the pharmacy stamped box instructions that stated to instill 1 drop into both eyes. Review of the facility policy Storage of Medications, revealed under (3.) Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for labeling before storing.",2020-09-01
3320,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2019-05-02,812,E,0,1,2VSL11,"Based on observation, interview, and review of the facility's policy titled Handling Cold Foods for Trayline, the facility failed to ensure that foods were held at the correct temperature before serving. Tuna salad on lettuce was not held at a temperature of 41 degrees or cooler in 1 of 3 dining rooms observed with food served in the dining room. The findings included: On 05/01/19 at 12:04 PM, observations of food temperatures revealed one tuna salad on top of lettuce that had a temperature of 48.3 degrees sitting on top of ice in a plastic tub. The Dietary Aide and the Dietary Technician were both aware of the temperature of the tuna salad. The Dietary Technician instructed the Dietary Aide to place the salad back on the ice. At 12:34 PM, the Dietary Aide plated an item from the tray line and a Certified Nursing Assistant picked up the tuna salad and placed it on the tray to be served. Delivery of the tray was stopped by the surveyor. During an interview at that time, the Dietary Technician confirmed the temperature had been 48.3 degrees. When asked, the Dietary Technician knew the tuna salad had to be maintained at a temperature of 41.0 degrees or less and had not stopped the Dietary Aide from placing the salad on a tray to be served. Review of the facility's policy titled Handling Cold Foods for Trayline, revealed 3. Cold temperatures will be taken and recorded prior to and halfway through service to assure foods are (less than or equal to) 41 (degrees) F (Fahrenheit).",2020-09-01
3321,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2019-05-02,867,D,0,1,2VSL11,"Based on interview and review of the facility's documentation, the facility failed to monitor results of a Performance Improvement Plan (PIP) to determine if changes were effective at ensuring foods were at the appropriate holding temperature or if the interventions should be revised. The findings included: On 05/02/19 at approximately 02:45 PM, the Nursing Home Administrator (NHA) provided a PIP (Performance Improvement Plan) related to recording of food temperatures and ensuring they were within regulations. Further review revealed the PIP was documented as completed on 03/29/19. Other issues also identified related to food service included in the PIP were documented as completed on 04/04/29. During an interview on 05/02/19 02:53 PM, the Nursing Home Administrator (NHA) confirmed the PIP was completed and that there was no plan in place for monitoring to ensure continued compliance. The NHA confirmed the PIP had been ineffective.",2020-09-01
3322,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-05-17,623,F,0,1,2M9S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the required written notice of transfer to the resident/ resident representative for Resident's #12, #51, #35 and # 22 at the time of a facility initiated transfer. 4 of 5 reviewed for transfer to the hospital. The findings included: Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. muscle weakness, [MEDICAL CONDITION],chronic pain, history of UTI's, [MEDICAL CONDITIONS],Essential Hypertension, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux disease, overactive bladder, urinary incontinence, abnormal weight loss, Cognitive communication on deficit, Wedge compression fracture of first lumbar vertebra, Major [MEDICAL CONDITION], lack of coordination, shortness of breath, pain in unspecified knee and [MEDICAL CONDITION]. During record review there was no documentation that the Resident/ Resident's Representative was notified of the transfer to the hospital as soon as practicable. During an interview on 05/15/18 at approximately 03:45 PM, the Director of Nursing (DON) stated, We have not provided written notification to the resident/ Resident's Representative of the transfer to the hospital. On 05/16/18 at approximately 10:46 AM the Unit Manager confirmed and stated, We make the Residents Representative (RR) aware at the time of a transfer to the hospital, but we have not given written notification to the RR. The facility admitted Resident #22 on 4/4/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Progress Note dated 3/21/18 at 1:28 PM indicated, Sent to ER as ordered by Nurse Practitioner, (RP) notified . The Progress Note dated 3/21/18 at 10:49 PM indicated, This writer spoke with LCMH staff Nurse and informed resident admitted to Hospital 2nd floor with Dx: UTI. Called residents (RP) to inform but already aware . There was no documentation in the medical record to indicate the resident and/or resident's Responsible Party was provided with a written notification of the reason for the transfer to the hospital. The facility admitted Resident #12 on 01/30/17 with [DIAGNOSES REDACTED]. At 1:23 PM on 05/16/2018, review of the Nursing Progress Notes revealed on 04/26/18 Nurse called into residents room by concierge due to resident not responding appropriately. Upon entering room resident was observed to have slow response. Mental status checked and responses were as follows (sic) where are you resident stated Martha Stewart, year 1977, no response when asked who our current president was. O2 (oxygen) saturation was 78% via NC (nasal canula) 3L/min (liters per minute). Resident was unable to follow simple breathing technique instructions. Lung sounds were clear upper and lower right lobe but diminished in left upper and lower lobe. Resident observed using accessory muscles. Vital signs were obtained and were as follows: B/P (blood pressure) 143/67 Temp (temperature) 97.9 Pulse 110 Resp (respirations) 21 O2 saturations fluctuating between 78-90%. Due to unstable o2 saturations ems (sic) was called at 7:38 pm. Resident left via stretcher at 8:20pm en route to Greenville per request of POA ( .). Resident #12 was admitted to the hospital and returned on 04/30/18. There was no documentation that written notice of transfer was provided to the resident or the resident's representative. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. On 05/15/18 at 10:10 AM, review of the Electronic Health Record revealed Resident #35 was hospitalized from 3/9-3/19/18 following a fall resulting in a [MEDICAL CONDITION]. Further review revealed Resident #35 was also hospitalized from 05/07-05/09/18. On 05/15/18 at 10:12 AM, review of Nursing Progress Notes revealed on 3/09/18 the resident's roommate cam outside of the room calling for help. The nurse entered the room and observed the resident on the floor on the left side of the bed. The resident said the left hip hurts a lot when touched. The NP was notified and order received for hip x-ray 2 views and pelvic x-ray. At 9:46 PM, the nurse documented X-ray results were as follows: There is a comminuted left intertrochanteric fracture with impaction. The joint shows no dislocation. Conclusion: Acute left [MEDICAL CONDITION]. EMS (Emergency Medical Service) was called and the resident left via stretcher at 8:00 PM and the resident was admitted to the hospital. The RP was notified by phone of the transfer but there was no documentation that written notice of transfer was provided to the resident or resident representative. At 9:21 AM on 05/16/2018, further review of the Nursing Progress Notes revealed on 05/07/18 the CNA (Certified Nursing Assistant) observed the resident exhibiting [MEDICAL CONDITION] activity and called the nurse. Vital signs were taken, the MD (Medical Doctor) was notified and a new order received to send the resident to the emergency room for evaluation. The Responsible Party was notified by phone. There was no documentation that the resident or resident representative received written notice of the reason of transfer.",2020-09-01
3323,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-05-17,625,F,0,1,2M9S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the Bed Hold Policy to the resident/ resident representative for Resident #12, #51, #35 and # 22 at the time of a facility initiated transfer. 4 of 5 reviewed for transfer to the hospital. The findings included: Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. muscle weakness, [MEDICAL CONDITION],chronic pain, history of UTI's, [MEDICAL CONDITIONS],Essential Hypertension, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux disease, overactive bladder, urinary incontinence, abnormal weight loss, Cognitive communication on deficit, Wedge compression fracture of first lumbar vertebra, Major [MEDICAL CONDITION], lack of coordination, shortness of breath, pain in unspecified knee and [MEDICAL CONDITION]. During record review there was no documentation that the Resident/ Resident's Representative was provided the Bed Hold Policy at the time of transfer to the hospital. During an interview on 05/15/18 at approximately 03:45 PM, the Director of Nursing (DON) stated, We have not provided the Bed Hold Policy to the resident/ Resident's Representative at the time of the transfer to the hospital. On 05/16/18 at approximately 10:46 AM the Unit Manager confirmed and stated, We make the Residents Representative (RR) aware at the time of a transfer to the hospital, but we have not sent the Bed Hold Policy when someone goes to the hospital. The facility admitted Resident #22 on 4/4/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Progress Note dated 3/21/18 at 1:28 PM indicated, Sent to ER as ordered by Nurse Practitioner, (RP) notified . The Progress Note dated 3/21/18 at 10:49 PM indicated, This writer spoke with LCMH staff Nurse and informed resident admitted to Hospital 2nd floor with Dx: UTI. Called residents (RP) to inform but already aware . There was no documentation in the medical record to indicate the resident and/or resident's Responsible Party was provided with written information related to the facility's Bed-Hold Policy and Reserve Payment Policy upon transfer to the hospital. The facility admitted Resident #12 on 01/30/17 with [DIAGNOSES REDACTED]. At 1:23 PM on 05/16/2018, review of the Nursing Progress Notes revealed on 04/26/18 Nurse called into residents room by concierge due to resident not responding appropriately. Upon entering room resident was observed to have slow response. Mental status checked and responses were as follows (sic) where are you resident stated Martha Stewart, year 1977, no response when asked who our current president was. O2 (oxygen) saturation was 78% via NC (nasal canula) 3L/min (liters per minute). Resident was unable to follow simple breathing technique instructions. Lung sounds were clear upper and lower right lobe but diminished in left upper and lower lobe. Resident observed using accessory muscles. Vital signs were obtained and were as follows: B/P (blood pressure) 143/67 Temp (temperature) 97.9 Pulse 110 Resp (respirations) 21 O2 saturations fluctuating between 78-90%. Due to unstable o2 saturations ems (sic) was called at 7:38 pm. Resident left via stretcher at 8:20pm en route to Greenville per request of POA ( .). Resident #12 was admitted to the hospital and returned on 04/30/18. There was no documentation that the facility's bed hold policy was provided to the resident or the resident's representative. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. On 05/15/18 at 10:10 AM, review of the Electronic Health Record revealed Resident #35 was hospitalized from 3/9-3/19/18 following a fall resulting in a [MEDICAL CONDITION]. Further review revealed Resident #35 was also hospitalized from 05/07-05/09/18. On 05/15/18 at 10:12 AM, review of Nursing Progress Notes revealed on 3/09/18 the resident's roommate came outside of the room calling for help. The nurse entered the room and observed the resident on the floor on the left side of the bed. The resident said the left hip hurts a lot when touched. The NP was notified and order received for hip x-ray 2 views and pelvic x-ray. At 9:46 PM, the nurse documented X-ray results were as follows: There is a comminuted left intertrochanteric fracture with impaction. The joint shows no dislocation. Conclusion: Acute left [MEDICAL CONDITION]. EMS (Emergency Medical Service) was called and the resident left via stretcher at 8:00 PM and the resident was admitted to the hospital. The RP was notified by phone of the transfer but there was no documentation that the facility's bed hold policy was provided to the resident or resident representative. At 9:21 AM on 05/16/2018, further review of the Nursing Progress Notes revealed on 05/07/18 the CNA (Certified Nursing Assistant) observed the resident exhibiting [MEDICAL CONDITION] activity and called the nurse. Vital signs were taken, the MD (Medical Doctor) was notified and a new order received to send the resident to the emergency room for evaluation. The Responsible Party was notified by phone. There was no documentation that the resident or resident representative received a copy of the facility's bed hold policy.",2020-09-01
3324,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-05-17,760,E,0,1,2M9S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policy and manufactures recommendations, the facility failed to administer the correct amount of medication resulting in significant medication error for 1 of 2 residents reviewed for insulin medication administration. Resident # 62 did not receive the correct amount of insulin. The findings included: On [DATE] the facility admitted Resident #62 with a [DIAGNOSES REDACTED]. On [DATE] at 2:35 PM, an observation of the 200 unit rehab cart with LPN #1 revealed; Resident #62 had (1) open vial of Humalog insulin (Lot #C 7A) (,[DATE] remaining) with a puncture date of ,[DATE] and (1) open vial of [MEDICATION NAME] (Lot #7F015B) (,[DATE] remaining) with a puncture date of ,[DATE] and a hand written expiration date of [DATE] on the box. LPN #1 verified the Humalog and [MEDICATION NAME] were expired and indicated the insulin should have been removed from storage. On [DATE] at 3:00 PM, a review of Resident #62's Medication Administration Record [REDACTED]{(3) doses on [DATE], (1) dose on [DATE], (2) doses on [DATE], and (1) dose on [DATE]} of Humolog insulin and (3) doses {(1) dose on [DATE], (1) dose on [DATE], and (1) dose on [DATE]}of [MEDICATION NAME] after the expiration date. LPN #1 verified the Humalog and [MEDICATION NAME] vials were in-use after the expiration date. Review of the facility policy, Administering Medication, reveals under (9.) The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Review of the Humalog manufactures recommendations reveals under 16.2 Storage and Handling states, Do not use after the expiration date. In-use Humalog vials, cartridges, and Humalog KwikPen should be stored at room temperature, below 86 degrees (30 degrees C) and must be used within 28 days or be discarded, even if they still contain Humalog. Review of the [MEDICATION NAME] 100 Units/ML vial manufactures recommendations states under the section Storage: Discard all containers in use after 28 days, even if there is insulin left.",2020-09-01
3325,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-05-17,761,E,0,1,2M9S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, review of the facility policy, and review of the Humalog and [MEDICATION NAME] manufactures package insert instructions, the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 1 of 5 medication storage carts reviewed. Expired medication (insulin) was on the 200 unit rehab cart after the manufactures recommended expiration date. The findings included: On 5/14/18 at 2:35 PM, an observation of the 200 unit rehab cart with LPN #1 revealed, (1) open vial of Humalog insulin (Lot #C 7A) (1/2 remaining) with a puncture date of 4/13 and (1) open vial of [MEDICATION NAME] (Lot #7F015B) (1/3 remaining) with a puncture date of 4/13 and a hand written expiration date of 5/11/18 on the box. LPN #1 verified the Humalog and [MEDICATION NAME] were expired and in-use, and indicated the insulin should have been removed from storage. Review of the facility policy, Storage of Medications, revealed under procedure (K.) Medications requiring stored in refrigerator until opening are kept in cart at room temperature once refrigerator medication has been opened. Each opened box shall be dated when opened, have beyond use date, and have nurse's initials. Refer to manufactures recommendations for use of storage date once refrigerator product has been opened and stored on cart. Also procedure (N.) states, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal and reordered from the pharmacy if a current order exists. Review of the Humalog manufactures recommendations reveals under 16.2 Storage and Handling states, Do not use after the expiration date. In-use Humalog vials, cartridges, and Humalog KwikPen should be stored at room temperature, below 86 degrees (30 degrees C) and must be used within 28 days or be discarded, even if they still contain Humalog. Review of the [MEDICATION NAME] 100 Units/ML vial manufactures recommendations states under the section Storage: Discard all containers in use after 28 days, even if there is insulin left.",2020-09-01
3326,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-05-17,812,F,0,1,2M9S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 2 of 2 kitchens reviewed and has the potential to affect 69 of 69 residents with ordered diets as evidenced by failing to do the following: Air dry pans, dispose of expired food, plate food sanitarily, and clean (hood, oven, fans, floors, ice scoop holder, microwave, can opener). The findings included: On [DATE] at 10:25 AM, an initial tour of the main kitchen with the Certified Dietary Manager (CDM) revealed: 1.) (6) 2 inch shot gun pans, (9) ,[DATE]th pans, and (4) ,[DATE] pans stacked wet in clean pan shelf. 2.) The hood above the stove and ovens was dripping grease behind the cooking line onto a motor of the convection oven which also had a build-up of dust. Furthermore, one of the hoods grease catch pans was over flowing with grease. The CDM stated an outside service cleaned the hood every (3) months. (MONTH) of (YEAR) was the last service date recorded on a sticker attached to the hood. 3.) The ice scoop holder did not have drainage and had black/white debris floating and growing in the water at the bottom. 4.) Standup refrigerator had (1) 64 ounce bulk container of Franks Red Hot sauce with a best by date of (MONTH) 19, (YEAR) that was half full. 5.) Walk-in refrigerator had (7) bundles of Asparagus without an expiration date that had a white fuzzy substance growing on them. 6.) Dry storage room had (6) heads of Cabbage that were rotten with brown discolored leaves and was dripping a brown malodorous liquid onto the floor, furthermore, (5) flies were on and around the cabbage. 7.) (1) Fan in the main kitchen had a build-up of dust, also the walk-in refrigerator (3) fans had a build-up of a white fuzzy substance growing and was blowing onto the food. 8.) Microwave in main kitchen had food build-up on the door, and food spillage/spatter inside. 9.) Oven doors and oven interior in main kitchen had build-up of grease. 10.) Can opener in main kitchen had a build-up of food debris and rust. 11.) (2) men in the food preparation area of the main kitchen did not have a facial hair restraint covering their mustache. 12.) Floors in the main kitchen and dry storage had a build-up of a black substance and food debris under all equipment and racks. On [DATE] at 12:20 PM, during an observation of the lunch line plating with the CDM revealed the Dietary Tech #1 donned gloves touched the bread bag, plate cart handle, plates, pans, plate covers, and scoop handles, then proceeded to handle buns, hamburger, cheese, onion, lettuce, tomato, and French fries with the gloved hands without changing gloves. The CDM verified Dietary Tech #1 was plating food with his/her hands and indicated that utensils should be used when handling food. On [DATE] at 10:45 AM, an observation of the main kitchen with the CDM revealed: 1.) Can opener in main kitchen build-up of food debris and rust. 2.) (1) Fan in the main kitchen had a build-up of dust, also the in walk-in refrigerator (3) fans had a build-up of a white fuzzy substance growing and was blowing onto the food, and (1) fan in the dish washing area and (1) fans in the dishware drying area had a build-up of dust. 3.) All floors in the main kitchen and dry storage had a build-up of a black substance and food debris under all equipment and racks. 4.) (1) man in the food preparation area of the main kitchen did not have a facial hair restraint covering their mustache On [DATE] at 11:10 AM, during an interview, the CDM verified the (12) observations on the [DATE] initial tour and the (5) [DATE] observations. Review of the facility policy, Cleaning Procedures & Schedules, states under procedures: POTS AND PANS: (3.) Air dried OVENS/CONVECTION OVENS: (1.) All racks and drip trays are debris and grease free, no visible buildup of grease; (2.) Interior of ovens is free of debris and grease, no grease buildup; (5.) Glass in door is clear HOOD/HOOD FILTERS: (1.) Hoods should be smooth to the touch and free of grease, dust, and dirt. CAN OPENERS (MANUAL/COUNTER TOP): (1.) Blade, gear, handle, and table mount free of stickiness, dirt, food, and grease buildup, smooth to the touch REFRIGERATORS/FREEZERS: (3.) All fans and vents should be free of dust, grease, and dirt STOREROOM: Walls, ceiling, doors, and floor should be free of dust, dirt, stains, spots, and debris FLOORS: (1.) Should be free of debris, dirt, grease, and spills Review of the facility policy, Dress Code Food Service Department states under Facial hair All facial hair other than a mustache are to be covered with a hairnet. Review of the facility policy, Ice Machine and cleaning policy states, Food service personnel are responsible for attached Ice scoop and holder. Both of these are to be run through the dish machine on a weekly basis when on staff cleaning schedule. This is on the weekly cleaning sheet. Observation of Unit 3 on [DATE] at approximately 12:20 PM revealed staff serving lunch to residents in the dining areas. At that time, Certified Nurses Assistant (CNA) #1 was observed to touch food with his/her bare hands while setting-up resident's plates. CNA #1 was observed to remove the top of a hamburger bun with bare hands, touch the lettuce and tomato with bare hands, place the top of the hamburger bun back in place with bare hands, and cut the hamburger in ,[DATE] while using bare hands to hold the hamburger bun in place on the plate. Further observation revealed CNA #1 touched the hamburger bun with his/her bare hands when cutting hamburgers in ,[DATE] for 2 other residents.",2020-09-01
3327,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-05-17,814,D,0,1,2M9S11,"Based on observations, interview, and review of the facility's policy, the facility failed to dispose of garbage and refuse properly for 1 of 1 refuse container area reviewed for garbage disposal. Trash and grease were not contained in refuse containers leaving grease, trash, and medical waste visible. The findings included: On 5/14/18 at 1:00 PM, an observation of the dumpster area and grease container outside behind the kitchen revealed 8 plastic bottles, 4 boxes, 2 bags of trash, food wrappers, and (2) blue medical gloves on the ground behind and between the dumpster's. Also, the grease container was on uneven pavement and had spillage/black substance (2 feet by 4 feet) leaking onto the pavement which was emptying into a ground water drain on the pavement. On 5/15/18 at 11:00 AM, an observation with the Certified Dietary Manager (CDM) of the dumpster area and grease container outside behind the kitchen revealed 8 plastic bottles, 4 boxes, 2 bags of trash, food wrappers, and (2) blue medical gloves on the ground behind and between the dumpster's. Also, the grease container was on uneven pavement and had spillage/black substance (2 feet by 4 feet) leaking onto the pavement which was emptying into a ground water drain on the pavement. On 5/15/18 at 11:05 AM, during an interview, the CDM verified the grease and debris on the ground near the dumpster's and grease container area, s/he further indicated that no debris or grease should be on the ground. Review of the facility policy, Left over grease refuse, Dumpster area stated, It is the policy that the area for this storage area to stay neat and clean of all refuse rather it be grease on the ground or trash in the dumpsters. Procedure: On a daily basis, as food service personnel or any other personnel who take out trash to recognize spillages and report them to Food service operation for immediate cleanup. Upon recognition, the Food service staff are to clean these areas.",2020-09-01
3328,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-05-17,880,D,0,1,2M9S11,"Based on observations, interview, review of the facility policy and the Center for Disease Control Prevention safety recommendations, the facility failed to follow a procedure to ensure precautions were observed for the disposal of contaminated equipment for 1 of 1 resident observed for finger stick blood sugar. A Finger stick device was not disposed of in an approved sharps container on the 300 unit. The findings included: On 5/15/18 at 11:36 AM, during an observation of Resident #25's med pass on the 300 unit, Licensed Practical Nurse (LPN) #2 used a finger stick device to penetrate the residents' finger to produce blood to monitor the residents' blood sugar. LPN #2 then placed the finger stick device into the general trash can on the medication cart. There was a sharps container on the medication cart. Following the observations LPN #2 verified the finger stick device was placed into the general trash and indicated that the device should have been placed into the sharps container on the cart. Review of the facility policy, Blood Sampling - Capillary (Finger Sticks) states, under Steps in the procedure (.7) Discard lancet and platform into the sharps container. Review of the Center for Disease Control Prevention recommendations revealed under Infection Prevention during Blood Glucose Monitoring and Insulin Administration, section Blood Glucose Monitoring, Fingerstick Devices bullet #2 states, Dispose of used lancets at the point of use in an approved sharps container. Never reuse lancets.",2020-09-01
3329,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2018-05-17,908,D,0,1,2M9S11,"Based on observation, interview, and facility policy, the facility failed to maintain equipment in a safe operating condition for 1 of 1 convection ovens reviewed. The convection oven in the main kitchen had a large build-up of grease and dust on the motor. The findings included: On 5/14/18 at approximately 10:25 AM, during initial tour of the main kitchen with the Certified Dietary Manager (CDM) revealed the motor in the rear of the convection oven had a large build-up of dust and grease which was dripping from the hood above. The grease was draining into the vents of the rear of the motor. The CDM verified the heavy build-up of grease and dust and was asked if the hood and ovens were on a cleaning schedule. The CDM stated, The hood is on a 3 month cleaning schedule from an outside contractor. Following the observation of the grease dripping from the hood and interview with the CDM, another observation of the hood revealed a contractor sticker indicating (MONTH) (YEAR) as the last cleaning date of the hood. The CDM verified the contractor sticker indicating (MONTH) (YEAR) as the last service date. Review of the facility policy,[NAME]Cleaning stated, Hoods are to be cleaned by a contractor trained in professional hood cleaning on a 6 month basis.",2020-09-01
4877,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2016-05-12,274,D,0,1,LJQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify a significant change in status and conduct a Significant Change in Status Assessment as required for Resident #18, 1 of 3 residents reviewed with a change in status. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. At 11:21 AM on 05/11/2016, Review of the MDS (Minimal Data Set) revealed Resident #18 had a significant change in status on a 4/10/16 Quarterly Assessment when compared to the Admission assessment dated [DATE]. Improvement was noted in cognition from a staff assessment of short and long term memory problems and rarely making decisions to having a BIMS (Brief Interview for Mental Status) score of 14, indicating the resident was cognitively intact. Resident #18 was also noted to have an improvement in verbal behaviors and eating went from extensive assistance to supervision. The resident also was noted to have a decline in mood from a staff assessment of mood indicators with a score of 1 to a resident interview with a score of 5 and a decline in ambulation from limited assistance to activity did not occur At 11:42 AM on 05/11/2016, review of the Progress Notes revealed a note dated 4/21/16 by Social Services that Resident #18 had improved cognitively overall. Further review revealed no documentation by nursing that the resident had improved performance in ADLs (Activities of Daily Living). During an interview on 05/12/2016 at 4:07 PM, the RN (Registered Nurse) MDS Coordinator confirmed Resident #18 had improvements in cognition, behaviors, and eating and a decline in mood and ambulation. The MDS Coordinator stated that s/he was not responsible for doing sections C (Cognition) or D (Mood) but confirmed that s/he was responsible for coordinating the assessment and that a Significant Change in Status Assessment should have been done.",2019-07-01
4878,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2016-05-12,279,D,0,1,LJQ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify the risk for weight loss or develop a comprehensive care plan for actual weight loss for Resident #114, 1 of 4 residents reviewed for nutrition. The findings included: The facility admitted Resident #114 with [DIAGNOSES REDACTED]. At 3:13 PM on 05/12/2016, review of the Weight records revealed the resident had an admission weight on 4/08/16 of 105.7 pounds. On 4/13/16 the weight was recorded as 103.0 pounds, on 4/18/16 98.5 pounds, on 4/19/16 98.9 pounds , on 4/25/16 95.1 pounds, and on 4/27/16 94.7 pounds. The resident had a total weight loss of 11.0 pounds, a significant loss of 10.4% At 4:29 PM on 05/12/2016, review of the care plan revealed no care plan for nutrition, potential or actual weight loss. During an interview on 05/12/2016 at 5:02 PM, the RN (Registered Nurse) MDS Coordinator confirmed Resident #114 had a significant weight loss. The RN further stated that the resident's weight loss had not been discussed at the weekly risk meeting until 5/5/16 and that there was no care plan for nutrition, potential or actual weight loss.",2019-07-01
5987,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,157,D,0,1,9JKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify the physician of changes in residents conditions potentially requiring physician intervention for 1 of 1 sampled resident reviewed with orders for TED ([MEDICAL CONDITION]-deterrent) hose. Staff failed to notify the attending physician that Resident #8 suffered from [MEDICAL CONDITION] and refused to wear TED hose as ordered. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 1/12/15 at 4:51 PM, record review revealed an order for [REDACTED]. At 4:55 PM on 1/12/15, observation revealed the resident was not wearing the TED hose. On 1/13/15 at 8:50 AM, observation revealed the resident was out of bed, dressed, and was not wearing the TED hose. At 10:43 AM on 1/13/15, record review revealed Telephone Orders dated 11/24/14 for T-Hose on in morning, T-Hose off (at) HS (bedtime), 12/17/14 for TED Hose, and 12/22/14 for Clarification TED Hose on in am, off at HS Apply to bilateral LEs (lower extremities). Review of the Telephone Orders also revealed an order dated 12/11/14 Set up appt (appointment) .Cardiology Dx (diagnosis) new [MEDICAL CONDITION]. Review of the Doctor's Progress Notes revealed a 12/11/14 note that stated .Leg swelling not much improved .Ext: (Extremities) [MEDICAL CONDITION] 2+ R (right) 1+ L (left) .Ted hose in place. The note further stated the assessment and plan were Dependent [MEDICAL CONDITION] - (check) ECHO (echocardiogram) (check) BNP (brain natriuretic peptide) Send to .Cardiologist. A progress note dated 12/17/14 from the Cardiologist was reviewed that stated Pt (patient) has swelling R >> (greater than) L .Needs TED Hose. Review of the Treatments Administration History on 1/14/15 at 9:10 AM for 12/22/14 through 1/13/15 revealed Resident #8 refused to wear the TED hose on 12/22/14 and 12/23/14 and notified MD (Medical Doctor) to advise dated 12/22/14. Review of history also revealed the TED hose were signed off daily from 12/24/14 through 1/13/15 AM shift as being applied and removed though observation revealed the resident was not wearing the hose on 1/12 or 1/13/15. Review of the nursing progress notes revealed Resident #8 refused the TED hose on 12/6 but decided to let CNA (Certified Nursing Assistant) help put them on, 12/7 .does refuse to have TED hose placed early in morning, but then later will allow the TED hose to be put on, 12/17 New order for hose that go up on thighs to decrease [MEDICAL CONDITION] to legs bilateral, 12/20 Resident insisted that the thigh high TED hose be removed ., 12/21 Resident refuses this morning to wear TED hose, (she/he) said (she/he) was in (her/his) right mind and (she/he) didn't want to wear them. On 12/22/14 the nursing progress notes indicated Clarification order written for ted hose. Ted Hose on in am, off at hs. Apply to bilateral lower extremities. Res (resident) refused ted hose this am. Stated that (she/he) did not want them. MD notified via communication book . No documentation was located in the record that the Cardiologist was notified of the resident's refusal to wear the TED hose or that the facility had followed up with the attending physician when no response was received related to the resident's refusal documented in the communication book. During an observation and interview on 1/13/15 at 5:10 PM, Licensed Practical Nurse (LPN) #2 confirmed there were 3 orders for the TED hose and confirmed on observation that the resident was not wearing the TED hose. The LPN asked the resident if they (CNAs) were putting them on and the resident stated, No. During an interview at 9:37 AM on 1/14/15, LPN #2 stated the facility had received no response from the doctor regarding the 12/22/14 note in the communication book and that there was no documentation of any follow up. The LPN also confirmed the staff had signed off the TED hose on 1/12/15 and 1/13/15 and that s/he had observed the resident on 1/13/15 without the hose.",2018-07-01
5988,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,244,E,0,1,9JKN11,"Based on observations, interviews and review of the facility's policy entitled Dietary Services and the facility's documented meal service times, the facility failed to act upon grievances voiced by residents as stated in the group interview. Three of 5 residents in attendance stated that meals were served at least one (1) to one and one-half (1 1/2) hours late for at least one meal each day. One anonymous resident/family and one of four residents selected for individual interviews (Resident #9) complained of meals being served late. Meals were also observed to be served late in 1 of 3 dining areas. The findings included: A Group Interview was conducted with five residents on 1/13/15 at approximately 10:30 AM. Three of the five residents in attendance stated that meals were served at least one (1) to one and one half (1 1/2) hours late for at least one (1) meal each day, usually dinner. Two (2) of the residents were from Unit 2 and one (1) from Unit 1. One (1) resident from Unit 2, stated that s/he no longer ordered the alternate meal due to the meal consistently being served after s/he had gone to bed. When asked by the surveyor if they had spoken with anyone at the facility or filed a grievance, each of the three stated that they had spoken to the dietary manager on multiple occasions and had seen no change in the service times. One resident stated that this had been brought to the facility's attention as far back as (MONTH) 2014. Review of the meal times provided by the facility indicated that dinner should be served by .5:45 PM on Unit 1 and 6:00 PM on Unit 2. The facility's Dietary Services Policy stated that the meal service times were: .Breakfast 8:00 AM, Lunch 12:00 PM and Dinner 6:00 PM . During an interview prior to entering the facility for survey, the Ombudsman stated that a concern had been voiced by a family member and/or resident who wished to remain anonymous related to trays being served and residents being fed late. During the initial tour of Unit 2 on 1-12-15 at approximately 4:00 PM, Resident #9 stopped this surveyor and stated s/he had concerns with food carts and trays being given out late. S/he stated, My food is not hot or warm by the time it's given out by the CNA (Certified Nursing Assistant). The resident indicated that the trays were sitting for an extended period of time, not being passed out in a timely manner. Review of the 10-1-14 Quarterly Minimum Data Set (MDS) Assessment revealed Resident #9 was bedridden and had a Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. On 1-15-15 at 8:30 AM, review of the (MONTH) 2014 through (MONTH) 2014 Resident Council Meeting minutes revealed repeated complaints about late tray delivery (7-31-14, 9-26-14, 10-30-14, and 11-25-14). On 1-12-15 at approximately 6:00 PM, meal observation revealed that the two carts for Unit 2 had not come from the kitchen at the scheduled delivery time of 6:00 PM. The first cart came to the unit at 6:34 PM and serving started in the Dining Room at 6:37 PM. The second cart arrived on the unit at 6:53 PM and the first tray was served at 6:55 PM. The CNAs went back and forth from one cart to the other to be able to serve the residents at the tables sequentially, thus delaying tray service for those whose tablemates had trays on the second cart. During an interview on 1-12-15 at approximately 6:38 PM, CNA #6 stated that the trays were late and were supposed to come out at 6:00 PM. During an interview on 1-12-15 at approximately 7:00 PM, Registered Nurse (RN) #4 stated that the residents that could feed themselves were served first out of Cart 1. During observation of the lunch meal on 1-13-15, the first cart came to Unit 2 at approximately 12:23 PM. Cart 2 arrived at 12:33 PM at which time tray service began from both carts. During an interview regarding the tray service process at 12:00 PM on 1-13-15, CNA #7 stated trays were passed out first in the Dining/Day Room, then to the residents eating in their rooms, and lastly to the totally dependent residents who needed to be fed. During an interview on 1-13-15 at approximately 8:55 AM, CNA #7 stated that in the dining room, there were 2 totally dependent residents and 2 requiring limited assistance by staff. There were 18 independent residents.",2018-07-01
5989,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,278,D,0,1,9JKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure that 2 of 12 sampled residents were accurately assessed. Resident #4 had inconsistent coding of communication and cognitive status on the Minimum Data Set (MDS) Assessment. Psychiatric [DIAGNOSES REDACTED].#11. The findings included: Record review on 1-14-15 at approximately 10:15 AM revealed that Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the 10-26-14 Quarterly MDS Assessment revealed that these [DIAGNOSES REDACTED]. During an interview on 1-14-15 at approximately 12:00 PM, the MDS Coordinator confirmed that the psychiatric [DIAGNOSES REDACTED]. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. On 1/13/15 at approximately 2:13 PM, review of the Minimal Data Set (MDS) assessment dated [DATE] revealed the resident was coded as understood and usually understands in Section B related to communication. Further review revealed that the question Should Brief Interview for Mental Status (BIMS) be Conducted? was answered No. (resident is rarely/never understood). Continued review of Section C revealed that the staff interview had been conducted regarding the resident's cognitive status instead of attempt made to conduct the resident interview (BIMS). The resident was coded as having short term and long term memory problems and Cognitive Skills for Daily Decision Making was coded as Severely Impaired - never/rarely made decisions. During an interview on 1/14/15 at 10:15 AM, the MDS Coordinator confirmed that the coding of communication on the MDS was inconsistent with the coding of the resident's cognitive status for completion of the BIMS.",2018-07-01
5990,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,279,D,0,1,9JKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop comprehensive care plans that include measurable goals and objectives with interventions to address care and services for medical and nursing needs for 2 of 9 sampled residents reviewed for care plan development. The care plan for Resident #5 did not address Diabetes Mellitus, pain, fall risk, use of safety devices, or psychoactive medication use. The care plan for Resident #8 did not address Hypertension, diuretic therapy, psychoactive medication, Vascular Insufficiency or the presence of a lower extremity wound. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 1/12/15 at 4:36 PM, record review revealed monthly cumulative Physician order [REDACTED]. On 1/14/15 at 9:40 AM, review of the physician's orders [REDACTED]. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 1/12/15 at 6:10 PM, review of the monthly cumulative Physician order [REDACTED]. On 1/14/15 at 1:25 PM, review of the care plan revealed no identified problem areas with planned interventions for depression with administration of psychoactive/antidepressant medication. The resident's Hypertension, potential for dehydration related to diuretic therapy, potential for falls, the use of safety devices, the [DIAGNOSES REDACTED]. During an interview on 1/14/15 at 3:40 PM, the Minimal Data Set Coordinator reviewed the comprehensive care plan for Resident #5 and confirmed that it did not address Diabetes or FSBS, pain, fall risk and use of safety devices, or psychoactive medication. The MDS Coordinator further confirmed the care plan for Resident #8 did not address Hypertension, potential for dehydration, psychoactive medication use, or the right lower extremity wound.",2018-07-01
5991,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,280,D,0,1,9JKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to review and update the care plans to reflect the current status of 4 of 12 sampled residents reviewed for revision of care plans. Resident #5's care plan was not updated after an anticoagulant was discontinued. Resident #8's care plan was not updated after a fall or to address new onset of [MEDICAL CONDITION] and refusal of treatment. Resident #12's care plan was not updated after conversion to hospice. Resident #13's care plan did not address placement of a WanderGuard bracelet as an approach for exit seeking behavior. The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Record review on 1/14/15 revealed an 8/13/13 physician's orders [REDACTED]. An interview at 4 PM on 1/14/15, Registered Nurse (RN) #3 confirmed that Resident #13 did have a WanderGuard on his/her right wrist and that s/he checked the function of the WanderGuard each shift. The nurse reviewed the care plans for Resident #13 and confirmed there was no care plan for the WanderGuard, how often it should be checked for placement and function, or when it should be replaced. A review of Resident #12's record for Hospice Care was conducted on 1/14/15 at approximately 9:55 AM. The facility's care plan had been updated on 10/30/14 to include Resident appears to be near the end of life with obvious health decline. On 10/31/14 the resident was admitted to Hospice Care. The facility's care plan for Resident #12 contained no update to include Hospice Care. On 1/14/15 at approximately 11:45 AM, during an interview with the Minimum Data Set (MDS) Coordinator, s/he verified that the facility had not updated the resident's care plan to include Hospice and stated that s/he was not aware that it should be updated when a change of condition assessment was done for Hospice. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of the care plan on 1/14/15 at 1:25 PM revealed a problem dated 5/5/14 that the resident had a history of [REDACTED]. The last care plan conference was listed on the care plan as 10/21/14 and the intervention had not been discontinued. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 1/12/15 at 4:51, record review revealed an order for [REDACTED].>> (greater than) L(eft) .Needs TED Hose. Review of the Treatments Administration History on 1/14/15 at 9:10 AM for 12/22/14 through 1/13/15 revealed Resident #8 refused to wear the TED hose on 12/22/14 and 12/23/14. Review of the nursing progress notes revealed Resident #8 refused the TED hose on 12/6 but decided to let CNA (Certified Nursing Assistant) help put them on, 12/7 .does refuse to have TED hose placed early in morning, but then later will allow the TED hose to be put on. On 1/14/15 at 1:25 PM, review of the resident's care plan revealed [MEDICAL CONDITION] had not been identified as a problem area and the care plan had not been updated to include application of TED hose or the resident's refusals to wear them. Review of the Nurses Notes on 1/13/15 at 2:55 PM revealed the resident sustained [REDACTED]. Review of the care plan revealed that fall risk had not been identified as a problem area and the care plan had not been updated following the fall. During an interview on 1/14/15 at 3:40 PM, The Minimal Data Set (MDS) Coordinator confirmed the care plans had not been updated for Resident #5 or #8.",2018-07-01
5992,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,281,D,0,1,9JKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the American Journal of Nursing, (MONTH) 2007, the facility failed to accurately document treatment application for one of one resident reviewed with orders for TED ([MEDICAL CONDITION] deterrent) hose. The nurse initialed that TED hose were applied to Resident #8 when they were not observed to be on the resident for two consecutive days of the survey. The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 1/12/15 at 4:51, record review revealed an order for [REDACTED]. On 1/13/15 at 8:50 AM, observation revealed the resident was out of bed and dressed and was not wearing the TED hose. Review of the Treatments Administration History on 1/14/15 at 9:10 AM revealed the TED hose were signed off daily on 1/12 and 1/13/15 AM shift as being applied and removed though observation revealed the resident was not wearing the hose on 1/12 or 1/13/15. During an observation and interview on 1/13/15 at 5:10 PM, Licensed Practical Nurse (LPN) #2 confirmed on observation that the resident was not wearing the TED hose. The LPN asked the resident if they (Certified Nursing Assistants) were putting them on and the resident stated No. The LPN also confirmed the staff had signed off the TED hose on 1/12/15 and 1/13/15 and that s/he had observed the resident on 1/13/15 without the hose. Review of the American Journal of Nursing, (MONTH) 2007, pages 58-60, revealed the following: Regardless of the practice setting, nurses must preserve the integrity of the record in the following ways. Accurate and complete patient information must be entered on all paper and electronic documentsDocumentation should include completed treatments, procedures, .as well as those that have not been completed and the reason they were not completed.",2018-07-01
5993,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,371,E,0,1,9JKN11,"Based on observations and interviews, the facility failed to maintain the cleanliness of resident-use refrigerators on 3 of 3 units. Each had dried food/liquid spills in the unit, scattered debris, black substance on the door seal, and/or cracked/broken seal around the door. In addition, based on observation and interview, facility staff failed to serve food in a sanitary manner to prevent transmission of disease/infection on 2 of 3 Units during meal observation. 4 staff members were observed handling resident's food with their bare hands. The findings included: On 1/13/15 at approximately 9:40 AM, the resident refrigerator on Unit 1 was observed to have dried spills and debris on the shelves and floor of the unit. This was verified at the time of the observation by Dietary Staff #1. At 10:04 AM on 1/13/15, the Unit 2 resident refrigerator had a thick blackish substance in and on the seal around the door, dried spills and food debris on the shelves and the seal around the door was cracked and torn across the bottom of the door. This was verified at the time of the observation by Certified Nursing Assistant (CNA) #7. At 10:10 AM on 1/13/14, the Unit 3 refrigerator had heavy build up of dried spills on the racks, shelves and door shelves, the floor of the unit and the doors. This was verified at the time of the observation by CNA #8. On 1/14/15 at approximately 10:25 AM, the Unit 3 resident refrigerator had spills and debris in the door shelves, the drawer tracks, solid shelves and seal. The was again verified by CNA #9. The refrigerators on Units 1 and 2 were also unchanged and remained soiled. The maintenance worker observed the seal on the Unit 2 refrigerator and stated they would replace it. A policy was requested to identify staff responsible for maintaining resident refrigerators but was not received. During meal observation on Unit 1 at 6:22 PM on 1/12/15, Certified Nursing Assistant (CNA) #4 was observed to serve 3 residents their evening meals. In each case, the CNA picked up the top of the hamburger bun with his/her bare hands to spread mayonnaise on the bun. On one occasion, the CNA held the bun with bare hands while cutting the bun in half. After the meal, the CNA confirmed, Yes, I did pick up the buns with my bare hands and cut the sandwich with my bare hands. On 1/12/15 at 6:00 PM, meal observation on Unit 3 revealed Certified Nursing Assistant (CNA) #1 replacing the top of a resident's hamburger bun with bare hands on a resident's plate. At 6:02 PM, CNA #2 removed the top of a second resident's hamburger bun with bare hands, spread mayonnaise on the bun, and replaced it on the sandwich. At 6:04 PM, CNA #3 removed the top of another resident's hamburger bun with bare hands, spread mayonnaise on the bun, and replaced it on the sandwich. At 6:05 PM, CNA #1 confirmed that s/he had used her/his bare hands to replace the top of the bun. CNA's #2 and #3 also confirmed that they had used their bare hands while preparing the residents' hamburgers.",2018-07-01
5994,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,496,D,0,1,9JKN11,"Based on personnel record reviews and interview, the facility failed to complete Certified Nursing Assistants (CNA) Registry verification prior to hire for 2 of 2 CNA records reviewed. The findings included: Personnel records for Certified Nursing Assistants A and E were checked on 1/14/15 for Registry verification prior to hire. CNA A was hired 12/11/14. A registry check was done on 10/21/13 but had not been done prior to this rehire date of 12/11/14. CNA E had a hire date of 11/20/14. No registry verification could be located for this CNA prior to hire. At 12:30 PM on 1/14/15, the Administrator reviewed the records and confirmed that registry verifications had not been done for the above staff as noted.",2018-07-01
5995,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,499,D,0,1,9JKN11,"Based on personnel record reviews and interview, license verification was not completed for 2 of 2 licensed nurses prior to hire. The findings included: Personnel records for Registered Nurse (RN) B, and Licensed Practical Nurse (LPN) D were reviewed on 1/14/15 for license verification prior to hire. Registered Nurse B, with a hire date of 11/10/14, had no license verification in his/her personnel folder. LPN D, with a hire date of 12/12/14, had a license check done on the date of hire and was in the facility for orientation on that date. No evidence was provided that the license was verified prior to the nurse's actual start of work time. At 12:30 PM on 1/14/15, the Administrator reviewed the records and confirmed that license verifications had not been done, or had not been done timely, for the above staff.",2018-07-01
5996,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,502,D,0,1,9JKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain laboratory (lab) tests as ordered for 2 of 10 sampled residents reviewed for provision of lab services (Residents #4 and #5). The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. On 1/14/15 at 11:35 AM, review of the laboratory results in the record revealed a Complete Metabolic Panel (CMP) dated 9/9/14 with an elevated Creatinine. On the lab report, the physician/nurse practitioner had written a note to repeat a Basic Metabolic Panel (BMP) in 1 week. Further review revealed no results for a BMP dated 1 week after the CMP. During an interview on 1/14/15 at 11:35 AM, the Interim Director of Nursing confirmed there were no results in the record and at 12:42 PM confirmed that the lab test had not been obtained as ordered. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 1/12/14 at 5:35 PM, review of the monthly cumulative physician's orders [REDACTED]. Further review revealed an 8/14/14 order for a HGB A1C (glycated hemoglobin test) every 3 months that was scheduled for March, June, (MONTH) and December. On 1/14/15 at 9:40 AM, record review revealed no [MEDICATION NAME] Acid Level result for (MONTH) and no HgbA1c result for December. During an interview on 1/14/15 at 3:21 PM, Licensed Practical Nurse (LPN) #2 confirmed that the [MEDICATION NAME] Acid Level and HgbA1c had not been obtained as ordered.",2018-07-01
5997,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,504,D,0,1,9JKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility obtained laboratory services (labs) without physician's orders for Resident #5, 1 of 10 sampled residents reviewed for laboratory services. A Comprehensive Metabolic Panel (CMP) and HgbA1c (glycated hemoglobin test) were obtained without physician's orders. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 1/14/15 at 9:40 AM, record review of the lab results in the resident's record revealed Hgb A1c tests were completed on 9/23/14 and 10/3/14. CMP studies were done on 9/8/14 and 12/2/14. Review of the monthly cumulative Physician's Orders and Telephone Orders revealed the HgbA1c was ordered every 3 months and the CMP was ordered every 6 months (March and September). No telephone orders could be located for the 10/3/14 Hgb A1c or for the 12/2/14 CMP. During an interview on 1/14/15 at 3:21 PM, Licensed Practical Nurse #2 confirmed there were no orders for either test.",2018-07-01
5998,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,507,D,0,1,9JKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have results of laboratory (lab) tests available for clinical management in the residents' records for 2 of 10 sampled residents reviewed for laboratory services. Resident #1 had lab tests on 10/5/14 and Resident #8 had lab tests on 11/10/14, 12/1/14, and 12/11/14, with no reports found in the residents' records. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 1/13/15 revealed a 9/4/14 physician's orders [REDACTED]. On 9-5-14, a [MEDICATION NAME] Level was drawn and the result was 10.4 ug (micrograms)/ml (milliliter) H(igh) (reference range of 4.00-10.00 ug/ml). The report stated: Panic result: Call to (Registered Nurse) at 11:23 .read back. A 9/5/14 note on the lab report indicated that the level was to be repeated on 10-4-14. Review of the resident's record revealed no lab result for this date. Interview with Licensed Practical Nurse #1 and Registered Nurse (RN) #2 on 1/14/15 confirmed there was no lab result in the record. RN #2 called the lab and verified that it had been done on 10/3/14 with a Panic result: Call to (RN) at 10:42 .read back. However, s/he confirmed the copy had never been placed in the resident's record. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. The resident was receiving an antibiotic upon admission to the facility. On 1/13/15 at 10:15 AM, review of the Telephone Orders revealed a 11/10/14 order for a [DIAGNOSES REDACTED] ([MEDICAL CONDITION]) laboratory (lab) test, an order dated 11/17/14 to recheck a Magnesium Level in 2 weeks, and an order dated 12/11/14 for a Magnesium Level, BNP (Brain Natriuretic Peptide), [MEDICATION NAME], CBC (complete blood count) and BMET (Basic Metabolic Panel) to be drawn the following morning. Record review revealed none of these lab results were available in the resident's record. On 1/14/15 at 9:42 AM, Licensed Practical Nurse (LPN) #2 confirmed the labs were not in the record and provided copies of the lab results that had been received by the facility on 1/13/15.",2018-07-01
5999,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,513,D,0,1,9JKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain diagnostic reports as required for 1 of 1 sampled residents reviewed with orders for an Echocardiogram. Resident #8 did not have results in the clinical record for an Echocardiogram (ECHO). The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. On 1/13/15 at 10:15 AM, record review revealed a 12/11/14 Telephone Order for ECHO Dx. (diagnosis) [MEDICAL CONDITION]. Further record review revealed no ECHO results were located in the chart. During an interview on 1/14/15 at 9:10 AM, Registered Nurse #1 confirmed the ECHO results were not in the resident's record. At 9:42 AM on 1/14/15, a copy of the ECHO result was provided by the facility. Licensed Practical Nurse #2 reviewed the result and confirmed it had been received by the facility at 9:30 AM on 1/14/15.",2018-07-01
6000,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-01-15,520,E,0,1,9JKN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement an appropriate plan of action to correct identified quality deficiencies in a timely manner related to late and/or missing Minimum Data Set (MDS) Assessments for Residents #3 and #4 and 17 non-sampled residents. The findings included: Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 1/13/15 revealed a Quarterly Assessment had been completed on 4/16/14 and 9/28/14 (greater than 5 months apart). Another assessment was due for 12/28/14. When pulled up on the computer for MDS (Minimum Data Set) the assessment for 12/28/14 read in progress not completed. This was confirmed with the MDS Coordinator. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. On 1/13/15 at 2:13 PM, paper and/or computerized record review for Resident #4 revealed a 9/3/14 Admission Minimum Data Set (MDS) Assessment. Further review revealed a Quarterly Assessment with an Assessment Reference Date (ARD) of 11/26/14 listed as in process in the computer. During an interview on 1/14/15 at 10:15 AM, the MDS Coordinator confirmed the Admission Assessment was the only completed assessment. S/he further confirmed a Quarterly Assessment with an ARD of 11/26/14 had been opened but not completed. The MDS Coordinator provided copies of the MDS assessments for Resident #4 with a note attached that stated, We have previously made a QA (Quality Assessment) for these late assessments and are working towards getting up to date. On 1/14/15 at 12:15 PM, the MDS Coordinator stated s/he had been officially in the position since 10/27/14. The Coordinator stated s/he had identified that there were missing/late assessments at that time and thought s/he could catch them up,but had been unable to do so. The Coordinator further stated s/he probably did not request help at that time but may have mentioned it in passing. The Coordinator stated s/he had reported it to management the week before the survey. During the interview, the Coordinator stated s/he thought there were about 27 late assessments. A copy of an MDS QA dated 1/6/15 was provided by the facility which included the following action plan: 1. All staff trained in MDS work will work on helping the MDS coordinator catch up uncompleted assessments over the next 3 weeks. 2. Health Care Manager will meet with MDS coordinator weekly for the next 3 months to ensure the MDS assessments are being completed timely after they are caught up. Review of the MDS Assessments Due 1/14/15-2/14/15 report printed 1/14/15 at 4:06 PM revealed 1 Admission Assessment, 2 Annual Assessments, 11 Quarterly Assessments, and 5 Discharge Assessments for a total of 19 assessments, 18 that were in Process and 1 which was not scheduled. Due dates extended back to 9/14. During an interview on 1/14/15 at 3:05 PM, the facility's Consultant stated s/he had first visited the facility on 10/9-10/10/14 and on 11/19/14. The Consultant also stated s/he had identified the facility had a problem with late assessments on 1/6/15 and stated they did before. The Consultant stated the MDS Coordinator was new in the position and had attended training 9/17-9/18/14. The Consultant also stated s/he had been working more with the new Director of Nursing and now had another Interim Director of Nursing. S/he noted s/he would have concentrated more on PPS (Perspective Payment System) assessments. During an interview at 5:28 PM on 1/14/15, Licensed Practical Nurse (LPN) #2 (Health Care Manager) confirmed that s/he had written the QA plan. The LPN further stated s/he and one Registered Nurse were trained in the MDS Assessment process. LPN #2 also stated that s/he had received a schedule from the MDS Coordinator of assessments to be done but that s/he had not provided a copy to the RN. The LPN Health Care Manager also stated s/he had not calculated how many assessments needed to be done each week to get caught up. The LPN confirmed that the MDS Coordinator had expressed that s/he was falling behind approximately 1 week previously but had not informed her/him of any missing assessments. The Health Care Manager confirmed that no audit had been initiated to determine the extent of the problem. S/he did not know how many assessments were late or missing but thought maybe 15 assessments were listed on the schedule received from the MDS Coordinator. On 1/15/15 at approximately 10:00 AM, an interview was conducted with the LPN Health Care Manager, the Nursing Home Administrator and the Clinical Consultant. The LPN stated the next assessment due date as listed on the computerized report was the date it needed to be completed. The Consultant disagreed and stated that was the date the next ARD date was due and further stated s/he will have to figure it out. The consultant stated s/he had started checking the computer list last night and that not all the assessments listed were past due. The Consultant also stated s/he had counted 11 OBRA (Omnibus Budget Reconciliation Act) assessments that were past due and confirmed that this number did not include discharge assessments. The consultant and the LPN confirmed the QA plan did not include performing an audit of all residents' assessments to determine the scope of the deficiency. The Consultant confirmed the QA was not effective without that information.",2018-07-01
6001,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-07-09,226,D,1,0,H3LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents. Housekeeper #1 reported an allegation of abuse to the supervisor on duty related to Certified Nurse Aide (CNA) #1's treatment of [REDACTED]. CNA #3, who was present in the room at the time of the incident, failed to report the allegation of abuse. CNA #1 continued to work for the remainder of his/her shift and the incident was not reported to the Health Care Manager, Director of Nursing or Administrator until approximately 2 hours after the initial allegation. One of one residents reviewed for abuse. The findings included: The facility reported an allegation of verbal abuse for CNA #1 directed toward Resident #1. The facility sent the Initial 24-Hour Report form on 6/8/15 for the incident that occurred on 6/5/15 at 1:50 PM. The report indicated the housekeeper overheard CNA #1 making derogatory statements to the resident and reported it. Review of the Timecard Legend revealed CNA #1 worked until 3:10 PM on 6/5/15. CNA #3 was present in the room with CNA #1 at the time of the incident. CNA #3 failed to report the allegation per facility policy. Review of the facility's Time Line of Events for the alleged incident indicated CNA #1 was suspended on 6/6/15. Review of CNA #1's Timecard revealed s/he worked 7:05 AM-3:10 PM on 6/5/15 and 6:57 AM-8:00 AM on 6/6/15. Review of the Registered Nurse (RN) Supervisor's facility-obtained statement dated 6/5/15 indicated Housekeeper #1 told him/her about an allegation of verbal abuse concerning Resident #1 and CNA #1. The RN Supervisor told Housekeeper #1 to write a statement of what occurred. In an interview with the surveyor on 7/7/15 at approximately 1:30 PM, the Unit 1 Manager stated s/he left the facility between 12:30-12:45 on 6/5/15. The DON told him/her about the incident on Monday 6/8/15. The Unit 1 Manager had talked to CNA #1 about his/her attitude before. CNA #1 would say s/he was tired and had become quick tempered with residents. CNA #1 had voiced that s/he would have to change Resident #1 several times during the day. In an interview with the surveyor on 7/7/15 at approximately 3:20 PM, the Health Care Manager stated s/he was at the facility on 6/5/15. The supervisor on duty told him/her about the incident at approximately 4:00 PM. The supervisor handed him/her the statements and walked out of his/her office. The statements indicated staff overheard a CNA being verbally abusive to Resident #1 and two CNAs came out of the room. The Health Care Manager reviewed the statements and called the DON who was out of town. The Health Care Manager called the DON because s/he was not sure about reporting the incident. The DON told him/her to take CNA #1 and CNA #3 off the schedule and not let them work until the investigation was complete. The DON did not tell the Health Care Manager the timeframe for reporting. The DON stated s/he would take care of it. The DON took over the investigation at that time. Later on 6/5/15 the Health Care Manager talked with the supervisor who said a nurse came and reported the incident to him/her. The two CNAs and the housekeeper who reported the incident were already gone for the day when the Health Care Manager found out about the incident. The DON returned to the facility on Monday 6/8/15. The Health Care Manager stated that typically staff would come to him/her or the DON to report an incident. The Health Care Manager did not ask the supervisor why s/he did not come tell him/her about the incident sooner. In a telephone interview with the surveyor on 7/8/15 at approximately 2:32 PM, Housekeeper #1 stated that on 6/5/15 s/he was cleaning a room, could not remember which room, and heard loud voices. S/he went out into the hall and the voices were coming from Resident #1's room. Housekeeper #1 heard a female yell that s/he was disgusting, nasty and something was wrong with him/her. They also stated s/he was mentally ill. Housekeeper #1 then saw CNA #1 come out of the room. Housekeeper #1 stepped back into the room s/he was cleaning so CNA #1 would not see him/her. S/he stepped back into the hall and heard CNA #1 yell at Resident #1 to roll over and then heard the resident grunt. Housekeeper #1 then saw CNA #1 and CNA #3 come out of Resident #1's room. Housekeeper #1 went to his/her supervisor who told him/her to go and tell the nurse. Housekeeper #1 went and told the nurse on duty who told him/her s/he needed to tell the supervisor. They went and told the supervisor. The supervisor told Housekeeper #1 to write a statement of what happened and s/he did. The incident happened at approximately 1:40 PM. In a telephone interview with the surveyor on 7/9/15 at approximately 12:40 PM, the DON stated that Housekeeper #1 overheard CNA #1 tell Resident #1 s/he was nasty. The housekeeper reported the incident to the nurse who reported it to the supervisor. The Health Care Manager called him/her at approximately 4:30 PM on 6/5/15 to tell him/her about the incident because s/he was off that day. The DON stated s/he did not know s/he needed to report the incident to the state agency, s/he thought the weekend did not count. The DON also stated that CNA #1 should have been suspended pending the investigation. The DON stated that neither the nurse nor the supervisor reported the incident immediately to the Health Care Manager. The DON stated the incident should have been reported immediately to the Health Care Manager and CNA #1 should have been removed from the floor. Review of the facility's Resident Behavior and Facility Practices Policy revealed any alleged abuse shall be investigated using guidelines that included the following: staff will provide steps to prevent further injury to the resident and protection from further potential abuse while the investigation is in process, the nursing supervisor and the administrator will be notified immediately, the investigation will begin promptly and reporting to state certification as necessary for investigation. The facility will provide steps to protect the resident from further potential abuse while any investigation of abuse is in progress to include reassignment or suspension of suspect. Attached to the facility's Resident Behavior and Facility Practices Policy was a copy of South Carolina Department of Health and Environmental Control's Timeframes for Reporting. The Timeframes for Reporting indicated an allegation of abuse should be reported immediately to certification but not to exceed 24 hours after discovery of the incident.",2018-07-01
6002,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-07-09,280,D,1,0,H3LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to periodically review and revise the resident's comprehensive care plan. Resident #1 was noted to have several recommendations from a consultant psychiatrist. The resident's care plan was not updated to reflect the interventions. One of one residents reviewed for care plans. The findings included: Review of the medical record revealed Resident #1 had [DIAGNOSES REDACTED]. Review of the care plan revealed behavioral symptoms, resident keeps his hands in undergarments in public areas, was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to redirect as needed and provide alternative activity if allowed by resident. The care plan indicated all approaches listed had a start date of 3/6/15. There was no reference to medication interventions for Resident #1's behavior. Review of Resident #1's medical record revealed a Psychiatry Note dated 5/8/15. The note had a fax date of 5/12/15 printed on it. The note listed the reason for the consult as resident reportedly locking himself in the bathroom. Resident is masturbating openly in front of others. Staff unable to stop behaviors. The treatment plan and recommendation section of the note indicated will get in contact with nursing home to discuss behavioral modification for masturbating in public, which could be the best intervention. The interventions included using distraction to get the patient's attention to something else, try to avoid friendly touch especially by female staff, try to keep the patient away from other female residents and decrease contact as much as they can, try to control the content seen at the TV for something less stimulating, if patient has to sit in public try to cover the patient with a blanket if this can partially solve the problem. Review of Resident #1's follow-up Psychiatry Note dated 6/23/15 indicated behavioral modifications were discussed previously with the nursing staff at the facility, which are strongly recommended. The Unit 1 Manager provided the surveyor with an inservice dated 5/14/15. The inservice indicated it was for interventions regarding resident's care given. There were no details of the interventions that were discussed with staff. Resident #1 was observed on initial tour of the facility on 7/7/15 at approximately 9:35 AM. Resident was noted in the dining room on Unit 1. Resident was self-propelling in a wheelchair. Resident noted to place his/her hands down his/her pants and then remove several times within a few minutes. There was no blanket across the resident 's lap. In a telephone interview with the surveyor on 7/8/15 at approximately 2:45 PM, CNA #5 stated that s/he did care for Resident #1 at times but did not attend an inservice on interventions for his/her behaviors. S/he also stated that no one told him/her anything about interventions for Resident #1's behavior. Review of the inservice sign-in sheet dated 5/14/15 provided by the Unit 1 Manager revealed CNA #5's signature on the sheet. In an interview with the surveyor on 7/7/15 at approximately 3:15 PM, the Unit 1 Manager stated that s/he should have updated Resident #1's care plan with the new interventions from the psychiatrist. S/he stated they usually do not list specific psychiatric medications just psychiatric medications as ordered. The social worker usually updates the care plan for behaviors but since s/he talked with the medical facility (psychiatrist) about the interventions s/he should have updated the care plan. In an interview with the surveyor on 7/7/15, at approximately 3:20 PM the Health Care Manager was asked about the care plan being updated to reflect the interventions recommended by the psychiatrist for Resident #1. S/he confirmed the care plan should have been updated to reflect the interventions. In an interview with the surveyor on 7/7/15 at approximately 3:00 PM, CNA #2 stated s/he does care for Resident #1 but did not attend an inservice on interventions for his/her behavior. S/he stated that the Unit 1 Manager talked with him/her about the interventions. S/he was told when Resident #1's behavior occurs if s/he is out of his/her room to cover him/her with a sheet. If s/he is in his/her room to make sure the curtain is closed between the beds. Review of the inservice sign-in sheet dated 5/14/15 provided by the Unit 1 Manager revealed CNA #2's signature on the sheet. In an interview with the surveyor on 7/7/15 at approximately 1:40 PM, CNA #4 stated Resident #1 had a mental decline over the past 1-2 years. The resident 's behavior started about a year ago. CNA #4 stated that s/he works with Resident #1 a lot, helps change him/her and works with him/her almost every day. S/he would tell him/her to move his/her hand or would take him/her to his/her room before. Resident #1 had an appointment with the psychiatrist approximately 1 month ago. S/he said to leave him/her be and to just cover him/her up. In an interview with the surveyor on 7/7/15 at approximately 1:30 PM, the Unit 1 Manager stated the psychiatrist recommended to put a blanket over the resident when behavior occurred and medication changes. The Unit 1 Manager stated s/he educated staff who work with Resident #1 on the interventions recommended by the psychiatrist. In a telephone interview with the surveyor on 7/9/15 at approximately 12:40 PM, the DON (Director of Nursing) reviewed Resident #1's care plan and CNA (Certified Nurse Aide) care plan and confirmed the interventions recommended from the Psychiatrist consult were not listed. The DON stated that the interventions should have been implemented and put on the care plans.",2018-07-01
6003,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2015-07-09,319,D,1,0,H3LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a resident who displays psychosocial adjustment difficulty received the appropriate treatment and services to correct the assessed problem. Resident #1 was referred to a psychiatrist related to increased behavior. The psychiatrist recommended interventions for the facility to put into place for the resident. The interventions were not reviewed with staff or noted on the care plan. One of one residents reviewed for behavior. The findings included: Cross refer to F-280 as it related to the failure of the staff to implement the psychiatrist's recommendations for Resident #1 related to increased sexual behaviors. Review of the medical record revealed Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was observed on initial tour of the facility on 7/7/15 at approximately 9:35 AM. Resident was noted in the dining room on Unit 1. Resident was self-propelling in a wheelchair. Resident noted to place his/her hands down his/her pants and then remove several times within a few minutes. There was no blanket across the resident's lap. Review of Resident #1's medical record revealed a Psychiatry Note dated 5/8/15. The note had a fax date of 5/12/15. The note listed the reason for consult as resident reportedly locking him/herself in the bathroom. Resident is masturbating openly in front of others. Staff unable to stop behaviors. The treatment plan and recommendation section of the note indicated will get in contact with nursing home to discuss behavioral modification for masturbating in public, which could be the best intervention. The interventions included using distraction to get the patient's attention to something else, try to avoid friendly touch especially by female staff, try to keep the patient away from other female residents and decrease contact as much as they can, try to control the content seen at the TV for something less stimulating, if patient has to sit in public try to cover the patient with a blanket if this can partially solve the problem. Review of Resident #1's follow-up Psychiatry Note dated 6/23/15 indicated behavioral modifications were discussed previously with the nursing staff at the facility, which are strongly recommended. Review of the care plan revealed behavioral symptoms, resident keeps his/her hands in undergarments in public areas, was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to redirect as needed and provide alternative activity if allowed by resident. The care plan indicated a start date for the approaches as 3/6/15. The Unit 1 Manager provided the surveyor with an inservice dated 5/14/15. The inservice indicated it was for interventions regarding resident's care given. There were no details of the interventions that were discussed with staff. In a telephone interview with the surveyor on 7/8/15 at approximately 2:45 PM, CNA #5 stated that s/he did care for Resident #1 at times but did not attend an inservice on interventions for his/her behaviors. S/he also stated that no one told him/her anything about interventions for Resident #1's behavior. Review of the inservice sign-in sheet dated 5/14/15 provided by the Unit 1 Manager revealed CNA #5's signature on the sheet. In an interview with the surveyor on 7/7/15 at approximately 3:15 PM, the Unit 1 Manager stated that s/he should have updated Resident #1's care plan with the new interventions from the psychiatrist. In an interview with the surveyor on 7/7/15, at approximately 3:20 PM the Health Care Manager confirmed the care plan should have been updated to reflect the interventions. In an interview with the surveyor on 7/7/15 at approximately 3:00 PM, CNA #2 stated s/he does care for Resident #1 but did not attend an inservice on interventions for his/her behavior. S/he stated that the Unit 1 Manager talked with him/her about the interventions. S/he was told when Resident #1's behavior occurs if s/he is out of his/her room to cover him/her with a sheet. If s/he is in his/her room to make sure the curtain is closed between the beds. Review of the inservice sign-in sheet dated 5/14/15 provided by the Unit 1 Manager revealed CNA #2's signature on the sheet. In an interview with the surveyor on 7/7/15 at approximately 1:40 PM, CNA #4 stated Resident #1 had a mental decline over the past 1-2 years. The resident 's behavior started about a year ago. CNA #4 stated that s/he works with Resident #1 a lot. CNA #4 helps change Resident #1 and works with him/her almost every day. They would tell him/her to move his/her hand or would take him/her to his/her room before. Resident #1 had an appointment at the psychiatrist approximately 1 month ago who said to leave him/her be and to just cover him/her up. In an interview with the surveyor on 7/7/15 at approximately 1:30 PM, the Unit 1 Manager stated the psychiatrist recommended to put a blanket over the resident when behavior occurred and medication changes. The Unit 1 Manager stated s/he educated staff who work with Resident #1 on the interventions recommended by the psychiatrist. In a telephone interview with the surveyor on 7/9/15 at approximately 12:40 PM, the DON(Director of Nursing) reviewed Resident #1's care plan and CNA(Certified Nurse Aide) care plan and confirmed the interventions recommended from the Psychiatrist consult were not listed. The DON stated that the interventions should have been implemented and put on the care plans.",2018-07-01
7118,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2014-06-02,224,D,1,0,ZIVW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, review of the facility investigation and record review, the facility failed to prevent the misappropriation of the resident's personal funds. Certified Nurse Aide (CNA) #1 allegedly misappropriate approximately $2,700.00 from Resident #1. One of one resident reviewed for misappropriation of property. The findings included: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record revealed the Quarterly Minimum (MDS) data set [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 11. The facility reported an allegation of misappropriation of Resident #1's property on 2/19/14. The description of the incident included, 2/18/2014 at 7 PM met with . POA (power of attorney) for Resident #1 and information was disclosed multiple checks made payable directly to CNA #1 from May - November 2013 totaling over $2,700. Resident denies any knowledge of why these checks would be written . The Five-Day Follow-Up Report dated 3/24/14 indicated Resident #1 handled his/her own financial affairs prior to asking CNA #1 for assistance. CNA #1 violated company policy on Financial Misconduct/ Dishonesty Policy. Review of the Nurse's Notes dated 10/5/13 at 6:45 (PM) indicated the resident stated s/he had over $1,000 stolen from him/her since at the facility. Resident #1 was also noted to have some cash money and unsigned checks scattered about in the room. Resident was encouraged to place his/her things in drawer and s/he said s/he would. A Nurse's Noted dated 1/13/14 at 11:15 AM indicated the resident was transported out of the facility to the hospital for evaluation. A green checkbook, a brown wallet with a $5.00 bill and 2 blank checks, and a checking statement were locked in a cabinet in the medication room. The nursing notes revealed no other documentation related to Resident #1's financial affairs. Review of the Social Progress Note dated 11/19/13 revealed Resident #1 is his/her own decision maker. Resident #1 accused his/her family of using his/her funds. The family denied this allegation. In a telephone interview with the surveyor on 6/2/14 at approximately 1:35 PM, Resident #1's power of attorney (POA) stated that Resident #1's check book was kept in a lock box in the Director of Nursing's (DON) office. The POA stated that Resident #1 complained some time in November (2013) that his/her bank balance was low. The POA talked with the DON about the resident's concerns. The DON stated that s/he talked with CNA #1 who denied taking any money from Resident #1 and the matter was dropped. The POA stated that they talked with the DON a second time about the concerns. The POA then decided that s/he would start managing Resident #1's finances on 1/27/14. The POA obtained copies of Resident #1's checks and noted checks that were made out to CNA #1. The POA stated that s/he was not aware that CNA #1 was writing checks for the resident prior to the allegation. In an interview with the surveyor on 5/21/14 at approximately 11:55 AM, the facility Administrator stated that Resident #1 and CNA #1 were friends. The Director of Nursing (DON) at the time of the incident, who is now retired, gave CNA #1 a key to the safe in her/his office so that CNA #1 could get the resident's checkbook whenever s/he wanted it. The Administrator stated that s/he was not sure if the DON knew CNA #1 was writing checks. The Administrator stated that the facility did not know CNA #1 was helping Resident #1 write checks until the family called with concerns. Resident #1 received bank statements for his/her checking account at the facility. The Administrator stated that Resident #1 accused his/her family of taking his/her money earlier in the year (2013) and the family stepped back from the resident's finances. In an interview with the surveyor on 5/21/14 at approximately 11:55 AM, the Unit 1 Manager stated that CNA #1 would go out and get items for Resident #1. The Unit 1 Manager was not sure where the money came from to buy those items. In a telephone interview with the surveyor on 5/27/14 at approximately 10:35 AM, the Minimum Data Set (MDS) Registered Nurse (RN) stated that s/he was in the meeting when the resident accused his/her family of taking his/her money. The MDS RN stated that CNA #1 was also at the meeting because s/he had said Resident #1 had made statements to him/her about his/her family trying to take his/her money.",2017-06-01
7119,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2014-06-02,226,D,1,0,ZIVW11,"On the day of the complaint inspection, based on interviews, record review and review of the South Carolina Baptist Ministries for the Aging Financial Misconduct/ Dishonesty Prevention Policy, the facility failed to implement written policies and procedures that prohibit misappropriation of resident property. Certified Nurse Aide (CNA) #1 allegedly misappropriate approximately $2,700.00 from Resident #1. One of one resident reviewed for misappropriation of funds. The findings included: Cross refers to F-224 as it relates to the failure of the facility to prevent the misappropriation of the resident's personal funds. Certified Nurse Aide #1 allegedly used $2700.00 of Resident #1's money without his/her permission. The facility self-reported an allegation of misappropriation of resident property on 2/19/14 alleging that CNA #1 misappropriated property from Resident #1. The description of the reportable incident included .Multiple checks made payable directly to CNA #1 from May - November 2013 totaling over $2,700. Resident denies any knowledge of why these checks would be written . The Five-Day Follow-Up Report dated 3/24/14 indicated Resident #1 handled his/her own financial affairs prior to asking CNA #1 for assistance with his/her affairs. In an interview with the surveyor on 5/21/14 at approximately 11:55 AM, the facility Administrator stated that Resident #1 and CNA #1 were friends. S/he stated the Director of Nursing (DON) during the time of the incident, who is now retired, gave CNA #1 a key to the safe in her/his office so CNA #1 could get the resident's checkbook whenever s/he wanted it. The Administrator stated that s/he was not sure if the DON knew CNA #1 was writing checks. The Administrator stated that the facility did not know CNA #1 was helping Resident #1 write checks until the family called with concerns. Review of the South Carolina Baptist Ministries for the Aging Financial Misconduct/ Dishonesty Prevention Policy indicated, All employees have a responsibility to report suspected violations . Managers and supervisors must: 1. Become aware of what can go wrong in their area of authority. 2. Implement and maintain effective monitoring, review, and control procedures that will prevent acts of wrongdoing. 3. Implement and maintain effective monitoring, review, and control procedures that will detect acts of wrongdoing promptly, should preventive efforts fail. The policy also indicated .The relationship which often develops between employees and residents creates a special ethical issue for all employees. Simply stated, it is entirely too easy for employees to hint, suggest, encourage, or even arrange for residents to make gifts to them, either presently or by bequest in a will . The following specific rules are immediately in force: 1. Present/ Gifts. Employees may not accept present gifts from residents or their families. When refusal of a gift would be offensive to or not understood by a resident, the employee may temporarily accept the gift and must immediately report it to the administrator . Review of the facility's Resident Behavior and Facility Practices Policy revealed all staff members are required to receive abuse prevention training through orientation and at least annually to include: what constitutes abuse, neglect and misappropriation of resident property . The policy also indicated prevention would include .The staff will provide safeguards to protect personal property to include . offer to protect and lock any valuables in the safe; and review in quarterly care planning any problems related to personal property.",2017-06-01
7276,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2013-05-01,309,D,0,1,X3VO11,"**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 evaluate the effectiveness of pain medication for Resident # 18. ( 1 of 3 sampled residents reviewed for pain management) The findings included: The facility admitted Resident # 18 on 4/1/13 with [DIAGNOSES REDACTED]. Record review on 5/1/13 revealed the resident was receiving [MEDICATION NAME] 10-325 1 tab q6h prn (every 6 hours as needed) and routinely every morning. Review of the MAR (Medication Administration Record) for the month of April revealed the resident had received PRN (as necessary) pain medication 50 times plus the regular dose every morning. A progress note written on 4/12/13 by the physician noted the continued pain and stated see order. The Director of Nursing (DON) and RN #2 (Registered Nurse) reviewed the medical record, could not locate where an order had been written and verified the surveyors concern. The DON called the physician on 5/1/13 and the physician confirmed he/she had forgotten to write the order. An order was obtained at this time to discontinue the previous order for the routine [MEDICATION NAME]. A new order was obtained to begin a [MEDICATION NAME] every 72 hours and to change the [MEDICATION NAME] prn to 10/325 to every 4 hours as needed for break through pain.",2017-04-01
7277,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2013-05-01,333,D,0,1,X3VO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on an observation made during medication administration, interviews and review of the facility's policy entitled [MEDICATION NAME] Patches, the facility failed to ensure that the [MEDICATION NAME] Patch for Resident #29 was applied and removed as ordered by the physician. The findings included: On 4/30/13 at approximately 9:05 AM,during an observation of medication administration on Unit 2, Licensed Practical Nurse (LPN) #2 prepared medications including a [MEDICATION NAME] Patch for Resident #29. The LPN removed the previous patch from resident's right upper chest and placed a new patch. The patch removed from the resident's chest was observed to be dated 4/28/13, which indicated that the patch had been worn for 48 hours. The date on the removed patch was verified by LPN #2, who stated should have been removed on the evening of 4/28/13 at 9:00 PM. The date on the patch was also verified by Registered Nurse #1. LPN #2 also verified that the patch dated 4/28/13 was signed as removed on 4/28/13 at 9:00 PM, a new patch placed on 4/29/13 at 9:00 AM and removed on 4/29/13 at 9:00 PM. The resident was examined and no other patches were found to be on the resident. On 4/30/13 at 3:35 PM, in an interview with the facility's Consultant Pharmacist,she/he stated that the standard for facility is to apply [MEDICATION NAME] Patches in the morning and remove it at bed time. She/he stated that leaving the patch on may cause a headache or orthostatic [MEDICAL CONDITION]. Review of the facility's policy entitled [MEDICATION NAME] Patches, indicated .5. After removing the old patch .9. Apply new patch to a clean, dry site .",2017-04-01
7278,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2013-05-01,371,E,0,1,X3VO11,"On the days of the survey, based observation, interview, and policy review, the facility failed to store fresh dining trays and soiled dining trays in a sanitary manner. The facility staff was observed to store used trays in the same cart warmer with trays that had yet to be served in 1 of 4 dining rooms. The findings included: On 4/29/2013 at 12:15 PM observation of Unit 100 dining room at the lunch meal revealed five staff members passing trays to residents in the dining room. The Staff delivered the trays to the residents and set up their meal. While setting up their meal. they removed the plate, cups, bowls, and silverware from the tray which left the plate warmer and the trash on the tray. Staff then took the tray and put it back into the cart warmer with trays that had yet to be served. On 4/30/2013 at 12:20 PM observation of the Unit 100 dining room during the lunch meal revealed serving staff putting used trays and trash back into the warming carts with trays that had yet to be served. On 4/30/2013 at 12:25 PM an interview with Licensed Practical Nurse #1 confirmed the Surveyors observations. On 5/1/2013 at 10:00 AM interview with the Dietary Manager revealed the the meal service system had changed in approximately the last three weeks from serving residents the whole tray to removing the food from the tray and placing it on the table. He/She stated that the Dietary Department did not have a policy related to serving trays in the dining room. On 5/1/13 at 10:20 AM during an interview and policy review with the Director of Nursing (DON) revealed the new Meal Service Directions were posted on 4-24-2013. The Meal Service Directions did not address any policy or procedure concerning tray handling after resident tray set up, as verified by the DON.",2017-04-01
7279,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2013-05-01,492,E,0,1,X3VO11,"On the days of the survey, based on record review and interviews, the facility failed to ensure that Medicare claims were filed when requested and failed to stop charging residents upon request of a demand bill. Two of 3 Skilled Nursing Facility Advance Beneficiary Notices reviewed (SNFABN) were not filed as requested. (Resident #55 and #100). The findings included: An interview on 4/30/13 at approximately 3 PM was conducted with the Social Services Director to obtain a list of residents who in the last six months had additional medicare days left after being informed that their Medicare coverage had ended. Per the Social Services Director, they had no residents that had requested a demand bill. Review of the Medicare Non Coverage Notice and SNFABN form revealed Resident #55 requested a demand bill on 2/20/13 and Resident #100 also requested a demand bill on 1/28/13 that was not filed. Further review of the SNFABN form with the Social Service Director confirmed the top box was checked which indicated the request for a demand bill. An interview on 5/01/13 at approximately 8:39 AM with the Director of Finance confirmed the findings that based on the forms being checked in the top block indicating the family/responsible party requested a demand bill and the s/he was not aware that a demand bill was requested. The Executive Administrator was present during the interview and stated s/he was not aware of a demand bill request. The Director of Finance stated s/he had informed the Executive Administrator that they did not have any demand bills in the past 6 months. The Executive Administrator and the Director of Finance stated the family/responsible party may have checked the form in error and they would find out additional information, An interview on 5/01/13 at approximately 12:45 PM with the Executive Administrator revealed the Social Services Department reportedly misunderstood the form and thought checking the top box (Option 1) indicated they did not want a demand bill. The Executive Administrator stated they will be calling the families of Res. #55 and #100 to determine if the want a demand bill. Option 1 on the SNFABN stated: Yes. I want to receive these items or services. I understand that Medicare will not decide whether to pay unless I receive these items or services. I understand you will notify me when my claim is submitted and that you will not bill me for these items or services until Medicare makes it decision, If Medicare denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, either out of pocket or through any other insurance that I have. I understand that I can appeal Medicare's decision.",2017-04-01
8284,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2012-02-08,280,D,0,1,6G5L11,"**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 facility's Wandering/Elopement Risk Policy, the facility failed to review and revise a care plan for 1 of 1 sampled resident with exit seeking behaviors. (Resident #13's care plan was not updated related to placement and location of wanderguard bracelet). The findings included: The facility admitted Resident #13 on 9/16/08 with diagnosed that included Altered Mental Status, [MEDICAL CONDITION], Hypertension and Dementia. Record review on 2/08/12 at approximately 11:30 AM revealed a Nurse's Note dated 10/31/11 that indicated resident was found outside Unit 2 by staff. The Nurse's Note further indicated the resident was not wearing a wanderguard bracelet and the writer immediately placed one on resident's left wrist. A Nurse's Note dated 12/15/11 indicated the resident tried to leave the facility several times. There was no documentation to indicate if the wanderguard was checked or located on the left wrist. Review of the facility's Wandering/Elopement Risk Policy indicated in #2 under procedure With each quarterly, annual, or significant change assessment, the Wandering/Elopement Risk Assessment is to be completed and the care plan revised/updated to reflect the current needs of the resident. An observation on 2/08/12 at 12:30 PM revealed the resident was in his room seated in a chair. There was no wanderguard located on the resident's left wrist. The resident's care plan, incorrectly dated as last reviewed 3/20/12, indicated the resident was at risk for elopement but stated the Resident will not wear a wanderguard; he will remove all that are applied. It had not been revised to reflect the resident was currently wearing a wanderguard or where it was located. Review of the MAR (Medication Administration Records) for November 2011, December 2011, January 2012 and February 2012 did not indicate the location of the wanderguard. An interview on 2/08/12 at approximately 12:45 PM with LPN (Licensed Practical Nurse) #3 revealed the resident was able to remove the wanderguard from his wrist. LPN #3 further confirmed the care plan and the MAR indicated [REDACTED]. During the observation LPN #3 informed resident he wanted to see his bracelet. The LPN checked both of the resident's wrists and could not locate the bracelet. LPN #3 then checked the resident's left ankle and located the wanderguard bracelet. LPN #3 stated she did not know when the bracelet was placed on the left ankle and confirmed there was no documentation to indicate when the bracelet was placed on the left ankle. An interview on 2/08/12 at approximately 1:25 PM with the ADON (Assistant Director of Nursing) revealed the facility did not have an incident report to investigate the 10/31/11 exit seeking behavior. The ADON stated the wanderguard was removed from the resident's wrist because the resident was able to remove it. The ADON further confirmed the care plan was not updated to reflect the placement of the wander guard bracelet.",2016-06-01
8285,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2012-02-08,309,D,0,1,6G5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, intake and output was not recorded each shift per physician order [REDACTED]. The findings included: The facility admitted Resident # 1 on 2/08 and readmitted her on 3/18/10 with [DIAGNOSES REDACTED]. Record review on 2/7/12 revealed documentation of a recent UTI (Urinary Tract Infection) on 12/15/11 for which an antibiotic was ordered. The physician's orders [REDACTED]. The date beside the order was 12/14/10. The last documentation of I & O on the MAR (Medication Administration Record) was during October, 2011 with only initials but no actual amounts of intake or output. During an interview with the Unit Manager (Registered Nurse # 1), she reviewed the resident's record and thinned record. An order to check I & O q (every) shift was found dated 9/2/10. RN #1 continued to review the record but could not locate a discontinuation order for the I & O. She checked the MAR for February and found no documentation that I & O was being recorded. The nurse confirmed the staff were not recording intake and output on this resident per the physician's orders [REDACTED].",2016-06-01
8286,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2012-02-08,323,G,0,1,6G5L11,"**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 2 of 6 sampled residents reviewed for falls remained free from accident hazards by providing adequate supervision and assistance devices to prevent accidents. For Resident #1 the facility failed to implement interventions to prevent recurrence and reduce risk after a fall. Resident #8 sustained 3 falls resulting in a shoulder dislocation and tibial fracture on separate occasions resulting from failure of the facility to provide appropriate training, supervision, and/or changes in the care plan interventions to prevent recurrence. The findings included: The facility admitted Resident #8 on 06/12/06 with [DIAGNOSES REDACTED]. Record review on 02/07/12 at 3:30 PM revealed that an incident report was written on 12/31/11 at 10:10 PM which stated, Resident was laying on floor in front of recliner chair. Staff attempted to use the lift to transfer, no connection was made. Resident slide out of recliner onto floor. The documented equipment being used at the time of the incident was lift. Nurses Notes for 12/31/11 stated that Resident #8 was complaining of right knee pain, left and right ankle pain. Resident #8 was sent to the emergency room for evaluation. Nurses Notes on 1/1/12 at 3:40 AM revealed that Resident #8 returned from the emergency room with a [DIAGNOSES REDACTED]. The second incident report, for Resident #8, which was dated for 10/21/11 at 11:15 AM stated, staff getting res (resident) off toilet on stand-up lift. Res slid out sling lowered to floor by staff. C/O (complaints of) R (right) shoulder pain, cannot move R arm and c/o R knee to ankle pain can move R leg. The documented equipment being used at the time of the incident was a stand-up lift. Nurses Notes revealed Resident #8 was sent to the emergency roiagnom on [DATE] at 12:40 PM for evaluation of right shoulder and right knee pain. Nurses Notes revealed that Resident #8 returned to the facility on [DATE] at 1:00 AM with the [DIAGNOSES REDACTED]. Continued review of the Nurses Notes dated 10/23/12 revealed that Resident #8 was wearing a sling on the right arm and mild discoloration was seen from right shoulder to neck. The third incident report for Resident #8, which was dated for 8/25/11 at 10:00 AM stated, Staff taking res (resident) to bathroom. Started sliding out of harness. Slid to floor. no injuries noted. The documented equipment being used at the time of the incident was a stand-up lift. Review of the Nurses Notes confirmed that Resident #8 slid out of the harness of the stand-up lift while going to the bathroom and that there were no apparent injuries. Upon review of the Therapy Screening Referral dated 8/25/11, regarding Resident #8's fall, it was documented on the referral wrong lift (sling) used for this transfer. Documented on the therapy screening referral dated 10/21/11 regarding Resident #8's fall out of stand-up lift was noted max assist with all transfers use full body lift per safety. Documented on the Rehab Pre-Admission Worksheet dated 10/25/11 was that Resident #8 was total assistance for transfers and total body lift staff assistance times two. There were two additional undated Rehab Pre/Admission Worksheets documenting that Resident #8 required total assistance with stand lift for all transfers with two staff and maximal/total assistance for transfers with Hoyer lift for bed to chair and bed to toilet. Physical Therapy and Occupation Therapy daily notes for 10/21/11 noted Resident #8 required maximal assistance for activities of daily living and transfers. During an interview with the acting Director of Nursing (DON) on 2/7/12 at 4:30 PM the surveyor requested the facility's policy and inservice training documentation for the staff who were assigned to transfer the residents requiring either a stand-up or Hoyer lift. The inservice documentation sheets provided by the DON completed on 9/1/11, 4/1/11, and 3/2/11 did not contain the signatures of the individuals listed on the incident reports from 8/25/11, 10/21/11 and 12/31/11. The facility's policy and procedure for lifts provided by the DON included directions: at least two people are present during transferring . An interview was conducted on 07/08/12 at 1:45 PM with Physical Therapy Assistant (PTA) #1 regarding when Resident #8 was changed from a stand-up lift to a Hoyer lift. After record review PTA #1 stated that she could not determine since two of the Rehab Admission Worksheets had not been dated. The PTA did identify that Resident #8 was assessed for use of a Hoyer lift on 10/25/11. When asked who was responsible for training the staff regarding the proper use of the stand-up and Hoyer lift, PTA stated therapy staff does the training only when nursing staff asks the therapy department for the training. The surveyor interviewed Certified Nurses Assistant (CNA) #3 (listed on the incident report dated 10/21/11) about who she had received her training from regarding the use of the stand-up lift. CNA #3 stated she was instructed by former DON approximately one year previously. When asked who instructed CNA #3 on how to use the Hoyer lift, she stated she learned from other CNA's on the floor. The facility failed to provide evidence of initial and ongoing training related to use of resident care equipment. Record review revealed a care plan that the resident was at risk for fall/injury which contained two added hand written interventions. The interventions were not dated and intervention #14 stated use appropriate lift according to therapy recommendations. The care plan was not specific as to which lift was to be used and there were no changes in interventions following the 3 falls. The care plan was not updated following the most recent fall incident dated 12/31/11. The facility admitted Resident # 1 on 2/08 and readmitted her on 3/18/10 with [DIAGNOSES REDACTED]. During record review on 2/7/12 skin sheets were noted with multiple documentation's of bruising to the resident's arms, legs, and toes. Incident reports were requested for the periods of documentation; however, only two reports were provided by the facility. A report dated 8/13/11 documented a fall in the day room with a skin tear to right hand. The report documented as steps taken to prevent recurrence : Morse Fall Scale Complete, Res.(resident) may need around the clock sitter. The Post Fall Assessment showed at the time of the fall no alarms were being used for this resident. The report noted the resident was on Lexapro 20 mg (milligrams), Trazadone 50 mg, and Lorazepam 0.5 mg. The Falls Prevention Follow-up had 2 areas checked: care plan updated to reflect fall , additional interventions added to care plan, and continue POC (plan of care). Report to Risk Committee. No other recommendations were made by the committee. Morse Fall Scale Assessments were also noted in the medical record dating back to 3/18/11. The resident scored as a high risk for falls. Sensor alarm i.e.: bed alarm and/or chair alarm initialed with low bed also initialed on the 3/18/11 assessment. Other Morse Fall Scale assessments dated 6/6/11, 6/19/11, 8/13/11, 9/18/11, and 12/18/11 also scored the resident as high risk for falls. Each of the sheets had lines drawn to include all the interventions listed for low risk and high risk, but never any new interventions. Review of the Resident's Care Plan for risk of falls documented falls on 6/6/11, 7/13/11, and 8/13/11. Interventions # 8, #9, #10, and #11 had been added to the care plan but there were no dates as to when the intervention had been added. A chair alarm when up in chair was added as an additional intervention. ( #10). An interview with the Unit Manager (RN #1) revealed that the resident had a bed alarm and a chair alarm. Review of the Physicians Orders only revealed and order for a bed alarm. The nurse stated an order would have been obtained in order to apply a chair alarm. Actual visual inspection at 11 AM on 2/8/11 of the resident seated in her wheel chair by the nurse and surveyor revealed no chair alarm in place. The sitter staying with the resident stated, She has never had a chair alarm. She has a bed alarm. During the two days of the survey, the resident was always noted up in her wheel chair. Interviews revealled the sitter only stays during the day leaving the facility responsible for the resident's supervision and safety. The sitter was not oberved during the supper meal. The incident on 8/13/11 occurred at 5:30 PM and the sitter was not present.",2016-06-01
8287,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2012-02-08,371,F,0,1,6G5L11,"On the days of the survey, based on observations and interview, the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility freezer contained unlabeled/undated food. Kitchen equipment was observed soiled with dried food splatters or contained food debris, food items were not labelled nor dated, stored foods were improperly wrapped, The findings included: On 2/7/2012 at 9:20 AM, during tour of the facility's kitchen with the Dietary Manager, the Tilt Grill and the Deep Fryer contained a large amount of food debris and the oil was a dark color. A table top stand mixer had dried food splatters. The can opener attached to a counter had a black substance around the base where it was attached to the counter and in the area where the opening tip rested on the counter. The walk-in freezer had a large bag of breaded chicken strips which were taken out of the original box and had not been dated or labeled. The freezer also contained a frozen chicken which had been wrapped in aluminum foil and was partially exposed with no date. The Dietary Manager stated that the Tilt Grill and Deep Fryer were to be cleaned on the day of the tour. She removed the partially wrapped chicken from the freezer. As she removed the chicken, she stated they know they are not supposed to do that. On 2/8/2012 at 9:10 AM, during an additional tour with the Dietary Manager, the Deep Fryer was observed to contain a large amount of food debris and dark colored oil. The Tilt Grill had been cleaned. The mixer also continued to have dried splatters. The Dietary Manager stated that the Deep Fryer had been cleaned on 2/7/12 but had been used after the cleaning A cleaning schedule was requested but not provided prior to exiting the facility.",2016-06-01
8288,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2012-02-08,425,D,0,1,6G5L11,"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 2 of 3 medication rooms. The findings included: On 2/8/12 at 10:24 AM, observation of the 300 Unit medication room revealed one 1 milliliter (ml) vial (10 tests) Tuberculin Purified Protein Derivative, Diluted/Aplisol, opened with a puncture date of 1/2/12. 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 2/8/12 at 10:38 AM, Licensed Practical Nurse (LPN) #1 revealed that the House Supervisor (LPN or Registered Nurse) spot checks the medication room periodically for expired medications, but there is no schedule. On 2/8/12 at 11:06 AM, observation of the 100 Unit medication room revealed one punch card of 30 tablets of Cetirizine HCl (hydrochloride) 10 mg (milligram), expired 1/31/12. During an interview on 2/8/12 at 11:33 AM, LPN #2 revealed that night shift nurses were responsible to check expiration dates on weekends and also periodically. She added that Pharmacy also comes once every couple of months and checks for expired medications.",2016-06-01
8289,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2012-02-08,514,D,0,1,6G5L11,"**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 clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented for Resident #4, 1 of 10 residents reviewed for allergies. Resident #4 had allergies listed on admission records and the History and Physical which were not on the Physician order [REDACTED]. The findings included: The facility admitted Resident #4 on 4/19/2011 with [DIAGNOSES REDACTED]. The resident was found to be alert and orientated and scored a 14 on his BIMS.(Brief Interview for Mental Staus). On 2/7/2012 at 2:10 PM, during review of Resident #4's medical chart, allergy documentation was reviewed. A discharge form from a hospital dated 4/2/2011 stated that the resident was allergic to Latex and [MEDICATION NAME]. A facility History and Physical (H&P) dated 4/22/2011 and signed by the attending physician indicated allergies to Latex and [MEDICATION NAME]. Another H&P from a different hospital documented the resident's allergies as [MEDICATION NAME], Latex and Shellfish. A Patient Transfer form dated 12/24/2011 also listed the resident's allergies as [MEDICATION NAME], Latex and Shellfish. An Admission/Readmission Clinical Care assessment dated [DATE] indicated the allergies were Latex, Natural Rubber, [MEDICATION NAME] and Shellfish. An assessment dated [DATE] had the allergies documented as [MEDICATION NAME] and [MEDICATION NAME] and on 4/19/11 as Latex, [MEDICATION NAME] and [MEDICATION NAME]. The POF for 12/11, 1/12/and 2/12 contained documentation of Latex and Natural Rubber as the resident's allergies. The MAR's also contained the same allergy documentation. The MAR's and POFs revealed that the resident received [MEDICATION NAME] 20 milligrams once a day. On 2/7/2012 at 4:35 PM, vinyl gloves were observed being used by the staff and in the resident's room. On 2/8/2012 at 8?20 AM, during an interview with Registered Nurse (RN) #2, she reviewed and verified the allergy discrepancies for Resident #4. At 9:05 AM, RN #2 stated that she had interviewed the resident and that he stated he was not allergic to any of the listed items. He also stated his only allergy was to Scallops. RN #2, contacted the physician for a clarification order for the allergies and provided a copy to the surveyor. At 10:15 AM, In an interview with the resident, he verified that the nurse had spoken with him about his allergies and that he had told her his only allergy was scallops.",2016-06-01
9268,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2012-02-27,225,D,1,0,664M11,"On the day of the complaint investigation, based on information provided by the facility and interviews, the facility failed to notify the State Agency of their final, 5 day report regarding a misappropriation investigation. One of one investigation of alleged misappropriation of funds was not reported to the State Survey and Certification Agency. The findings included: On 02/27/2012 an unannounced visit was made to the facility to investigated a facility reported allegation of misappropriation of one resident's funds. During the investigation the facility provided a summary of their investigation. Review of the investigation revealed the facility had not obtained a statement from the alleged perpetrator. The summary stated they had discussed the allegation with the perpetrator and she wanted the facility to make a payment plan. During an interview with the Executive Director, and Administrator on 3/2/12 at 9:20 AM, they confirmed they had not obtained a statement from the alleged perpetrator. They also confirmed they had not sent a five day report to the State Survey and Certification Agency. ""We were not aware that we needed to send a five day report.""",2015-06-01
9269,MARTHA FRANKS BAPTIST RETIREMENT CENTER,425334,ONE MARTHA FRANKS DRIVE,LAURENS,SC,29360,2012-02-27,226,D,1,0,664M11,"On the day of the complaint investigation, based on interviews and review of the facility's written abuse policies, the facility failed to follow the policies related to reporting to the State Survey and Certification Agency. The findings included: On 02/27/2012 a review of the facility's written abuse policies and procedures revealed the following: ""...Reporting: The facility shall report all alleged violation and all substantiated incidents to the state agency and to all other agencies as required by law (see attached Timeframe for Reporting): ..."" Review of the DHEC Certification - Complaint Reporting Timeframe referred to under the reporting heading, page 1 of 1 stated, ""...Facility investigation results sent? ...Note: Results of thorough investigation are sent within 5 working days of the incident..."" Cross Refers to F-225 as it relates to the facility failure to send the 5 Day Follow-up Report to the State Survey and Certification Agency.",2015-06-01
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
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
590,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2020-02-07,583,D,1,1,NWK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to provide privacy while administering medications. Eye drops and [MED] were administered without the privacy curtain pulled and/or the door closed for one of one resident receiving eye drops and one of 2 residents receiving an injection.(Resident #4 and Resident #81) The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Observation of medication administration on 2/6/20 at 1:30 PM revealed Registered Nurse(RN)#1 did not pull the privacy curtain or close the door during the administration of eye drops. During the administration of the eye drops, Resident #4's roommate and a visitor were observed in the room. The facility admitted Resident #81 with [DIAGNOSES REDACTED]. Observation of medication administration on 2/6/20 at 12:00 PM revealed during the administration of [MED], Licensed Practical Nurse(LPN)#1 did not pull the privacy curtain or close the door. During an interview with LPN #1 on 2/6/20 at 5:00 PM, s/he confirmed privacy was not provided during the administration of [MED]. During an interview with RN #1 on [DATE] at approximately 1:56 PM, s/he confirmed privacy was not provided during the administration of eye drops. No facility policy was provided addressing privacy during administration of medications.",2020-09-01
591,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2020-02-07,812,E,1,1,NWK011,"> Based on observation, interview and review of facility policy titled Food Safety, the facility staff failed to handle and store foods in accordance with professional standards in 1 of 1 kitchens and failed to provide a hands free trash can near the hand washing sink in 1 of 2 unit food service areas. The findings included: On [DATE] at approximately 10:10 AM, during initial kitchen tour, accompanied by Food and Beverage Manager the following was observed: a gallon size plastic container of tartar sauce dated [DATE], boxes of produce placed on floor of walk-in cooler, 1/2 full gallon size container of Greek salad dressing with no open date and no expiration date; gallon size container of BBQ sauce open with no date, spillage on container and on two shelves; 32 ounces chopped garlic in oil open with no date; clear plastic storage container with off white flaky substance with no label to indicate contents and no date opened. Also, in the freezer, 2 boxes of food stored on floor, 2 open bags of french fries, 1 package of hush puppies and 1 bag of pepperoni all with no label indicating date opened. The Food and Beverage Manager observed and acknowledged the improperly labeled and stored food items. On [DATE] at approximately 12:00 PM while on the Rehabilitation Unit, the hand washing sink had no hands-free trash can available to dispose of used paper towels. On [DATE]20 at approximately 12:03 PM the Certified Dietary Manager stated the trash can was inside the cabinet of the hand washing sink and confirmed the hands-free trash can was not properly placed next to the hand washing sink. On [DATE]20 at approximately 1:45 PM, review of facility policy titled Food Safety Section IV W. stated that all stored food items require a product identifier/ label and use by date. The facility policy entitled Food Safety in the Receiving and Storage Section B. stated that food must be stored in a manner to allow air circulation around food and that repackaged food will be placed in a leak-proof, pest proof, non-absorbent, sanitary container with a tight fitting lid. The Policy also states that containers will be labeled with the name of the contents and dated when it was transferred to the new container.",2020-09-01
592,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2020-02-07,880,D,1,1,NWK011,"> Based on observation, interview, and review of the facility policy titled Hand washing, facility staff during the laundry process failed to wash hands after removal of gloves for one of one laundry observation. In addition, staff failed to wash hands after removal of gloves, during medication administration, for 2 of 4 observations during medication pass when gloves were worn. The findings included: During observation of the laundry process on [DATE]20 at 10:20 AM, Laundry Staff #1 was observed donning gloves to obtain soiled laundry bags and placed them in the laundry cart. After loading the cart, Laundry Staff #1 removed his/her gloves and did not wash his/her hands and continued to the next unit. During observation of medication administration on 2/6/2020 at 1:15 PM, Registered Nurse (RN) #1 was observed discontinuing an intravenous antibiotic from a Resident. RN #1 removed his/her gloves and exited the room without washing his/her hands. During observation of medication administration on 2/6/2020 at 1:30 PM, RN #1 was observed administering eye medication to a Resident, removed his/her gloves, and exited the room without washing his/her hands. During an interview with Laundry Staff #1 on [DATE]20, after the observation, s/he agreed that s/he did not wash his/her hands after removal of gloves. During an interview with RN #1 on [DATE]20 at approximately 1:30 PM, RN#1 stated s/he did not remember if hand washing had been done after the removal of gloves. S/he stated it was his/her practice to perform hand washing after removal of gloves. On [DATE]20 at approximately 3:15 PM, a review of the facility policy titled Hand washing revealed the following under Procedures: Hand washing will be performed before and after applying or administering eye drops or ointment, after gloves are removed, between resident contact, and when otherwise indicated to avoid transfer of microorganisms to other residents.",2020-09-01
593,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,157,D,0,1,PD4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility policy titled, Resident Condition Changes That Require Physician Notification Guidelines, the facility failed to ensure the responsible party and/or an interested family member was notified of the development of a pressure ulcer for Resident #180 and #203 for 2 of 3 residents reviewed with pressure ulcers. The findings included: The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 8/11/2017 at approximately 2:50 PM of the medical record for Resident #180 revealed Resident #180 was admitted 7 days prior to the development of a stage II pressure area to his/her sacral area. Review on 8/11/2017 at approximately 2:50 PM of the nurses notes for Resident #180 did not include documentation to ensure that the responsible party nor the spouse was notified of the development of a stage II pressure ulcer located on the sacrum of Resident #180. An interview on 8/11/2017 at approximately 3:00 PM with Licensed Practical Nurse (LPN) #2 confirmed that the responsible party/interested family member had not been notified of the development of a stage II pressure area on the sacrum of Resident #180. Review on 8/11/2017 at approximately 3:30 PM of the facility policy titled, Resident Condition Changes That Require Physician Notification Guidelines, states on page 3 under, Expectations, Number 1, Licensed nurses (staff and management) are expected to recognize resident situations/conditions that require physician notification. The nurse shall complete an assessment of the condition, including levels of urgency. The nurse shall implement appropriate interventions and have accurate information available when contacting the physician. Number 4 states, The licensed nurse shall also notify, the Unit Nurse Manager/Nursing Supervisor and the Resident and/or family. Also, Provide appropriate follow-up with staff who do not comply with facility guidelines. The facility admitted Resident #203 with [DIAGNOSES REDACTED]. Record review on 8/10/17 of the Nursing Weekly Wound Progress Review revealed Resident #203 developed a Stage II pressure area on the right heel on 7/17/17. On 7/28/17 documentation on the Nursing Weekly Wound Progress Review stated the resident had developed a deep tissue injury to the left heel. Review of the Nursing Weekly Wound Progress Review and the Nurse's Notes during that time revealed the responsible party was not notified of the development of the wounds.",2020-09-01
594,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,272,D,0,1,PD4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure the Minimum Data Set (MDS) assessment was coded correctly for a sacral Stage II pressure ulcer acquired after admission to the facility for Resident #180 for 1 of 3 residents reviewed for pressure ulcers. The findings included: The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 8/10/2017 at approximately 2:50 PM of the medical record for Resident #180 revealed he/she was admitted 7 days prior to the development of a Stage II pressure ulcer of the sacrum. Review on 8/10/2017 at approximately 4:50 PM of the MDS assessment coded on admission revealed under Section M0210 - Unhealed Pressure Ulcer(s) which asked the question, Does this resident have one or more unhealed pressure ulcer(s) at Stage I or higher? was coded with a (0) to indicate, no. Further review on 8/11/2017 at approximately 3:00 PM of the MDS assessment coded as the 14 day assessment revealed under Section M0210 coded with a (1) which indicated that Resident #180 had an unhealed pressure ulcer(s) at a Stage I or higher. Section M0300 - B. Stage 2 - number 2 was coded with a (1) and asks, Number of these Stage II pressure ulcers that were present on admission/entry or reentry, to indicate that the pressure ulcer was not acquired in the facility but the resident was admitted with the pressure ulcer of the sacrum. During an interview on 8/11/2017 at approximately 3:15 PM with the MDS/Care Plan Coordinator confirmed that the 14 day MDS assessment had been coded incorrectly and provided a corrected MDS assessment to indicate Resident #180 was not admitted with a Stage II pressure ulcer on his/her sacrum.",2020-09-01
595,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,280,C,0,1,PD4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to document participation of all required disciplines in the Care Plan Conferences for Residents #15, #42, #45, #46, #48, #56, #88, #180 and #203. There was no signature to verify attendance by a Dietary Representative and/or Certified Nursing Assistant (CNA) on the Plan of Care Conference Summaries for 9 of 9 sampled residents whose Care Plans were reviewed. The findings included: The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Review of the Care Plan on 08/10/17 at 12:47 PM revealed that the signature section of the Plan of Care Conference Summary sheet did not document participation by a CNA, Dietary representative or Physician in the formulation of the plan. The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Review of the Care Plan 0n 08/10/17 at 10:43 AM revealed that the signature section of the Plan of Care Conference Summary sheet did not document participation by a CNA, Dietary representative or Physician in the formulation of the plan. The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Review of the Care Plan on 08/10/17 at 4:27 PM revealed that the signature section of the Plan of Care Conference Summary sheet did not document participation by a CNA, Dietary representative or Physician in the formulation of the plan. In an interview on 08/11/17 at 11:31 AM the Minimum Data Set (MDS) Coordinator #2, stated, if there is no signature, there is no way to verify participation. In an interview on 08/11/17 at 12:34 PM, the Director of Nursing stated the facility does not have a Care Plan policy. The facility admitted Resident #203 with [DIAGNOSES REDACTED]. Record review on 8/10/17 of the resident's care plan dated 7/13/17 revealed Dietary and the Certified Nursing Assistant did not participate in the care plan process. The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review on 8/10/2017 at approximately 11:02 AM of the medical record for Resident #48 revealed a form titled, Plan of Care Conference Summary, dated 5/17/2017 and indicated that Social Services and the rehab/therapy staff were the only disciplines involved with planning the care for Resident #48. Further review on 8/10/2017 at approximately 11:05 AM of the form indicated that Dietary, the Registered Nurse (RN) and the Certified Nursing Assistant (CNA) involved with the resident's care did not have input into developing the plan of care for Resident #48. Review on 8/10/2017 at approximately 11:15 AM of a second form titled, Plan of Care Conference Summary, dated 7/18/2017 for Resident #48 and indicated that Dietary and the CNA involved with the care for Resident #48 did not participate and have input into the care planning process for Resident #48. The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 8/10/2017 at approximately 4:53 PM of the medical record for Resident #180 revealed a form titled, Plan of care Conference Summary, dated 6/1/2017 revealed that Dietary and the CNA involved with the caring for Resident #180 did not have input nor were they involved in developing the plan of care for Resident #180. Resident #15 was admitted with [DIAGNOSES REDACTED]. There was no documentation of CNA (Certified Nurse Assistant), Nurse, or Dietary participation in care plan, per the Plan of Care Conference Summary dated 6/23/17. Resident #46 was admitted with [DIAGNOSES REDACTED]. There was no documentation of CNA participation in care plan, per the Plan of Care Conference Summary dated 6/1/17. Resident #88 was admitted with [DIAGNOSES REDACTED]. There was no documentation of CNA participation in care plan, per the Plan of Care Conference Summary dated 6/13/17.",2020-09-01
596,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,314,E,0,1,PD4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of the facility policy titled Categories/Staging of Pressure Ulcers and review of LLR Advisory Opinion #46, the facility failed to have a Registered Nurse stage pressure ulcer wounds for 3 of 3 pressure ulcers reviewed.(Resident #203, #48 & #180) The findings included: The facility admitted Resident #203 with [DIAGNOSES REDACTED]. Record review on 8/10/17 of the Nursing Weekly Wound Progress Reviews revealed Licensed Practical Nurse(LPN)#2 documented the stage of the wound. Further review of the wound notes revealed there was no documentation a Registered Nurse was with LPN #2 during the staging of the wound. During an interview with the Director of Nursing(DON) on 8/11/17 at approximately 12:45 PM, he/she stated the wound nurse was Wound Care Certified(WCC) and the facility policy states if a LPN is WCC they can stage a resident's wound. He/she continued by stating wounds are discussed at risk meetings and the risk meetings are signed by Registered Nurses. The DON during the interview stated he/she made rounds with the wound nurse and sometimes performs wound care when the WCN is not available. No documentation could be provided by the DON regarding making rounds with the WCN and staging resident's wounds. Review of the facility policy titled Categories/Staging of Pressure Ulcers revealed the following: .It is the position of Five Star Senior Living that staging pressure ulcers be performed by a Registered Nurse OR a Licensed Practical/Vocational Nurse who holds a current certification as a wound care nurse, unless otherwise indicated in your state specific scope and standards of nursing practice. Review of the LLR(Labor, Licensing and Regulation) Advisory Opinion #46 states the following: It is not within the role and scope of the Licensed Practical Nurse to evaluate and/or stage vascular, diabetic/neuropathic or pressure ulcers. The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review on 8/9/2017 at approximately 2:46 PM of the medical record for Resident #48 revealed a form titled, Nursing Initial Wound Evaluation, and indicated a Stage III pressure wound to the Coccyx. No documentation could be found to ensure a Registered Nurse had staged the pressure wound. Further review on 8/9/2017 at approximately 2:50 PM of a form titled, Weekly Wound Progress Review Form, indicated that the pressure wound assessed on the coccyx of Resident #48 had been staged by a Licensed Practical Nurse (LPN). The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 8/10/2017 at approximately 2:53 PM of the medical record for Resident #180 revealed a form titled, Initial Wound Review, and was signed and staged as a stage II by a Licensed Practical Nurse at time of discovering the sacral pressure ulcer. No documentation could be found in the medical record for Resident #180 to ensure a RN had staged the new found pressure ulcer. Further review on 8/10/2017 at approximately 3:00 PM of a form titled, Weekly Wound Progress Review Form, indicated weekly the LPN continued to assess and stage the sacral wound. No documentation was found to ensure a RN was present at the time of the staging and assessment process for Resident #180's sacral pressure wound.",2020-09-01
597,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,329,D,0,1,PD4911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure behavior monitoring for resident with Physician order [REDACTED].#15 identified as receiving [MEDICATION NAME] for behavior disturbances did not have any monitoring of the efficacy of the medication and/or adverse consequences. The findings include: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Record review on 8/09/2017 at approximately 3:30 PM revealed a Physician order [REDACTED].) Has hallucinations & delusions. -Order Date- 6/28/2017 1045. Record review on 8/09/2017 reveals no evidence of behavior monitoring in the Physician Orders. An interview on 08/10/2017 at 12:55 PM with LPN #1, who verified no order for monitoring behavior for medication, [MEDICATION NAME]. A review of the policy titled: Psychopharmacological Medication states 3.2 Psychopharmacological and Sedative/Hypnotic, Residents who use psychopharmacological and sedative/hypnotic medications must be reviewed on a regular basis and there must be monitoring for efficacy of the medications and Adverse Consequences. On 8/10/2017 at approximately 1:15 PM, the facility provided a copy of Physician order [REDACTED].=s/s of Dementia with behavioral disturbance, 3=Target mood/behavior: combative/resistive to care, screaming out, fidgeting behaviors, yelling, no easily redirectable every shift Document Behavior, # of Episodes, Interventions, Outcome and side effects.",2020-09-01
598,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,371,E,0,1,PD4911,"Based on interview, observation and record review, the facility failed to ensure: 1)Labeling and dating of refrigerated food 2)Cold foods on serving line were held at or below 41 degrees, and, 3) Safe storage of foods in refrigerator; cooked gravy was stored in refrigerator beneath raw eggs in 1 of 1 kitchen and 2 of 2 dining rooms. The findings include: During initial tour of the kitchen, on 08/08/2017 at 9:05 AM, observed 5 partially open packages of sliced cheese which had been rewrapped in clear plastic were not labeled or dated. The General Manger verified the cheese was not labeled and said the cheese should have be labeled when the package was opened and rewrapped. The Facility Policy and Procedure titled, Food Safety in Receiving and Storage, . 2.0 Procedure, The following guidelines will be followed for Receiving and Storage:, General Food Storage Guidelines, 3. Food that is repackaged will be placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight fitting lid. The container will be labeled with name of the contents and dated with the date it was transferred to the new container. On 8/10 at 4:40 PM in the Health Care Dining Room, the temperatures were taken for dinner meal service by the Dietary Employee and were as follows: Puree Ham 55.4 degrees, Sliced [NAME]toes and Lettuce 47.3 degrees. The dietary employee stated that the correct cold food temperature 35 to 40 degrees for serving line, and food must be removed from the line if not at the correct cold food temperature. The foods were removed from the line before meal service and taken back to the kitchen and put in the freezer to be chilled down, returned to the dining room at 5:15 PM, the Puree chicken salad was 39.3, Sliced [NAME]toes and Lettuce 40.1 degrees. On 8/10 at 4:55 PM in the Rehab Center Dining Room the General Manager delivered meals and took the temperatures of food prior to meal service. The Chicken Salad Sandwich was 46.5 degrees, the Potato Salad was 42.8 degrees. The General Manager said the temperatures were incorrect and the food was removed and returned to the kitchen for chilling. On 8/10 at 5:40 PM, the General Manager brought the re-chilled plates for the Rehab Center Dining Room and the temperatures were 37.5 degrees, and the chicken salad and potato salad were 34.0 degrees. A review of the facility Policy and Procedure titled, Safe Food Temperatures, 3.11 Procedure, Adhere to the following practice guidelines: .4.Cold foods will be held at 41 degrees or lower during meal service (on the trayline). On 08/11/2017 at 9:01 AM, observed a pan of brown gravy stored on lower shelf of cooler beneath raw eggs, verified with the kitchen manager who stated it should not be there and removed from cooler. A review of the facility Policy and Procedure titled: Food Safety in Receiving and Storage, states Cold Food Storage Guidelines, 6. Cooked and ready-to-eat foods will be stored above raw foods (including shell pasteurized eggs) in the refrigerator to prevent cross-contamination",2020-09-01
599,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,372,D,0,1,PD4911,"Based on observation, interview and record review,the facility failed to ensure the area surrounding the outside grease storage receptacle was maintained and free from spillage and leaking grease in one of one grease storage receptacle. The findings include: An observation on 08/11/2017 at 10:08 of the grease storage receptacle had spillage of black greasy substance on the concrete surface which the container was stored and the gravel in front of the grease receptacle. An interview on 8/11/2017 at approximately 10:30 AM with the General Manager of Dining and he/she said that they don't know when they are going to pick up the grease from the grease container. On 08/11/2017 at 10:48 AM, the Director of Maintenance verified the spillage of grease on gravel area and concrete surface. He/She said that the company which picks up the grease comes about every 8 weeks and, further he/she stated that there was a problem recently where they did not come timely and that is how the spillage of the black grease in the gravel area occurred. He/She said that he/she tried to clean with degreaser and this did not clean this area up. He/She provided a letter dated 8/11/2017 from Valley Proteins, Inc. which stated: .Re: Customer Number 1 (Used Waste Oil), the following is a confirmation for service for raw material services at your facility: Confirmation of Service, Service: Valley Proteins provides raw material service for the removal of waste kitchen grease. Valley Proteins furnishes these services on an 8 week frequency. We last serviced on 6/29/17. The next service expected on or around 8/14/2017. We have servicing your location since (MONTH) 1994.",2020-09-01
600,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,441,D,0,1,PD4911,"Based on observations, interviews and review of the facility policy titled, Laundry Handling Practices, and, Standard Precautions, the facility failed to handle soiled linen in a manner to prevent the spread of infections in 1 of 1 laundry room. The facility further failed to ensure soiled linen was bagged before leaving the resident's room and placing it in a soiled bin in the hallway on 1 of 2 halls. The findings included: An observation on 8/11/2017 at approximately 10:30 AM revealed the Laundry Worker vigorously shaking soiled linen before placing it in the soiled bins in the laundry room. Further observation on 8//11/2017 at approximately 10:35 AM revealed the Laundry Worker removing soiled linen from the soiled linen bins located in the hallway that was not bagged before placing it in the bin. During an interview on 8/11/2017 at approximately 10:45 AM the Laundry Worker stated, we shake out the linen to ensure nothing is wrapped up in it and so nothing like forks and knives are put in the washers. During the interview the Laundry Worker also confirmed that the soiled linen was not bagged prior to putting it in the soiled linen bins in the hallway. He/she went on to say that sometimes it is bagged and sometimes it is not. Review on 8/11/2017 at approximately 11:30 AM of the facility policy titled, Laundry handling Practices, under Procedure, number 3 states, Handle contaminated laundry as little as possible, with minimal agitation. Number 4 states, Bag or contain contaminated laundry bagged/contained where it is used. Do not sort or rinse in the location of use, move to identified area in laundry. Review on 8/11/2017 at approximately 11:50 AM of the facility policy titled, Standard Precautions, number 7 states, Linen: Transport linen that is soiled with blood, body fluid, secretions, or excretions in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments.",2020-09-01
601,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,456,E,0,1,PD4911,"Based on observations, interviews and review of the manufacturers recommendations for the facility's clothes dryers, the facility failed to ensure an excessive build up of lint was removed from inside and behind 4 of 4 clothes dryers. The findings included: An observation on 8/11/2017 at approximately 9:00 AM of the facility laundry room revealed 4 of 4 clothes dryers with an excessive build up of lint inside the clothes dryers, on the sides of the lint baskets, the upper sides of the dryers and on the wiring system. Further observation on 8/11/2017 at approximately 9:00 AM revealed a build up of lint behind the clothes dryers on the belts and ducts and on the back panels of the dryers. An interview on 8/11/2017 at approximately 9:15 AM with the Laundry Worker and the Maintenance Director confirmed the findings. Review on 8/11/2017 at approximately 9:40 AM of the Manufacturers Recommendations for the clothes dryers states under, Daily, Keep tumbler area clear and free of combustible materials, gasoline, and other flammable vapors and liquids. Number 2, reads, Remove all accumulated lint in the lint compartment area. Lightly brush any lint that may be left on the lint screen. Lint left in the lint compartment is drawn back onto the lint screen and will restrict proper air circulation. Number 5 states, Wipe any accumulated lint off of the thermostat sensing probe, cabinet hi-limit thermostat or thermistor. Failure to do so will allow a a buildup of lint in this area to act as an insulator, causing the tumbler to overheat.",2020-09-01
602,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2017-08-11,463,D,0,1,PD4911,"Based on record review, interview and observation, the facility failed to provide a functioning call bell for all residents. Two call bells were observed difficult to operate and two call bells did not function.(4 of 30 residents reviewed) The findings included: During room rounds on 8/8-9/17, the following was observed: Room 102P-call bell did not activate x 3 attempts; Room 105B-call bell did not activate after resident attempted to ring call bell; Room 207A-call bell did not activate; Room 207B-call bell did not activate. On 8/8/17 at 11:45 AM, Certified Nursing Assistant #1 and Licensed Practical Nurse(LPN)#3 confirmed the call bells for 207A and 207B would not activate. On 8/8/17 at approximately 4:00 PM, the Maintenance Director stated a wire had to be replaced and could not tell the surveyor how long the call bell had not been working or how often the call bells were checked to make sure they were in good working condition. On 8/11/17 at approximately 11:30 AM, the environmental tour was done with the Director of Nursing and call bells in Rooms 102P, 105B, 207A and 207B were checked and were functioning. During an interview with the Maintenance Director on 8/11/17, he/she stated call bells in a couple of rooms are checked randomly on a monthly basis. He/she could not tell the surveyor when the above rooms were checked last.",2020-09-01
603,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2018-10-11,623,D,0,1,BXWS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide written notification upon transfer for Resident #128, 1 of 2 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at approximately 10:22 AM revealed Nursing Notes dated 09/28/18 and 09/05/18 documenting orders to send Resident #128 to the emergency room for evaluation. No documentation of written Notice of Transfer being provided to the resident or resident representative was located in the medical record. In an interview on 10/10/18 at approximately 2:30 PM, the Director of Nursing confirmed the facility did not send written notices at transfer to the resident or the resident representative.",2020-09-01
604,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2018-10-11,625,D,0,1,BXWS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide written notification upon transfer for Resident #128, 1 of 2 sampled residents reviewed for hospitalization . The findings included: The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at approximately 10:22 AM revealed Nursing Notes dated 09/28/18 and 09/05/18 documenting orders to send Resident #128 to the emergency room for evaluation. No documentation of written Notice of Bed Hold being provided to the resident or resident representative was located in the medical record. In an interview on 10/10/18 at approximately 2:30 PM the Director of Nursing confirmed the facility did not send written notices of Bed Hold Policy to the resident or the resident representative.",2020-09-01
605,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2018-10-11,812,E,0,1,BXWS11,"Based on observation and interview, the facility failed to follow standard practices for ensuring safe food handling. The findings included: During initial tour of the facility kitchen on 10/09/18 at approximately 1:08 PM with the Executive Chef the following was observed: Reach-in cooler held open food bags and/or containers of chicken salad, potato salad, sausage links, chopped garlic and lettuce with no markings to indicate date opened. Also, there were green peppers and cucumbers with black and white mold spots. Observation in the freezers revealed fish fillets (2 bags), potato skins, and hashbrowns inside the kitchen freezer and in the freezer across the hallway bread, cooked pasta, fish, meatballs, unbaked dinner rolls, hot dogs and cookies were observed with no dating as to when opened. In the dry storage area, an open bag of pancake/waffle mix less than half full, not in a plastic bag, was observed sitting on a shelf but not dated. During the observation, the Executive Chef stated these items should have been dated at the time they were opened and prior to placing for storage as per facility policy.",2020-09-01
5396,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2015-05-21,157,D,0,1,PCKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the Responsible Party was notified of a change in condition for 2 of 15 residents reviewed for notification. The facility failed to notify the Responsible Party of changes in orders and mental status for Resident #5 and changes in orders for Resident #22. The findings included: Resident #5 was admitted to the facility with [DIAGNOSES REDACTED].>Review of Resident #5's Nurse's Notes on 05/20/15 at 10:20 AM revealed that on 03/18/15 a new order was given for [MEDICATION NAME] 10 milligrams (mg)/day, on 04/04/15 Resident #5 refused all of her medications and said she didn't want to keep going, and on 05/12/15 a new order was given for TED hose to be worn daily. Further review of the Nurse's Notes revealed no documentation that the Responsible Party (RP) had been notified of the new orders or Resident #5's medication refusal and mood state. In an interview on 5/20/15 at 4:33 PM, Licensed Practical Nurse (LPN) #1 confirmed that there was no documentation in the Nurse's Notes indicating that the RP had been contacted regarding the new orders or Resident #5's medication refusal and mood state. LPN #1 confirmed that per facility procedures, the RP should have been notified of the new orders on 03/18/15 and 05/12/15 and the medication refusal and mood state noted on 04/04/15 and that notification should have been documented in the Nurse's Notes. Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #22's physician's orders [REDACTED]. Review of Resident #22's Nurse's Notes revealed no documentation that the RP had been notified of the change in orders. In an interview on 5/20/15 at 4:33 PM, LPN #1 confirmed that there was no documentation in the Nurse's Notes indicating that the RP had been contacted regarding the new orders for Resident #22. LPN #1 confirmed that per facility procedures, the RP should have been notified of the change in orders and that notification should have been documented in the Nurse's Notes.",2018-12-01
5397,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2015-05-21,280,D,0,1,PCKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews and fact sheet titled, [DIAGNOSES REDACTED], the facility failed to review and revise the Comprehensive Plan of Care for physician ordered interventions to reduce and or prevent falls for 1 of 3 residents reviewed for accidents. (Resident #94) The findings included: The facility admitted Resident #94 with [DIAGNOSES REDACTED]. Review on 5/21/2015 at approximately 9:52 AM of incident reports for Resident #94 revealed multiple falls. Resident #94 fell from bed onto fall mats on 2/9/2015 at 9:00 AM, with no injury. He/she fell from a wheel chair and sustained a laceration to his/her left eyebrow on 3/2/2015 and was sent to the emergency department. He/she fell with speech therapy on 4/22/15. Resident #94 fell again on 4/22/2015 and sustained a laceration to the right side of his/her head and lip. He/she was sent to the emergency room and returned later with sutures to both head and lip. He/she fell on [DATE] and sustained a small open area to left jaw and was bleeding from his/her mouth. Again on 5/17/2015 he/she fell from the bed onto the fall mat and sustained no injury. Review on 5/21/2015 at approximately 9:52 AM of a fact sheet from the National Institute of Neurological Disorders and Stroke, titled, [DIAGNOSES REDACTED] under, What is [DIAGNOSES REDACTED]?, states, [DIAGNOSES REDACTED] (PSP) is a rare brain disorder that causes serious and progressive problems with control of gait and balance, along with complex eye movement and thinking problems. This disorder begins slowly and continues to get progressively worse, and causes weakness by damaging certain parts of the brain. Under a section titled,What are the symptoms?, states, the most frequent first symptom of PSP is a loss of balance while walking. Individuals have unexplained falls or a stiffness and awkwardness in gait. Sometimes the falls are described by the person experiencing them as attacks of dizziness. Review on 5/21/2015 at approximately 10:05 AM of the Comprehensive Plan of Care for Resident #94 revealed a problem which states.At risk for falls related to history of falls, palsy, restless leg and arm movements. The goal states, .will remain free of injury related to falls through review date of 8/12/2015. Review of the approaches/interventions included, Anticipate needs and meet as able. Also, evaluate for adaptive device as needed on a continued basis. Low bed, fall mats at bedside. Another intervention stated, Gather information on past falls and attempt to determine cause of falls. And an intervention which states, anticipate and intervene to prevent injury/future falls. Instruct in use of call light for assistance and respond to call light promptly. Provide transfer assistance as needed. Physical therapy/Occupational therapy and treatment as needed. No other specific interventions were included on the care plan to decrease falls and/or prevent falls. Review on 5/21/2015 at approximately 12:09 PM of a physician order [REDACTED]. No mention of the bed and chair alarms was included on resident #94's plan of care. During an interview on 5/21/2015 at approximately 4:00 PM with the Care Plan Coordinator he/she verified that the interventions were in place. He/she and I went into Resident #94's room and checked the alarms for placement and the functioning of the alarms. The care plan coordinator confirmed at that time that the interventions had not been added to the Comprehensive Plan of Care for resident #94.",2018-12-01
5398,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2015-05-21,282,E,0,1,PCKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to follow the planned interventions for 1 of 3 residents reviewed for fall prevention measures. Facility staff failed to place a fall mat to the right side of the Resident #16's bed. Additionally, the facility failed to follow the care plan related to fluid restriction for 1 of 1 resident reviewed for [MEDICAL TREATMENT](Resident #209) and failed to follow positioning measures for 2 of 2 residents reviewed for positioning.(Resident #22 & #64) The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Record review on 5/20/15 of the nurse's notes revealed Resident #16 had fallen on floor on right side on 4/27/15 at 5:45 PM and 4/29/15 at 9:00 PM. Review of the resident's care plan revealed on 4/29/15 the care plan had been updated to include low bed to mat. Observations of the resident on 5/19/15 at 10:16 AM, 5/19/15 at 11:08 AM, 5/19/15 at 2:00 PM, and 5/21/15 at 5:27 PM revealed the resident was lying in a low bed without a mat beside the bed. On 5/21/15 at 5:48 PM, the Care Plan Coordinator(CPC) stated the resident should have a mat to the right side of the bed. Upon observation of the resident on 5/21/15 at approximately 5:50 PM, the CPC confirmed the mat was not by the bed as the care plan directed. The facility admitted Resident #209 with [DIAGNOSES REDACTED]. Record review on 5/21/15 revealed physician's orders [REDACTED]. On 4/24/15 the physician's orders [REDACTED]. Further review of the resident's care plan revealed the resident was care planned on 4/24/15 for (1) liter fluid restriction. During record review, a recording of the resident's fluid restriction was not found. During an interview with LPN #2 on 5/21/15 at 5:13 PM, he/she stated he/she had not been measuring nor documenting the fluids the resident received. Resident #64 was admitted to the facility with [DIAGNOSES REDACTED]. Observation of Resident #64 on 5/18/15 at 5:12 PM revealed that s/he was seated in a wheelchair with his/her feet dangling above the floor and no footrests were on the wheelchair. Observation of Resident #64 on 5/19/15 at 9:53 AM that s/he was again seated in a wheelchair with his/her feet dangling above the floor and no footrests were on the wheelchair. Observation of Resident #64 on 5/20/15 from 11:50 until 12:17 revealed s/he was again seated in a wheelchair with her/his feet dangling above the floor and his/her legs positioned behind the leg rests with no attempts made by staff to reposition his/her legs. Review of Resident #64's Care Plan revealed that Occupational Therapy had added bilateral leg rests to his/her wheelchair for comfort and to assist with positioning. In an interview on 5/21/15 at 3:55 PM, the facility MDS Coordinator stated that per Resident #64's Care Plan s/he should have leg rests on his/her wheelchair at all times and that s/he should be positioned with his/her legs on the rests. Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. Observation of Resident #22 on 05/18/15 at 5:20 PM revealed s/he was in the dining room preparing to be fed dinner. Resident #22 was seated in a Geri-chair leaning to the right. Staff was noted to reposition Resident #22 3 times from 5:20 PM until 5:55 PM, but s/he kept sliding to the right and leaning over the arm of the chair. Observation of Resident #22 at 11:50 AM on 05/20/15 revealed s/he was again seated in a Geri-chair. A small pillow was placed on Resident #22's right side, however, s/he was leaning over the arm of the chair and continued leaning further and further over the side of the arm until 12:16 PM with no attempts by staff to reposition him/her. Observation of Resident #22 on 05/20/15 from 4:50 PM until 5:21 PM revealed that his/her body was sideways in her/his Geri-chair, with his/her upper body leaning over the left arm of the chair. Review of Resident #22's Care Plan on 05/21/15 at 3:25 PM revealed that his/her body should be positioned straight in her/his Geri-chair. In an interview on 5/21/15 at 3:57 PM, the facility MDS Coordinator stated that per Resident #22's Care Plan s/he have a straight body alignment in her/his Geri-chair and should not be leaning to the side.",2018-12-01
5399,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2015-05-21,309,E,0,1,PCKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of the facility policy titled Fluid Restriction, the facility failed to follow/document fluid restriction and failed to consistently monitor the catheter site for 1 of 1 resident reviewed for [MEDICAL TREATMENT].(Resident #209) Additionally, the facility failed to follow positioning interventions as ordered for 2 of 2 residents reviewed for positioning.(Resident #22 & #64) The findings included: The facility admitted Resident #209 with [DIAGNOSES REDACTED]. Record review on 5/21/15 revealed physician's orders for a fluid restriction on 4/22/15 for 1200 cubic centimeters(cc). On 4/24/15 the physician's orders were changed to one liter fluid restriction. Further review of the resident's care plan revealed the resident was care planned on 4/24/15 for (1) liter fluid restriction. During record review, documentation of the resident's fluid restriction was not found. Further record review revealed the resident's catheter site was located on the right chest wall. There was no documentation of monitoring of the site on 4/19, 4/20, 4/22, 4/23, 4/24, 4/25, 4/27, 4/28, 4/29/2015 and 5/7, 5/8, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/18, 5/19/2015. During an interview with Licensed Practical Nurse(LPN) #2 on 5/21/15 at 5:13 PM, he/she stated he/she had not been measuring nor documenting the fluids the resident received, he/she had just been eyeballing how much fluid was given. LPN #2 was unaware of how much fluids could be given to the resident by nursing. Per Dietary and review of the care plan, the resident received 240cc of fluids with each meal. During the interview, LPN #2 stated the catheter access site should be monitored for bleeding and infection. Review of the facility policy on 5/21/15 titled Fluid Restriction revealed under the Procedure Section #4 the following: Nursing will initiate/document I&O measurements documented on the I&O sheet every 8 hours and calculate 24-hour totals. Based on observation, record review, and interview, the facility failed to ensure that care and services were provided to maintain well-being for 1 of 1 residents reviewed for [MEDICAL TREATMENT] and 2 of 2 residents reviewed for positioning. The facility failed to ensure that nursing documentation related to fluid restrictions and monitoring of catheter site was completed for Resident #209 and failed to ensure that correct positioning was provided for Residents # 22 and 64. The findings included: Resident #64 was admitted to the facility with [DIAGNOSES REDACTED]. Observation of Resident #64 on 5/18/15 at 5:12 PM revealed that s/he was seated in a wheelchair with his/her feet dangling above the floor and no footrests were on the wheelchair. Observation of Resident #64 on 5/19/15 at 9:53 AM that s/he was again seated in a wheelchair with his/her feet dangling above the floor and no footrests were on the wheelchair. Observation of Resident #64 on 5/20/15 from 11:50 until 12:17 revealed s/he was again seated in a wheelchair with her/his feet dangling above the floor and his/her legs positioned behind the leg rests with no attempts made by staff to reposition his/her legs. Review of Resident #64's Care Plan revealed that Occupational Therapy had added bilateral leg rests to his/her wheelchair for comfort and to assist with positioning. In an interview on 5/21/15 at 3:10 PM Licensed Practical Nurse (LPN) #1 confirmed that Resident #64 was positioned in his/her wheelchair with her/his legs dangling and that s/he should not be positioned in that manner. In an interview on 5/21/15 at 3:55 PM, the facility MDS Coordinator stated that per Resident #64's Care Plan s/he should have leg rests on his/her wheelchair at all times and that s/he should be positioned with his/her legs on the rests. Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. Observation of Resident #22 on 05/18/15 at 5:20 PM revealed s/he was in the dining room preparing to be fed dinner. Resident #22 was seated in a Geri-chair leaning to the right. Staff was noted to reposition Resident #22 3 times from 5:20 PM until 5:55 PM, but s/he kept sliding to the right and leaning over the arm of the chair. Observation of Resident #22 at 11:50 AM on 05/20/15 revealed s/he was again seated in a Geri-chair. A small pillow was placed on Resident #22's right side, however, s/he was leaning over the arm of the chair and continued leaning further and further over the side of the arm until 12:16 PM with no attempts by staff to reposition him/her. Observation of Resident #22 on 05/20/15 from 4:50 PM until 5:21 PM revealed that his/her body was sideways in her/his Geri-chair, with his/her upper body leaning over the left arm of the chair. Review of Resident #22's Care Plan on 05/21/15 at 3:25 PM revealed that his/her body should be positioned straight in her/his Geri-chair. In an interview on 5/21/15 at 3:10 PM LPN #1 confirmed that Resident #22 should not be leaning to the side in his/her Geri-chair and that staff should assist him/her with maintaining a straight body posture. In an interview on 5/21/15 at 3:57 PM, the facility MDS Coordinator stated that per Resident #22's Care Plan s/he have a straight body alignment in her/his Geri-chair and should not be leaning to the side.",2018-12-01
5400,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2015-05-21,323,E,0,1,PCKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents reviewed for accidents. Resident #16 with a history of falls to the side of the bed was observed without a floor mat. Additionally, a hydroculator in the therapy department was observed unsecured. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Record review on 5/20/15 of the nurse's notes revealed Resident #16 had fallen on floor on right side on 4/27/15 at 5:45 PM and 4/29/15 at 9:00 PM. Review of the resident's care plan revealed on 4/29/15 the care plan had been updated to include low bed to mat. Observations of the resident on 5/19/15 at 10:16 AM, 5/19/15 at 11:08 AM, 5/19/15 at 2:00 PM, and 5/21/15 at 5:27 PM revealed the resident was lying in a low bed without a mat beside the bed. During an interview with Licensed Practical Nurse #1 and #4 on 5/21/15 at approximately 5:30 PM, both stated they did not know if the resident should have a mat by the bed and could not find an order for [REDACTED]. During an interview with Certified Nursing Assistant on 5/21/15 at 6:24 PM, he/she was unsure if the resident had a floor mat but believed the resident had landing strips. On 5/21/15 at 5:48 PM, after review of the resident's care plan, the Care Plan Coordinator(CPC) stated the resident should have a mat to the right side of the bed. Upon observation of the resident on 5/21/15 at approximately 5:50 PM, the CPC confirmed the mat was not by the bed as the care plan directed. Observation on 05/18/15 from 4:20 PM until 6:34 PM revealed that a hydroculator was turned on in a gym area and the outside surface was very hot to touch. A hinged lock was on the side of the hydroculator, but it was not locked. At 6:34 PM, the facility Director of Nursing (DON) entered and locked the unit after being notified by the survey team that it was on and unlocked. There were no residents observed in the area of the hydroculator during the time it was unlocked and it was not accessible from the area of the facility housing residents with known issues with wandering. The unit was accessible from the rehabilitation unit in the facility. Review of the facility policy for the hydroculator revealed that the water temperature inside the unit was maintained between 160 and 175 degrees Fahrenheit. In an interview on 05/18/15 at 6:34 PM, the DON confirmed that the hydroculator should have been locked to prevent any chance of accident.",2018-12-01
5401,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2015-05-21,371,F,0,1,PCKJ11,"Based on observation, record review, and interview, the facility failed to ensure food was stored, prepared, and served in a sanitary manner. The facility failed to ensure that refrigerator temperatures were in the correct range, that logs of refrigerator temperatures were maintained, that staff knew what safe food temperatures were and did not attempt to serve food that was not in a safe food temperature range, that staff were able to calibrate digital thermometers used to take food temperatures, and that foods were served in a sanitary manner. The findings included: Observation in the facility kitchen on 05/18/15 at 4:25 PM revealed that kitchen staff #1 was in the kitchen working with food and had only half of her/his hair covered with a hairnet. In an interview on 05/21/15 at 3:30 PM, the facility Certified Dietary Manager (CDM) stated that all hair should be covered with a hairnet when staff members were in the kitchen. Observation in the main dining room on 05/20/15 at 4:55 PM revealed that Dietary Aide #1 was using a digital thermometer to take food temperatures. In an interview on 05/20/15 at 4:59 PM, Dietary Aide #1 stated she did not know how to calibrate the digital thermometer. In an interview on 05/21/15 at 6:22 PM, the facility CDM stated that there was not a facility policy or procedure for calibrating digital thermometers. Observation in the main dining area on 05/20/15 at 5:10 PM revealed that the fortified pudding had a temperature of 56 degrees Fahrenheit. Observation at 5:15 PM revealed that a Certified Nursing Assistant picked up the pudding to serve to the residents. Interview with Dietary Aide #1 on 05/21/15 at 5:10 PM revealed that the pudding was prepared in house and was a cold food item. Dietary Aide #1 stated that cold food items should be below 41 degrees Fahrenheit and if they were above that temperature the items should be placed back into refrigeration until they returned to a temperature below 41 degree. Interview with the facility CDM on 05/21/15 at 5:17 PM revealed that cold food items that reached a temperature of above 41 degrees should be discarded. Observation on 05/21/15 at 12:10 PM revealed that both small refrigerators in the 500 unit dining area had temperatures reading over 50 degrees. One refrigerator held milk and the other refrigerator held opened bottles of salad dressing Observation at 12:20 PM revealed that a Certified Nursing Assistant removed a bottle of salad dressing to give to a resident. Dietary Aide #2 was observed telling staff to discard all of the items in both refrigerators on 05/21/15 at 12:30 PM. In an interview on 05/21/15 at 6:20 PM, the facility CDM revealed that the temperature logs for both small refrigerators on the 500 unit that had temperatures reading over 50 degrees could not be located for the month of (MONTH) (YEAR). Interview with Dietary Aide #2 on 05/21/15 at 12:15 PM revealed that cold foods should be held below 41 degrees Fahrenheit and that the foods in both refrigerators should be discarded. Review of the facility policy regarding safe food temperatures revealed that cold foods should be held at 41 degrees Fahrenheit or lower and hot foods should be held at a temperature of 135 degrees Fahrenheit or higher. In an interview on 05/21/15, the facility CDM confirmed that the safe temperature policy for cold foods required holding at 41 degrees or lower and for hot foods required holding at 135 degrees or higher and that these temperature guidelines should be followed at all times. On 5/20/15 at 4;55 PM, Dietary Aide #4 stated temperatures for the supper meal had already been taken. After review of the temperature log and upon further interview, Dietary Aide #4 stated he/she had not taken the temperatures of the cold sandwiches. At that time, the Dietary Aide was asked to calibrate the thermometer. During the observation of the calibration of the thermometer, the Dietary Aide was prompted to add more ice to the bath to calibrate the thermometer. During the taking of the food temperatures, the chicken salad sandwich was observed to be 70.3 degrees and the cold cut sandwich was 43.8 degrees. The Certified Dietary Manager(CDM) was asked what was the appropriate temperature for cold foods which he/she stated a range of 32-45 degrees. Both sandwiches were removed from the line. During the temping of the replacement sandwich, the CDM was observed touching the sandwich with bare hands and the temperatue of the sandwich was 59.7 degrees. Another replacement cold cut sandwich was 58.6 degrees. A pattie melt sandwich was 128.8 degrees. All the items were removed at the time of the temping of the item.",2018-12-01
5402,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2015-05-21,431,E,0,1,PCKJ11,"Based on observation, interview, and review of the facility's Audit for Expired Medications and Supplies, the facility failed to place open dates on items and failed to ensure expired supplies were not stored with other supplies for resident use in 2 of 3 medications carts and 1 of 2 medication rooms. Additionally, conflicting open dates were noted on medications. The findings included: Observation of the medication cart on the Resident Care Unit on 5/18/15 at 5:44 PM revealed the following: (1) Advair 250/50 with Lot #4ZP7193 opened 4/17/15 written on the container and 4/22/15 written on the bag containing the medication; (1) Polyethylene Glycol 3350 NF Powder for Oral Solution with Lot # 81 with no open date. During an interview at the time of the findings, Licensed Practical Nurse(LPN)#2 stated when nurses open bottles they should date the bottle and should look at the expiration date. Observation on 05-18-15 at approximately 6:00 PM of the 500 Unit Rehab to Home Med Room revealed 1 Silicone(NAME)Dover Foley Catheter, Lot # 58, 12 French (Fr), 5 cubic centimeters (cc), latex free, had expired as evidenced by use by 04-2014 noted on the package. During an interview on 05-18-15 at approximately 6:00 PM with Licensed Practical Nurse (LPN) #3, he/she, verified the Silicone(NAME)Dover Foley Catheter had expired. He/she revealed the supplies are checked weekly by the Supply Manager. During an interview on 05-19-15 at approximately 1:38 PM with the Supply Manager, he/she verified he/she had been responsible for checking the supplies in the 500 Unit Med Room weekly and had recently checked the supplies. During an interview on 05-21-15 at approximately 4:40 PM with Registered Nurse (RN) #1, he/she stated, We do not have a facility policy related to the storage of supplies but a weekly supply audit is done. Review of the facility Audit for Expired Medications and Supplies dated 04-09-15 through 05-11-15 revealed there had not been any supplies observed expired in 500 Unit Rehab to Home Med Room. An observation on 5/18/2015 at approximately 5:53 PM of the 200 Hall medication cart revealed the medication Mintox Antacid/Antigas, 12 fluid ounces, NDC 4, manufactured by Major PH 200-200-20 oral suspension, Substitution for Mylanta had no open date. Further observation on 5/18/2015 at approximately 5:55 PM of the 200 Hall medication cart revealed the medication Milk of Magnesia, 16 fluid ounces, 400 milligrams (mg) per 5 milliliters (ml) with NDC # 6, manufactured by Major had no open date. During interview on 5/18/2015 at approximately 6:00 PM with Licensed Practical Nurse (LPN) #2, he/she verified the Mintox and the Milk of Magnesia did not have an open date. When asked, What is your procedure when opening stock medications and he/she stated, we write the open date on them. During an interview on 5/21/2015 at approximately 2:58 PM with the Assistant Director of Nurses (ADON), when asked about a policy for including the open date on stock medications, and he/she stated, we do not have a policy for writing an open date on stock medications when they are opened.",2018-12-01
5403,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2015-05-21,441,D,0,1,PCKJ11,"Based on observation, interview and review of the facility policy titled, Hand Washing, and the facility's nurse check off sheet titled, Med Pass Technique Audit Tool, the facility failed to follow a procedure for hand washing while administering medications for 1 of 4 nurses observed administering medications during the med pass observation. The findings included: During a medication pass observation on 5/20/2015 at approximately 4:30 PM Licensed Practical Nurse (LPN) #3 dropped a lancet (used for finger stick blood sugars) on the floor. He/she picked up the lancet from the floor and put it in the sharps container. He/she did not wash or sanitize his/her hands and proceeded into a resident's room to administer medications. LPN #3 was observed opening a straw and placing it in a cup of water in order for him/her to swallow medications and had not washed or sanitized his/her hands. An interview on 5/20/2015 at approximately 4:30 PM with LPN #3, confirmed he/she had not washed or sanitized his/her hands after picking up the lancet from the floor and before going into a resident's room to administer medications. Review of the facility policy titled, Hand Washing, on 5/21/2015 at approximately 4:35 PM states under section 1.0 Purpose, Proper hand washing technique must be used at all times when indicated. Hand washing is the most important component for managing the spread of infection. Section 2.0 Scope, states, All staff. Section 3.0 Fundamental Information states, Hand washing is one of the most crucial measures in reducing transmission of pathogens in healthcare settings. Review of the facility's check off sheet for Licensed Practical Nurses and for Registered Nurses on 5/21/2015 at approximately 5:00 PM titled, Med Pass Technique Audit Tool section 4.0 states, Infection control/aseptic technique correct.",2018-12-01
6765,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2014-01-24,157,D,0,1,OM4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey based on record review, review of the facility provided policy related to notification of the responsible party and interview the facility failed to notify residents legal representative and/or the physician's in a timely manner for 2 of 6 residents reviewed for notification. Resident #33 responsible party not notified of lethargic event resulting in a medication change and Resident #76 physician was not notified of recent fall. The findings included: Review of the medical record for Resident #33 on 1/23/2014 at approximately 10:30 am revealed a nurses note dated 12/2113. The nurses note read 12n (12:00 noon)- res (resident) noted to be lethargic today. Unable to stay awake to eat etc., Dr. _____ called made aware. T.O. (telephone order) D/C (discontinue) all previous [MEDICATION NAME] orders and start [MEDICATION NAME] 100 mg po (by mouth) hs(hours of sleep) only. Continued review revealed no documentation to suggest the responsible party for Resident #33 had been informed of the situation. Interview with LPN (licensed practical nurse) #1 on 1/24/2014 at 3:00 PM revealed the family/responsible party should have been notified of the situation as there had been a change in the residents condition. Review of facility policy titled Clinical Practice Information Memo number: CPIM- Resident Condition Changes that Require Physician Notification Guidelines-Expectations: #4 revealed the licensed nurse shall also notify the resident and/or family. The facility failed to follow this policy and thus failed to notify the residents family in reference to a change in the residents condition. Resident #76 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 1/24/2014 at approximately 1:35 PM revealed a Nurse's Note dated 1/7/2014 and written at 7:45 PM which stated, resident's wheel chair alarm sounding, and resident found on floor in hallway. Resident complained of right arm pain. Review of the incident report on 1/24/2014 at approximately 1:35 PM verified the responsible party was notified on 1/7/2014 at approximately 8:00 PM. No documentation was found in the Medical Record or on the Incident Report to indicate the Physician had been notified of the fall. During an interview on 1/24/2014 at approximately 2:45 PM with the Director of Nursing (DON), he/she stated: There is no documentation in the medical record that states the Physician was notified. He/ she also stated, The Physician should always be notified of any accidents including falls. Review of facility policy, Resident Fall Management Guidelines, Section 3.0, titled Procedure, #8 states,Communicate all resident falls to the attending Physician and the resident's family upon occurrence of the fall. Review of facility document, Resident Condition Changes that Require Physician Notification Guidelines', states #1, A situation/condition that would warrant immediate physician notification and intervention, under Emergent: bullet 2 is Falls.",2017-09-01
6766,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2014-01-24,274,D,0,1,OM4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and an interview, the facility failed to formulate a significant change assessment within 14 days for 1 of 1 sampled residents newly admitted to Hospice. (Resident #77) The findings included: Resident #77 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 1/24/2014 at approximately 10:30 AM revealed a Physicians's Order dated 8/19/2013 for Resident #77 to be admitted for Hospice Services with a new [DIAGNOSES REDACTED]. Review of Resident#77's Comprehensive Assessments revealed a Significant Change in status dated 7/6/2013 and another Significant Change in status dated 9/18/2013. The significant change completed on 7/6/2013 was 44 days prior to admission to Hospice and the significant change assessment completed on 9/18/2013 was 30 days after being admitted for Hospice care and services. An interview with the Minimum Data Set (MDS) Coordinator on 1/24/2014 at approximately 10:30 AM verified that a significant change in status assessment had not been completed within the 14 days of the change in condition for which Resident #77 was admitted to Hospice.",2017-09-01
6767,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2014-01-24,280,D,0,1,OM4511,"**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 review and revise care plans for 1 of 1 care plan reviewed for Hospice, 1 of 1 care plan reviewed for pressure ulcers and 1 of 3 care plans reviewed for range of motion. Resident #77's care plan was not updated to reflect Hospice services and a pressure sore. Resident #31's care plan was not updated to reflect the removal of a cast. Resident #52's care plan was not updated to include devices for a contracture. The findings included: The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Record review on 1/23/14 revealed Resident #31 sustained a [MEDICAL CONDITION] Olecranon (elbow) on 10/19/13. Review of the current care plan revealed the following interventions for the fractured left elbow: 1) Circulation assessment to affected arm; 2) Medicate for pain as ordered; 3) Check cast qs(every shift) for rough edges and tightness; 4) Check circulation of fingers to affected arm; 5) Follow-up appt(appointment) with MD Observation of the resident on 1/22/14 at 10:39 AM, 1/23/14 at 3:43 PM, and 1/24/14 at 2:54 PM revealed the resident did not have a cast on his/her left arm. When interviewed, facility staff were unable to provide a specific date when the cast was removed. No documentation was noted in the nurse's notes to reflect the date of the removal of the cast. An orthopedic note dated 12/9/13 recommended activities as tolerated; no additional treatment was indicated and to follow-up as needed. The care plan was not updated to reflect the removal of the cast and inaccurately described the resident's current care needs. The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Record review on 1/21/14 revealed a therapist recommendation dated 10/8/13 for the patient to wear a left palm protector hand splint 4 hours on/4 hours off. Staff was advised to monitor for areas of pressure. Further review revealed the splint was discontinued on 12/17/13 due to the resident's refusal. On 1/22/14 and 1/23/14, the resident was observed in the dining room with a hand roll in his/her lap. On 1/24/14, Resident #52 was observed wearing a palm protector which was confirmed by the Physical Therapist. Review of the CNA (Certified Nursing Assistant) care plan revealed there was no device listed related to the resident's contractures. Review of the resident's current interdisciplinary care plan did not list any devices for the resident's left hand contractures. An interview with CNA # 1 on 1/24/14 at 3:55 PM confirmed the hand roll and/or palm protector was not listed on the care plan. S/he stated that s/he did not know where the palm protector came from. He/she stated the nurses complete the CNA care plan and update it when necessary. During an interview with LPN (Licensed Practical Nurse) # 1 on 1/24/14, he/she stated that the CNA care plan had not been updated and there was nothing on the care plan to reflect contracture devices. During an interview with the MDS (Minimum Data Set) Coordinator on 1/24/14 at 3:00 PM, he/she stated MDS staff is responsible for updating the care plan and that a reasonable amount of time for updating the care plan would be within 24-48 hours. Resident #77 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 1/23/2014 at approximately 2:52 PM revealed a physician's orders [REDACTED]. Also included in Resident #77's medical record were physician's orders [REDACTED]. Additional treatments not included on the plan of care included the use of Multipodus boots and a treatment to the right heel dated 10/21/2013. Review of Resident #77's Comprehensive Plan of Care on 1/23/2014 at approximately 3:00 PM revealed the plan of care did not include Hospice Services, wound care specific to pressure ulcers nor the use of the Multipodis boot. During an interview on 1/23/2014 at approximately 3:00 PM with the Minimum Data Set (MDS)/ Care Plan Coordinator, she/he confirmed the findings.",2017-09-01
6768,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2014-01-24,329,D,0,1,OM4511,"**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 titled Psychopharmacological Medication Use last revised 1/1/13, the facility failed to ensure that residents medication regimen was free of unnecessary medications. Resident #26 did not have an appropriate [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #26 with the [DIAGNOSES REDACTED]. Record review on 1/24/14 at approximately 11:42 AM, revealed a Physician's Telephone order which noted 1/11/14 [MEDICATION NAME] 0.5 mg (milligrams)IM (Intramuscular) now and may repeat in 2 hrs and then D/C (discontinue) and 1/14/14 [MEDICATION NAME] 25 mg po (by mouth) q hs (every night) DX (diagnoses): behaviors. During an interview with Registered Nurse #1 on 1/24/14 at approximately 1 PM, he/she confirmed the surveyor's findings and stated that the resident should have had a behavior monitoring sheet attached to the Medication Administration Record [REDACTED] During an interview with the Medical Director on 1/24/14 at approximately 3:00 PM, s/he stated due to the resident's combative behavior I ordered [MEDICATION NAME] for the resident. [MEDICATION NAME] was ineffective for the' resident due to persistent behaviors. The nurses explained to me that the resident displayed behaviors of kicking, fighting and spitting. I cannot recall if they specifically stated anything about delusions or any Psychotic episodes. We used the [MEDICATION NAME] for behaviors and the resident does not have a [DIAGNOSES REDACTED]. I did not consult with the pharmacist, s/he comes down periodically I plan on evaluating the resident for continue use of the [MEDICATION NAME]. Review of the facility policy titled Psychopharmacological Medication Use last revised 1/1/13 revealed under procedures 1.1. Where Physician/Prescriber orders a psychopharmacologic medication for a resident, facility should ensure that the Physician/Prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacological medication is necessary. 2. Facility staff should monitor the resident's behavior pursuant to facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychopharmacological medication Facility staff should monitor behavioral triggers, episodes, and symptoms. Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions.",2017-09-01
6769,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2014-01-24,334,D,0,1,OM4511,"On the days of the survey, based on record review and interview, the facility failed to provide documented evidence of education for 2 of 5 sampled resident's reviewed for education of the risks and benefits of immunizations.(Residents #31 and #52) The findings included: During record review of sampled residents #31 and #52, the education for risk and benefits related to vaccine administration was not documented as given to the resident or responsible party prior to administration or refusal of the vaccine for the year 2013. On 1/23/14 at 4:11 PM, the DON (Director of Nursing) confirmed there was no documentation on the medical record related to the family giving consent for the Influenza Vaccine for Resident #31. On 1/24/14, the ADON (Assistant Director of Nursing) stated the facility sends a letter to the families related to the Influenza Vaccine. Review of the letter stated the following:We will be giving Flu vaccines to all of our current Residents in Skilled Nursing and Assisted Living in early November. I have enclosed an authorization form for you to complete and return to The Manor by October 19th if you wish your Family Member to receive a 'Flu Vaccine. NO vaccines will be given without a completed authorization form. There was no follow-up to confirm that the families received the information mailed.",2017-09-01
6770,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2014-01-24,371,E,0,1,OM4511,"On the days of the survey, based on observations and interview, the facility failed to store, prepare and distribute food under sanitary conditions as evidenced by food items not being discarded by the use by date; unsanitary equipment in the kitchen and in 2 of 2 dining rooms; and staff in the food preparation area without wearing a beard restraint. The observations had the potential to affect all resident's serviced by the affected areas. The findings include: During an initial tour of the kitchen on 1/21/14 at approximately 12: 23 PM, the surveyor observed 2 loaves of bread stored with the used by date of 1/18/14. Further observation of the kitchen on 1/21/14 revealed dust and grease build up on the back splash of the stove and staff with facial hair walking through the kitchen without wearing a beard restraint. On 1/23/14 at approximately 10:27 AM, during a repeated tour, the surveyor observed the can opener soiled with metal shavings and debris on the blade. During an observation of the dining rooms in the facility on 1/23/14 at approximately 11:00 AM, the surveyor observed 2 of 2 microwaves on each unit with a build up of food splatters and debris. During an interview with the Food Service Director on 1/23/14 at approximately 12:03 PM, s/he confirmed the surveyor's findings.",2017-09-01
6771,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2014-01-24,428,E,0,1,OM4511,"On the day of the survey based on record review and interview the facility failed to ensure each residents drug regimen was reviewed by a pharmacist for irregularities and appropriate dose administration for 3 of 8 residents reviewed drug regimen review. Residents medical records contained no evidence of a physician review of pharmacy reviews/recommendations for Residents #71, #33 and #25. The findings included: Review of the medical record for Resident #25 on 1/23/2014 at approximately 2:00 PM revealed pharmacy monthly reviews from August 2013 thru January 2014. Continued review revealed no documentation to indicate recommendations made by the pharmacist had been reviewed/considered by the physician. The recommendations included: 8/31/2013 MD (physician) asked to review Aspirin 325 mg (milligrams) dose while on Warfarin 9/26/2013 administration of two medications in the same pharmacology category (calcium channel blockers) 10/24/2013 higher incidence for DVT (deep vein thrombosis) while on Megace especially non-ambulatory resident. Current medication regimen includes: Warfarin with Aspirin dosed at 325 mg and Megace 400 mg twice daily, MD review aspirin dose reduction at this time? Weight and appetite review, Synthroid requires lipid TSH: if not available obtain MD order, 11/18/2013 routine administration from prn (as needed) order for Xanax 0.5 mg q8h (every eight hours) for anxiety: with at least a daily dose, may consider a longer duration benzodiazepine such as Klonopin routinely for motor restlessness? 1/08/2014 resident is taking Depakote for mood stabilization, please make sure the following are documented in the Behavior Plan of Care: all non-pharmacologic person-centered interventions tried before medications were administered, the specific target behaviors identified, and desired outcome related to the behaviors, and all care givers made aware of target behavior and expected outcomes. The record revealed no documentation to indicate the above recommendations had been addressed by the physician. Interview with LPN #1 (Licensed Practical Nurse) on 1/24/2014 at 2:19 PM verified behavior monitoring had not been completed for Resident #25 aside from nursing entries and that resident behavior/side effects tracking sheets were used for residents receiving psychotropic medications only even though the resident received Depakote as a mood stabilizer. Review of the medical record for Resident #33 on 1/23/2014 at approximately 3:00 PM revealed pharmacy monthly reviews from January 2013 thru January 2014 without evidence of the Physician's response. 2/14/2013 CBC (complete blood count) noted 8-12 HGB (hemoglobin) 11.2, medication regimen include ferrous sulfate 325 mg bid (twice daily) with vitamin that contains 27 mg elemental iron. Could iron administration be reevaluated at next MD visit? 4/11/2013 Lexapro 20 mg daily with low dose Effexor XR 37.5 mg daily. Consider reevaluation of Effexor at this time: doses lower than 75 mg per appear to act like SSRI (selective serotonin uptake inhibitor) only and limited NE (neurotransmitter) effect. 5/9/2013 2-13 HCT (hematocrit) 45 continues on Iron twice daily with Vitamin and Iron, consider discontinue both iron and vitamin at this time. 6/17/2013 Namenda discontinue 5 mg dose: will review with MD. Review iron administration at this time twice daily with vitamin that contains iron 10/22/2013 Ditropan XL 24 hour release preparation is currently administered as Ditropan XL 5 mg twice daily super pubic cath (catheter) noted with spasms of bladder, consider conversion to single XL 10 mg daily dose, Ferrous sulfate 325 mg bid with vitamin that contains minerals and iron, taper iron at this time 1/9/2014 MD review iron administration, Ferrous sulfate 325 mg daily with Vitamin and Minerals that contains another 27 mg elemental iron, most current labs indicate 8-13 a HCT of 42.3 and HGB 13.6, repeat CBC to determine need? Review of the medical record for Resident #71 on 1/23/2014 at approximately 1:00 PM revealed pharmacy monthly reviews from August 2013 thru January 2014 without evidence of the Physician's response. 10/23/2013 Resident is taking Depakote for mood stabilization, please make sure the following are documented in the Behavior Plan of Care: all non-pharmacologic person-centered interventions tried before medications were administered, the specific target behaviors identified, and desired outcome related to the behaviors, and all care givers made aware of target behavior and expected outcomes. 1/8/2014 Erythromycin prokinetic effect: review effectiveness, side effects if any noted, Depakote for seizures or mood stabilization: review low level, last seizure, Midodrine has dizziness as supporting DX (diagnosis) listed with medication, review orthostatic blood pressure especially with sinemet lopressor, digoxin administration, syncope? Potassium without diuretic (digoxin noted). Interview with LPN#1 (Licensed Practical Nurse) on 1/24/2014 at 2:33 PM revealed no recommendations for December 2013 or January 2014 had been reviewed by the physician and that he/she was not sure how recommendations made by the pharmacist were reviewed by the physician.",2017-09-01
6772,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2014-01-24,502,D,0,1,OM4511,"**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 or obtain laboratory services to meet the needs of Resident # 99. The facility failed to obtain laboratory orders for 1 of 1 residents reviewed for [MEDICAL TREATMENT]. The findings include: The facility admitted Resident #99 with the [DIAGNOSES REDACTED]. Review of the resident's care plan on 1/24/14 at approximately 8:30 AM revealed a concern for a potential for complications related to [MEDICAL TREATMENT]. The approach stated: Labs as ordered by Medical Director (MD) and report results to MD communication with xxx [MEDICAL TREATMENT]. Review of the resident's medical record on 1/24/14 at approximately 8:54 AM revealed the 1/1/14-1/31/14 Cumulative physician's orders [REDACTED]. The medical record did not contain complete CBC and CMP for 3 months. The last full CBC and CMP available was obtained on 10/16/13. On 1/24/13 at approximately 9:11 AM, the wound care nurse stated that the [MEDICAL TREATMENT] center was responsible for obtaining the resident's CBC and CMP. During an interview with Licensed Practical Nurse #2 on 1/24/13 at approximately 1:30 PM, s/he confirmed the surveyor findings and stated that the [MEDICAL TREATMENT] center was obtaining the labs monthly rather than weekly. S/he verified that the facility did not have a system in place to assure that the [MEDICAL TREATMENT] center was drawing the resident's labs as ordered by the physician.",2017-09-01
7586,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2012-09-26,155,D,0,1,CTH411,"**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 Resident #7 the right to formulate an advance directive.(1 of 13 residents reviewed) The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the medical record on 9/24/12 revealed a document titled Preferred Intensity of Medical Care and Treatment signed by the resident's Power of Attorney. Further review revealed that the resident had not been deemed incompetent by two physicians to make health care decisions. The resident was a new admit and at the time of the survey was alert and oriented x 3. On 9/26/12, during an interview with the Unit Manager, he/she confirmed that there was no paperwork on the chart to authorize another to make healthcare decisions for the resident.",2016-12-01
7587,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2012-09-26,156,C,0,1,CTH411,"On the days of the survey, based on review of residents' funds and interview, the facility failed to complete the required Centers for Medicare and Medicaid Services (CMS) Form, The Medicare Liability Notices and Beneficiary Appeal Rights and further failed to complete 3 of 3 mandated Liability Notices: Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) in a timely manner for three of three residents. The findings included: On 09-26-12 at approximately 11:45 AM, review of 3 of 3 residents' funds revealed the facility had not completed the required CMS Form, The Medicare Liability Notices and Beneficiary Appeal Rights or the mandated SNFABNs in a timely manner. During an interview on 09-26-12 at approximately 11:45 AM with the Director of Social Services, she revealed she had not been using the required CMS Form and had not been informed to use the SNFABN form.",2016-12-01
7588,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2012-09-26,157,D,0,1,CTH411,"**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 the Responsible Party was notified for a change in the Resident's condition per policy entitled Change in a Resident's Condition or Status for one of thirteen Resident's reviewed for medication changes or transfer to the emergency room . The findings included: Resident # 2 was admitted with [MEDICAL CONDITION], Bladder Spasms, [MEDICAL CONDITION] and [MEDICAL CONDITION]. During a record review on 9/24/12 at 3:10pm, the record revealed a Telephone Order dated 5/26/12 for [MEDICATION NAME] 5 milligrams twice a day and a Telephone Order dated 6/9/12 for Transport to ER (emergency room ) for evaluation and tx. (treatment). During an interview on 9/25/12 at 10:45am, the Unit Supervisor was unable to verify written documentation of Representative notification of a change in Resident's medication orders or the order to transport the Resident to the emergency room . Review of the policy Change in a Resident's Condition or Status on 9/26/12 at 5:30pm, the policy stated Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. Policy also stated The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.",2016-12-01
7589,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2012-09-26,253,E,0,1,CTH411,"On the days of the survey, based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 3 of 3 units. The findings included: On 9/24/12 at 3:05 PM, the following was observed: 1) dusty ceiling fan noted in the dining room porch area; 2) dusty vents noted in the following bathrooms - 602, 603, 605, 606, 607, 608, 610, 611, and 612; 3) 2 ceiling vents in dining area dusty; On 9/25/12 at 10:15 AM, the following was observed: 4) dusty vent noted in the following bathrooms - 404, 101, 102, 103, 104, 301, 302, 303, 201, 202, 207, 208, 209, 210, 211, 212, 213; on 9/24/12 at 3:25 PM and 9/25/12 at 10:40 AM, dust build-up was noted on vent in room 205; 5) dust build-up noted on wall vent across from 402; On 9/25/12 at 11:00 AM, the following was observed: 6) two dusty ceiling vents in the shower room on the 600 Hall; 7) dust noted on the ceiling vents in the shower room on the 200 Hall. Environmental rounds were made with the Maintenance Director on 9/26/12 and during that time, he/she confirmed the dust build-up on the vents. He/she stated at that time that when the bathrooms are cleaned daily, that the vents should be cleaned also. Cleaning schedules were not provided during the survey. A work schedule with steps for exhaust fans was provided which states to clean vents using vacuum and air compressor, when needed to remove all dust.",2016-12-01
7590,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2012-09-26,280,D,0,1,CTH411,"**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 the care plan for one of eleven sampled Residents for review of care plans. The findings included: Resident #8 admitted with the [DIAGNOSES REDACTED]. During a record review on 9/26/12 at 10:20am, the Nurse's Notes dated 9/16/12 stated the Resident fell in the day room and on 9/20/12 the Nurse's Notes dated 9/20/12 stated the Resident fell and hit her head on the bedside table. During a record review on 9/26/12 at 11:07am, the Care Plan noted Resident #8 was at risk for falls related to poor safety awareness and unsteady gait. No new interventions were noted on the Care Plan after the 9/16/12 or 9/20/12 falls. During an interview with the Medicare Coordinator on 9/26/12 at 11:05am, he/she stated the Resident is Supervised. The Medicare Coordinator reviewed the care plan and was not able to verify that the care plan was updated with a new intervention for the 9/16/12, and 9/20/12 falls. During a review of the policy on 9/26/12 at 12:15pm, entitled Resident Fall Management Guidelines, the procedure stated under #6 to Develop and implement an immediate intervention plan to prevent recurrence (utilize Fall Investigation Worksheet). The policy also stated under #9 The interdisciplinary team reviews all resident falls within 24-72 hours to evaluate the circumstances and probable cause(s) for the fall then modifies and implements a care plan to prevent repeat falls.",2016-12-01
7591,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2012-09-26,281,E,0,1,CTH411,"**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 that meet professional standards of quality. Resident's #1, #7, and #9 with transcription errors and Resident #3 with no order written to discontinue laboratory test. Resident #7 administered [MEDICATION NAME] every day instead of every other day. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review revealed discharge orders from the hospital on [DATE] for Epoetin Alfa([MEDICATION NAME]) to be given every 3-4 weeks. Review of the admission orders [REDACTED]. Further review of the record revealed no clarification order for the Epoetin Alpha. During an interview with the Unit Manager on 9/26/12, he/she stated that the Epoetin Alfa was to be administered in the physician's office. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Record review revealed discharge orders from the hospital on [DATE] for Multivitamins with Minerals daily; [MEDICATION NAME] 5 mg(milligrams), and [MEDICATION NAME] 250 mg every 48 hours times 3 more doses. Further review revealed Multivitamins with Minerals and [MEDICATION NAME] were not transcribed on the Medication Administration Record. Review of the Medication Administration Record [REDACTED]. During an interview with the Unit Manager on 9/26/12, he/she stated that the Multivitamin had not been transcribed and that she had spoken to the family member and had been told that the resident did not do well on [MEDICATION NAME]. Further record review revealed no clarification order for the Multivitamin and [MEDICATION NAME]. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review revealed discharge orders from the hospital on [DATE] for [MEDICATION NAME] Acid 500 mg daily. Further review of the physician orders [REDACTED]. During an interview with the Unit Manager on 9/26/12, he/she confirmed the [MEDICATION NAME] Acid had not been transcribed. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 09-24-12 at approximately 2:30 PM of the physician's orders [REDACTED].#3 revealed an order of [MEDICATION NAME] (Vanc) Trough/Basic Metabolic Panel (BMP) every (q) week. Further record review on 09-24-12 at approximately 2:30 PM of the labs completed for Resident #3 revealed a Vanc Trough level had not been acquired since 09-14-12. During an interview on 09-24-12 at approximately 4:00 PM with the Unit Manager, she, after chart review, verified a Vanc Trough level had not been acquired weekly. The Unit Manager revealed she had notified the Physician regarding the Vanc Trough results on 09-14-12 and stated he did not want additional labs drawn for Vanc Trough levels. The Unit Manger further stated, I'll take care of the order.",2016-12-01
7592,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2012-09-26,323,E,0,1,CTH411,"**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 ensure that the environment remain as free from hazards as possible and each resident receive adequate supervision to prevent accidents. The salon was unlocked with multiple hazardous materials unsecured. A housekeeping cart was observed with scissors on top of the cart. Resident #8 with falls with no interventions implemented for 1 of 11 residents reviewed for falls. The findings included: On 9/25/12 at 10:00 AM, a housekeeping cart was noted in front of the conference room with sharp scissors observed on top of the cart. At 10:05 AM, the housekeeper visited the cart and left the cart for approximately two minutes. The housekeeper moved the cart and again left the cart for approximately two minutes times two. The cart was not seen again with the scissors. On 9/25/12 at 11:10 AM, the salon was noted to be unlocked. Further observation revealed the following items unsecured in the salon: 1) (3) partially filled 15.2 fluid(fl) ounces(oz) of Revlon Fanciful Rinse 2) (3) partially filled 11 oz bottle of Revlon Fanciful Rinse 3) (1) 7 oz Isopluse 24h(hour) Holding Spray 4) (1) 6 oz Sure Regular Scent Antiperspirant 5) (3) 7 oz. White Rain and 1 Unscented Extra Hold Hairspray 6) (1) 8 oz. CT Procleaner Hair Care Solution 7) (1) 8 oz. CT Fragrance Free Enriched Conditioner 8) (1) 3 oz. Amber Dusting Powder 9) (1) 8 oz. Connela Design and Shine 10) (1) gallon Faberge Ultra Hold Professional Fast Drying Sculpting Hair Spray 11) (2) 6 oz. Fanciful Color Styling Mousse 12) (1) 8.5 oz Purology Serious Color Care 13) (1) 9 oz. Pinaud Club Man Finest Talc 14) (1) 15 oz. VO5 Volume Conditioner 15) (1) 14 oz. Suave Sleek Conditioner/&Total Conditioner 16) (1) 2 oz. Body /Hand Lotion 17) (1) 11 oz. Gillette Foaming Lotion 18) (1) 8 oz. Carolina non-aerosol Spray Mousse 19) (1) 8 oz. Perineal Wash 20) (1) 8.5 oz Nucleica Transfix Spray Gel 21) (1) 15 oz Suave Refreshing Waterfall Mist Conditioner 22) (1)31.5 oz Clairol Professional Shimmer Lights Conditioning Shampoo 23) (1) 33.8 oz Scruples Emergency Repair for Damaged Hair 24) (1) 1 pair of scissors 25) (4) disposable razors 26) ( 1) 21 oz Comet Cleanser 27) (1) 22 fl. oz Citrus II Hospital Germicidal Cleaner 28) (1) 32 fl. oz Sensible Solution Water Soluble Deodorizer 29) (1) Xcess Styling Gel 30) (1) 10 fl. oz. Dermasil Dry Skin Treatment 31) (1) Precision Brand Knife 32) (1) 11 fl. oz. Selsun Blue 33) (1) haircutting scissors 34) (1) 5.5 fl. oz April Hair Spray 35) (1) 5 oz. White Rain Volumizing Weightless Mousse 36) (1) 8 oz. Salon Professional Firm Style Finishing Spray 37) (1) unlabeled spray bottle 38) (1) 2.4 oz Clairol Nice/Easy Color Blend Formula 39) (1) 2.4 oz Clairol Color Blend Activator 40) (5) 4 oz. Neutralizer Design Freedom 40) (1) 3.4 oz Waving Lotion Design Freedom 41) (1) 2 oz Revlon Color Silk Creme Color Developer 42) (1) 1.4 fl. oz. Color Easy Color Cream 43) (1) 2 fl. oz. Revlon Color Silk Ammonia Free Colorant 44) (1) 2.4 fl oz. Clairol #1 Color Blend Formula 45) (1) Kit Color Easy 46) (1) 1.96 fl. oz. Clairol Nice/Easy #3 Color Seal Conditioning Gloss 47) (1) 32 fl. oz. Wella Color Touch Intensive Immulsion 48) (1) 8 oz. Curl it Up Leave In Conditioner 49) (1) 6 oz. Sally Hansen Natural Cold Wax Hair Remover 50) (1) Keystone Cleaner and Polish During the observation of the Salon, an employee entered the room without hesitation, visited the restroom and exited. Two surveyors were in the Salon for approximately one hour. Many of the items listed above had warnings to keep out of the reach of children; could cause skin irritation; keep out of eyes; do not inhale vapors; flammable; external use only; call Poison Control if ingested; could cause blindness; and harmful or fatal if swallowed. At 12:30 PM, the door to the Salon remained unlocked. Salon Information was posted outside of the Salon next to the door which listed hours of operation as Wednesday, Thursday, and Friday from 9:00 AM - 4:00 PM. At 3:13 PM on 9/25/12, the Assistant Director of Nursing confirmed that the door to the Salon was unlocked. Resident #8 admitted with the [DIAGNOSES REDACTED]. During a record review on 9/26/12 at 10:20am, the Nurse's Notes dated 9/16/12 stated the Resident fell in the day room and was transported to the emergency room for evaluation. On 9/26/12 at 10:20am the Nurse's Notes dated 9/20/12 stated the Resident fell and hit her head on the bedside table and was transported to the emergency room for evaluation. During a record review on 9/26/12 at 11:07am, the Care Plan noted Resident #8 was at risk for falls related to poor safety awareness and unsteady gait. During an interview with the Medicare Coordinator on 9/26/12 at 11:05am, he/she stated the Resident is Supervised. The Medicare Coordinator reviewed the care plan and he/she was not able to verify that the care plan was updated with an intervention to prevent further falls for the 9/16/12, and 9/20/12 falls. During a review of the policy on 9/26/12 at 12:15pm entitled Resident Fall Management Guidelines, the procedure stated under #6 to Develop and implement an immediate intervention plan to prevent recurrence (utilize Fall Investigation Worksheet). The policy also stated under #9 The interdisciplinary team reviews all resident falls within 24-72 hours to evaluate the circumstances and probable cause(s) for the fall then modifies and implements a care plan to prevent repeat falls.",2016-12-01
9159,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2011-07-20,425,E,0,1,E57N11,"On the days of the survey, based on observation, record keeping and interview, 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 finding included: On 7/19/11 at approximately 9:15 AM, inspection of the Hall 2 Medication Room revealed the following: - One opened vial of Tuberculin Purified Protein Derivative (PPD), Mantoux, Tubersol 5 TU (test units)/0.1 ml (milliliter) 50 tests/vial with manufacturer lot number C3761AA was found in the medication refrigerator. This vial was open and had not been dated by the facility as to date of opening. Facts and Comparisons, page 2001, states "" Discard vials in use for more than 30 days because of possible oxidation and degradation that may affect potency. "" - One IV (intravenous) bag labeled by Grand Strand Regional Medical Center to containing Sodium Chloride 0.9 % (percent) 250 ml (milliliters) and vancomycin HCl (hydrochloride) 1500 mg (milligrams). This IV bag was dated 7/6/11 and the label stated to return to pharmacy if not started within 24 hours. LPN (Licensed Practical Nurse) #1 verified this finding on 7/19/11 at approximately 9:25 AM. LPN # 1 stated that the facility policy is to date Tuberculin PPD when opened and discard after 30 days. LPN # 1 stated that the IV bag of vancomycin had expired and that it should have been sent back to the pharmacy. LPN #1 stated that the resident for whom it had been prepared was no longer in the facility.",2015-07-01
9160,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2011-07-20,367,E,0,1,E57N11,"**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 the prescribed nutritional supplement for 2 of 9 residents reviewed for therapeutic diets (Residents #4 and 8). The findings included: Resident #8 admitted [DATE] with [DIAGNOSES REDACTED]. Record review on 7/19/11 at approximately 10:15am revealed a physician's orders [REDACTED]. Further review of the record revealed that the resident had had a weight loss of 8.8 lbs from 4/1/11 to 6/6/11. Observation of the lunch meal on 7/19/11 at approximately 12:10pm revealed the resident was not served a Magic Cup. Review of the tray card at that time indicated that a Magic Cup should be given at lunch and dinner. Observations of the evening meal on 7/19/11 at approximately 5:15pm revealed the resident again did not receive a Magic Cup. Interview with Dietary Aide #1 on 7/19/11 at approximately 5:20pm indicated that the Dietary Aides were responsible for making the Magic Cup available to the Certified Nursing Assistants (CNA) to give to the residents. Interview with CNA #1 at that time indicated that the CNAs were responsible to read the tray cards and provide the supplements as indicated. Observation at that time revealed the Magic Cups were available to the CNAs. Interview with the Beverage and Food Director on 7/20/11 at approximately 10:15am indicated that the CNAs were responsible to provide any nutritional supplements listed on the tray cards. The facility admitted Resident #4 on 08/31/07 with the following [DIAGNOSES REDACTED]. The Record Review on 7/19/11 at 12 Noon, revealed that the July 2011 Physicians Orders included, ""Magic Cup Three Times Daily."" The Vital Signs and Weight Record dated 02/01/11 documented the resident's weight at 161 lbs., on 04/01/11 the record documented his weight as 149 lbs. and on 06/16/11 the record documented his weight as 144.1. On 06/13/11, the Nutritional Care Services Progress Note written by the Registered Dietician revealed that the resident received an altered diet of ground meat related to his ""chewing problem."" The noted stated that the resident had a current weight of 144 lbs. and stated he had a weight loss of 7.4% in one month and 10.3% weight loss in 6 months. The Nutritional Care Services Progress Note further documented that the resident received a supplement with med pass of 240 cc (cubic centimeters) TID (three times per say) and a Magic Cup 4 oz. TID to increase calories. During the lunch meal observation on 7/19/11 at 12:25 PM the resident received 2 grilled cheese sandwiches, okra and tomatoes, iced tea and water. The dessert for that meal was sherbet. No Magic Cup or dessert was observed on the resident's tray. An interview was conducted with Certified Nurses Aide(CNA) #1 who was serving the trays in the dining room and she stated that the Magic Cups go out on the residents' tray with the meal and dessert was served after the main meal. The resident was assisted with feeding by CNA #2 during lunch and when interviewed at 12:50 PM CNA #2 stated that the resident had finished eating and had eaten 1 and 1/2 sandwiches and refused the okra and tomatoes. The CNA stated this was all the resident had eaten. There was no Magic Cup or sherbet bowl observed on the tray. During the dinner meal observation on 7/19/11 at 5:15 PM, the resident's tray included ground chicken, macaroni and cheese, carrot salad, biscuit, cranberry juice and water. CNA #3 was feeding the resident in the dining room. During an interview at that time, the CNA stated that the resident would get dessert after the meal. When questioned if he would receive anything else, she stated that he would receive a snack later in the evening. This surveyor inquired about a Magic Cup and CNA #3 responded that he usually got a Magic Cup, but didn't get it this evening.",2015-07-01
9161,MYRTLE BEACH MANOR,425070,"9547 HIGHWAY 17, NORTH",MYRTLE BEACH,SC,29572,2011-07-20,281,E,0,1,E57N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interview , review of The Nursing 2011 Drug Handbook by Lippincott, Williams and Wilkins and per the manufacturer's recommendation, facility nursing staff failed to rotate medication patch ([MEDICATION NAME]) application sites per the manufacturer's recommendations (Resident # 12 and one random resident) The findings include: The facility admitted Resident #12 on 4/30/10 with a readmission date of [DATE] with the following Diagnosis: [REDACTED]. Review of the medical record on 7/20/11 revealed orders for [MEDICATION NAME] 9.5 mg (milligrams)/24 hour patch, apply one patch topically once daily. Review of the MAR (Medication Administration Record) revealed there was no documentation to note the area where each patch was applied. During a interview on 7/20/11 at 9:20 AM with LPN's (Licensed Practical Nurse) #2 and #3, when ask how often an application site was changed for resident's wearing an [MEDICATION NAME], they both stated it is changed every 24 hours. ""We can't put it back in the same spot for 24 hours."" LPN # 1 showed this surveyor another resident's MAR (Resident A) and noted it had a space to indicate site used, but only had LC and RC (left chest and right chest) for the month of June. At this time LPN #2 looked the medication up in The Nursing 2011 Drug Handbook by Lippincott, Williams and Wilkins, and she stated ""it says to change site daily and don't use the same site within 14 days."" Both nurses and the ADON (Assistant Director of Nursing) stated that they were not aware of the need to rotate application sites and to not use the same site for 14 days. At 9:30 AM, the DON (Director of Nursing) stated ""It should be every 14 days, but I know there has never been an inservice about this by the Pharmacist or myself"". 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.""",2015-07-01
3211,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2018-01-23,609,D,1,0,LW0K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to report an unwitnessed injury of unknown origin in a timely manner for Resident #1 for 1 of 3 residents reviewed with unwitnessed injuries. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review on 1/22/2018 at approximately 11:00 AM of the medical record for Resident #1 revealed a form titled, SBAR (Situation Background Assessment and Request) dated 12/13/2017 at 7:30 AM and has documentation that Resident #1 fell from bed to floor. The SBAR also indicated that Resident #1 has a head contusion, a left hand contusion and complained of left hip and left shoulder pain. Further review on 1/22/2018 at approximately 11:10 AM of a report titled, Patient Falls Incident Report, for Resident #1 and indicated a bone fracture and a head contusion from the unwitnessed injury. Review on 1/22/2018 at approximately 11:10 AM of the hospital, Discharge Instructions, made no mention of a head contusion. The discharge instructions from the hospital did state, Your exam shows you have a fractured shoulder blade or scapula. This type of injury may happen in auto accidents or from a direct blow to the back or the shoulder. Review on 1/22/2018 at approximately 11:30 PM of the MDS (Minimum Data Set) assessment for Resident #1 dated 10/24/2017 indicates in Section C 1000 Cognitive Skills for Daily Decision Making for Resident #1 is coded with a 3 as Severely Impaired. The coding under Functional Status Section G for Resident #1 is total care with all activities of daily living. Bed mobility is coded as a 4 for total dependence and requires support to aid in moving and turning a 3 for 2 persons to physically assist. Transfers are coded the same, requiring total care and requiring the assistance of 2 persons to transfer Resident #1. Section G 0400 is coded 2 for upper and lower extremity impairment on both sides. Further review on 1/22/2018 at approximately 11:30 PM of the MDS assessment dated [DATE] is a Significant Change assessment for Resident #1. Under Section C1000 Cognitive Skills for Daily Decision Making is coded with a 3 as Severely Impaired. The coding under Functional Status Section G for Resident #1 in Bed Mobility is coded with a 3 for extensive assistance and requires the assistance of 1 to assist. Transfer is coded as Resident #1 requires extensive assistance (3) and needs the assistance of 2 to aid in transferring and is coded with a (3). During an interview on 1/22/2018 at approximately 1:30 PM with CNA (Certified Nursing Assistant) #1 stated, I was not working with the resident that fell . I was working with the resident in the B bed. I walked out of the room to get supplies and when I walked back in the room, the resident in A bed was lying on the floor on his back and was haling me. I went over to him/her and he/she did not appear to be in pain. I did notice an open cut on his/her head. He/she did not tell me that he/she was reaching for the remote control, but I assumed he/she was either reaching for the remote control or the candy dish on the over the bed table. During an interview on 1/22/2018 at approximately 2:00 PM with Licensed Practical Nurse #1 stated, when I got in the room the resident in A bed was lying on the floor on his/her left side complaining of pain to his left shoulder and left hip. I did notice a contusion of the head and it was bleeding. We actually sent him/her out because of the [MEDICATION NAME] he/she was taking. I was told he/she was reaching for the remote control and fell out of bed. The bed was in the low position but not the lowest position. He/she did not have use of side rails, I think we did away with side rails in this facility. No documentation could be found in the facility to ensure the incidents were investigated nor were injuries reported to the State Agency in a timely manner.",2020-09-01
3212,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2018-01-23,610,D,1,0,LW0K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to investigate an unwitnessed injury for Resident #1 for 1 of 3 residents reviewed with unwitnessed injuries. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review on 1/22/2018 at approximately 11:00 AM of the medical record for Resident #1 revealed a form titled, SBAR (Situation Background Assessment and Request) dated 12/13/2017 at 7:30 AM and has documentation that Resident #1 fell from bed to floor. The SBAR also indicated that Resident #1 has a head contusion, a left hand contusion and complained of left hip and left shoulder pain. Further review on 1/22/2018 at approximately 11:10 AM of a report titled, Patient Falls Incident Report, for Resident #1 and indicated a bone fracture and a head contusion from the unwitnessed injury. Review on 1/22/2018 at approximately 11:10 AM of the hospital, Discharge Instructions, made no mention of a head contusion. The discharge instructions from the hospital did state, Your exam shows you have a fractured shoulder blade or scapula. This type of injury may happen in auto accidents or from a direct blow to the back or the shoulder. Review on 1/22/2018 at approximately 11:30 PM of the MDS (Minimum Data Set) assessment for Resident #1 dated 10/24/2017 indicates in Section C 1000 Cognitive Skills for Daily Decision Making for Resident #1 is coded with a 3 as Severely Impaired. The coding under Functional Status Section G for Resident #1 is total care with all activities of daily living. Bed mobility is coded as a 4 for total dependence and requires support to aid in moving and turning a 3 for 2 persons to physically assist. Transfers are coded the same, requiring total care and requiring the assistance of 2 persons to transfer Resident #1. Section G 0400 is coded 2 for upper and lower extremity impairment on both sides. Further review on 1/22/2018 at approximately 11:30 PM of the MDS assessment dated [DATE] is a Significant Change assessment for Resident #1. Under Section C1000 Cognitive Skills for Daily Decision Making is coded with a 3 as Severely Impaired. The coding under Functional Status Section G for Resident #1 in Bed Mobility is coded with a 3 for extensive assistance and requires the assistance of 1 to assist. Transfer is coded as Resident #1 requires extensive assistance (3) and needs the assistance of 2 to aid in transferring and is coded with a (3). During an interview on 1/22/2018 at approximately 1:30 PM with CNA (Certified Nursing Assistant) #1 stated, I was not working with the resident that fell . I was working with the resident in the B bed. I walked out of the room to get supplies and when I walked back in the room, the resident in A bed was lying on the floor on his back and was haling me. I went over to him/her and he/she did not appear to be in pain. I did notice an open cut on his/her head. He/she did not tell me that he/she was reaching for the remote control, but I assumed he/she was either reaching for the remote control or the candy dish on the over the bed table. During an interview on 1/22/2018 at approximately 2:00 PM with Licensed Practical Nurse #1 stated, when I got in the room the resident in A bed was lying on the floor on his/her left side complaining of pain to his left shoulder and left hip. I did notice a contusion of the head and it was bleeding. We actually sent him/her out because of the [MEDICATION NAME] he/she was taking. I was told he/she was reaching for the remote control and fell out of bed. The bed was in the low position but not the lowest position. He/she did not have use of side rails, I think we did away with side rails in this facility. No documentation could be found in the facility to ensure the incidents were investigated nor were injuries reported to the State Agency in a timely manner.",2020-09-01
3213,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2017-01-26,272,D,0,1,Z0U211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for two of 18 residents (#158 and #280) for incontinence and pressure ulcers. The findings include: 1. On 01/24/2017 at 2:15 PM the admission MDS assessment completed on 8/12/16 for resident #158 was reviewed. The resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. The MDS dated [DATE] was reviewed and Section H0300 of the MDS assessment indicated the resident had occasional incontinence. On 11/9/16 a 90-day (quarterly) MDS assessment was completed for resident #158. Section H0300 of the MDS assessment indicated the resident was always incontinent. On 01/24/2017 at 3:25 PM the MDS was reviewed with MDS nurse #4. MDS nurse #4 reviewed the admission assessment dated [DATE]. MDS nurse #4 stated she used the nurses' notes, assessments and staff interviews to complete the assessment. MDS nurse #4 pulled up the DART chart, (documentation from nursing assistants) but didn't know if she used that data when she completed the admission MDS assessment. The DART chart indicated the resident was frequently incontinent from the 8/16 assessment (ARD) assessment reference date and always incontinent for 11/16 assessment (ARD). On 01/24/2017 at 3:57 PM Licensed Practical Nurse (LPN) #18 was interviewed. LPN #18 stated the resident always had episodes of incontinence. LPN #18 stated the resident would sometimes use the call light to go to the bathroom, but sometimes would not get up up to go to the bathroom or sometimes ask for the bed pan, but at times was already incontinent. LPN #18 stated she felt the resident had not had a decline in incontinence. On 01/24/2017 at 3:58 PM Certified Nurse Aide (CNA) #31 was interviewed. CNA #31 stated the resident was incontinent of bowel at times and other times she will ask for the bed pan. CNA #31 stated sometimes the resident will tell you she needs to go to the bathroom and is continent and other times she wants her brief changed because she was already incontinent. CNA #31 felt there had been no changes with the resident's incontinence episodes. On 01/24/2017 at 4:02 PM the Director of Nursing (DON) #3 was interviewed. DON #3 stated the resident had not had a decline in urinary incontinence. The resident was frequently incontinent according to the DART charting in (MONTH) (YEAR) and it was in place for the (MONTH) admission MDS assessment. DON #3 stated she talked with MDS nurse #4 and verified the only documentation that was reviewed by MDS nurse #4 was the nurses notes, the nursing admission assessment and interviews with the staff. DON #3 verified MDS nurse #4 did not use the DART charting and therefore the (MONTH) (YEAR) admission assessment was not an accurate comprehensive assessment. 2. Review of Resident #280's clinical record conducted on 01/25/17 at 9:00 AM revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Weekly Wound Assessment Record dated 01/10/2017 revealed the resident had a DTI (deep tissue injury) which measured 13 cm x 6 cm. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] Section M0210 Unhealed Pressure Ulcer(s) Does the resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher was marked No. During Interview conducted on 01/25/17 at 12:20 PM with Minimum Data Set Coordinator staff #1 stated the reference date for the Annual Minimum Data Set assessment was 01/17/17 and per his/her documentation they did not identify the resident had a suspected deep tissue injury and therefore did not code the Admission MDS dated [DATE] section M0210 correctly to identify the suspected deep tissue injury as identified by the nursing staff on 01/10/2017.",2020-09-01
3214,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2017-01-26,280,D,0,1,Z0U211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observations the facility failed to review and revise the care plans for three of three residents (278,79,69) who were identified as fall risk. The findings included: 1. On 01/25/2017 at 8:42 AM the medical record for resident #278 was reviewed. The resident was admitted on [DATE] with a fracture of left femur, history of falling and [MEDICAL CONDITION]. The resident had a fall and fracture on 12/28/16 at home and was hospitalized from [DATE] to 1/13/17. Upon admission. a fall assessment was completed and the assessment indicated the resident had a fall in the past 30 days and was at high risk for falls. The initial care plan dated 1/13/17 was reviewed. The care plan for falls/safety risk indicated no boxes were checked next to fall interventions until 1/15/17 after a fall occurred. The care plan had interventions that included: mat at bedside, chair and bed alarm. A Fall/Safety Care Plan dated 1/13/17 was reviewed was hanging on the resident's closet door. The care plan had the following interventions:non-skid proper fitting footwear, bed in low position and locked, call light in reach and answer promptly, remind to use call light and ask for assistance, mats to bedside floor when in bed on right side of bed, non skid mat to chair cushion, safe, clutter free environment and non skid footwear. The Fall/Safety Care Plan dated 1/13/17 did not have chair alarms for placement/function each shift. On 01/25/2017 at 9:15 AM Licensed Practical Nurse (LPN) Unit Manager #27 was interviewed. LPN #27 stated the initial care plan was done on 1/13/17 and verified the boxes indicating the interventions were not filled in. The resident had a fall on 1/15/17 at 1:20 am and the care plan was updated at that time. LPN #27 located in the resident's room the care plan that is posted on the closet door for the nursing staff to use when providing care. LPN #27 verified it was completed by the same nurse who did the initial care plan and was dated 1/13/17. On 01/25/2017 at 9:21 AM Certified Nurse Aide (CNA) #5 was interviewed. CNA #5 stated the resident was more confused when she first came and made attempt to get out of bed. CNA #5 stated the resident is better now and will sometimes ask for help. CNA #5 stated the resident does not set off the alarm on her shift, but was not sure if it alarms on the night shift. On 01/24/2017 at 2:03 PM the resident was observed sitting in a wheelchair in the dining area having a snack with other residents and staff. Resident #278 had a personal alarm attached. On 01/25/2017 at 8:38 AM the resident was observed sitting in a wheelchair in main area by the nurses' station at a table. Resident #278 had a personal alarm attached. On 1/25/17 at 3:23 PM LPN #15 was interviewed. LPN #15 stated she was the admitting nurse and implemented the initial plan of care for falls. LPN #15 stated she did not implement a fall mat because the resident was ambulatory. LPN #15 stated the resident had a fall on 1/15/17 and when she came in the next morning she evaluated the resident. LPN #15 verified the resident should not have fall mats d/t they could increase the resident's risks of falls and she should not have alarms on. On 01/25/2017 at 4:08 PM observations were made with LPN #27 in the room of resident #278. The resident was lying in a low bed with a mat to the right side of bed. LPN #27 stated the personal alarm was discontinued from the resident on 1/15/17. LPN #27 stated she did not know why the resident had a personal alarm on yesterday. LPN #27 verified the fall mats were on the care plan and was in place. On 01/25/2017 at 4:11 PM LPN #15 and LPN #27 was interviewed together. LPN #15 stated she assessed the resident on 1/15/17 after the resident fell that morning at 1:20 am. LPN #15 verified the personal alarms were discontinued and the she did not update the care plan. LPN #15 stated she did not put the fall mats in place when she admitted the resident because the resident's fall was when she was ambulating and not a fall from bed. The night shift nurse added the fall mat next to bed the night of the fall on 1/15/17 at 1:20 am. LPN #15 stated she left the fall mats on the care plan and did not remove them from the care plan on 1/15/17. LPN #15 verified she should have updated the care plan when she assessed the resident's fall on 1/15/17 and the fall interventions were reviewed and the personal alarms were discontinued. LPN #15 verified there were two different care plans on the resident's closet door that is used by the staff to provide care. LPN #15 verified the two care plans were inconsistent, one said personal alarms were to be used and the Fall/Safety Care Plan did not. 2. Record review on 01/25/2017 at 9:57 AM revealed the most recent minimum data set (MDS) assessment dated [DATE] documented Resident #69 had [DIAGNOSES REDACTED]. The MDS further stated the Resident #69 had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Resident #69 was independent with walking in the room with set-up help only. On 01/25/2017 at 9:46 AM, the Post Falls Nursing assessment dated [DATE] was reviewed. The document stated Resident #69 was observed sitting on the floor with back against wall. The long term intervention was an anti-slip mat (Dycem) placed in wheelchair. On 01/25/2017 at 5:11 PM, Certified Nursing Assistant (CNA) #31 was interviewed regarding the fall interventions for Resident #69. CNA #31 opened the closet door and looked at the Fall Safety Care plan dated 01/28/15. The Fall Safety Care Plan dated 01/28/15 had interventions of check alarms for placement/function each shift. However, the tabs alarm section was marked d/c (discontinued) on 02/12/15. The non-skid mat to chair cushion was not checked and appeared to have whiteout tape. She stated Resident #69 had a tab alarm on the bed. The tab alarm was observed on the right bed rail. She stated the alarm is placed on the resident at night. CNA #31 was asked how she knew all fall interventions for Resident #69. She stated there should be a Plan of Care behind the closet door. CNA #31 verified no plan of care on the closet door. At the time of the observation; Resident #69 was seated on a Dycem mat in the wheelchair. On 01/25/2017 at 5:20 PM, an interview was conducted with Unit Manager #1 regarding Resident #69's falls and the plan of care. Unit Manager #1 stated a Patient Plan of Care was located on the back of the closet door. At the time of the interview, she verified there was no plan of care on the back of the closet door. When she located the plan of care, she verified no alarms were marked and a Dycem to the wheelchair was dated 01/15/17. She also verified a bed alarm on the bed rail. At the time of the observation, Unit Manager #1 stated Resident #69 doesn't use the bed alarm. Unit Manager #1 verified the Fall Safety Care Plan was not consistent with the Patient Plan of Care for Resident #69. She further verified the plans had not been revised with the current interventions. On 01/26/17 at 9:20 AM, an undated Post Fall policy and procedure was reviewed. The policy stated staff were to update the care plan under the falls section and white safety sheet on resident door (date and initials). 3. On 01/24/2017 at 2:15 PM, the clinical record for Resident #79 was reviewed. the Diagnostic Problem List documented [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] documented impaired balance during transitions as an indicator for falls. The functional status stated Resident #79 required extensive assistance of one person for bed mobility, transfer, and toilet use. The Brief Interview for Mental Status (BIMS) score was 7; thereby, indicating severe cognitive impairment. On 01/24/2017 at 2:38 PM, a Post Falls Nursing assessment dated [DATE] was reviewed. The assessment documented at 9:36 PM, Resident #79 was sitting up on the floor by the bathroom door and had a small scratch on left side of face. An immediate intervention was to toilet the resident every 2 hours with assistance. On 01/24/2017 at 2:40 PM, the Patient Plan of Care located on the back of the closet door was reviewed. The toileting schedule was to toilet every 2 hours between 11:00PM and 7:00AM. The Fall Safety Care Plan also located on the back of the closet door stated to offer toileting every 2 hours while awake. On 01/25/2017 3:07 PM, an interview with Unit Manager #1 and RN #15 regarding the discrepancies in the care plans and the system for documenting fall interventions. They stated the post falls nursing assessment recommends an immediate intervention to prevent future falls. LPN #23 verified she wrote the intervention to toilet Resident #79 every two hours after the fall due to the resident trying to go to the bathroom and needing assistance. Discussed the toileting discrepancy between the Fall Safety Care Plan stating to offer toileting every 2 hours while awake and the Patient Plan of Care stating to toilet every 2 hours between 11pm and 7am. Unit Manager #1 stated it is protocol to toilet every 2 hours; however, she could explain the discrepancy between the Fall Safety Care Plan meant to prevent falls. On 01/24/2017 at 3:58 PM, an interview was conducted with certified nursing assistant (CNA) #31. She was asked how she knows what care to provide to Resident #79. She stated the care plan was behind the closet door. The care plan stated to toilet every 2 hours from 11:00pm to 7:00am. The Fall Safety Care Plan documented to offer toileting every 2 hours while awake. On 01/26/17 at 9:20 AM, an undated Post Fall policy and procedure was reviewed. The policy stated staff were to update the care plan under the falls section and white safety sheet on resident door (date and initials).",2020-09-01
3215,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2018-04-27,759,E,0,1,JB8411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to ensure that it was free of a medication error rate of 5 % (percent) or greater. The medication error rate was 10.7 % based on 3 of 28 opportunities for error. The findings include: On 4/23/18 at approximately 4:18 PM LPN (Licensed Practical Nurse) # 1 was preparing medications for administration to Resident # 80 with RN (Registered Nurse) # 1 watching and making prompts such as crush meds. LPN # 1 crushed one tablet of [MEDICATION NAME] 1,000 mg (milligram) and placed the crushed medication into a medicine cup. He/she then opened and emptied one capsule of [MEDICATION NAME] 40 mg into the same medicine cup and mixed both medications with applesauce. LPN # 1 stated that the meal for Resident # 80 would be served soon. LPN # 1 administered the two medications to Resident # 80 and discarded the medicine cup into a bedside trash can. It was noted by the Surveyor that not all of the medicine cup contents had been administered to the resident and on 4/23/18 at approximately 4:29 PM LPN # 1 was asked to retrieve the discarded medicine cup from the trash can. LPN # 1 verified that medications remained in the medicine cup and that not all of the medications had been administered to Resident # 80. (Errors 1 & 2) During medication pass reconciliation on 4/23/18 at approximately 4:35 PM, a review of the April, (YEAR) physicians orders revealed that the [MEDICATION NAME] 1,000 mg had been ordered TAKE 1 TWICE A DAY WITH MEALS. Continued observations of Resident # 80 revealed that his/her meal tray was not served until 5:26 PM on 4/23/18. On 4/23/18 at approximately 5:50 PM a review of the Facility policy for Times of Administration showed that Medications ordered with a meal may be given at any time from the moment the resident begins eating up to one hour after the meal is finished. (Error 3)",2020-09-01
3216,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2018-04-27,842,D,0,1,JB8411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure the accuracy of medical records for Resident #41, 1 of 7 sampled resident reviewed for hospitalization related to charting for wrong resident; Resident #64, 1 of 1 sampled resident reviewed for Death related to updating physician and for Resident #123, 1 of 1 sampled resident reviewed for Death related to incomplete charting of change in condition. The findings included The facility admitted Resident #41 with [DIAGNOSES REDACTED]., Hernia, Cataract, Oxygen Dependence, Constipation, Breast Lump Left Side, Hypertension and [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 11:19 AM revealed a Nurse's Note [DATE] stating: Received UA C&S (Urine Analysis Culture & Sensitivity) notified MD (Medical Doctor)/ Caris Hospice. New Order [MEDICATION NAME] 500 MG BID (two times each day) times 10 days. Then recheck urine. Family aware. In an interview on [DATE] at 1:08 PM Registered Nurse (RN) #1 verified that the chart belonged to Resident #41 and also that Resident #41 was not on Hospice. RN #1 stated the information was for a different resident. In an interview on [DATE] at approximately 1:20 PM the Director of Nursing (DON) reviewed and verified RN #1 corrected the entry prior to copying for this surveyor. The DON provided a copy of facility policy on documentation by Nursing which stated, The goal of nursing documentation is to provide a timely recording of pertinent information regarding the safe and appropriate treatment, interventions, and responses, legibly written in the patient's individual medical record. Documentation purpose: Accurately reflect care given . The facility admitted Resident #64 with [DIAGNOSES REDACTED]. Record review on [DATE] of the nurse's notes revealed on [DATE] at 6:00 PM, Resident #64 had a coughing spell; at 10:00 PM nurse's notes state Resident #64 had an episode of emesis and the resident's temperature was 101.8 degrees Fahrenheit; and at 11:00 PM oxygen was started due to Resident #64's oxygen saturation was ,[DATE]. There was no documentation in the nurse's notes indicating the physician was notified of the above findings. Further record review revealed on [DATE] at 11:00 AM, Resident #64's temperature was 100.7 degrees Fahrenheit. On [DATE] at 1:00 AM, Resident #64's temperature was 102.2 degrees Fahrenheit. The physician was not notified of the elevated temperatures until [DATE] at 2:00 PM. During an interview with Registered Nurse #3 on [DATE], s/he confirmed there was no documentation in the nurse's notes the physician was notified at the time of the incidents on [DATE], [DATE], and [DATE]. S/he further stated the physician was asked to write a statement to the effect s/he was notified of the incidents. The physician on [DATE] wrote notes and dated the notes [DATE] and [DATE] as late entries. Information provided by the facility under VIII. Nursing revealed the following: The goal of nursing documentation is to provide a timely recording of pertinent information regarding the safe and appropriate treatment, interventions and responses, legibly written in the patient's individual medical record. Documentation purpose: Accurately reflect care given; Demonstrate treatment results; Provides for coordination of care; Communicates clinical findings to all interdisciplinary team members; Furnishes data for a variety of uses; Is used in quality management reviews; Provides a record of services provided as a means of justifying reimbursement from insurers or private payors. Resident #123 was admitted with [DIAGNOSES REDACTED]. During review of the medical record on [DATE] at 10:57 AM, The Nurse's Notes states: [DATE], 11:00 AM: Resident admitted to Hospice Services, MD (Medical Doctor) discharged all but comfort meds( medications), POA (Power of Attorney) updated XXX[DATE]: 2:30 PM, Seen by Hospice Nurse, vss, afebrile, declining condition. Hospice will see often now. Nephew/niece updated Resident weak and not eating, drinking very little but encouraged. The last entry on the Nurses Notes: [DATE], 2:30 PM Patient not responding, looking upwards. Skin warm/dry, no distress observed, ,[DATE], P 101, R22, Pulse ok @9890, T(Temperature) T 97.9 degrees. Family updated by Hospice. On [DATE] at 11:46 AM, during an interview with the Medical Records Clerk, he/she verified that the last nurses note documented was on [DATE]. He/She said that he/she was going to check and see if medical record additional information in the overflow as the resident expired on [DATE]. The Medical records clerk said that there should be more documentation and he /she is going to look for it. The form titled DHEC .Death Notification, Name of deceased , Resident #123, date of death , [DATE], Time of Death 7:05PM, Place of Death, NHC Garden City, .and form is signed by RN#4. T [DATE] 12:28 PM Interview with RN#3, Unit Manager regarding last entry in medical record. He/she said that he/she would expect a note by nursing or Caris (Hospice), saying vitals, and that Hospice was notified and they handle notifications from there. [DATE] 03:23 PM DON interviewed and said it was him/ her expectation that there would be documentation in Nurses Notes on the resident's death and that Hospice was notified. Hospice faxed on [DATE] at 12:44 Fax # 189 pages ,[DATE] titled, CH Death DC Summary, which states date of death [DATE], 7:05 Pm by The Summary of Care provided during hospice admission states: Patient expired at 7:05 Pm at NHC and was pronounced by RN #4, assigned RN with no pulse, no respirations and no blood pressure, PCG .was notified as well as longtime friend per PCG request. Post Mortem care provided. The form titled VIII. Nursing, states: The goal of nursing documentation is to provide timely recording of pertinent information regarding the safe and appropriate treatment, interventions and responses, legibly written in the patient's individual medical record What information should the nurse document? 1) Any action taken in response to patient problem or because of center routines and requirements 4) Any unusual incident about the patient., 5) Every observation about the patient by the nurse.",2020-09-01
3217,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2019-06-27,550,D,0,1,M9NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to treat one (Resident #321) out of four residents with dignity and respect. Specifically, Resident #321 had three instances where they soiled themselves due to staff not responding quickly enough to the call light. Findings included: According to the Face Sheet, Resident #321 was admitted to the facility 05/30/19. [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment, dated 06/06/19, Resident #321 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. S/he required extensive assistance with toileting. Resident #321 was interviewed on 06/25/19 at 10:06 AM. S/he said that call lights take a long time to get answered. S/he said s/he had to soil him/herself twice because staff didn't answer the call light in time. S/he said it happened once while s/he was laying in bed. The other time it happened, it was in his/her wheelchair. S/he could not get transferred to the toilet in time, so s/he had to sit back in her wheelchair, where s/he soiled herself. Both of the instances occurred late at night. S/he said that having to soil him/herself made him/her feel absolutely awful. Resident #321 was interviewed a second time on 06/26/19 at 4:04 PM. S/he said s/he had to soil him/herself once again yesterday around 3:30 PM-4:00 PM. S/he said it wasn't as bad as the instances before, but they still had to change his/her clothes and clean him/her up. S/he hit the call light and a Certified Nurse Aide (CNA) came into the room. The CNA said s/he could not help him/her because s/he (the CNA) had a cast on his/her arm. The CNA turned off the call light and said s/he would find someone else to help. Resident #321 said s/he only needed supervision in the bathroom now, so that CNA could have helped him/her if s/he listened to him/her. Resident #321 said no one came back. She waited approximately 15-20 minutes and then she re-hit her call light. CNA #52 answered the call light shortly after s/he turned it on. The resident had already soiled him/herself slightly and the CNA took him/her to the bathroom. S/he had a visitor during that time and s/he was embarrassed. S/he was very upset about the situation. S/he spoke with Licensed Practical Nurse (LPN) #28, who then spoke with Registered Nurse (RN) #11, who was the unit manager. Resident #321 was asked about the other two instances again. S/he said the first instance that occurred in the bed happened shortly after s/he was admitted . The other instance that occurred in the wheelchair happened a week or two later. S/he said s/he always anticipated having to go to the bathroom and pressed his/her call light. S/he did not wait until s/he could not hold it any longer before pressing the call light. Review of the Point of Care Bowel/Bladder Category Report revealed the resident was marked as being incontinent of bladder during the night shift on 05/31/19 and 06/19/19. LPN #28 was interviewed on 06/27/19 at 1:55 PM. S/he said Resident #321 could express his/her needs and is able to tell staff if s/he needed something. S/he was alert and oriented. S/he said the resident soiled him/herself two days ago, but it was not as bad as it could have been. The resident was upset, so s/he spoke with him/her. The first CNA that came into the room was not aware Resident #321 could do things supervised, so s/he went to find another CNA that could transfer him/her. S/he said the whole situation was avoidable. The CNA needed to better communicate with Resident #321 about why s/he could not help him/her. S/he spoke with the CNA and told him/her not to turn off the call light before the task was completed. When s/he spoke with Resident #321, s/he was upset and embarrassed because s/he had a guest at the time. LPN #28 said if it was him/her that it happened to, s/he would be very upset and embarrassed as well. As a resident, no one wants to soil themselves. S/he said that the resident had not expressed to him/her that s/he had to soil him/herself two other times. S/he was not aware of the other two instances. RN #11, who was the unit manager, was interviewed on 06/27/19 at 2:08 PM. S/he said that LPN #28 spoke with Resident #321 after the incident two days ago. The resident was upset that his/her call light was turned off prior to the task being completed. S/he was not aware that the resident soiled him/herself. S/he was not aware of the other two instances s/he soiled him/herself either. If it happened to him/her, s/he would be upset as well. CNA # 52 was interviewed on 06/27/19 at 3:01 PM. S/he was the CNA that took Resident #321 to the bathroom two days ago. S/he said the resident's pad in his/her underwear was wet, but s/he was not soaking wet with urine. S/he assisted Resident #321 to the bathroom, where s/he finished voiding. S/he said the call light was on when s/he entered the room. The Director of Nursing was interviewed on 06/27/19 at 3:13 PM. S/he was not familiar with the resident. S/he was not aware that the resident had soiled him/herself. S/he said if the instances made him/her upset, then it would be a dignity concern. S/he did not want their residents to be upset.",2020-09-01
3218,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2019-06-27,641,D,0,1,M9NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interviews, the facility failed to accurately code information correctly for three of 40 sampled residents (Resident #25, #95 and #28) whose Minimum Data Set (MDS) assessments were reviewed. Findings included: 1. Resident #25 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment dated [DATE] revealed that section N (N0410) was coded inaccurately as the resident receiving an anticoagulant for 7 days in the last 7 days during the review period. A review of the Medication Administration for (MONTH) 2019 through (MONTH) 2019 revealed that Resident #25 was not prescribed an anticoagulant. 2. Resident #95 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed that section P (P0100) was coded inaccurately as Resident #95 having a trunk restraint and used less than daily during the review period. An observation was made of the Resident #95 on 06/26/19 at 10:30 AM sitting up in his/her wheelchair near the nurse's station with no trunk restraint in place. An interview was conducted with the Director of Nursing (DON) on 06/26/19 at 11:50 AM. The DON stated that it is his/her expectation that the residents be coded on the MDS according to what they have. An interview was conducted with the MDS Coordinator #154 on 06/26/19 at 11:55 AM. The MDS Coordinator #154 stated that it was a data coding error and it is his/her expectation that the MDS are coded accurately. 3. According to the Face Sheet, Resident #28 was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the admission MDS assessment, dated 04/16/19, Resident #28 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. S/he required extensive assistance for all activities of daily living (ADL). Section M (M0210) was coded inaccurately, as it indicated the resident did not have one or more unhealed pressure ulcers at a Stage 1 or higher. According to the baseline care plan, completed 04/04/19, Resident #28 had a current pressure ulcer on his/her left heel. The wound management documentation in the electronic health record documented Resident #28 had a pressure ulcer to the left heel. The pressure ulcer was present on re-admission. On 06/24/19 at 10:30 AM, the resident was observed to have a wound on his/her heel. This was seen when Registered Nurse (RN) #16 provided the treatment. RN #17, who was the wound nurse, was interviewed on 06/27/19 at 11:34 AM. S/he said Resident #28 admitted with the wound on his/her heel. It was an unstageable pressure ulcer on his/her left heel. Resident #28 still had the pressure ulcer. MDS Coordinator #154 was interviewed on 06/27/19 at 12:00 PM. When s/he completed Section M of the admission MDS, s/he said s/he spoke with the floor nurse and the nurse told him/her the area on the heel was not a pressure ulcer. It was a skin tear. S/he looked at the Weekly Wound Assessment Record, that was paper, and there was a B in the row that explained whether the wound was a pressure ulcer or another type of wound. A number indicated a pressure ulcer and a letter indicated another type of wound. Written on the sheet next to location documented L (left) heel pressure. Next to the stage of the wound, Stage 2 was crossed out and unstageable was written next to it. MDS Coordinator #154 said s/he did not see the stage was unstageable. S/he went by the column with the B, which indicated it was another type of wound other than a pressure ulcer. S/he said s/he should have actually looked at the wound to confirm whether it was a pressure ulcer or not. S/he should not have taken the word of the nurse. S/he realized that it is actually a pressure ulcer and should have been coded. MDS Coordinator #154 was interviewed for a second time on 06/27/19 at 1:50 PM. S/he spoke with the DON and after looking through more information, it was clear that it was a pressure ulcer. The miscoding was his/her error. S/he didn't look at everything s/he should have.",2020-09-01
3219,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2019-06-27,686,D,0,1,M9NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to prevent cross contaminating during wound care. The wound care observation affected one (Resident #28) of three wound care observations done. Findings included: According to the Face Sheet, Resident #28 was re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment, dated 04/16/19, Resident #28 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 13 out of 15. S/he required extensive assistance for all activities of daily living (ADL). Section M (M0210) was coded inaccurately, as it indicated the resident did not have one or more unhealed pressure ulcers at a Stage 1 or higher. Resident #28's left heel wound was observed on 06/24/19 at 10:30 AM. Registered Nurse (RN) #16 completed the treatment and dressing change. The resident's feet were elevated on a pillow. The nurse removed the old bandage and placed it on the pillow next to the foot. The bandage had a very small amount of drainage in it. S/he sprayed the wound with wound cleanser, wiped the wound with gauze, and then placed the heel/wound back onto the pillow. S/he lifted the heel back up and finished the treatment, which included putting Santyl on the wound and then placing gauze and a bandage on it. RN #17, who was the wound nurse, was interviewed on 06/27/19 11:34 AM. S/he said s/he did not always have assistance when s/he provided the treatment for [REDACTED]. S/he used the resident's bootie to wedge underneath the calf, which kept the heel/wound elevated and off of the pillow while s/he provided the treatment. S/he said the heel/wound should never touch the pillow, especially after just cleansing it. This could re-contaminate the wound. S/he normally provided treatment once per week and the floor nurse provided the treatment on the other days. The Director of Nursing was interviewed on 06/27/19 at 11:38 AM. S/he said a heel wound should not touch the pillow after being cleansed for contamination reasons. That could put drainage on the pillow and the wound could get re-contaminated if it is placed on the pillow after being cleansed.",2020-09-01
3220,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2019-06-27,880,D,0,1,M9NH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to prevent cross contaminating during medication administration. This was evidenced by two different nurses dropping medications onto the Med Cart then placing the dropped pills into the medication cup and administrating it to the residents. This affected two residents (Resident #22 and #82) out of five residents observed for Medication Pass. Findings included: 1. During medication administration, Licensed Practical Nurse (LPN) #30 was observed preparing meds for Resident #22 at 9:47 AM on 06/26/19. One of the pills ([MEDICATION NAME] 0.25.mg) was accidentally dropped onto the Med Cart while getting it out of the medication card that was locked in narcotics bin. LPN #30 picked up the pill with her ungloved hand and placed it into the med cup that had applesauce in it. The medications were administered to the resident. The resident preference is to have his/her pills in applesauce to make them easier to swallow. During medication administration, LPN #47 was observed preparing meds for Resident #82 at 9:00 AM on 06/27/19. One of the pills ([MEDICATION NAME] ER 50 mg) was accidentally dropped onto the Med Cart while getting it out of the sealed packet from pharmacy. LPN #47 used two spoons from the Med Cart to pick up the pill and placed it in the med cup with the other medications. The medications were observed being taken by this surveyor. When LPN #47 saw the surveyor writing down notes s/he stated, I guess I should have wasted that pill and gotten another one out, shouldn't I? Surveyor told LPN #47 to do what s/he normally did. An interview with the Director of Nursing (DON) was done on 06/26/19 at 11:40 AM. The DON stated that his/her expectations would be for the nurse to waste (dispose of) the dropped pill and get another one out. On 06/27/19 at 2:35 PM, the DON was notified of a second observation of a nurse dropping a pill onto the med cart and administering it to the resident after picking it up with two spoons. The DON stated that there was no policy for dropping medications. S/he also verified that there were additional medications available to use in such a situation.",2020-09-01
4694,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2016-03-18,157,D,0,1,6C7S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the family related to implementation of a new medication for Resident #47, 1 of 2 residents reviewed for notification. The findings included: The facility admitted Resident #47 with [DIAGNOSES REDACTED]. Record review on 3/16/16 revealed a physician's orders [REDACTED]. Further record review of the nurse's notes did not reflect the family of Resident #47 had been notified of the implementation of the new medication. During an interview with the Director of Nursing on 3/18/16 at 3:58 PM, he/she stated the resident was alert and oriented and the facility would not have had any reason to call the family. He/she continued by stating the physician had visited the family multiple times related to the resident's condition. No documentation was presented during the survey to indicate the family had been notified of the implementation of [MEDICATION NAME].",2019-09-01
4695,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2016-03-18,242,D,0,1,6C7S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident had the right to choose their schedules for 1 of 3 sampled residents reviewed for choices. Resident #151 was not afforded the right to make choices related to shower frequency. The findings included: The facility admitted Resident #151 with [DIAGNOSES REDACTED]. During an interview on [DATE] at 1:19 PM, Resident #151 stated, No when asked, Do you choose how many times a week you take a bath or shower? Resident #151 stated (s)he would like to bathe more frequently than currently scheduled because this revived him/her. Record review of the CNA (Certified Nursing Assistant) book revealed Resident #151 was scheduled to shower on Tuesdays and Fridays. Review of the shower documentation in the CNA book from (MONTH) 1, (YEAR) through (MONTH) 12, (YEAR) revealed Resident #151 had no more than two documented showers each week. Review of the Interview for Preferences form dated [DATE] under, Choose between a tub bath, shower, bed bath, or sponge bath revealed, 1 Very important Shower every other day. Interview with License Practical Nurse (LPN) #4 on [DATE] at 2:02 PM confirmed Resident #151 was currently scheduled to bathe twice weekly on Tuesdays and Fridays.",2019-09-01
4696,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2016-03-18,278,E,0,1,6C7S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately assess one of one sampled residents reviewed for Hospice. Resident #46 had two MDS assessments coded incorrectly related to terminal diagnosis. The findings included: The facility admitted Resident #46 with [DIAGNOSES REDACTED]. Record review on 3/17/2016 at 2:10 PM revealed a physician's orders [REDACTED]. The Hospice and attending physicians signed the Hospice Certification of Terminal Illness on 8/4/2015. This certification stated, This is to certify that the beneficiary, named below, is terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. Review of the 10/28/15 and 1/25/16 quarterly MDS assessments revealed they were coded incorrectly in Section J, Health Conditions, J1400 Prognosis. Although the Hospice Certification of Terminal Illness was on file, the MDS was coded to indicate that the resident did not have a life expectancy of less than 6 months. During an interview on 03/18/2016 at 1:13 PM, the MDS Coordinator (Registered Nurse #2) reviewed the assessments and verified the Hospice certification. The nurse stated s/he had always coded J1400 as 0 (no terminal illness/life expectancy of less than 6 months) because s/he had been taught to do so and it was outside of her/his scope of practice to fill out the form that indicated s/he could predict the death of a resident.",2019-09-01
4697,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2016-03-18,282,E,0,1,6C7S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident care plans were followed for fall interventions for 1 of 5 sampled residents reviewed for falls (Resident #151). The findings included: The facility admitted Resident #151 with [DIAGNOSES REDACTED]. Observation revealed Resident #151 was in bed asleep on 3/14/2016 from 10:00 AM to 11:00 AM, in bed asleep at 1:00 PM, and going from the bed to the bathroom unassisted at approximately 3:00 PM with floor mats folded up and standing against the headboard of the bed and no tab alarm observed or sounding. Resident #151 was observed in bed asleep on 3/15/2016 at 9:00 AM, 10:30 AM, and 11:30 AM with floor mats folded up and standing against the headboard of the bed. Observation on 3/16/2016 at 11:57 AM revealed Resident #151 was in bed with no fall mats beside the bed. Resident #151 was observed on 3/17/2016 at 3:28 PM sitting on side of the bed with floor mats folded up and propped against the end of the bed. Record Review of the POS [REDACTED]. Review of the Care Plan revealed the following: floor mat and tabs alarm at all times when in bed. Observation and interview with Licensed Practical Nurse (LPN) #5 in Resident #151's room on 3/17/2016 at 3:37 PM confirmed the floor mat for Resident #151 was folded up and against the head of the bed and the tab alarm was on a shelf and not in use. LPN #5 stated the resident preferred to have the bedside table and walker near the bed to go to the bathroom and (s)he removed the alarm. Further interview with LPN #5 on 3/17/2016 at 3:46 PM revealed the mat was only used at night since the resident was up and down during the day going to the bathroom and that the resident removed the alarm as soon as it started to sound though the Care Plan stated these were to be used at all times when in bed. Interview with Registered Nurse (RN) #1 on 3/17/2016 at 4:13 PM revealed Resident #151 was noncompliant with the tab alarm and this needed to be discontinued. (S)he stated the mat was only being used at night though the Care Plan stated it was to be used at all times when the resident was in bed.",2019-09-01
4698,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2016-03-18,309,D,0,1,6C7S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure orthopedic consults were completed for 1 of 1 residents reviewed for consult follow-up (Resident #151). The findings included: The facility admitted Resident #151 with [DIAGNOSES REDACTED]. Record review of a physician progress notes [REDACTED].#151 revealed: Pt (patient) s/p (status [REDACTED].L hip Xrays - TFN in place - stable .F/u (follow-up) in 8 weeks - 2/8/15 (sic) @ 8:15 AM. Interview with Registered Nurse #1 on 3/18/2016 at 12:10 PM confirmed no information was available regarding the 2/8/2016 orthopedic follow-up and it may have been canceled due to the resident having psychiatric issues at that time.",2019-09-01
4699,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2016-03-18,323,E,0,1,6C7S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide devices to prevent accidents and remove hazards from areas accessible by residents. Fall interventions were not observed in place for 1 of 5 sampled residents reviewed for falls (Resident #151). There were unsecured hazards in 2 of 3 units. Bathroom disinfectant was unsecured in the 300 hall dining room and denture tablets were unsecured in a resident bathroom on the 100 hall. The findings included: The facility admitted Resident #151 with [DIAGNOSES REDACTED]. Observation revealed Resident #151 was in bed asleep on 3/14/2016 from 10:00 AM to 11:00 AM, in bed asleep at 1:00 PM, and going from the bed to the bathroom unassisted at approximately 3:00 PM with floor mats folded up and standing against the headboard of the bed and no tab alarm observed or sounding. Resident #151 was observed in bed asleep on 3/15/2016 at 9:00 AM, 10:30 AM, and 11:30 AM with floor mats folded up and standing against the headboard of the bed. Observation on 3/16/2016 at 11:57 AM revealed Resident #151 was in bed with no fall mats beside the bed. Resident #151 was observed on 3/17/2016 at 3:28 PM sitting on side of the bed with floor mats folded up and propped against the end of the bed. Record review of the Post Falls Nursing Assessments revealed Resident #151 had falls on 2/8/2016 (lying on floor), 2/10/2016 (sitting on floor with legs under bed), and 2/15/2016 (on floor next to bed). Review of the Care Plan revealed the following: floor mat and tabs alarm at all times when in bed. Observation and interview with Licensed Practical Nurse (LPN) #5 in Resident #151's room on 3/17/2016 at 3:37 PM confirmed the floor mat for Resident #151 was folded up and against the head of the bed and the tab alarm was on a shelf and not in use. LPN #5 stated the resident preferred to have the bedside table and walker near the bed to go to the bathroom and (s)he removed the alarm. Further interview with LPN #5 on 3/17/2016 at 3:46 PM revealed the mat was only used at night since the resident was up and down during the day going to the bathroom and that the resident removed the alarm as soon as it started to sound though the Care Plan stated these were to be used at all times when in bed. Interview with Registered Nurse (RN) #1 on 3/17/2016 at 4:13 PM revealed Resident #151 was noncompliant with the tab alarm and this needed to be discontinued. (S)he stated the mat was only being used at night though the Care Plan stated it was to be used at all times when the resident was in bed. During room observation on 3/14/16 at 4:00 PM, a box of Polident tablets were noted in the resident's bathroom in room 114. Review of the warnings for Polident tablets revealed the tablets could cause serious eye irritation, cause breathing difficulty if inhaled and if ingested in large amount to contact Poison Control. The Unit Manager was notified on 3/14/16 of the Polident tablets located in the bathroom of room 114.",2019-09-01
4700,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2016-03-18,329,D,0,1,6C7S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview the facility failed to ensure all medications had adequate indications for use for one of five sampled residents reviewed for unnecessary medications. Licensed Practical Nurse (LPN) #8 administered [MEDICATION NAME] to Resident #46 who had a known allergy to this medication. The findings included: Review of 2/1/16 Nurse's Notes on 3/16/2016 at approximately 2:00 PM revealed the following entry on 2/1/16 at 11 PM .Started vomiting at 8:45 PM. Continues to vomit several more times. [MEDICATION NAME] noted on standing orders and given for vomiting. Allergy to [MEDICATION NAME] noted after administration MD Notified. Verbal orders for [MEDICATION NAME] 25 mg 1-2 tabs PO (by mouth) every 4 hours as needed Review of the standing orders in the medical record revealed the following statement: Standing orders have been approved to be initiated by nursing staff in the absence of a physician after checking for allergies [REDACTED]. (Suppository) q (every) 4 hours prn (as needed)/nausea or vomiting. Record review revealed a current physician's orders [REDACTED]. Record review of the (MONTH) (YEAR) Medication, Treatment and Task Administration Record Report revealed that this medication was administered on (MONTH) 17 and was effective for nausea. Although [MEDICATION NAME] was noted as a current order and was known to be effective for this resident, [MEDICATION NAME] was administered per standing order. Continued record review revealed allergies [REDACTED]. 1. Red allergy sticker posted in the front of the medical record. 2. The Monthly Nursing Summary Report. 3. The Patient Care Plan. 4. The Medication Treatment and Task Administration Record Report. 5. The physician's orders [REDACTED]. Interviews were conducted with nursing staff on 3/17/2015 at 1:30 PM regarding the process for new medication orders. Interviews with Licensed Practical Nurses (LPNs) #2, #3 and #1 on the 100 unit revealed that each would check allergies [REDACTED]. :",2019-09-01
4701,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2016-03-18,371,F,0,1,6C7S11,"Based on observations, interviews and review of the facility policy titled, Cleaning Procedures, Refrigerators/Freezers, and Hygienic and Safety Practices, the facility failed to prepare, distribute and serve food under sanitary conditions in 1 of 1 kitchen reviewed. The findings included: During an observation on 3/16/2016 at approximately 11:30 AM during the temping of foods for lunch service, noted a staff member not wearing gloves, dropped the thermometer into the pureed turkey. The staff member did not notice that there was a problem with serving the pureed turkey. When brought to his/her attention, the turkey was removed and replaced. Then the Dietary Manager proceeded to temp foods without gloves, wearing jewelry and fingernail polish. During an interview on 3/16/2016 at approximately 11:45 AM with the Dietary Manager, this surveyor asked about the facility policy on wearing jewelry in the kitchen and wearing fingernail polish. He/she stated, No fingernail polish is not allowed. He/she went on to say that jewelry was ok. Review on 3/16/2016 at approximately 1:30 PM of the facility policy titled, Cleaning Procedures, Refrigerators/Freezers, under Frequency: states, Daily, Monthly, and as needed. Under, Method: Daily cleaning of refrigerators and freezers:, # 1. States, Keep shelves and floor clean of any food particles or debris. Review on 3/16/2016 at approximately 1:30 PM of the facility policy titled, Hygienic & Safety Practices, under Guidelines: # 4. states, While preparing food, Dietary partners may not wear jewelry on their arms and hands except for a wedding band. # 5. states, Unless wearing intact gloves in good repair, a food service partner may not wear fingernail polish or when working with exposed food.",2019-09-01
7409,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2013-03-07,371,D,0,1,ZMR411,"On the days of the survey based on observation, interview and review of the facility Policy entitled Safety & Sanitation Best Practice Guidelines revised date 1/2011 the facility failed to distribute and serve food under sanitary conditions as evidenced by staff failure to wash hands when entering the kitchen to refill a pitcher to be used in the food service area. The findings included: During observation of the lunch meal service on 3/6/13 at approximately 11:55 A.M. the surveyor observed a dietary aide leave the tray line in the dining room and enter the kitchen without washing his/her hands. The dietary aide proceeded to place ice into a pitcher. The surveyor had the Food Service Supervisor stop the aide from taking the pitcher out of the kitchen. The Food Service Supervisor confirmed that the Dietary aide did not wash their hands after entering the kitchen. Review of the facility's policy entitled Safety & Sanitary Best Practice Guidelines on 3/7/13 revealed: All partners handling food products or contacting equipment used in food preparation should wash their hands and forearms with soap and warm water . The Guidelines of the policy further revealed, Hands should be washed .after leaving and returning to a food preparation area .or after touching anything that might contaminate hands, such as .work surfaces .",2017-03-01
7410,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2013-03-07,514,D,0,1,ZMR411,"On days of the survey, based on record review and interviews, the facility failed to provide documentation of Hospice Services as evidenced for 1 of 2 residents reviewed for Hospice Services (Resident #1). The findings included: Resident #1 was admitted to Hospice Services on 2/13/13. Record review on 3/6/13 at approximately 9:20 AM revealed a lack of documentation available to substantiate provision of Hospice Services. Interview with RN (Registered Nurse) #1, Nurse Manager, on 3/6/13 at approximately 1:00 PM verified the lack of documentation on the Medical Record related to Hospice Services. RN # 1 stated s/he was not sure of the services provided by Hospice or the frequency of visits from the Hospice Nurse, CNA (Certified Nursing Assistant), Social Services or Chaplain and verified the frequency was not in the Medical Record. Registered Nurse #1 also verified that the Hospice CNA (Certified Nursing Assistant) had not documented 5 visits with Resident #1 for Activities of Daily Living, including 2/15/13, 2/22/13, 2/25/13, 2/27/13, and 3/1/13 on the facility's Caregiver Sign In Log located at the Nurses desk. An interview on 3/6/13 at approximately 4:00 PM with Registered Nurse #2, Case Manager, with Hospice, verified the documentation for Hospice Services and visits from Certified Nursing Assistant was not in Resident #1's Medical Record, but was faxed to facility on 3/6/13 at approximately 15:54 PM. On 3/6/13 at approximately 18:39 PM the Hospice Plan of Care for Resident #1 that was not on the medical record was also faxed to the facility.",2017-03-01
8343,NHC HEALTHCARE - GARDEN CITY,425324,9405 HWY 17 BYPASS,GARDEN CITY,SC,29576,2016-03-18,166,E,0,1,6C7S11,"Based on record review and interview, the facility failed to implement the grievance process. There was no evidence of residents grievances and resolutions which has the potential to effect any resident or family who voices a grievance. The findings included: On 3/16/16 at approximately 3:00 PM the grievance log was requested. Review of the Complaint and Grievance Report on 3/16/16, only listed the disciplines with the number of complaints/grievances. For instance dietary, nursing, social services etc. There was no description of the grievance to include the resident's name, or type of grievance such as call bells, cold food, staff etc. At the bottom of each page for each month a statement was written which states all complaints and grievances were resolved to the satisfaction of all parties. The facility would be unable to track and trend areas of concern or identify patterned deficient practice. During an interview on 3/16/16 at 3:50 PM, the Administrator stated the facility only kept the paper with the disciplines identified with the number of grievances under each discipline. Once a grievance is filed, we give the issue to whoever is most appropriate to handle the situation. Once the facility feels as though the grievance has been resolved, we discard the grievance form. The form is an internal form and once the issue is resolved the facility has no need to keep it. Review of the patient rights booklet lists the grievance procedure but does not address the issue of keeping a log which states what the grievance was and how the facility came to a resolution. No facility grievance policy was provided during the survey.",2016-05-01
1484,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2017-02-10,247,D,0,1,FPZ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility's policy entitled Transfer/Discharge Policy, the facility failed to provide prior notice of a change in roommate for 1 of 2 residents reviewed for Admission, Transfer and Discharge. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. During an interview on 02/08/17, a family member stated that Resident #6 had 2 roommate changes in the previous nine months. The responsible party also stated that staff had not notified him/her about the changes. Review of the Social Services Notes on 02/10/17 at 9:30 am revealed that Resident #6 had roommate changes on 08/11/16 and 09/02/16. There was no evidence of notification of the responsible party. In an interview on 02/10/17 at approximately 9:30 am, the Director of Social Services stated that it was the facility's policy to notify responsible parties of roommate changes. The Director of Social Services could not locate documentation of the notice. During the interview with the Director of Social Services present, the Social Services Case Worker stated s/he did not know the responsible party needed to be notified. Review of the Transfer/Discharge Policy on 02/10/17 at approximately 9:30 am revealed that the resident and his representative shall be given reasonable notice prior to the effective date of transfer and the reason for the transfer.",2020-09-01
1485,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2017-02-10,282,D,0,1,FPZ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the care plan was followed related to implementation of fall prevention measures for 1 of 4 sampled residents reviewed for accidents. The care plan for Resident #173 included the use of a defined perimeter mattress (DPM) as an intervention for fall risks. The findings include: The facility admitted Resident #173 with [DIAGNOSES REDACTED]. Record review on 2/10/17 at 1:45pm revealed that Resident #173 had falls on 08/25/16, 09/03/16, 10/14/16, 10/18/16, 11/09/16, 11/30/16, 12/21/16 and 01/27/17. Further review of the incident reports revealed that investigation of the fall on 10/14/16 showed that the defined perimeter mattress (DPM) was not in place due to the evacuation. The recommendation was to replace the DPM to reduce the fall risk. Review of the care plan for Resident #173 on 02/09/17 at 1:52 pm revealed that due to a risk for recurrent falls, a DPM was one of the approaches for the goal of reducing risk for falls. During an interview on 02/10/17 at 3:55 pm, Certified Nursing Assistant (CNA) #2 demonstrated the bed alarm and confirmed that the mattress on the bed was not a DPM. During an interview on 02/10/17 at 4:23 pm, Licensed Practical Nurse (LPN) #2 observed and confirmed that the mattress was not a DPM. LPN #2 stated s/he was not familiar with the care plan and did not know what type of mattress was supposed to be on the bed.",2020-09-01
1486,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2017-02-10,323,D,0,1,FPZ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to implement fall prevention measures to reduce hazards and risks for 1 of 4 sampled residents reviewed for accidents. Resident #173 did not have a defined perimeter mattress (DPM) in place. The findings include: The facility admitted Resident #173 with [DIAGNOSES REDACTED]. Record review on 2/10/17 at 1:45pm revealed that Resident #173 had falls on 08/25/16, 09/03/16, 10/14/16, 10/18/16, 11/09/16, 11/30/16, 12/21/16 and 01/27/17. Further review of the incident reports revealed that investigation of the fall on 10/14/16 showed that the defined perimeter mattress (DPM) was not in place due to the evacuation. The recommendation was to replace the DPM to reduce risk. Review of the care plan for Resident #173 on 02/09/17 at 1:52 pm revealed that due to a risk for recurrent falls, a DPM was one of the approaches for the goal of reducing risk for falls. During an interview on 02/10/17 at 3:55 pm, Certified Nursing Assistant (CNA) #2 was demonstrating the bed alarm and confirmed that the mattress on the bed was not a DPM. During an interview on 02/10/17 at 4:23 pm, Licensed Practical Nurse #2 observed and confirmed that the mattress was not a DPM.",2020-09-01
1487,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2017-02-10,371,E,0,1,FPZ711,"Based on observation, interview and review of facility policy, the facility failed to maintain sanitary conditions for 1 of 1 kitchen and for 1 of 4 nourishment areas. For 1 of 4 nourishment fridges, the refrigerator was not maintained within appropriate temperature and there was no temperature log for the refrigerator. During the initial tour of the kitchen on 2/6/17 at 4:16 PM, the following were observed and verified by the Night Supervisor: A fan covered in dust was blowing air in the dish drying area next to a rack of clean mugs; Two containers, one labeled food thickener and the second labeled pureed bread mix, were covered in a sticky substance; and A cart that was used for baking ingredients was covered in built up food and grime. In the walk in cooler the following were observed and verified by the Night Supervisor: An opened container of chicken salad was not labeled or dated; An opened package of American Cheese was not labeled or dated; and The floor of the walk in cooler had lettuce, butter packets, debris, food splashed and built up grime. Built up debris was along the perimeter of the shelving. In the walk in freezer the following were observed and verified by the Night Supervisor: Food items on the floor under the shelving; and Built up ice on the floor. In the dry storage area the following were observed and verified by the Night Supervisor: Pepper packets, sugar packets on the floor under the shelving; Built up dirt under the wheels and along the perimeter of the shelving; [NAME] icing mix opened, not labeled or dated; and A cabinet with a sticky substance on the shelving. In the emergency food area the following were observed and verified by the Dietary Director: Emergency water bottles were covered in dust and a sticky substance; Bottles of soda were not stored 6 inches off the floor; The floor under the water bottles was visibly soiled with dirt, dust and dead bugs. The Cleaning of Dietary Environmental Services policy, dated 8/2010, stated environmental areas, both food contact and non-food contact, will be cleaned and sanitized as appropriate on a scheduled and as needed basis. During an observation on 2/8/17 at 11:23 AM, the temperature of the nourishment refrigerator in the 200 wing was 46 degrees Fahrenheit (F). A sign on the door of the refrigerator read safe zone for fridge is 32 - 40 degrees. The Dietary Manager verified the temperature at 46 degrees F and stated Maintenance did the temperature log for the nourishment refrigerator. There were two gallons of milk in the refrigerator. The milk in the first gallon was 42.8 degrees F and the milk in the second gallon was 42.2 degrees F. During an interview on 2/8/17 at 11:41 AM the Dietary Manager stated that per the Director of Nursing (DON), there is no temperature log for the refrigerator, and they just get checked everyday. During an interview on 2/8/17 at 11:50 AM the DON stated it was the responsibility of herself, the Assistant Director of Nursing (ADON) and the nursing staff to check the temperature of the nourishment refrigerators on a daily basis. She states they do not document the temperature of the nourishment refrigerators, and they are not required by corporate to keep a log. She stated food items such as juice, yogurt, applesauce, pudding and milk are stored in the nourishment refrigerators. She stated the nursing staff check the refrigerator, do not write it down, and she assumed they would have to remember it. During an interview on 2/8/17 at 12:20 PM, the ADON stated she had checked the nourishment refrigerators that morning. She stated I can tell you none of them were above 40.[NAME]was 38 at 5:30 AM,[NAME]was 36, Colony was 36. She stated they were only checked once a day, unless there was an issue. She stated there was no way of knowing how long the nourishment refrigerator in the 200 wing was above 41 degrees as the last time the refrigerator was checked was 5:30 AM. She stated they do not keep temperature logs for the nourishment refrigerators as corporate said it is not required.",2020-09-01
1488,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2017-02-10,431,D,0,1,FPZ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, review of the manufactures recommendations and facility policy, the facility failed to follow a procedure to ensure that expired medication was removed from medication storage in 1 of 5 medication storage rooms reviewed. Expired Tuberculin Purified Protein Derivative, (Mantoux) (PPD) (Tubersol) was in medication storage after the discard date. The findings included: On [DATE] at 4:30 PM, an observation of the 400 unit medication storage room with RN #1 revealed (1) half full vial of PPD (Lot # C5035AA) was opened with no puncture date. Following the observation RN #1 verified the PPD vial was open, 1/2 full, and not dated. RN #1 was asked if the PPD vials need to be dated after opening, RN #1 stated, Yes. RN #1 also stated that the PPD was received by pharmacy on [DATE] and could not determine when the vial was opened. On [DATE] at 9:00 AM, during an interview with the Directer of Nursing (DON), s/he compared an unopened vial of PPD (Lot # C5035AA) to the opened undated vial (Lot #C5035AA) that was found in the 400 storage room on [DATE]. The DON verified the unopened vial was ,[DATE] full and the opened undated vial was ,[DATE] full indicating the vial was used. Review of the facility policy entitled, Medication Storage InThe Facility, states under procedure (11.) Multi-dose vials, ophthalmics, otics, and other sterile products will be dated and initialed with the first puncture of the vial or opening. Multi-dose vials including insulin may be used after opening for 28 days unless the manufacturer has data to support longer dating. Specific exceptions per manufacture recommendations. Also, review of the manufacture recommendations for Tuberculin Purified Protein Derivative, (Mantoux) (PPD) (Tubersol) states under section Storage, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. Do not use after the expiration date.",2020-09-01
1489,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-03-01,656,D,1,0,E3S611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview the facility failed to implement the comprehensive care plan for 2 of 3 residents sampled. Resident #1 and Resident #2 's care plans were not followed related to falls. The findings included: Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] coded the resident with a Brief Interview of Mental Status (BIMS) of 10. The MDS indicated Resident #1 needed extensive to total assistance for all activities of daily living; requiring the assistance of two persons for transfer, bed mobility, toileting and dressing. S/he was frequently incontinent of bowel and bladder. The Quarterly MDS dated [DATE] coded the resident with a BIMS of 15 with ambulation on and off the unit requiring set up help only using an electric wheelchair. The resident fed him/herself after set up help and was occasionally incontinent of bowel and bladder. Review of the Departmental Notes dated 01/25/2018 at 10:39 PM revealed a late entry for 01/24/2018 at 6:00 PM that stated, Residents CNA (certified nurse aide) came out of his/her room calling for staff help and I immediately responded. Resident noted holding onto hand rails of sit to stand with both feet off stand and in kneeling position. Resident denied pain/discomfort other than his/her position. With the help of another staff member, resident was gently lowered to floor and then lifted back up with total lift and placed into bed. No apparent injury. A note dated 01/25/2018 at 12:59 AM indicated the resident vomited and stated s/he wasn't feeling good s/he was noted with a possible drooping mouth and an O2 saturation of 84%. The nursing supervisor was notified and EMS (emergency medical service) was called, the resident left the facility for the hospital at 12:25 AM via stretcher. Review of the hospital admission note dated 01/25/2018 indicated the resident was examined at 05:30 AM and admitted with an assessment and plan that stated: .UTI (urinary tract infection) with [MEDICAL CONDITION] ., [MEDICAL CONDITION] with rapid ventricular response .; hypokalemai ., acute kidney injury with creatinine 1.6 .; wounds, right lower extremity ./ PT/OT (physical therapy/occupational therapy .; [MEDICAL CONDITION] . Further review of the hospital admission for 01/25/2018 revealed an Orthopedic Trauma Service consultation dictated on 01/25/2018 at 6:13 PM that stated, x-rays reviewed include AP and lateral, left femur. They show a spiral [MEDICAL CONDITION], femoral shaft which is mildly displaced. Resident #1's femur was surgically repaired and s/he was discharged back to the facility on [DATE]. The initial assessment and plan on admission to the hospital did not mention treatment of [REDACTED]. Review of the facility 5 Day Follow up report dated 01/30/2018 stated that Resident #1 had a fall during transfer using the sit to stand lift. The resident's foot slipped off of the sit to stand lift and the CNA went to get assistance. S/he complained of knee pain initially and was given his/her normal scheduled pain medication, with no further voiced complaints. The resident was later sent out to the hospital for evaluation of vomiting and decreased O2 saturation. The resident was noted with a knot on his/her left knee and taken to x-ray the evening of 01/25/2018 and found to have a fractured femur. The facility investigation revealed the CNA did not follow facility policy with transfer. In an interview with the surveyor on 02/28/2018 at 3:20 PM Licensed Practical Nurse (LPN) #1 stated that s/he was in the hall passing meds around 6:00 PM on 01/24/2018 when CNA #1 came out in the hall and called for help. I walked in the room and s/he was alone, no straps were on the lift. LPN #1 stated that CNA #1 told her/him that the resident refused the straps. I assessed him/her, did range of motion, s/he had no complaints except that his/her left knee hurt, which was his/her usual complaint. I gave him/her the ordered Tylenol like every night. S/he didn't have any other complaints. I didn't call anyone, s/he didn't have an injury, I kept an eye on him/her, s/he said the Tylenol worked. S/he went out to the hospital about an hour after I left. Review of Resident #1's care plan initiated 07/12/2007 indicated Resident #1 as at risk for falls r/t (related to) impaired cognition r/t cognition with late effects, right side [MEDICAL CONDITION] and weakness . Approaches included resident requires use of motorized wheelchair for mobility, transfer per safe handling tool . Review of Resident #1's Safe Resident Handling Data Collection Form dated 12/14/2017 documented the resident was to use the sit to stand lift to toilet and the total lift for bed to chair transfer with 2 persons to operate the lifts. S/he's current weight was noted as 294.8 pounds at the time of the lift assessment. Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] coded the resident with severely impaired decision making skills. The MDS indicated Resident #2 needed extensive to total assistance for all activities of daily living; requiring the assistance of two persons for transfer and bed mobility; the resident required feeding. Review of Resident #2's care plan initiated 12/05/2017 indicated Resident #2 as at risk for falls r/t (related to) impaired mobility, weakness . Approaches included low bed with mats . Observation on 03/01/2018 at approximately 9:50 AM revealed Resident #2 in bed with the head of the bed elevated, mats were positioned on each side of the bed and the bed was in the high position, the curtain was pulled between Resident #2 and his/her roommate. This was confirmed by LPN #2. The care planned information regarding the low bed was posted above the resident's bed, along with turning and lift requirements.",2020-09-01
1490,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-03-01,689,D,1,0,E3S611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview the facility failed to ensure each resident received adequate supervision to prevent accidents. CNA (Certified Nursing Aide) # 1 provided ADL care to Resident #1 by his/herself and did not follow the resident's plan of care which called for two staff members. Resident #2 was care planned at risk for falls with interventions that included low bed. Resident #2 was observed by the surveyor with bed in high position. 2 of 3 residents sampled. The findings included: Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] coded the resident with a Brief Interview of Mental Status (BIMS) of 10. The MDS indicated Resident #1 needed extensive to total assistance for all activities of daily living; requiring the assistance of two persons for transfer, bed mobility, toileting and dressing. S/he was frequently incontinent of bowel and bladder. The Quarterly MDS dated [DATE] coded the resident with a BIMS of 15 with ambulation on and off the unit requiring set up help only using an electric wheelchair. The resident fed him/herself after set up help and was occasionally incontinent of bowel and bladder. Review of the Departmental Notes dated 01/25/2018 at 10:39 PM revealed a late entry for 01/24/2018 at 6:00 PM that stated, Residents CNA (certified nurse aide) came out of his/her room calling for staff help and I immediately responded. Resident noted holding onto hand rails of sit to stand with both feet off stand and in kneeling position. Resident denied pain/discomfort other than his/her position. With the help of another staff member, resident was gently lowered to floor and then lifted back up with total lift and placed into bed. No apparent injury. A note dated 01/25/2018 at 12:59 AM indicated the resident vomited and stated s/he wasn't feeling good s/he was noted with a possible drooping mouth and an O2 saturation of 84%. The nursing supervisor was notified and EMS (emergency medical service) was called, the resident left the facility for the hospital at 12:25 AM via stretcher. Review of the hospital admission note dated 01/25/2018 indicated the resident was examined at 05:30 AM and admitted with an assessment and plan that stated: .UTI (urinary tract infection) with [MEDICAL CONDITION] ., [MEDICAL CONDITION] with rapid ventricular response .; hypokalemai ., acute kidney injury with creatinine 1.6 .; wounds, right lower extremity ./ PT/OT (physical therapy/occupational therapy .; [MEDICAL CONDITION] . Further review of the hospital admission for 01/25/2018 revealed an Orthopedic Trauma Service consultation dictated on 01/25/2018 at 6:13 PM that stated, x-rays reviewed include AP and lateral, left femur. They show a spiral [MEDICAL CONDITION], femoral shaft which is mildly displaced. Resident #1's femur was surgically repaired and s/he was discharged back to the facility on [DATE]. The initial assessment and plan on admission to the hospital did not mention treatment of [REDACTED]. Review of the facility 5 Day Follow up report dated 01/30/2018 stated that Resident #1 had a fall during transfer using the sit to stand lift. The resident's foot slipped off of the sit to stand lift and the CNA went to get assistance. S/he complained of knee pain initially and was given his/her normal scheduled pain medication, with no further voiced complaints. The resident was later sent out to the hospital for evaluation of vomiting and decreased O2 saturation. The resident was noted with a knot on his/her left knee and taken to x-ray the evening of 01/25/2018 and found to have a fractured femur. The facility investigation revealed the CNA did not follow facility policy with transfer. In an interview with the surveyor on 02/28/2018 at 3:20 PM Licensed Practical Nurse (LPN) #1 stated that s/he was in the hall passing meds around 6:00 PM on 01/24/2018 when CNA #1 came out in the hall and called for help. I walked in the room and s/he was alone, no straps were on the lift. LPN #1 stated that CNA #1 told her/him that the resident refused the straps. I assessed him/her, did range of motion, s/he had no complaints except that his/her left knee hurt, which was his/her usual complaint. I gave him/her the ordered Tylenol like every night. S/he didn't have any other complaints. I didn't call anyone, s/he didn't have an injury, I kept an eye on him/her, s/he said the Tylenol worked. S/he went out to the hospital about an hour after I left. Review of Resident #1's care plan initiated 07/12/2007 indicated Resident #1 as at risk for falls r/t (related to) impaired cognition r/t cognition with late effects, right side [MEDICAL CONDITION] and weakness . Approaches included resident requires use of motorized wheelchair for mobility, transfer per safe handling tool . Review of Resident #1's Safe Resident Handling Data Collection Form dated 12/14/2017 documented the resident was to use the sit to stand lift to toilet and the total lift for bed to chair transfer with 2 persons to operate the lifts. S/he's current weight was noted as 294.8 pounds at the time of the lift assessment. Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] coded the resident with severely impaired decision making skills. The MDS indicated Resident #2 needed extensive to total assistance for all activities of daily living; requiring the assistance of two persons for transfer and bed mobility; the resident required feeding. Review of Resident #2's care plan initiated 12/05/2017 indicated Resident #2 as at risk for falls r/t (related to) impaired mobility, weakness . Approaches included low bed with mats . Observation on 03/01/2018 at approximately 9:50 AM revealed Resident #2 in bed with the head of the bed elevated, mats were positioned on each side of the bed and the bed was in the high position, the curtain was pulled between Resident #2 and his/her roommate. This was confirmed by LPN #2. The care planned information regarding the low bed was posted above the resident's bed, along with turning and lift requirements.",2020-09-01
1491,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,554,D,0,1,LWXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure 1 of 1 resident sampled for Self-Administration of Medication was assessed prior to being allowed to give own medication. Resident #25 was allowed to manage own insulin coverage without any assessment of his/her ability to do so. The findings included: The facility admitted Resident #25 with [DIAGNOSES REDACTED]. Use of Aspirin. Record review on 05/19/18 at approximately 5:53 PM revealed a nurse's note dated 05/09/18 stating, Finger Stick Blood Sugar (FSBS) 3x daily cover with sliding scale (SS) #1 .scheduled for 05/09/18 6:30 AM was held, he takes care of his own insulin. Further investigation revealed this occurred on 05/05-08/18. In an interview on 05/19/18 at approximately 7:52 PM the Director of Nursing (DON) stated Resident #25 was not assessed to determine whether clinically able to self-administer insulin. Review of facility policy on Standards of Care provided by the DON revealed, If a resident requests to self administer drugs, it is the responsibility of the interdisciplinary team to determine that it is safe for the resident to self-administer drugs before the resident may exercise that right",2020-09-01
1492,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,580,D,0,1,LWXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the Physician and the Responsible Party were notified of Resident #26's and Resident#111's significant weight loss in 2 of 11 residents reviewed for nutrition. The findings included: Resident #26 was admitted with [DIAGNOSES REDACTED]. During an observation of Resident #26's lunch on 05/18/18 at 01:33 PM, the resident was in her room, lunch tray in front of her/him, the food is untouched. During an observation of Resident #26's lunch on 5/19/18 at 1:03 PM, the resident was in her/his room and was feeding herself/himself with her/his right hand and he/she said she/he was hungry. , Review of the form titled Departmental Notes, an entry for Resident #26 on 5/16/2018 at 4:03 PM, Role: Dietary, Category, Nutrition, states: Weight review note: Resident noted with significant weight loss of 5.3% within 30 days, current weight 132 pound, down from 140 pound in 16 days. Current Height: 63 (inches), current BMI (Body Mass Index) 23.4. Resident transferred to hospital 05/09 related to UTI (Urinary Tract Infection) and returned 5/10 .Care plan is in place to address history of significant weight loss. An entry for Resident #26 on 2/27/18 at 1:53 PM, Role: Dietary, Category: Nutrition, states; Weight review note: Resident noted with significant weight loss of 10.28% within 180 days; current weight 134 pounds down from 149 pounds in 179 days .Resident was hospitalized for [REDACTED]. Review of the careplan for Resident #26 states: Problem Onset: 2/27/18, Resident #26 is at possible nutritional risk related to history of significant with loss. During an interview on 5/19/18 at 5:00 PM with the Registered Dietitian, he/she said that she/he reviews the resident's weights and resident's weight changes. The Registered Dietitian said that she/he notifies the nursing staff either of the significant weight changes and the Nursing Staff notifies the Physician and the Responsible Party of significant weight changes. During an interview on 5/19/18 at 6:00 PM,with the DON regarding notification of the physician and the responsible party for Resident #26, he/she stated that he/she was unable to locate any documentation in the Nurses's notes that the Physician or that the Responsible party had been notified of the significant weight losses in (MONTH) (YEAR) or (MONTH) (YEAR). Review of the facility form titled: Standards of Care states: I. Supervision The Assistant DON (Director of Nursing) shall make resident rounds each morning and afternoon as needed. Each resident shall be monitored, and any change in the resident's condition shall be documented in the nurse's notes and on the acute board for follow. The physician and the family (or the resident's representative) shall be informed of any change in the resident's condition.The ADON, Shift Supervisor, Charge Nurse, or designee shall be responsible for making calls to the physician. The facility admitted Resident #111 with [DIAGNOSES REDACTED]. Record review on 05/19/18 at approximately 9:59 AM revealed weights of 11/10/17 135, 12/14/17 128, for a loss of 5.19% in 30 days and 01/16/18 121 for a loss of 5.47% in the following 30 days. Review of the Progress Notes for Dietary revealed a Nutrition assessment was completed on 11/21/17. A Dietary Progress Note dated 01/24/18 stated Resident noted with significant weight loss of 10.37% within 90 days; current weight 121# down from 135.3 in 67 days. Current BMI 18.9 indicates underweight status with weight gain favorable. Current diet: Pureed (allowed soft sandwiches). Registered Dietician (RD) visited with resident during breakfast meal; observed 100% of milk and juice consumed, however with meal untouched. RD will provide milk times 2 with all meal trays, magic cup with breakfast (290 kcals, 9 grams protein) and ice cream with lunch/dinner meals. Further review revealed a Dietary Progress Note dated 03/22/18 Resident noted with significant weight loss of 1.6% within 180 days; current weight 118# .Resident continue to primarily only eat cereal and drinks ensure with prompting. Dietary provides cereal with all meals. Nursing stated resident has tried 2 Cal before and enjoyed it; therefore RD recommending 2 Cal 120 ml 2 times per day with Medpass to provide additional 480 kcals and 20 grams of protein. This same record review revealed a Nutritional Recommendations Form dated 03/22/18 stating Please contact Physician for consideration of the following recommendation: Two Cal 120mL BID. The reason for the recommendation was stated as significant weight loss/ Poor percentage of intake. The blanks for the information Date physician Contacted; Contacted by and Results of Physician Contact were all empty. In an interview on 05/19/18 at approximately 6:44 PM while reviewing a cop of the 24-Hour report dated 03/22/18 the Director of Nursing acknowledged that the Resident's Representative was notified of the change in diet but that the expectation would have been that the Physician would have also been notified of the change in Resident #111's condition. The DON provided a copy of the facility policy entitled Weight Changes which stated: Purpose: to ensure weight changes are identified and addressed in a systematic way. Policy: Significant as well as insidious, undesirable weight changes are identified, assessed, and interventions implemented in a timely manner. Procedures: 1. Weights are reviewed for significant or undesirable changes by the care plan team members . 2. Residents experiencing a 5% loss in 30 days or a 10% loss in 180 days are reviewed for a possible significant change assessment per the RAI manual guidelines. 3. Documentation of interventions, results and changes to the care plan are completed by the care plan team. 4. The resident, responsible party, physician and RD are notified of any unresolved, undesirable weight changes.",2020-09-01
1493,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,656,D,0,1,LWXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure development of a Comprehensive Care Plan related to Restorative Services for Resident #108, 1 of 5 sampled residents reviewed for Range of Motion; related to Nutrition for Resident #141, 1 of 11 sampled residents reviewed for Nutrition and related to self- administration of Insulin for Resident #25, 1 of 1 sampled residents reviewed for Self-Administration of Medication. The findings included: The facility admitted Resident #25 with [DIAGNOSES REDACTED]. Use of Aspirin. Record review on 05/19/18 at approximately 5:53 PM revealed a nurse's note dated 05/09/18 stating, Finger Stick Blood Sugar (FSBS) 3x daily cover with sliding scale (SS) #1 .scheduled for 05/09/18 6:30 AM was held, he takes care of his own insulin. Further investigation revealed this occurred on 05/05-08/18. In an interview on 05/19/18 at approximately 7:52 PM the Director of Nursing (DON) stated Resident #25 was not assessed to determine whether clinically able to self-administer insulin and the Care Plan was not developed for self-administration of medications. Review of facility policy on Standards of Care provided by the DON revealed, If a resident requests to self administer drugs, it is the responsibility of the interdisciplinary team to determine that it is safe for the resident to self-administer drugs before the resident may exercise that right. And also that a care plan is formulated regarding medications that the resident will self-administer. The facility admitted Resident #108 with [DIAGNOSES REDACTED]. Record review on 05/16/18 at approximately 2:02 PM revealed an order for [REDACTED]. In interviews on 05/17/18 the Director of Nursing at approximately 2:34 PM and OT #1 at approximately 3:46 PM each stated the orders should have been transcribed to be added to the physician's orders [REDACTED].#108's most recent order. The facility admitted Resident #141 with [DIAGNOSES REDACTED]. Record review on 5/16/18 at 5:50 PM of the resident's care plan revealed no care plan had been developed for nutrition. Review of the physician's orders [REDACTED]. Review of the nutritional notes revealed Resident #141 had been educated on the importance of protein in the diet and a Multivitamin and Vitamin C had been recommended. Further review of the medical record revealed the resident's weight on 4/20/18 was recorded as 114 pounds and on 5/11/18 the recorded weight was 109.6 pounds. During an interview with the Registered Dietitian on 5/19/18 at 5:29 PM, s/he stated a nutrition care plan had been developed on 5/19/18. The care plan was developed after the surveyor brought it to the attention of the facility.",2020-09-01
1494,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,657,D,0,1,LWXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the interdisciplinary care plans were updated for Kennedy Cups for Residents #137, #87, and #53 for 3 of 6 residents with therapy orders for Kennedy Cups. The findings included: Resident #137 was admitted with [DIAGNOSES REDACTED]. During an observation of the lunch service on 5/18/18 at 1:15 PM, Resident #137 was feeding herself/himsef and is using a weighted spoon to feed herself/himself the meringue topping on a piece of pie. Resident #137's Tray Card states: Puree Diet, Kennedy Cup. An observation was verified by LPN#4 that there was no Kennedy Cup on the tray. LPN #4 stated: I am going to get one. LPN#4 walked down the hall and got a Kennedy cup from the the Nutrition Consultant RD who was standing at the end of hallway. LPN #4 then carried the Kennedy cup to Resident #137's room, he/she then placed the Kennedy Cup on Resident#137's tray. The CNA in Resident #137's room said that he/she was getting ready to take Resident #137 to the Beauty Shop. Review of the Medical Record for Resident #137 shows a form titled: DIET/SUPPLEMENT/TUBE FEEDING COMMUNICATION FORM (Deliver to the Dietary Dept.) which states Date: 1/11/17, Name: Resident #137, Diet Order: K (Kennedy)-Cup to reduce spillage. The form titled: Occupational Therapy Plan of Care, for Resident #137 states: Treatment Diagnosis: [REDACTED]. Feeding Difficulties, Start of Care : 02/19/2018, Reason for Referral: .Pt(patient) has significant decline with ability to self feed compared with OT discharge on 1/25/18, Precautions: Needs assistive device for self feeding and w/c (wheelchair positioning). This form is signed by the Physician on 2/22/18. The form titled: NUTRITIONAL SCREENING REVIEW, for Resident #137 states: GENERAL INFORMATION, Feeding Ability/Assistive Devices: Independent/trayset-up only and Limited Assistance both categories have an x marked, Adaptive Feeding Device Details: Weighted Spoon k K-Cup.The section titled Summary states: .Lookback period 5/02-5/08: .self feeds during meal times with adaptive equipment. The form titled Care Plan for Resident #137, states: CNA CARE AND DATE COLLECTION GUIDE, states: Approaches, FYI (For Your Information)-SPECIAL INSTRUCTIONS-K-cup, weighted spoon with all meals. *********************************** Resident # 87 was admitted with [DIAGNOSES REDACTED]. During an observation of the Lunch service on 05/18/18 at 01:10 PM, Resident #87 was feeding herself. Resident #87's Tray Card states: Kennedy Cup on tray. An observation was verified by LPN #2 that there was no Kennedy Cup on the tray. He/She stated: (to the surveyor), I thought you were going to go and get the cup. LPN #2 when asked what should she do when an item is missing from the resident's tray, he/she said, I would go to the kitchen and get the item and then he/she left the room and went down the hall to obtain the missing Kennedy cup. Review of the Medical Record for Resident #87 shows a form titled: ORDER FORM which states Date: [DATE], (YEAR), Name: Resident #137, Special Request: K-Cup with meals. The form titled: OT (Occupational Therapy) -Therapist Progress and Discharge Summary, for Resident #87 states: Treatment Diagnosis: [REDACTED]. Feeding Difficulties, Start of Care : 09/26/2017, End of Care: 11/29/2017, Self Feeding-General, End of Goal Status as of 11/29/2017: Dc'd on 11/06/2017** .Supervision (Mild) with cues and adaptive equipment as needed. The form titled: NUTRITIONAL SCREENING/ REVIEW, for Resident #87 states: GENERAL INFORMATION, Feeding Ability/Assistive Devices: Independent/trayset-up only and Limited Assistance both categories have an x marked, Adaptive Feeding Device Details: K-Cup, Completion Information: Date/Time: 1/30/2018 by the Registered Dietitian. During an interview on 5/19/18 at 09:48 AM ,The Consultant RD said that he/she had removed the Kennedy Cup from Resident #87's CNA care plan as the resident had been refusing to use the Kennedy Cup. The Consultant RD verified that the Tray Card for Resident #87 still shows that resident has a Kennedy Cup listed on the tray card. The Consultant RD verified that there are no physician orders for Adaptive devices, the orders are made by the therapy department and a copy of the therapy order goes to the dietary department. The Dietary staff then updates the resident's tray card with the ordered adaptive device and then it prints on the tray card for each meal. ********* Resident #53 was admitted with [DIAGNOSES REDACTED]. During the meal observation in the Dining Room on 5/18/18 at 1:25 PM of Resident #53, who is being assisted by CNA #2. Resident #53's Tray Card states: Weighted spoon, food in bowls, weighted fork .Kennedy Cup. CNA # 2 verified that there is no Kennedy Cup on the tray and he/she said, I will hold cup for him/her. CNA #3 also verified that the Kennedy Cup was not on the resident's tray and he/she said that he/she would go get the Kennedy cup for Resident #53. Review of the Medical Record for Resident #53 shows a form titled: DIET/SUPPLEMENT/TUBE FEEDING COMMUNICATION FORM which states Date 1/24/2017, Name: Resident #53, *Please put all drinks in a K-Cup, the handle helps him/her hold the cup due to hand tremors. The form titled: NUTRITIONAL SCREENING/ REVIEW, for Resident #53 states: .GENERAL INFORMATION, Feeding Ability/Assistive Devices: Independent/trayset-up only and Limited Assistance both categories have an x marked, Adaptive Feeding Device Details: K-Cup,Food in Bowls, Weighted Utensils. Completion Information: Date/Time: 3/22/2018 by the Registered Dietitian. The form titled: Care Plan for Resident #53 states: Problem Onset: 10/17/2012, resolved 12/27/12, Resident #53 requires a Regular/NAS diet r/t dx [MEDICAL CONDITION] Onset: 10/23/2012 Another Care plan for Resident #53, states: Requires various levels of assistance with his adl's (activities of daily living) r/t dx of [MEDICAL CONDITION], Approaches, .*PROVIDE ADAPTIVE FEEDING EQUIPMENT (k-cup, Food in bowls, Weighted Utensils) The form for Resident #53 titled Care Plan, CNA CARE AND DATE COLLECTION GUIDE, states: Approaches, FYI (For Your Information)-SPECIAL INSTRUCTIONS-K-cup, food in bowls, weighted utensils with all meals. Interview with Dietary Consultant on 05/18/18 01:52 PM Regarding the missing Kennedy cups, he/she said they were in the kitchen and not put on trays. During a lunch meal dining observation on 5/18/2018 from approximately 1:00-1:30 PM ,Resident #137, #87, and #53 did not have the Kennedy Cup on their meal trays. Each resident's meal ticket which was placed on the meal trays stated , Kennedy cup. During an Interview with the Dietary Consultant on 05/18/18 01:52 PM regarding the missing Kennedy cups, he/she said they were in the kitchen and not put on trays. During an Interview with the Dietary Consultant on 5/19/18 at 09:48 AM, the Nutrition Consultant verified that the Kennedy Cups were typed on Resident #137, #87 and #53's tray cards and that the residents did not have the Kennedy Cups on their meal trays at lunch on 5/18/18. The Dietary Consultant further stated that anyone, a nurse or therapy can discontinue the adaptive equipment if not needed anymore. They would notify dietary so that dietary can update the tray card. The Dietary Consultant verified that there are no physician orders for adaptive eating equipment to be utilized for meals and to assist the resident with independence in eating. During an Interview with the DON on 05/19/18 at 09:50 AM, he/she verified that there is no physician order for [REDACTED]. Review of the facility form titled, Adaptive Feeding Devices, states: Purpose: To promote highest level of self feeding: Policy: Residents experiencing functional difficulties with self-feeding will be evaluated and adaptive devices will be provided as needed. Procedures: .3. Specialty self-feeding devices will be provided as recommended of a therapist .6. Use of self-feeding devices is addressed on the interdisciplinary care plan and resident care guide as well as periodic evaluation of effectiveness is documented in the Restorative and Dietary reviews. The devices are discontinued as needed with subsequent update of the care plan and resident care guide.",2020-09-01
1495,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,658,D,0,1,LWXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interview the facility failed to ensure that physicians orders were followed relevant to positioning of 1 of 4 residents observed during medication pass. (Cross refer F759) The findings include: On 5/14/18 at approximately 10:55 AM, LPN (Licensed Practical Nurse) # 1 woke up Resident # 7 from sleep and administered eleven medications by mouth and 2 medications by inhalation to the Resident who was lying in bed at an approximate angle of 25 degrees. On 5/14/18 at approximately 11:08 AM during medication reconciliation, a review of physician orders [REDACTED]. - Regular diet meat/thin liquids with strict aspiration precautions. Pt (patient) upright at 90 degrees for all PO (oral). During an interview on 5/14/18 at approximately 11:20 AM, LPN # 1 acknowledged that during medication administration Resident # 7 had not been positioned to 90 degrees as ordered by the physician.",2020-09-01
1496,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,688,E,0,1,LWXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide Restorative Services for 1 of 5 sampled residents reviewed for Range of Motion. Resident #108 did not receive Restorative Services to maintain or prevent decrease in Range of Motion. The findings included: The facility admitted Resident #108 with [DIAGNOSES REDACTED]. Record review on 05/16/18 at approximately 2:02 PM revealed an order for [REDACTED]. In interviews on 05/17/18 the Director of Nursing at approximately 2:34 PM and OT #1 at approximately 3:46 PM each stated the orders should have been transcribed to be added to the physician's orders [REDACTED].",2020-09-01
1497,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,759,D,0,1,LWXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interview the facility failed to ensure that it was free of a medication error rate of 5 % (percent) or greater. The medication error rate was 9.7 % based on 3 of 31 opportunities for error. (Cross Refer F658) The findings include: On 5/14/18 at approximately 10:55 AM, LPN (Licensed Practical Nurse) # 1 woke up Resident # 7 from sleep and administered one tablet of [MEDICATION NAME] 500 mg, one puff (inhalation) of Incruse Ellipta 62.5 mcg (micrograms) and one puff of Breo Ellipta 100-25 mcg (micrograms). It was noted that Resident # 7 was lying at an approximate angle of 25 degrees in bed, had not eaten breakfast, that the inhalations of Incruse Ellipta 62.5 mcg and Breo Ellipta 100-25 mcg were given one after the other with less than one minute separation between each each puff and that the mouth of Resident #7 was not rinsed after administration of the Breo Ellipta. On 5/14/18 at approximately 11:08 AM during medication reconciliation, a review of physician orders [REDACTED]. - [MEDICATION NAME] HCL ([MEDICATION NAME]) 500 MG: Give ONE tab (tablet) by mouth twice daily Dx (diagnosis): DM (diabetes mellitus) *Take with food: snack or after meal* (ERROR #1). - INCRUSE ELLIPTA 62.5 MCG INH Give ONE puff via oral inhaler once daily. Dx: [MEDICAL CONDITIONS] Wait 5 min between inhalations* - BREO ELLIPTA 100-25 MCG INH (inhaler) Give ONE puff via oral inhaler once daily . Dx: [MEDICAL CONDITION] *Rinse Mouth After Use* **Wait 5 min (minutes between inhalations** (ERRORS 2 & 3) - Regular diet meat/thin liquids with strict aspiration precautions. Pt (patient) upright at 90 degrees for all PO (oral). During an interview on 5/14/18 at approximately 11:20 AM, LPN # 1 acknowledged that Resident # 7 had not eaten breakfast, had not been positioned to 90 degrees as ordered by the physician, had not eaten breakfast prior to administration of [MEDICATION NAME] 500 mg, that a 5 minute separation between puffs of inhaled medications had not occurred and the Resident's mouth had not been rinsed after administration of Breo Ellipta.",2020-09-01
1498,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,810,E,0,1,LWXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure assistive eating devices as ordered by the Therapy Department were provided during meals for Resident #137, #87, and #53 for 3 of 6 residents with therapy orders for Kennedy Cups. The facility failed to ensure residents received adaptive devices during meals. Kennedy cups ordered for 6 of 163 residents. Meal observation of 3 residents with Kennedy cups ordered and were not received at lunch on 5/18/18. The findings included: Resident #137 was admitted with [DIAGNOSES REDACTED]. During an observation of the lunch service on 5/18/18 at 1:15 PM, Resident #137 was feeding herself/himself and is using a weighted spoon to feed herself/himself the meringue topping on a piece of pie. Resident #137's Tray Card states: Puree Diet, Kennedy Cup. An observation was verified by LPN#4 that there was no Kennedy Cup on the tray. LPN #4 stated: I am going to get one. LPN#4 walked down the hall and got a Kennedy cup from the the Nutrition Consultant RD who was standing at the end of hallway. LPN #4 then carried the Kennedy cup to Resident #137's room, he/she then placed the Kennedy Cup on Resident#137's tray. The CNA in Resident #137's room said that he/she was getting ready to take Resident #137 to the Beauty Shop. Review of the Medical Record for Resident #137 shows a form titled: DIET/SUPPLEMENT/TUBE FEEDING COMMUNICATION FORM (Deliver to the Dietary Dept.) which states Date: 1/11/17, Name: Resident #137, Diet Order: K (Kennedy)-Cup to reduce spillage. The form titled: Occupational Therapy Plan of Care, for Resident #137 states: Treatment Diagnosis: [REDACTED]. Feeding Difficulties, Start of Care : 02/19/2018, Reason for Referral: .Pt(patient) has significant decline with ability to self feed compared with OT discharge on 1/25/18, Precautions: Needs assistive device for self feeding and w/c (wheelchair positioning). This form is signed by the Physician on 2/22/18. The form titled: NUTRITIONAL SCREENING REVIEW, for Resident #137 states: GENERAL INFORMATION, Feeding Ability/Assistive Devices: Independent/trayset-up only and Limited Assistance both categories have an x marked, Adaptive Feeding Device Details: Weighted Spoon k K-Cup.The section titled Summary states: .Lookback period 5/02-5/08: .self feeds during meal times with adaptive equipment. The form titled Care Plan for Resident #137, states: CNA CARE AND DATE COLLECTION GUIDE, states: Approaches, FYI (For Your Information)-SPECIAL INSTRUCTIONS-K-cup, weighted spoon with all meals. *********************************** Resident # 87 was admitted with [DIAGNOSES REDACTED]. During an observation of the Lunch service on 05/18/18 at 01:10 PM, Resident #87 was feeding herself/himself. Resident #87's Tray Card states: Kennedy Cup on tray. An observation was verified by LPN #2 that there was no Kennedy Cup on the tray. He/She stated: (to the surveyor), I thought you were going to go and get the cup. LPN #2 when asked what should he/she do when an item is missing from the resident's tray, he/she said, I would go to the kitchen and get and the item and then he/she left the room and went down the hall to obtain the missing Kennedy cup. Review of the Medical Record for Resident #87 shows a form titled: ORDER FORM which states Date: [DATE], (YEAR), Name: Resident #137, Special Request: K-Cup with meals. The form titled: OT (Occupational Therapy) -Therapist Progress and Discharge Summary, for Resident #87 states: Treatment Diagnosis: [REDACTED]. Feeding Difficulties, Start of Care : 09/26/2017, End of Care: 11/29/2017, Self Feeding-General, End of Goal Status as of 11/29/2017: Dc'd on 11/06/2017** .Supervision (Mild) with cues and adaptive equipment as needed. The form titled: NUTRITIONAL SCREENING/ REVIEW, for Resident #87 states: GENERAL INFORMATION, Feeding Ability/Assistive Devices: Independent/trayset-up only and Limited Assistance both categories have an x marked, Adaptive Feeding Device Details: K-Cup, Completion Information: Date/Time: 1/30/2018 by the Registered Dietitian. During an interview on 5/19/18 at 09:48 AM ,The Consultant RD said that he/she had removed the Kennedy Cup from Resident #87's CNA care plan as the resident had been refusing to use the Kennedy Cup. The Consultant RD verified that the Tray Card for Resident #87 still shows that resident has a Kennedy Cup listed on the tray card. The Consultant RD verified that there are no physician orders for Adaptive devices, the orders are made by the therapy department and a copy of the therapy order goes to the dietary department. The Dietary staff then updates the resident's tray card with the ordered adaptive device and then it prints on the tray card for each meal. ********* Resident #53 was admitted with [DIAGNOSES REDACTED]. During the meal observation in the Dining Room on 5/18/18 at 1:25 PM of Resident #53, who is being assisted by CNA #2. Resident #53's Tray Card states: Weighted spoon, food in bowls, weighted fork .Kennedy Cup. CNA # 2 verified that there is no Kennedy Cup on the tray and he/she said, I will hold cup for him/her. CNA #3 also verified that the Kennedy Cup was not on the resident's tray and he/she said that he/she would go get the Kennedy cup for Resident #53. Review of the Medical Record for Resident #53 shows a form titled: DIET/SUPPLEMENT/TUBE FEEDING COMMUNICATION FORM which states Date 1/24/2017, Name: Resident #53, *Please put all drinks in a K-Cup, the handle helps him/her hold the cup due to hand tremors. The form titled: NUTRITIONAL SCREENING/ REVIEW, for Resident #53 states: .GENERAL INFORMATION, Feeding Ability/Assistive Devices: Independent/trayset-up only and Limited Assistance both categories have an x marked, Adaptive Feeding Device Details: K-Cup,Food in Bowls, Weighted Utensils. Completion Information: Date/Time: 3/22/2018 by the Registered Dietitian. The form titiled: Care Plan for Resident #53 states: Problem Onset: 10/17/2012, resolved 12/27/12, Resident #53 requires a Regular/NAS diet r/t dx [MEDICAL CONDITION] Onset: 10/23/2012 Another Care plan for Resident #53, states: Requires various levels of assistance with his adl's (activities of daily living) r/t dx of [MEDICAL CONDITION], Approaches, .*PROVIDE ADAPTIVE FEEDING EQUIPMENT (k-cup, Food in bowls, Weighted Utensils) The form for Resident #53 titled Care Plan, CNA CARE AND DATE COLLECTION GUIDE, states: Approaches, FYI (For Your Information)-SPECIAL INSTRUCTIONS-K-cup, food in bowls, weighted utensils with all meals. Interview with Dietary Consultant on 05/18/18 01:52 PM Regarding the missing Kennedy cups, he/she said they were in the kitchen and not put on trays. **************************************************** During a lunch meal dining observation on 5/18/2018 at Resident #137, #87, and #53 did not have the Kennedy Cup on their meal trays. Each resident's meal ticket which was placed on the meal trays stated , Kennedy cup. During an Interview with the Dietary Consultant on 05/18/18 01:52 PM Regarding the missing Kennedy cups, he/she said they were in the kitchen and not put on trays. During an Interview with the Dietary Consultant on 5/19/18 at 09:48 AM, the nutrition consultant verified that the Kennedy Cups were typed on Resident #137, #87 and #53's tray cards and that the residents did not have the Kennedy Cups on their meal trays at lunch on 5/18/18. The Dietary Consultant further stated that anyone, a nurse or therapy can discontinue the adaptive equipment if not needed anymore. They would notify dietary so that dietary can update the tray card. The Dietary Consultant verified that there are no physician orders for adaptive eating equipment to be utilized for meals and to assist the resident with independence in eating. Interview with the DON on 05/19/18 at 09:50 AM, he/she verified that there is no physician order for [REDACTED]. Review of the facility form titled, Adaptive Feeding Devices, states: Purpose: To promote highest level of self feeding: Policy: Residents experiencing functional difficulties with self-feeding will be evaluated and adaptive devices will be provided as needed. Procedures: .3. Specialty self-feeding devices will be provided as recommended of a therapist .6. Use of self-feeding devices is addressed on the interdisciplinary care plan and resident care guide as well as periodic evaluation of effectiveness is documented in the Restorative and Dietary reviews. The devices are discontinued as needed with subsequent update of the care plan and resident care guide.",2020-09-01
1499,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,812,F,0,1,LWXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure the kitchen walls, floors in food preparation areas are maintained clean in, and expired foods were discarded, food was not stored directly on the floor, staff member was wearing appropriate hair covering when working, 1 of 1 kitchen and that foods stored in refrigeration units were labeled and dated after opening. The findings included: During initial tour of the Dietary Department on [DATE] at 8:11, observations of the following were verified by the Registered Dietitian: 1) Inside the Walk in Cooler there was a container of Vanilla Almond Creamer with Use by [DATE] stamped on the container a Dietary Team Member stated How did this get here? This was immediately discarded by the Registered Dietitian. 2) There is a collection of dust on the wall behind the cooking surface of the oven. 3) The 6 Ceiling vents located directly above the trayline where the breakfast food is being plated there is a heavy coating of dust around the vent openings. 4) The wall behind the clean pan rack has a collection of gray dust, and the ceiling vent above clean pans rack is dusty, paint is peeling on the ceiling above the pan rack, [DATE] 09:05 AM 5) The wall located beside the doorway leading to the dining room has a ceiling vent above that has a heavy collection of black dust and there is black dust on the wall,. 6) The can opener is mounted to the table and the can opener base is soiled and the area directly above the blade has built on soil and grease. During an observation which was verified by the Consultant Dietitian and the Registered Dietitian on [DATE] at 07: 00 AM: 1)Above the dishmachine wall, the clean dish end the yellow wall has black specks of mysterious black substance. The wall pained black directly above the clean end of the dishmachine has a mysterious gray substance on the wall. 2) The Light fixture above the Beverage Preparation area cling is soiled with dust and the wall soiled with food debris. 3) The 6 Ceiling vents located directly above the trayline where the breakfast food is being plated there is a heavy coating of dust around the vent openings. (This is the second observation, first observation [DATE]) 4) The wall behind the clean pan rack has a collection of gray dust, and the ceiling vent above clean pans rack is dusty, paint is peeling on the ceiling above the pan rack. ( (This is the second observation, first observation [DATE]) 5) The wall located beside the doorway leading to the dining room has a ceiling vent above that has a heavy collection of black dust and there is black dust on the wall,.(This is the second observation, first observation [DATE]) 6) The floors throughout the kitchen are dirty and in disrepair, when the Dietary Consultant was asked why the floors were soiled he/she said We have floor replacement budget. Review of the form titled: Cleaning of Dietary Environmental Surfaces, states, Policy: Environmental area, both food contact and non-food contact, will be cleaned and sanitized on a scheduled and as needed basis., Procedures: 4. Floors shall be cleaned on a daily basis and as needed. 7. Periodic cleaning of ceilings, light fixtures, vents and ventilation's systems shall be scheduled and completed by the maintenance department. During an observation on [DATE] at 7:07 AM, 2 maintenance employees came into the kitchen pushing rolling refrigerator. One of the maintenance employees had a baseball hat on and the other maintenance employee, Floor Technician #1 had no hair covering on his/her head, and when he was asked by a Dietary Team Member to put on hair covering he/she smiled and kept walking through the kitchen. During an interview with the Dietary Consultant RD, he/she said it is the expectation that anyone who enters the kitchen should have a hair covering on the head, and indicated that the department keeps a collection of hair covering by the entrance to the kitchen. During an observation on [DATE] from 7:30 AM to 8:20 AM, there were 7 stacks of over 30 cases of food siting directly in the floor in the main hallway of the facility outside the dining room. The food vendor was delivering an order of food during this period of time and continued to placed each new stack of food directly on the floor. Observed residents in wheelchairs pass by the stacks of food as well as team members walking by. This observation was verified with the RD and RD Dietary Consultant RD. The Dietary Consultant RD said that the delivery is usually not on floor, but placed on on small black racks that keep the food off of the floor surface. The facility form titled: Storage of Food and Supplies, states, .3. Dray and staple food items are stored on dollies at least six inches from the floor . During an observation on [DATE] at 09:05 AM, the[NAME]Unit's Refrigerator has a Sunsweet Prune Juice container 46 ounce which has been opened and is not labeled with the open date. This observation was verified by RN#1. During an observation on [DATE] at 09:12 AM, the[NAME]Hall Unit's Refrigerator has 60 ounce container of Ocean Spray Apple juice which has written on the side of the container ,[DATE] this observation was LPN #2 verified who stated: We throw away after 3 days should be in the garbage. He/She removed and discarded in the garbage. During an observation on [DATE] at 9:19 AM, the C Unit/Colony Hall's refrigerator has a 46 ounce container of Sunsweet Prune Juice which is opened and partially used and has written on the side of the container ,[DATE]. This observation was verified by Unit's refrigerator has 3 partially opened containers of juice and a gallon of whole milk all have been opened and there is no open date on the 2 containers of Ocean Spray Apple Juice, 60 ounce and the one container of Orange Juice Ocean Spray/60 ounce and 1 gallon of milk opened and no open date. This observation was verified by RN #4, he/she called the Dietary asked them to remove. RN #4 stated: Opened products in the refrigerator are like insulin you have to label it when you open it. The facility form titled: Storage of Food and Supplies, states: Procedures:1 Non-TCS( Time Temperature control for safety), food should be dated when opened . The 2013 Food Code, page 450, states .Date marking is the mechanism by which the Food Code requries active manageraila control of the temperatures and time combinations for cold holding. Date marking requirements apply to containers of process food that have been opened and to food prepared by a food establsihment, in both cases if held for more than 24 hours, and while the food is under the control of the establishment.",2020-09-01
1500,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,851,C,0,1,LWXD11,"Based on record review and interview, the facility failed to submit staffing information based on payroll data in a timely manner as required by the Centers for Medicare and Medicaid services. The findings included: Review of the CASPER Report 1702S revealed the following: Staffing Summary Report 1/1/17-3/31/17 submitted 5/16/17; Staffing Summary Report 4/1/17-6/30/17 submitted 8/15/17; Staffing Summary Report 7/1/17-9/30/17 submitted 11/15/17. At the time of the finding, staff responsible for submitting the Staffing Summary Report was unavailable to confirm the submission dates.",2020-09-01
1501,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2018-05-19,921,D,0,1,LWXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, random observations of resident rooms and observation with the Housekeeping Director, services were not provided as necessary to maintain a sanitary, orderly and comfortable interior for 1 of 4 units observed. The findings included: During random observations during the survey process and during environmental rounds with the Housekeeping Director on 5/18/18 at 4:45 PM, the following was observed: room [ROOM NUMBER]-bathroom door observed with damage; room [ROOM NUMBER]B-damage to wall beside bed, damage to bathroom door, worn area on corner of wall in entrance of room; room [ROOM NUMBER]B-bathroom door and door facing with damage; room [ROOM NUMBER]-damage to bathroom door; room [ROOM NUMBER]-damage to bathroom door. Chair guard on unit at nurse's station observed with multiple scrapes. During the tour, the Housekeeping Director confirmed the above findings. At approximately 5:00 PM on 5/18/18, the above findings were shared with the Administrator. Environmental rounding logs could not be found at the time of the survey. The Administrator stated the facility was in search of a Maintenance Director and someone from corporate was coming down to provide assistance. In addition, the Administrator stated doors were listed for corporate to review.",2020-09-01
1502,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2019-07-11,578,D,0,1,ZPCJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy titled, Implementation Of Advance Directives And Do Not Resuscitate Orders, the facility failed to ensure Resident #60, not deemed unable to make own healthcare decisions, was afforded the right to make own decision related to code status for 1 of 1 residents reviewed for advance directives. The findings included: The facility admitted Resident #60 on 6/21/2018 and readmitted the resident on 9/18/2018, with [DIAGNOSES REDACTED]. Review on 7/10/2019 at approximately 9:00 AM of the medical record for Resident #60 revealed a form titled, Medical Condition Certification, which stated, This resident DOES possess decisional capacity to make healthcare decisions for self. The form was signed by the attending physician. Further review on 7/10/2019 at approximately 9:00 AM of the medical record for Resident #60 revealed a form titled, DNR OR FULL CODE ADMISSION DECLARATION, signed by Resident #60, requesting to be a Full Code. During an interview on 7/10/2019 a approximately 11:20 AM with the Social Service Assistant, confirmed that Resident #60 was not deemed unable to make own health care decisions. The Social Service Assistant stated, I failed to get the resident to sign a form giving a family member permission to sign documents for him/her. A Declination of Signature form signed by Resident #60 on 6/21/19 was provided by the facility; however, the list of documents and paperwork the resident had been afforded the opportunity to sign upon readmission did not include advance directives and the section stating the reason for choosing not to sign admission documents and paperwork was blank. Review on 7/10/2019 at approximately 5:19 PM of the facility policy titled, Implementation Of Advance Directives And Do Not Resuscitate Orders, states under Policy, It is the policy of (facility) to honor requests to withhold or withdraw care, including life sustaining care, extraordinary measures and resuscitation when such requests are accompanied by supporting documents and a valid order of the resident's attending physician. Under Procedure, number 1. Physician Procedure: Competent Residents states that this facility, recognizes the fundamental right of informed competent adult residents to direct the course of their medical care. Requests of competent residents to withhold or withdraw care, including life sustaining care, extraordinary measures and resuscitation shall be honored when accompanied by a valid order of the resident's attending physician.",2020-09-01
1503,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2019-07-11,602,D,1,1,ZPCJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to protect Residents #76 and #13 for 2 of 4 residents reviewed for misappropriation of property and/or funds. The findings included: The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 07/09/19 at approximately 8:41 am revealed Resident #76 was admitted to the facility on [DATE]. A sheet entitled Inventory of Personal Effects dated the same date stated three rings were included in his/her personal belongings. In a statement on 05/27/19, the Social Services Assistant (SSA) reported that Resident #76 informed him/her that a ring was missing. The SSA stated s/he assisted Resident #76 with looking for the ring but it could not be located. Resident #76 reported last seeing the ring in the drawer where it was kept on 05/24/19 because it was not worn over the weekend. Review of the facility investigation into loss revealed Resident #76 was known to be very meticulous concerning the placement of his/her valuables and that Resident #76 had requested compensation but the facility unsubstantiated the allegation of misappropriation and declined to make restitution. In an interview on 07/09/19 at approximately 3:30 PM, the Director of Social Services confirmed the facility did not plan to make restitution to Resident #76 at that time as the ring was the resident's mother's class ring and no value could be determined. In a subsequent interview on 07/10/19 at approximately 9:55 AM, the Director of Social Services confirmed a replacement ring was purchased for Resident #76. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/11/2019, Resident #13 reported to the facility that s/he was missing a bag of coins that contained approximately $20 out of their room. The money was last seen prior to Resident #13 leaving their room for therapy. Upon return to the bedroom, the money was missing. During the investigation by the facility, one staff member's written statement acknowledged visualizing the money in the bedroom. The facility failed to investigate any further and concluded that the missing money was not their responsibility although it had been seen by staff. During an interview with Resident #13 on 7/9/19 at approximately 10:52 AM, s/he stated the money had not been replaced and s/he was made to feel that it was their fault for it being missing. During an interview with the Director of Nursing on 7/11/19 at approximately 2:39 PM, s/he stated, Police are only called if the alleged item is suspected as stolen. It is at the facility's discretion to determine whether an item is stolen or missing. When asked by the surveyor if any additional investigation was completed due to staff witnessing the money and Resident #13, who had a Brief Interview of Mental Status (BIMS) score of 15, saying that the money was missing, the Director of Nursing (DON) stated, No. In addition, the DON stated in order for items or money to be returned, the facility must determine the value of it. When asked if Resident #13 would receive restitution, the DON replied, I am not sure.",2020-09-01
1504,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2019-07-11,607,E,1,1,ZPCJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to implement the abuse policy for Residents #13, #76, #136, and #137 (3 out of 4 residents reviewed for abuse, and 1 of 6 residents reviewed for injuries of unknown origin). The findings included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/11/2019, Resident #13 reported to the facility that s/he was missing a bag of coins that contained approximately $20 out of their room. The money was last seen prior to Resident #13 leaving their room for therapy. Upon return to the bedroom, the money was missing. During the investigation by the facility, one staff member's written statement acknowledged visualizing the money in the bedroom. The facility failed to investigate any further and concluded that the missing money was not their responsibility, although it had been seen by staff. During an interview with the Director of Nursing (DON) 7/11/19 at approximately 2:39 PM, s/he stated, Police are only called if the alleged item is suspected as stolen. It is at the facility's discretion to determine whether an item is stolen or missing. When asked by the surveyor if any additional investigation was completed due to staff witnessing the money and Resident #13, who had a Brief Interview of Mental Status (BIMS) score of 15, saying that the money was missing, the DON stated, No. Review of the facility's policy titled; Lost of Missing Articles Policy, it states all attempts will be made to locate the missing article. The facility admitted Resident #137 on 1/31/2019 with [DIAGNOSES REDACTED]. Review on 7/11/2019 at approximately 11:58 AM of the medical record for Resident #137 revealed a reported injury of unknown origin without a thorough investigation by the facility. During an interview on 7/11/2019 at approximately 2:30 PM with the DON he/she confirmed that no statements were compiled from staff working on the hall during the time of the alleged injury of unknown origin. The DON confirmed that her statement was the only one written and filed for the alleged injury of unknown origin for Resident #137. He/she also confirmed the facility policy was not followed for alleged abuse. Resident #136 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 07/09/2019 revealed on 12/23/2018 Resident #136 made allegations that she was raped by a male the night before. The supervisor interviewed the resident and discrepancies were noted with the time of the incident. Resident #136 told the supervisor that the incident had occurred an hour earlier. Documentation reflected that the resident had been up in his/her wheelchair at the nurses's station an hour prior to the incident being reported by the resident. A body audit was completed with no abnormalities noted. The family was notified of the allegation. No abuse was substantiated by the facility. No male staff or visitors were noted in the resident's room prior to the incident or the night before. The resident had discrepancies in recollection and had a decline in Activities of Daily Living going from a one person to a two person transfer. A Urine Culture was obtained on 12/29/2018 after multiple attempts to obtain a urine specimen with the results showing no growth. Further interventions were for female caregivers only to continue to be assigned to the resident. The MD was noted on 12/27/2018 at 10:30 AM according to the 5-day follow up report. During an interview on 07/09/2019 at approximately 11:45 AM, the DON confirmed there was no exam by the MD. Interview with the DON on 07/09/2019 at 11:45 AM revealed the DON stated that no police report was filed because they did not see any evidence from the body audit to indicate rape and the family had reported to staff that the resident had made this allegation before. The DON attempted to find that documentation, but none was presented. The DON stated no male was even working at the time of the allegation or the night before, the resident initially stated it occurred an hour ago, and then stated last night. The DON further stated the facility had problems with reporting allegations and that they had even talked to the Chief of Police, who stated they only want the facility to report if any evidence of a crime has occurred. Review of the facility's policy on 7/11/2019 at approximately 4:00 PM titled, Policy & Procedure for Reporting Suspected Crimes Under the Federal Elder Justice Act under Facility Reporting, it stated the facility will file a report to .local law enforcement. The facility failed to follow the facility abuse policy for an allegation of rape. Police were not called or a report obtained. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 07/09/19 at approximately 8:41 am revealed Resident #76 was admitted to the facility on [DATE]. A sheet entitled Inventory of Personal Effects dated for the same date stated three rings were included in his/ her personal belongings. In a statement on 05/27/19, the Social Services Assistant (SSA) reported that Resident #76 informed him/her that a ring was missing. The SSA stated s/he assisted Resident #76 with looking for the ring but it could not be located. Resident #76 reported last seeing the ring in the drawer where it was kept on 05/24/19 because it was not worn over the weekend. Review of the facility investigation into loss revealed Resident #76 was known to be very meticulous concerning the placement of his/her valuables and that Resident #76 had requested compensation but the facility unsubstantiated the allegation of misappropriation and declined to make restitution. In an interview on 07/09/19 at approximately 3:30 PM the Director of Social Services confirmed the facility did not plan to make restitution to Resident #76 at that time as the ring was the resident's mother's class ring and no value could be determined. In a subsequent interview on 07/10/19 at approximately 9:55 AM the Director of Social Services confirmed a replacement ring was purchased for Resident #76.",2020-09-01
1505,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2019-07-11,608,E,1,1,ZPCJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to report suspicions of crime to law enforcement for incidents involving Residents #13, #76, and #136 (3 of 4 residents reviewed for abuse). The findings included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/11/2019, the facility submitted a report to the state agency that Resident #13 had alleged that s/he was missing money out of their room. On 7/11/2019 at approximately 2:15 PM, review of the facility's investigation report showed there had been no contact to the police for the allegation of missing property. During an interview with the Director of Nursing (DON) on 7/11/2019 at approximately 2:39 PM, s/he stated that the police had not been notified due to the police not liking to be called for these types of things. Review of the facility's policy on 7/11/2019 at approximately 4:00 PM titled, Policy & Procedure for Reporting Suspected Crimes Under the Federal Elder Justice Act under Facility Reporting, it stated the facility will file a report to .local law enforcement. Resident #136 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 07/09/2019 revealed on 12/23/2018 Resident #136 made allegations that she was raped by a male the night before. The supervisor interviewed the resident and discrepancies were noted with the time of the incident. Resident #136 told the supervisor that the incident had occurred an hour earlier. Documentation reflected that the resident had been up in his/her wheelchair at the nurses's station an hour prior to the incident being reported by the resident. A body audit was completed with no abnormalities noted. The family was notified of the allegation. No abuse was substantiated by the facility. No male staff or visitors were noted in the resident's room prior to the incident or the night before. The resident had discrepancies in recollection and had a decline in Activities of Daily Living going from a one person to a two person transfer. A Urine Culture was obtained on 12/29/2018 after multiple attempts to obtain a urine specimen with the results showing no growth. Further interventions were for female caregivers only to continue to be assigned to the resident. The MD was noted on 12/27/2018 at 10:30 AM according to the 5-day follow up report. During an interview on 07/09/2019 at approximately 11:45 AM, the DON confirmed there was no exam by the MD. Interview with the DON on 07/09/2019 at 11:45 AM revealed the DON stated that no police report was filed because they did not see any evidence from the body audit to indicate rape and the family had reported to staff that the resident had made this allegation before. The DON attempted to find that documentation, but none was presented. The DON stated no male was even working at the time of the allegation or the night before, the resident initially stated it occurred an hour ago, and then stated last night. The DON further stated the facility had problems with reporting allegations and that they had even talked to the Chief of Police, who stated they only want the facility to report if any evidence of a crime has occurred. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 07/09/19 at approximately 8:41 am revealed Resident #76 was admitted to the facility on [DATE]. A sheet entitled Inventory of Personal Effects dated for the same date stated three rings were included in his/her personal belongings. In a statement on 05/27/19, the Social Services Assistant (SSA) reported that Resident #76 informed him/her that a ring was missing. The SSA stated s/he assisted Resident #76 with looking for the ring but it could not be located. Resident #76 reported last seeing the ring in the drawer where it was kept on 05/24/19 because it was not worn over the weekend. Review of the facility investigation into loss revealed Resident #76 was known to be very meticulous concerning the placement of his/her valuables and that Resident #76 had requested compensation but the facility unsubstantiated the allegation of Misappropriation and declined to make restitution. In an interview on 07/09/19 at approximately 3:30 PM the Director of Social Services confirmed the facility did not file a police report related to the missing ring.",2020-09-01
1506,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2019-07-11,610,E,1,1,ZPCJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to complete thorough investigations for 2 out of 4 residents reviewed for abuse (Residents #13 and #76) and for 1 of 6 residents reviewed for injuries of unknown origin (Resident #137). The findings included: The facility admitted Resident #137 on 1/31/2019 with [DIAGNOSES REDACTED]. Review on 7/11/2019 at approximately 11:58 AM of the medical record for Resident #137 revealed a reported injury of unknown origin without a thorough investigation by the facility. During an interview on 7/11/2019 at approximately 2:30 PM with the Director of Nursing (DON), he/she confirmed that no statements were compiled from staff working on the hall/unit during the time of the alleged injury of unknown origin. The DON confirmed that his/her statement was the only one written and filed for the alleged injury of unknown origin for Resident #137. He/she also confirmed the facility policy was not followed for alleged abuse. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/11/2019, Resident #13 reported to the facility that s/he was missing a bag of coins that contained approximately $20 out of their room. The money was last seen prior to Resident #13 leaving their room for therapy. Upon return to the bedroom, the money was missing. During the investigation by the facility, one staff member's written statement acknowledged visualizing the money in the bedroom. The facility failed to investigate any further and concluded that the missing money was not their responsibility, although it had been seen by staff. During an interview with the DON on 7/11/19 at approximately 2:39 PM, s/he stated, Police are only called if the alleged item is suspected as stolen. It is at the facility's discretion to determine whether an item is stolen or missing. When asked by the surveyor if any additional investigation was completed due to staff witnessing the money and Resident #13, who had a Brief Interview of Mental Status (BIMS) score of 15, saying that the money was missing, the DON stated, No. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 07/09/19 at approximately 8:41 am revealed Resident #76 was admitted to the facility on [DATE]. A sheet entitled Inventory of Personal Effects dated for the same date stated three rings were included in his/her personal belongings. In a statement on 05/27/19, the Social Services Assistant (SSA) reported that Resident #76 informed him/her that a ring was missing. The SSA stated s/he assisted Resident #76 with looking for the ring but it could not be located. Resident #76 reported last seeing the ring in the drawer where it was kept on 05/24/19 because it was not worn over the weekend. Review of the facility investigation into loss revealed Resident #76 was known to be very meticulous concerning the placement of his/her valuables and that Resident #76 had requested compensation but the facility unsubstantiated the allegation of misappropriation and declined to make restitution. The investigation only contained a statement from the SSA which included second hand accounts from two Nursing Assistants. No interviews were conducted with other nursing staff or with the resident's room mate. No police report was included in the investigation. In an interview on 07/09/19 at approximately 3:30 PM, the Director of Social Services confirmed the facility did not file a police report related to the missing ring.",2020-09-01
1507,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2019-07-11,698,D,0,1,ZPCJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to provide a thermal regulation device (i.e., ice pack) or thermal tote when transporting a packed meal with Resident #587 to [MEDICAL TREATMENT] (1 of 1 residents reviewed for [MEDICAL TREATMENT]). The findings included: The facility failed to provide [MEDICAL TREATMENT] Resident #587 with a thermal tote or ice pack with the packed meal that was transported with Resident #587 to a scheduled [MEDICAL TREATMENT] treatment on 07/10/2019. Resident #587's [MEDICAL TREATMENT] chair time for 7/10/2019 was at 06:30 AM and the resident had the remaining zip lock on his/her bedside table at 4 PM the same day with yogurt unopened, but not packed in a manner to maintain acceptable temperature ranges. The facility policy titled, Dietary Operations- Packed Meals was provided by the Director of Nursing on 7/9/2019 at 5:28 PM. The policy was reviewed and it stated in Procedure under #3 that meals will be packed in a manner to maintain food temperatures within an acceptable range using an ice pack or other cooling method.",2020-09-01
1508,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2019-07-11,759,D,0,1,ZPCJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to ensure a medication administration error rate of less than five percent for 4 of 26 opportunities observed. This affected Residents #97, #21, and #102. The findings included: An observation on 7/10/2019 at approximately 8:45 AM of medication administration by Licensed Practical Nurse (LPN) #1 in which Resident #97 received [MEDICATION NAME] 50 micrograms, 1 spray each nostril 2 times daily. LPN #1 did not shake the medication prior to administering it to Resident #97. An observation on 7/10/2019 at approximately 4:40 PM of the medication administration for Resident #21 revealed the LPN administering [MEDICATION NAME] 3.125 milligrams by mouth to be given 2 times daily. The LPN additionally administered [MEDICATION NAME] 500 milligrams 0.5 tablet by mouth 2 times daily. Review of the medical record on 7/10/2019 at approximately 6:00 PM for Resident #21 revealed a physician's orders [REDACTED]. The medication was not observed given with food or a meal. An observation on 7/10/2019 at approximately 5:20 PM of the medication administration for Resident #102 revealed the LPN administering Vitamin C 500 milligrams crushed with [MEDICATION NAME] and placed in a teaspoon size amount of apple sauce. Review of the medical record on 7/10/2019 at approximately 6:00 PM for Resident #102 revealed a physician's orders [REDACTED].",2020-09-01
1509,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2019-07-11,761,D,0,1,ZPCJ11,"Based on observation and interview, the facility failed to ensure medications were secured in locked medication carts for 1 of 8 medication carts. The findings included: During medication storage review of Drayton Hall, on 7/11/19 at 03:11 PM, one medication cart was found unlocked and unattended. The Registered Nurse Unit Manager for Drayton Hall verified the cart was unlocked and stated, It should be locked.",2020-09-01
1510,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2019-07-11,812,F,0,1,ZPCJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure proper labeling and/or dating and removable of expired items from facility food supply in 1 of 1 kitchens. The findings included: Initial tour of the facility kitchen on [DATE] at approximately 11:15 AM with the Dietary Manager revealed observation of a box containing a large bag of flaked coconut with a use by date of [DATE], re-closable plastic bag of yellow sliced cheese with date of [DATE] and no other date; re-closable plastic bag with white sliced cheese with no date, cucumbers with black and white spots of decay/rot. Located on the bread rack were multiple packages of 16 count hamburger and hotdog buns with a use by date of [DATE]. In the dry goods storage area there was a large bucket of pre-mixed fudge frosting dated received on [DATE], opened [DATE] and a printed Best By date of [DATE]. Several food items with multiple dates that could not be differentiated were also observed. In an interview on [DATE] at approximately 11:15 AM, the Dietary Manager stated the loaves of bread dated [DATE] were received frozen and were taken out as needed but no date was put on them for tracking once placed on the shelf.",2020-09-01
4609,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2016-03-24,328,D,0,1,QCN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide oxygen as ordered for Resident #135, 1 of 1 sampled resident reviewed for Respiratory Care. The facility did not set the resident's oxygen concentrator per the physician's orders [REDACTED]. The findings included: The facility admitted Resident #135 with [DIAGNOSES REDACTED]. In addition, the resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact. Resident #135 was observed in bed on 3/22/2016 at 3:45 PM with oxygen infusing via nasal canula at 2 liters per minute. The resident was observed in bed on 3/23/2016 at 12:51 PM with oxygen infusing via nasal canula at 2 liters per minute. Record review of the Physician order [REDACTED]. During an interview with the Director of Nursing (DON) on 3/23/2016 at 1:15 PM the DON confirmed the resident's oxygen was ordered at 3 liters per minute. At 1:20 PM, with the DON present, the resident was observed in bed with oxygen infusing via nasal canula at 2 liters per minute. The DON confirmed the oxygen was set at 2 liters per minute. The DON stated the oxygen should be set at 3 liters per minute and adjusted the oxygen concentrator setting to 3 liters per minute. The DON had nursing check the resident's oxygen level and this was within normal limits. During an interview with Resident #135 on 3/23/2016 at 1:30 PM, Resident #135 stated she/he had never adjusted the setting on the oxygen concentrator.",2019-10-01
6460,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2015-02-02,226,D,1,0,SHI811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility Abuse and Neglect Policy, the facility failed to implement written policies and procedures that prohibit misappropriation of resident property. Resident #1 (1 of 3 residents reviewed for misappropriation of property) had personal property allegedly taken by a staff member, which was not reported timely to the appropriate state agency. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 13. Review of a facility reported incident on 1/29/15 at approximately 11:00 AM, revealed that on 1/16/15 the facility reported that the property (cell phone) of Resident #1 had been taken by a staff member. The incident further stated that on January 5, 2015 Resident #1 notified Social Services that her/his personal cell phone was missing. Investigation was initiated and statements obtained from staff and a search was conducted to find her/his phone. It was not found during the search. On January 10, Certified Nurse Aide (CNA) #1 notified the charge nurse that s/he had just received a call from the number which was posted at the nursing desk as Resident #1's missing phone and the call was from CNA #2. The report stated that on January 12 (2015) the phone number saved in CNA #1 phone from CNA #2 was Resident #1's phone number. In an interview with the surveyor on 1/29/15 at approximately 2:45 PM Certified Nurse Aide (CNA) #1 reviewed her/his facility obtained written statement dated 1/10/15 and confirmed that s/he was called by CNA #2 from the telephone number posted as belonging to Resident #1. In a telephone interview with the surveyor on 2/2/15 at approximately 1:45 PM Licensed Practical Nurse (LPN) #1 stated s/he looked at the number on CNA #1's phone and it was the number listed in Resident #1's medical record. LPN #1 then called the Director of Nursing (DON) on 1/10/15 at approximately 5:53 PM, to inform the DON about what they had discovered. An interview with the surveyor on 2/2/15 at 2:40 PM the Director of Nurses confirmed that s/he was informed by LPN #1 on 1/10/15 that the incoming phone number on CNA #1 phone was the same as Resident #1's phone number. A review of the policy and procedure for Neglect/Abuse provided by the facility on 1/29/15 revealed that Misappropriation of resident property was listed under the abuse/neglect policy. Listed as the protocol for reporting abuse for South Carolina: Immediately notify: 1. Person in charge 2. Administrator or designee Notify as soon as possible, but no later than 24 hours: 1. Bureau of Certification .",2018-02-01
8319,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2012-05-23,281,D,0,1,FBTO11,"**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 professional resource Perry & Potter 7th Edition of Clinical Nursing Skills and Techniques, the facility failed to meet professional standards of care related to documentation of wound care for one of four residents reviewed for clinical standards related to documentation of wound care. Nursing staff failed to complete and/or document pressure ulcer treatments for Resident #25. The findings included: The facility admitted Resident #25 on 5-3-12 with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on 5-10-12 for treatment of [REDACTED]. Record review on 5-22-12 at 10:35 AM revealed that the resident was admitted with six areas of compromised skin integrity. The 5-3-12 Skin Observation form noted deep tissue injury left and right first toes (1 x 1 centimeter each), right third toe with a scab (no measurements), stage II ulcer on the right buttock (5 x 3.5 x .3 centimeters), stage II ulcer on the left buttock (5 x 4 centimeters), and a stage II on the right heel (5.5 x 5). Admission Physician order [REDACTED]. to left first toe tip pressure ulcer daily ; Clean right buttock pressure ulcer with wound cleanser-pat dry-apply skin prep periwound-air dry-apply foam (dressing)-change every Mon., Wed., and Friday; Clean left buttock pressure ulcer with wound cleanser-pat dry-apply skin prep periwound-air dry-apply foam-change every Mon., Wed., and Friday. Review of the Treatment Administration Records revealed that the treatments scheduled to be administered on Mondays, Wednesdays, and Fridays to the Stage II areas were only documented as completed on 5-4-12. The treatments for 5-7-12 and 5-9-12 were noted with an N (not administered). The four areas to be treated with skin prep on a daily basis were also noted with an N for 5-7-12 and 5-9-12. All pressure ulcer treatments were noted as omitted because resident was not available (Out for [MEDICAL TREATMENT]). Although these were daily treatments, there was no evidence that the treatment times and/or days had been adjusted to accommodate [MEDICAL TREATMENT] clinic on the same days. Review of the e-chart revealed no documentation that the treatments had been done as ordered. During an interview on 5-22-12 at 4:40 PM, the Wound Nurse verified the documentation as noted. She stated that the resident left early in the mornings for [MEDICAL TREATMENT] and was gone most of day shift . She would usually catch him in the morning before [MEDICAL TREATMENT]. She stated that, if not done according to the scheduled time, she would do them after [MEDICAL TREATMENT] or evening shift would do them. When asked where this would be documented, she stated, It should be documented on the treatment sheet. The Wound Nurse reviewed the e-chart, but was unable to locate when/if the treatments were done as ordered. During an interview on 05-23-12 at approximately 4:00 PM with the Director of Nursing (DON), she provided a statement from the Wound Care Nurse which stated, The treatment to right and left buttock pressure ulcers was done on May 7th and May 9th prior to resident leaving for [MEDICAL TREATMENT]. The system did not allow me to chart administered because the charge nurse put him out prior to me being able to document. The DON stated, The treatments were done but the nurse should have documented them prior to the resident leaving. Review of the professional resource of Perry & Potter 7th Edition of Clinical Nursing Skills and Techniques, page 60 states: A medical record must be accurate because it is a legal document.care not documented is care not done as far as a court of law is concerned.",2016-05-01
8320,WHITE OAK MANOR - CHARLESTON,425128,9285 MEDICAL PLAZA DR,CHARLESTON,SC,29418,2012-05-23,323,E,0,1,FBTO11,"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. Observations of 4 of 5 units revealed concerns related to wheelchairs/ geri-chairs with torn/cracked or missing armrests, unsecured chemicals, unsteady tables/chairs used for resident dining, , The findings included: During initial tour on 5/21/12, the following was observed: Ashley Unit - one small black wheelchair near the nursing station with left and right armrest torn. Edisto Unit - one geri-chair in room 509 A with right armrest torn. Drayton Unit - in the dining room - two wheelchairs with cracked/torn armrests and one wheelchair with missing armrest. On 5/21/12 at 5:23 PM, observation of the Boone Unit revealed an unsecured partially filled 18 oz.(ounces) can of Multi-Surface Cleaner and Polish with a label warning harmful or fatal if swallowed/ eye irritant; and one 21 oz. Oxygen Bleach Cleanser with a warning on the label as an eye irritant. On 5/21/12 at 4:30 PM, observation of the main dining room revealed 9 of 27 chairs were found to be unsteady and 1 of 13 tables unsteady. An unsecured cabinet was observed which contained (18) 4 oz. bottles(partially full or full) Instant Hand Sanitizer with Aloe with 70% Ethanol. On 5/22/12, the following was observed: Edisto Unit - two wheelchairs located in room 510 with torn and/or cracked armrests. Ashley Unit - one small black wheelchair near the nursing station with left and right armrest torn; at 11:15 AM, one unsecured soiled utility room with a housekeeping cart with one 1 lb.(pound) 4.4 oz. container of Hydrogen Peroxide Cleanser Disinfectant Wipes with a label warning - eye irritant. On 5/22/12 at 5:00 PM, the Housekeeping Supervisor verified the wipes were not secured. Boone Unit - 4:00 PM - one geri-chair in room 208 with cracks on edge of both armrests had a small hole in one arm of the geri-chair. On 5/22/12 at 3:15 PM, LPN(Licensed Practical Nurse)#1 confirmed the soiled utility room on the Boone Unit was unlocked and at that time, LPN #1 removed the Multi-Surface Cleaner and Polish and the Oxygen Bleach Cleanser. On 5/23/12 the following was observed: Edisto Unit - two wheelchairs located in room 510 with torn and/or cracked armrests confirmed by the Unit Manager. Boone Unit - 1:45 PM - one geri-chair in room 208 with cracks on the edge of both armrests and a small hole in one arm of the geri-chair. On 5/23/12 at 2:45 PM, during an observation of the main dining room, 9 of 27 chairs were unsteady and 3 of 13 tables were unsteady. Observation of an unsecured cabinet revealed 6 partially filled and/or full 4 oz. bottles of Instant Hand Sanitizer with Aloe containing 70% ethanol was observed. On 5/23/12 at 3:30 PM, environmental rounds were made with the Maintenance Director in which the concerns were shared and verified During an interview with the Maintenance Director, he stated that he relied on the housekeeping staff to inform him of any concerns related to the dining area; for concerns on the units, a maintenance log was posted and checked two times a day for any concerns; and for wheelchairs located in therapy, the therapy staff should notify maintenance if repairs were needed on equipment before issuing them to residents.",2016-05-01
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
1095,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,580,D,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the physician of significant weight loss for 1 of 9 residents reviewed for nutrition. The findings included: Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 2/15/18 revealed that Resident #26 had an unidentified significant weight loss of 6.9% from August 2017 to October and 10.34% from August 2017 to January 2018. Resident #26's weight on 8/7/17 was 174.8lbs, on 9/4/17 was 163.8lbs and on 1/1/18 was 153lbs. Further review of Resident's record revealed that the physician and responsible party were not notified until 12/8/17 of Resident's continued weight loss but an intervention was not in place until 12/12/17. Further review also indicated that Resident #26 was care planned for mechanically altered food texture and a therapeutic diet, but not for weight loss or potential for weight loss. On 2/15/18 at 3PM, the Director of Nursing (DON) stated the care plan is not updated, but I will happily update it now for you. A revised care plan was submitted the following day. In an interview with LPN #1 on 2/15/18 at 330PM, LPN stated that the weight of 174.8lbs that was entered in the computer for 8/7/17 was incorrect, which made the written weight listed in the hard chart also incorrect. A note on the Vital Signs and Weight Record for 8/7/17 read weight in [MEDICAL CONDITION] in error. Additionally, a dietary note written by the Certified Dietary Manager (CDM) on 8/18/17 stated, Nurses re-weighed resident and still in WBW range. CBW 174.8 on 8/7-previous weight of 164.8 was an error. No weight loss indicated. Continue POC. The Registered Dietitian (RD) confirmed that the dietary department did not identify significant weight loss from 8/7/17-9/4/17.",2020-09-01
1096,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,622,D,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility policy entitled Transfer or Discharge, Emergency (2016), the facility failed to record the events surrounding a resident fall and transfer to the hospital for treatment of [REDACTED]. According to hospital records, Resident #530 was admitted following a fall which was not recorded in the facility's medical records. The findings included: The facility admitted Resident #530 with [DIAGNOSES REDACTED]. Record review on 2-15-18 at 2:43 PM revealed 9-18-17 Physician's Orders to transport the resident to the hospital. Review of Nurse's Notes at 2:25 PM on 2-15-18 revealed no entry regarding the reason for transport to the emergency room for evaluation. No transfer form was located in the record. Further review revealed a hospital History and Physical that stated Resident #530 had been found on the floor next to her (his) bed. A hematoma was noted on her (his) forehead. The patient appeared to be agitated and was groaning. During an interview at 4:45 PM on 2-15-18, the Director of Nursing (DON) reviewed the record and verified the Physician's Telephone Order to transfer the resident. S/he stated that the order should have included the reason for transfer. The DON could find no record of the fall in the Nurses Notes. S/he stated no incident/accident report or transfer record had been completed and there was no entry on the 24 Hour (shift) Report. The facility policy provided by the DON on 2-16-18 at 10:27 AM and titled Transfer or Discharge, Emergency states: 4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures:.b. Notify the receiving facility that the transfer is being made; .d. Prepare a transfer form to send with the resident; e. Notify the representative (sponsor) or other family member; f. Assist in obtaining transportation.",2020-09-01
1097,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,623,C,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the ombudsman of all facility-initiated transfers as required for 2 of 2 sampled residents reviewed for hospitalization (Residents #530 and #28). The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Review of Nurse's Notes at 12:08 PM on 2-13-18 revealed that the resident's family member reported a [MEDICAL CONDITION] while s/he and a second family member were feeding the resident on 9-25-17. While Certified Nursing Assistants were getting her/him ready to lie down, Resident #28 slumped over and eyes were gazing. The physician was notified and an order received to Transfer to (hospital) for evaluation of A[CONDITION] (altered mental status). The resident was seen in the emergency room for worsening [MEDICAL CONDITION]/dehydration and returned to the facility. The facility admitted Resident #530 with [DIAGNOSES REDACTED]. Record review on 2-15-18 at 2:43 PM revealed 9-18-17 physician's orders [REDACTED]. Further review revealed a hospital History and Physical that stated Resident #530 had been found on the floor next to her (his) bed. A hematoma was noted on her (his) forehead. The patient appeared to be agitated and was groaning. The resident was admitted to the hospital with [REDACTED]. During an interview on 2-15-18 at 9 AM, when asked about notification of the Ombudsman, the Director of Nursing stated that the Ombudsman had not been notified of any facility-initiated transfers to the emergency room or hospital. S/he said,That's not how we understood it (the regulation).",2020-09-01
1098,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,657,D,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to update the care plan with interventions for steady weight loss for #26. One of 9 reviewed for nutrition. Findings included: Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 2/15/18 revealed that Resident #26 had unidentified significant weight loss from August 2017 to October 2017of 6.9% and from August 2017 to January 2018 of 10.34%. Resident #26's weight on 8/7/17 was 174.8lbs, on 9/4/17 was 163.8lbs and on 1/1/18 was 153lbs. Further review of Resident #26's records indicated that the Resident was care planned for mechanically altered food texture and a therapeutic diet, however weight loss or potential for weight loss was not addressed. On 2/15/818 at 3PM, an interview with the Director of Nursing (DON) was conducted and DON was asked to verify that the care plan was not updated for the Resident's continued weight loss and stated the care plan is not updated, but I will happily update it now for you. A revised care plan was issued on 2/16/18 at 9AM.",2020-09-01
1099,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,684,D,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to monitor bowel movements for 2 of 2 residents reviewed for constipation. Resident #11 and #82 both went more than 3 days without a bowel movement with no intervention put in place to assist. The findings included: Resident #82 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #11 was admitted to the facility with [DIAGNOSES REDACTED]. Record review of Resident #82's medical record on 2/14/18 revealed that Resident went more than three days without having a bowel movement and no interventions were imposed. Resident #11's medical record was reviewed on 2/15/18 and revealed the same finding. In an interview with Resident #82 on 2/15/18 at 11AM, Resident was asked about his/her bowel movement pattern. Resident stated I went this morning, but I usually have problems with it. On 2/15/18 at 12PM, the Director of Nursing (DON) was asked to verify that according to documentation, both Residents went more than three days without a bowel movement. DON confirmed and stated It may be a night shift documentation error. DON returned at 1215 and stated that he/she spoke with the unit manager and unit manager states Resident is sometimes continent of bowel and bladder. He/she is given prune juice every day and says that he/she goes to the bathroom. DON then stated At the end of every shift, the charge nurse is supposed to pull up SMartChart to ensure that all residents have been documented on before the CNA leaves. Furthermore, the unit manager is supposed to pull Bowel Monitoring report daily and notify the physician if there has not been a bowel movement in three days. DON confirmed that nurses had not been reviewing the report as required and stated that the facility physician does not have any standing orders for anything; he would rather be called with issues regarding residents.",2020-09-01
1100,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,687,D,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, the facility failed to ensure foot care for 1 of 1 sampled resident with mycotic toe nails reviewed for foot care (Resident #[AGE] ). The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. On 2-16-18 at 10:41 AM, Resident #[AGE] was observed with thick, discolored, long great toe nails as verified by Certified Nursing Assistant (CNA) #1 who was completing her/his bath. Great toenails were thick, chalky, and dark brown to black in places. The left great toe nail was greater than 1/2 inch in length above the top of the toe. When asked about podiatry visits, the CNA stated s/he was unaware when the resident had last been seen, but that CNAs were not allowed to clip toenails. At 12 PM, CNA #1 stated that, if not seen by podiatry, the family would cut the nails if needed. S/he did not know how long the nails had been in that condition. During all other observations, the resident had on non-slip socks, but no shoes. Review of the medical record revealed that the last podiatry visit was on 9-8-16. At that time, it was noted that professional treatment of [REDACTED]. A revisit was planned in 8 weeks. During an interview at 11:03 AM on 2-16-18, when asked if Resident #[AGE] had been seen by the podiatrist since 2016, Licensed Practical Nurse (LPN) #2 (Unit Manager) reviewed the record and stated s/he did not know. S/he said s/he would check with Social Services and see if the resident was on the list. When asked if the resident had trouble ambulating, the LPN stated that the resident had not been walking as much recently, that her/his knees would buckle. During an interview at 11:59 AM on 2-16-18, the Assistant Director of Nursing stated that nursing submitted a list of names of residents needing to be seen by the podiatrist to Social Services. At 12:18 PM on 2-16-18, Social Services stated the facility had signed a contract with a new provider of podiatry services in 2017. There was an open enrollment, s/he thought in October, along with mass mailouts and calls to all family members. Social Services stated if the resident was not signed up for this provider, nursing was responsible to obtain podiatry services. S/he further stated that no one had gotten with her/him regarding any needed services for Resident #[AGE]. S/he checked the computer and stated that the resident had Medicaid and s/he didn't know why s/he hadn't been seen. Review of onychomycosis on emedicine.medscape.com revealed Onychomycosis can cause pain, discomfort, and disfigurement. as well as reducing quality of life. Patients with onychomycosis may present with. interference with standing, walking, and exercising.",2020-09-01
1101,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,689,D,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to record the events surrounding a fall, prevention measures in place, resident assessment, complete an incident/accident report, document any noted injuries and transfer to the hospital for treatment for 1 of 3 sampled residents reviewed for accidents (Resident #530). The findings included: The facility admitted Resident #530 with [DIAGNOSES REDACTED]. Record review on 2-15-18 at 2:43 PM revealed a 9-18-17 physician's orders [REDACTED]. Further review revealed a 9-18-17 hospital History and Physical that stated Resident #530 had been found on the floor next to her (his) bed. A hematoma was noted on her (his) forehead. The patient appeared to be agitated and was groaning. Review of Nurse's Notes at 2:25 PM on 2-15-18 revealed no entry regarding the reason for transport to the emergency room for evaluation. There were no Nurse's Notes recorded from 8-27-17 through 9-18-17 when it was noted that the resident was admitted to the hospital with [REDACTED]. No transfer form was located in the record. During an interview at 4:45 PM on 2-15-18, the Director of Nursing (DON) reviewed the record and verified the Physician's Telephone Order to transfer the resident. S/he stated that the order should have included the reason for transfer. The DON could find no record of the fall in the Nurses Notes. S/he stated no incident/accident report or transfer record had been completed and there was no entry on the 24 Hour (shift) Report.",2020-09-01
1102,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,690,D,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, policy review and interview, the facility failed to follow proper catheter care for res #37 for 1 of 2 observed for catheter care. The findings included: The facility admitted Resident #37 with [DIAGNOSES REDACTED]. During observation of suprapubic catheter care on 02/16/18 at 03:13 PM, Registered Nurse (RN) #1 failed to anchor the catheter to prevent tugging/pulling while cleansing the catheter proximally to distally while both washing and rinsing it. According to Mosby's Nursing Skills (2012), urinary catheters should be stabilized with the dominant hand during cleaning. During an interview on 02/16/18 at 04:07 PM RN #1 confirmed the observation and stated, I thought I would cross contaminate the catheter if I touched it up there.",2020-09-01
1103,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,692,D,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to identify and intervene for a resident's continued weight loss for 1 of 9 reviewed for nutrition. The findings included: Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 2/15/18 revealed that Resident #26 had unidentified significant weight loss from August 2017 to October 2017of 6.9% and from August 2017 to January 2018 of 10.34%. Resident #26's weight on 8/7/17 was 174.8lbs, on 9/4/17 was 163.8lbs and on 1/1/18 was 153lbs. Further review of Resident's record revealed that the physician and responsible party were not notified until 12/8/17 of Resident's continued weight loss but an intervention was not in place until 12/12/17. Further review also indicated that a dietary progress note was completed on 11/17/18 that stated Resident has had steady wt trending downward x 1[AGE] days. CBW 161 BMI 26.[AGE]. RD to follow up. Intakes recorded at 50-[AGE]%. However, the physician (MD) and responsible party (RP) were not notified until 12/8/17 and new orders were not received until 12/12/17. An interview on 2/15/18 at 310PM with Registered Dietician (RD), confirmed that the dietary department did not identify the significant weight loss from 8/7/17-9/4/17 and that interventions for continued weight loss were not started until 12/12/17.",2020-09-01
1104,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,770,D,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide laboratory services as ordered for Resident #[AGE], 1 of 5 sampled residents reviewed for hydration. A Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and [MEDICATION NAME] Acid Levels were not done every 6 months as required. The findings included: The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Record review on 2-16-18 at 10:45 AM revealed 10-26-16 physician's orders [REDACTED]. Review of laboratory reports revealed that the tests had been done on 5-4-17 but there was no record of them having been done in 11-17. During an interview at 11:48 AM on 2-16-18, after reviewing the records, Licensed Practical Nurse (LPN) #2 stated, They should have been done in November. The nurse reviewed the lab tracking log for routinely ordered tests and stated,It says to do it in May and November. After checking the computerized records, s/he said, I have it being done in 4/17 in the computer. At 12:04 PM, LPN #2 called the lab and found that nothing had been done for October or November of 2017.",2020-09-01
1105,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,808,D,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide the therapeutic diet as ordered for three of three meals observed for Resident #28, 1 of 9 sampled residents reviewed for nutrition. Resident #28 did not receive the renal, fortified mechanical soft diet with chopped meats as ordered. The findings included: The facility admitted Resident #28 with [DIAGNOSES REDACTED]. Record review at 3:26 PM on 2-12-18 revealed a physician's diet order for Renal, sugar free desserts, fortified mechanical soft, chop meats, add soup with lunch. Observation of the noon meal on 2-13-18 at 12:25 PM with Certified Nursing Assistant (CNA) #2 revealed that Resident #28 had consumed approximately 50% of the meal. There were greater than or equal to one-inch square cut meat pieces and carrots that were greater than 2 inches in length left on her/his tray. Review of the extended menus provided by the Registered Dietitian (RD) at 1:03 PM on 2-13-18 revealed the resident should have received chopped meat and chopped honey glazed carrots. During an interview at that time, the RD also brought a copy of mechanical soft diet information. The RD stated,The mechanical soft diet does not specify what 'chopped' means. During meal observation on 2-14-18 at 8:38 AM, Resident #28 received toast, scrambled eggs, chopped sausage, yogurt, cereal, and coffee. As there was no milk on the tray for the cereal, a family member went to get an 8 ounce carton for the resident. Review of the extended menus revealed that the resident should have received 4 ounces of juice and 4 ounces of milk, and should not have received sausage. Yogurt was not included on the menu, though there was evidence in the record that yogurt had been requested to give with her/his medications, instead of applesauce. During an interview at 4:25 PM on 2-14-18, the RD verified the menu and stated that Resident #28 should only get two 4 ounce servings of dairy per day. S/he stated,I have done inservice after inservice about following the menu. During observation of the breakfast meal on 2-15-18 at 9:15 AM, CNA #3 confirmed that Resident #28 received 4 ounces juice, scrambled eggs, chopped sausage, yogurt, an 8 ounce carton of milk, cereal, a biscuit and coffee. Review of the extended menus revealed that the resident should have received 4 ounces of milk and should not have received sausage. Also, the resident should have received white toast instead of the biscuit.",2020-09-01
1106,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,812,F,1,1,KY1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and review of the facility's policies and procedures the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The food trays, plates, bowls, cups, pitchers, and other food preparation containers were not clean and/or set to drain properly. Food items were not labeled and dated appropriately. Expired foods were not discarded. The dishwasher sanitation level did not register and there was no record of levels measured for 2 meals prior to the level check. The findings included: During the initial tour of the kitchen beginning at approximately 11:00 AM on [DATE], the following were observed with and verified by the Certified Dietary Manager (CDM): (1) At least 5 trays of wet cups were not inverted so they could drain. (2) Trays were stacked wet. (3) Clean dishes, including bowls, 4 plates, and 11 divided plates, were observed stacked with water and food particles on them. (4) Eight (8) wet pitchers were stored upside down on wire drying racks that had Lexan liners on them causing water to build up underneath. (5) The walk-in refrigerator contained several outdated and/or unlabeled food items and items that were improperly stored. These items included: sliced meat dated [DATE], an open bag of cheese slices dated [DATE], Swiss cheese dated [DATE], chopped bell peppers dated [DATE], an unidentified type of shredded cheese with no label or date, an unidentified type of cookie dough with no label or date, and a bag of Pimentos which had been removed from their original container dated [DATE]. (6) The reach-in refrigerator had a bag of tuna salad (as identified by the CDM) labeled as apples and a bag of mixed fruit labeled as apples with the date [DATE]. Also during the initial tour of the kitchen, while food was being prepared and placed on the steam table, a dietary staff member was observed in the kitchen without appropriate hair covering. A staff member also walked through the kitchen without her/his hair covered. During observation of the dish machine with the RD on [DATE] at 03:34 PM, 2 staff members were again observed in the kitchen without hair covered. Most of the dishes used for the noon meal had already been processed through the dish machine when the sanitation level of the low temp dish machine was checked with the RD. It did not register. Dietary Aide #1 stated the chemicals had been changed out a couple of days ago. Review of the work order noted this had been done the previous day. The log was requested for review to determine how long the machine had not been sanitizing dishes appropriately. The RD verified there was no record of sanitation levels having been measured for the breakfast and noon meals that day.",2020-09-01
1107,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2018-02-16,880,D,1,1,KY1411,"> Based on observation, interview, and review of the facility policy entitled Handwashing/Hand Hygiene, the facility failed to follow hand hygiene practices consistent with accepted standards of practice following 1 of 2 catheter care observations. Registered Nurse (RN) #1 failed to wash/sanitize hands before exiting the soiled utility room after contaminating them during disposal of soiled linen. The findings included: Following catheter care for Resident #37 on 02/16/18 at approximately 03:25 PM, Registered Nurse (RN) #1 entered the soiled utility room to place the used linens into the soiled linen container/bin. RN #1 did not wash or sanitize his/her hands before leaving the room after handling the soiled lid of the utility bin. RN #1 proceeded to enter the kitchenette to wash his/her hands, contaminating the kitchenette door handle. The facility policy entitled Handwashing/Hand Hygiene states under #7 Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . k. After handling used dressings, contaminated equipment, etc; During an interview on 02/16/18 at 04:03 PM, RN #1 confirmed the observation and stated, I should have used the sink in the dirty utility room to wash my hands.",2020-09-01
1108,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2019-02-28,761,D,0,1,6O4C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and USP (United States Pharmacopoeia) standards, the facility failed to remove expired medications from active storage in 1 of 6 medication carts and 1 of 3 treatment carts. The findings included: On 2/25/19 at approximately 1:18 PM, inspection of the Hall 100 Medication Cart 1 (Rooms 107-114) revealed an opened vial of [MEDICATION NAME] Injection 50 mg (milligram)/ml (milliliter), with an expiration date of 1/19 (1/31/19) belonging to Resident #40. On 2/25/19 at approximately 1:20 PM, this finding was verified by LPN (Licensed Practical Nurse) # 1. On 2/26/19 at approximately 10:32 AM, inspection of the Hall 200 Treatment Cart revealed one opened 250 ml container of USP Normal Saline, 0.9 % (percent) Sodium Chloride (1/3 full) by Nurse Assist, Lot 37, labeled by the manufacturer No antimicrobial or other substance added and Contents Sterile unless container is opened or damaged. One opened 250 ml container of Sterile Sodium Chloride 0.9% for Irrigation USP (1/4 full) by Aqua Care Lot 8, labeled by the manufacturer No antimicrobial or other substance has been added. On 2/26/19 at approximately 10:37 AM these findings were confirmed by LPN # 2. The USP standard for 0.9% Sodium Chloride for Irrigation is to Discard unused portion.",2020-09-01
1109,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2019-02-28,812,F,0,1,6O4C11,"Based on observation, interview, and food safety preparation standards, the facility failed to follow proper sanitization practices to prevent the outbreak of food borne illness in 1 of 1 kitchen. The dishwasher, 3 compartment sink, and red buckets had no sanitizer. The temperature log and measurement of sanitizer was incomplete. The findings included: During the initial tour of the kitchen on 02/25/19 at approximately 11:15 AM, the following observations were made and verified by the Certified Dietary Manager (CDM): (1) The red buckets were foamy. No sanitizer was used; only soap and water. (2) The 3-compartment sink registered no sanitizer when tested . (3) The dishwasher had no sanitizer when tested . Air was observed in the sanitizer line. The CDM immediately instructed staff to stop all meal preparation for lunch and instructed the staff to use disposable dishes and utensils. The Maintenance Director was contacted to look at the dishwasher. On 02/25/19 at 11:51 AM, the Maintenance Director cycled the dishwasher to remove the air in the line after adjusting the hose in the sanitation bucket. On 02/25/19 at 01:33 PM during an interview, the Maintenance Director stated, It took about 20 cycles to get the air out of the line. On 02/25/19 at 01:10 PM, review of the dishwasher log revealed testing for temperature and sanitizer was completed every morning for the month of February; however, the afternoon and evening documentation was missing from (MONTH) 16th-24th. During an interview on 02/25/19 at approximately 01:15 PM, the CDM stated, They should have been checking the sanitizer levels for breakfast, lunch, and dinner. The buckets and 3-compartment sink should have contained sanitizer. We are scheduling an inservice for all dietary staff. No log for testing the sanitizer level of 3-compartment sink was provided. The temperature log for the water was provided. On 02/25/19 04:02 PM, observation of the dishwasher and 3-compartment sink showed the sanitizer within acceptable limits tested by the CDM.",2020-09-01
1110,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2016-11-03,155,D,0,1,U4CH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the Adult Care Consent Act, Section 44-60-20 of the South [NAME]ina Code of Laws, the facility failed to afford 1 of 15 residents the opportunity to formulate his/her own Advance Directives. (Resident #110.) The findings included: The facility admitted Resident #110 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Do Not Resuscitate Request/Order form signed by the resident's family member indicating the resident's code status was Do Not Resuscitate. Review of the physician's orders [REDACTED]. Further review of the medical record indicated no documentation related to the resident's capacity to make his/her own healthcare decisions. The surveyor requested this information. During an interview on 11/03/16, the Director of Nursing (DON) reviewed the medical record and confirmed that there was no form attesting to the resident's capacity to make his/her own healthcare decisions. The DON stated that the DNR advance directive was done after admission, and the form with two physician's signatures was missing from the record. The DON stated that the Social Service department was responsible for getting the paperwork completed, and the form was overlooked. Review of the Adult Health Care Consent Act, Section 44-66-20 of the South [NAME]ina Code of Laws, indicates: (8) 'Unable to consent' means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner .A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient .",2020-09-01
1111,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2016-11-03,156,C,0,1,U4CH11,"Based on observation and interview, the facility failed to prominently display mandatory postings in a manner allowing convenient access by residents and visitors. Findings include: During observations on 11/02/16 at 3:30 PM and 11/03/16 at 1:54 PM, a posting of contact information for state licensing and survey agencies, Protection and Advocacy groups, Medicaid fraud reporting information and contact information for the Ombudsman ' s office was not found in the facility. During an interview and observation with the Administrator on 11/03/16 at 2:10 PM a posting could only be located on the locked wing of the facility. Further observation revealed that the posting could not be read and the display case could not be opened. The Administrator stated the case would be opened and the information placed in the other areas of the facility.",2020-09-01
1112,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2016-11-03,223,D,0,1,U4CH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide an environment free of verbal and physical abuse for Resident #43. Resident #43 with a reported incident of verbal and physical abuse. (1 of 2 residents reviewed for abuse) The findings included: The facility admitted Resident #43 with [DIAGNOSES REDACTED]. Record review revealed on 10/26/16 a family member reported an alleged incident of inappropriate contact between Resident #43 and Certified Nursing Assistant(CNA)#1. CNA #1 was immediately suspended and an investigation was initiated on 10/27/16. A 24 hour report was sent to the State Survey Agency on 10/27/16. A five day follow-up report was sent to the State Survey Agency on 10/31/16 with a conclusion of physical and verbal abuse. In addition to the State Survey Agency reporting, the facility contacted local Law Enforcement and a report was sent to the Department of Health and Environmental Control-Licensing and the Ombudsman. On 10/28/16, the Administrator contacted the SC CNA Abuse Registry to report the preliminary findings regarding CNA #1 in an effort to prevent him/her from taking a position with another facility and/or in case he/she was already working as needed at another facility. CNA #1 was terminated on 10/31/16 During an interview with the Administrator on 11/4/16, he/she stated the facility had placed several measures in place to prevent abuse from happening and provided the information to the surveyor. Review of the facility policies on 11/4/16 revealed Abuse Prohibition policies were in place.",2020-09-01
1113,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2016-11-03,246,D,0,1,U4CH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to accommodate Resident #26 with a callbell the resident could easily use. Resident #26 observed having difficulty utilizing a push button callbell. (1 of 1 reviewed for accommodation of needs.) The findings included: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. On 11/1/16 at 2:44 PM, Resident #26 was asked if he/she could ring his/her callbell. During the demonstration, Resident #26 took the callbell and pressed it to his/her head to try to activate the callbell. Resident #26 was asked if he/she could activate the callbell using his/her thumb. He/she responded by stating no. On 11/3/16 at approximately 3:30 PM, Resident #26 was visited by the surveyor and the Director of Nursing. At that time, Resident #26 was again asked to demonstrate the callbell usage. He/he again pressed the callbell to his/her head to try to activate the callbell. After the observation on 11/3/16, the Director of Nursing stated he/she was unaware the resident could not ring his/her callbell. During the interview with the Director of Nursing, he/she stated there was no assessment related to callbell usage nor was there documentation of a return demonstration of callbell usage upon admission.",2020-09-01
1114,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2016-11-03,325,D,0,1,U4CH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility's Spreadsheet of Diets, the facility failed to serve the most stringent therapeutic diet for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. Resident #168 did not receive the items listed for a renal diet. The findings included: The facility admitted Resident #168 with [DIAGNOSES REDACTED]. Record review on 11/2/16 revealed a current physician's orders [REDACTED]. Observation of the lunch meal on 11/2/16 at 12:52 PM revealed Resident #168 received the following on his/her lunch tray: pork loin, rice with gravy, fried okra, chocolate cake, corn muffin tea, water, salt packet and margarine. Review on 11/4/16 of the facility's Spreadsheet of Diets revealed the Renal diet listed roast pork loin, rice steamed okra, angel food cake with whipped topping, sweet tea or lemonade, corn muffin, pepper, margarine and honey. Observation of the lunch meal on 11/3/16 at 1:22 PM with the Director of Nursing revealed Resident #168 received the following on his/her lunch tray: baked chicken x 2 pieces, carrots, oven baked potatoes, roll, brownie, water, tea, coffee and sweetener. Review on 11/4/16 of the Spreadsheet of diets revealed the Renal diet listed salisbury steak, buttered noodles, carrots, vanilla pudding, sweet tea or lemonade, dinner roll, pepper, margarine. During an interview with the Dietary Manager on 11.3.16 at 1:42 PM, he/she stated the Renal diet was the most stringent of the diets and confirmed Resident #168 did not receive the most stringent diet. During the survey, no policies were provided related to serving the most stringent of diets ordered.",2020-09-01
1115,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2016-11-03,371,F,0,1,U4CH11,"Based on observations, interview, and review of facility inservices and policies, the dietary kitchen failed to prepare, distribute, and serve food under sanitary conditions as evidenced by failure to clean multiple kitchen surfaces of food build-up, failure to ensure the kitchen floor was cleaned of debris and soil, failed to ensure test strips used to test the sanitizing solution in the dishwasher were in-date, and failure to demonstrate the proper method of calibrating a food thermometer prior to taking food temperatures on the food line. The findings included: During the Initial Tour of the kitchen on 10/31/16 at approximately 11:15 AM with the Dietary Manager (DM) present, the kitchen floor was observed with multiple white-colored specks on the tile and grout throughout the kitchen. Multiple white specks were observed on plate covers stored on a metal rack beside the handwashing sink and trash can. A rack for holding trays was observed with areas of dark-colored buildup on the flat surfaces on the inside of the cart. The cart holding dry storage bins was observed to have a greasy film on the outside of the cart when touched. The outside of the oven doors were observed to have areas of visible dark-colored build-up. During observation of the dishwashing machine on 11/03/16 at approximately 9:00 AM, the surveyor asked for the policy related to the sanitizing solution used in the dishwasher. The DM provided the surveyor with the information and the container of strips used to test the dishwasher sanitizing solution. Observation of the test strips revealed an expiration date of 06/16 printed on the label. The surveyor observed food temperatures on 11/03/16 at approximately 11:35 AM with the DM, Assistant DM, and Kitchen Staff #1 present. Kitchen Staff #1 took the temperature of the first food item. After taking the food temperature, the surveyor asked Kitchen Staff #1 to demonstrate how the thermometer was calibrated. At that time, Kitchen Staff #1 placed the bimetallic stemmed thermometer into a cup with ice and water and proceeded to turn the thermometer dial without waiting for the thermometer to adjust to the ice/water temperature. When asked what he/she was doing, Kitchen Staff #1 replied that he/she needed to turn the dial to calibrate the thermometer. At that time, the Assistant DM stood beside the staff member and stated to just leave the thermometer in the cup; at which point, the staff member again proceeded to turn the dial. At that time, the Assistant DM obtained another thermometer and calibrated the thermometer correctly. After food temperatures were measured, multiple plate covers located on a rack near the tray line were observed with white specks which came off upon touch. Kitchen staff removed and washed the covers when the surveyor asked about the white specks. The surveyor requested copies of inservices related to calibrating a thermometer. The DM provided documentation that an inservice entitled Calibrating Thermometer was provided 9/16/16. Content information stated that staff should wait for 30 seconds before reading the temperature after placing the thermometer in ice water. During a tour of the kitchen with the Dietary Manager on 11/03/16 at approximately 1:45 PM, the following areas of concern were observed and confirmed by the DM: The kitchen floor was again observed with numerous white specks on the tiles and grout throughout the kitchen. A cart with trays was observed with food debris and build-up on the flat surfaces of the cart. The build-up was confirmed by the DM when he/she felt the debris with his/her hand. The outside of the oven doors were observed with areas of dark build-up, and the inside of the ovens were observed to have areas of dark-colored build-up. The bottom shelf of the preparation table was observed to have a build-up of light-colored particles which the DM confirmed by touch. Three transport light-colored carts in the kitchen were observed to have areas of dark residue, and the cart handles had dark-colored residue in the seams of the handles. Observation of a storage rack revealed a large frying pan whose bottom surface was discolored and sticky to touch as confirmed by the DM. The surveyor requested the facility's policy and schedule for deep-cleaning the kitchen. On 11/03/16 at approximately 3:00 PM, the DM provided the surveyor with a schedule which was dated from 11/05/16 forward. The DM stated that there was no cleaning schedule prior to the surveyor asking for this information.",2020-09-01
5140,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,201,D,0,1,WIDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to appropriately discharge 1 of 1 resident reviewed for elopement. Resident #153, assessed by the facility staff as an elopement risk, exited the building without staff supervision. After return to the facility Resident #153 was later transferred out to the hospital for evaluation and not returned to the facility. The findings included: The facility admitted Resident #153 with [DIAGNOSES REDACTED]. Resident #153 had a Brief Interview for Mental Status (BIMS) score of a 3 out of 15 on 7/3/2015. Review of the medical record on 9/1/2015 at approximately 2:21 PM revealed a nurse's note dated 7/11/2015 documenting resident has been very restless and angry today. He/she has refused to take meds at 1:00 PM. Police called and stated he/she was found out on street by (heavily traveled commercial intersection) - was taken to (hospital). Physician and Director of Nurses were notified. Further review revealed a nurse's note dated 7/11/2015 at 8:00 PM which states, Returned to facility. Resident is sleeping at present. Head to toe skin assessment done, reveals no current skin issues. Resident is easily aroused. Follows verbal commands. Resident arouses then drifts back off to sleep, Instructed by the Director of Nurses (DON) to transfer this resident to the .Hospital for the emergency department to evaluate. Spoke with the (hospital) nurse as to why this resident was being transported to (hospital). I stated, it was due to his/her wandering off the unit tonight, and refusal of medications last night and today. Ambulance service was notified for pick up. Another note at 12:30 AM reads, Ambulance here, resident transferred via stretcher to . hospital emergency room . Responsible party notified and DON made aware of the transfer. No further nurses notes were found as Resident #153 was not admitted back to the facility to complete his/her physical therapy. An interview with the DON on 9/1/2015 at approximately 2:30 PM confirmed that Resident #153 was sent out to the hospital due to elopement and did not return to the facility. During an interview on 9/2/2015 at approximately 3:20 PM with the Social Services Director, he/she stated, I guess he/she was sent out for an evaluation due to his/her diagnoses. No documentation could be found in the social service section of the medical record in regards to the elopement and the discharge. No documented evidence the resident would or would not be returning to the facility or a detailed discharge summary could be found in the medical record for Resident #153.",2019-04-01
5141,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,247,D,0,1,WIDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility, Admissions Booklet, the facility failed to ensure the resident and the responsible party was notified prior to a room/roommate change for 1 of 2 reviewed for notification. Resident #34 stated she had a roommate change and was not notified prior to the change and the facility had no documentation of notification. The findings included: The facility admitted Resident #34 with [DIAGNOSES REDACTED]. During an interview on 8/31/2015 at approximately 4:37 PM, Resident #34 revealed that he/she had had a roommate change and was not notified prior to the change. Review of the Nurse's Notes on 9/4/2015 at approximately 5:02 PM revealed nurse's notes that made no mention of a roommate change over the past several months. Review of the Social Service Progress Notes on 9/4/2015 at approximately 5:05 PM revealed Social Service notes that made no mention of a roommate change in the past several months. During an interview with the Director of Nurses on 9/4/2015 at approximately 5:30 PM he/she stated, if a resident has a room or roommate change it is not documented. I am sure we called the family and notified the resident, but we don't document that anywhere in the medical record. Review on 9/3/2015 at approximately 11:49 AM of an Admission Booklet, given to all residents and responsible parties on admission under, Patient's/Resident's Rights - Federal Law, number 19 states, Change of Room or Roommate. The Health Care Center must promptly notify the resident, and, if known, the resident's legal representative or interested family member before there is a change in room or roommate assignment. A resident may refuse any room transfer if the purpose of such transfer is to move the Patient/Resident from one level of nursing care to another level of nursing care.",2019-04-01
5142,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,272,J,0,1,WIDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of a form titled, Risk of Elopement/Wandering Review, the facility failed to ensure residents with the potential for elopement/wandering were completely and accurately assessed and identified before applying an Accu-Tech bracelet for monitoring. Residents #125, #153, #133, #110, #140, #108 were 6 of 6 residents sampled for accuracy of elopement assessments. The findings included: The facility admitted Resident #153 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 2:21 PM of Resident #153's medical record revealed a form titled, Risk of Elopement/Wandering Review, dated [DATE], [DATE] and ,[DATE]. All revealed Resident #153 is not at risk for elopement/wandering at this time. The assessment was not complete and accurate. Resident #153 exited the facility unsupervised on [DATE] even though he/she had an Accu-Tech bracelet applied. The facility admitted Resident #140 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 4:44 PM of Resident #140's medical record revealed a form titled, Risk of Elopement/Wandering Review, dated [DATE] and states, Resident is not at risk for elopement/wandering at this time. Resident #140 had an Accu-Tech bracelet on his/her lower extremity. The facility admitted Resident #133 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 12:11 PM of Resident #133's medical record revealed a form titled, Risk of Elopement/Wandering Review, dated [DATE]. The form stated Resident #133 is not at risk for elopement/wandering at this time. The assessment was not completed and accurate. Resident #133 had an Accu-Tech bracelet on his/her lower extremity. The facility admitted Resident #125 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 2:49 PM of Resident #125's medical record revealed a form titled, Risk of Elopement/Wandering Review. dated [DATE], [DATE], [DATE] and [DATE]. The summary of review revealed Resident # 125 is not at risk for elopement/wandering at this time. The summary also read, uses walker with ambulation, resident is confused and looking for deceased spouse and her car, etc. He/she is easily redirected. Will ask about going home at times. The assessment was not complete and accurate. Resident #125 was observed to have an Accu-Tech bracelet on his/her lower extremity. The facility admitted Resident #110 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 3:32 PM of Resident #110's medical record revealed a form titled, Risk of Elopement/Wandering Review, dated [DATE], [DATE] and [DATE] and each states, Resident is not at risk for elopement/wandering at this time. The assessment was not completed and accurate. Resident #110 had an Accu-Tech bracelet on his/her lower extremity. The facility admitted Resident #108 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 6:52 PM of Resident #108's medical record revealed a form titled, Risk of Elopement/Wandering Review, dated [DATE] and [DATE] and states, Resident is not at risk for elopement/wandering at this time. Resident #108 had an Accu-Tech bracelet on his/her lower extremity. During an interview on [DATE] at approximately 8:45 AM the Director of Nursing confirmed the Elopement/Wandering assessments were not complete and accurate for Residents #153, #125, #133, #110, #140, and #108. The facility provided an Allegation of Compliance to the survey team on [DATE]. The action plan included the following: I. Corrective Action taken to remove the Immediate Jeopardy; On [DATE] at approximately 2:45pm, the survey team notified the facility that an Immediate Jeopardy situation was present in regards to prior Elopement of resident on [DATE]. 1) Corrective Action was accomplished for the resident to have been affected by the deficient practice. Resident was returned to facility and was immediately placed on every 15 minute checks for safety and location. The wander guard was checked for placement and function on [DATE]. A body audit and assessment was completed with no signs of injury noted. Vital signs were stable on [DATE]. An Elopement Risk Assessment was completed on the resident on [DATE]. Code Silver walking rounds were initiated; all residents accounted for on each unit. The physician and legal representative were notified of the incident. An order was received from the Medical Director to send the resident to (the hospital) for psychiatric evaluation and treatment on [DATE]. The resident was discharged on [DATE]. 2. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur: Established time line and analysis of root cause. A 100% audit of all wander guards for placement and function was completed on [DATE]. Door code was changed. All staff were in-serviced by the Director of Nursing and Assistant Director of Nursing on the new code with instructions not to divulge that code to family, visitors or vendors; completed [DATE]. Code Silver Drills will be completed. Door signs posted on Main Entrance and Side Entrance doors warning visitors not to allow any person out of the facility without notification to facility staff on [DATE]. All nursing staff were in-serviced by the Assistant Director of Nursing beginning on [DATE] on policy for rounding and location of their residents, all nursing staff were educated by [DATE]. Maintenance continues to check all doors for wander guard function once per week. Resident wander guards will continue to be checked daily for placement and function. All findings were presented to the QA Committee for review and recommendation for continued intervention or amendment of plan on [DATE]. All ambulatory residents and any resident in a wheelchair who can self-propel, excluding those residents residing in our Secured Unit will have an elopement risk assessment completed by [DATE]. Any resident identified as at risk for elopement or wandering will have their care plan updated as appropriate by [DATE]. All new employees, including prn staff will be in-serviced/educated by Director of Nursing /Assistant Director of Nursing during orientation and prior to resident assignment on policy regarding rounding and location of their residents and door lock codes will not be divulged to visitors/family or vendors. Licensed nursing staff will complete an Elopement risk assessment for each residents upon admission, quarterly and at significant change. The Assistant Director of Nursing and/or Director of Nursing will in-service all Licensed Nurses on accurate completion of Elopement Risk Assessments, all new licensed nurses will be in-serviced during orientation and prior to resident assignment. Allegation of compliance date- [DATE]. Observations, record reviews, and interviews revealed the A[NAME] submitted by the facility on [DATE] had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on [DATE]. The Immediate Jeopardy at F272 was removed with the Scope and Severity of the citation lowered to a D.",2019-04-01
5143,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,280,D,0,1,WIDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure the Comprehensive Plan of Care was reviewed and revised related to elopement/wandering for 1 of 6 residents reviewed with Accu-Tech bracelets. Resident #133. The findings included: The facility admitted Resident #133 with diagnoses, including but not limited to, Dementia, Hearing Loss, Muscle Weakness, Lack of Coordination and Abnormality of Gait. Review on 9/2/2015 at approximately 12:30 PM revealed a physician's orders [REDACTED]. Check function every shift and PRN (as needed). Review on 9/2/2015 at approximately 12:30 PM revealed a Comprehensive Plan of Care that did not include the risk for elopement/wandering nor the use of the Accu-Tech Bracelet. An interview on 9/3/2015 at approximately 8:45 AM with the Director of Nurses confirmed the care plan had not been updated to include the risk of elopement/wandering nor the use of the Accu-Tech monitoring device.",2019-04-01
5144,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,282,J,0,1,WIDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure services were provided in accordance with the written Comprehensive Plan of Care for 1 of 6 residents reviewed for elopement and wandering. Resident #153 exited the facility unsupervised after demonstrating agitation and restlessness. The findings included: The facility admitted Resident #153 with [DIAGNOSES REDACTED]. Review on 9/1/2015 at approximately 2:21 PM of Resident #153's medical record revealed a Comprehensive Plan of Care with a problem date of 7/6/2015. The problem stated Resident #153 wanders at times. The goal read, Risk for elopement will be minimized daily through next review. An intervention included an Accu-Tech Bracelet. Further review of the Comprehensive Plan of Care for Resident #153 revealed another intervention which included, Provide .cues, re-direction and or supervision as needed. Resident #153 was noted to be restless and agitated on 7/11/2015 and exited from the nursing facility on 7/11/2015 unsupervised. Resident #153 was last observed in the facility at 6:15 PM and was out of the facility for approximately 45 minutes, when the police called the facility to inform them the resident had been picked up by them and they were taking the resident to the emergency room to be assessed. When notified by the police the facility staff was unaware the resident had eloped. An interview on 9/3/2015 at approximately 9:00 AM with the Director of Nursing confirmed that due to lack of supervision for Resident #153 no one noticed that Resident #153 had eloped. The facility provided an Allegation of Compliance to the survey team on 9/3/2015. The action plan included the following: I. Corrective Action taken to remove the Immediate Jeopardy; On 9/2/2015 at approximately 2:45pm, the survey team notified the facility that an Immediate Jeopardy situation was present in regards to prior Elopement of resident on 7/11/2015. 1) Corrective Action was accomplished for the resident to have been affected by the deficient practice. Resident was returned to facility and was immediately placed on every 15 minute checks for safety and location. The wander guard was checked for placement and function on 7/11/2015. A body audit and assessment was completed with no signs of injury noted. Vital signs were stable on 7/11/2015. An Elopement Risk Assessment was completed on the resident on 7/11/2015. Code Silver walking rounds were initiated; all residents accounted for on each unit. The physician and legal representative were notified of the incident. An order was received from the Medical Director to send the resident to (the hospital) for psychiatric evaluation and treatment on 7/11/2015. The resident was discharged on [DATE]. 2. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur: Established time line and analysis of root cause. A 100% audit of all wander guards for placement and function was completed on 7/11/2014. Door code was changed. All staff were in-serviced by the Director of Nursing and Assistant Director of Nursing on the new code with instructions not to divulge that code to family, visitors or vendors; completed 7/14/2015. Code Silver Drills will be completed. Door signs posted on Main Entrance and Side Entrance doors warning visitors not to allow any person out of the facility without notification to facility staff on 7/11/2014. All nursing staff were in-serviced by the Assistant Director of Nursing beginning on 7/14/2015 on policy for rounding and location of their residents, all nursing staff were educated by 7/24/2015. Maintenance continues to check all doors for wander guard function once per week. Resident wander guards will continue to be checked daily for placement and function. All findings were presented to the QA Committee for review and recommendation for continued intervention or amendment of plan on 7/17/2015. All ambulatory residents and any resident in a wheelchair who can self-propel, excluding those residents residing in our Secured Unit will have an elopement risk assessment completed by 9/3/2015. Any resident identified as at risk for elopement or wandering will have their care plan updated as appropriate by 9/3/2015. All new employees, including prn staff will be in-serviced/educated by Director of Nursing /Assistant Director of Nursing during orientation and prior to resident assignment on policy regarding rounding and location of their residents and door lock codes will not be divulged to visitors/family or vendors. Licensed nursing staff will complete an Elopement risk assessment for each residents upon admission, quarterly and at significant change. The Assistant Director of Nursing and/or Director of Nursing will in-service all Licensed Nurses on accurate completion of Elopement Risk Assessments, all new licensed nurses will be in-serviced during orientation and prior to resident assignment. Allegation of compliance date- 9/3/2015. Observations, record reviews, and interviews revealed the A[NAME] submitted by the facility on 9?3/2015 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on 9/3/15. The Immediate Jeopardy at F282 was removed with the Scope and Severity of the citation lowered to a D.",2019-04-01
5145,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,315,D,0,1,WIDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policy titled Incontinence Care, the facility failed to ensure appropriate incontinent care was provided to Resident #32. During incontinent care, the Certified Nursing Assistant was observed to touch the resident's clothing with a soiled glove, clean the resident from back to front and performed part of the care without donning a glove. 1 of 3 residents reviewed for incontinent care. The findings included: The facility admitted Resident #32 with [DIAGNOSES REDACTED]. Record review on 9/3/15 revealed an Annual Minimum Data Set which indicated Resident #32 was always incontinent of bladder. A bladder evaluation dated 3/24/15 stated the resident was unable to participate in a bladder program due to the resident's perception of the need to void was absent and the resident was unable to participate in a bladder training program due to Dementia. During observation of incontinent care on 9/4/15 at 10:09 AM, Certified Nursing Assistant (CNA) #5 was observed to turn the resident on his/her side touching the back of his/her sweater with a soiled gloved hand. Resident #32 was observed to have had a bowel movement and after wiping from front to back several times, CNA #5 wiped from back to front several times. CNA #5 removed his/her glove, observed more bowel movement on Resident #32, obtained a wipe and wiped the resident without a glove on his/her hand. CNA #5 reached into his/her pocket and removed a glove, donned the glove and placed a clean brief on Resident #32. On 9/4/15 at 12:52 PM, during an interview with CNA #5, he/she confirmed the above findings. Review of the facility policy titled Incontinence Care revealed under the procedure section the following: 5. Put on gloves, 6. Wash/use cleansing agent to all soiled skin areas, washing from front to back .7. Turn resident on side and cleanse buttocks area wiping toward back.",2019-04-01
5146,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,323,J,0,1,WIDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews and review of a form titled, Resident Incident Report, the facility failed to provide interventions and supervision to promote safety for residents identified as having the potential for elopement/wandering. Resident #153, 1 of 6 residents sampled for behaviors with elopement/wandering tendencies, exited the facility unsupervised after demonstrating agitation and restlessness. The facility was unaware of the resident's absence until notified by local authorities. The facility further failed to ensure Lancet's were disposed of properly and safely during medication pass for 1 of 1 finger stick blood sugar observed during med pass. The findings included: The facility admitted Resident #153 with [DIAGNOSES REDACTED]. A brief interview of mental status (BIMS) on 7/3/2015 indicated a score of 3 out of 15. Review of Resident #153's medical record on 9/1/2015 at approximately 2:21 PM revealed a Nurses Note dated 7/10/2015 at 7:00 PM noting, Out of bed, propelling self throughout the unit, very agitated this shift, refused all bedtime medications stated, I don't want them. Responsible party notified, left message, no call back. Review of the nurses notes dated 7/11/2015 at 2:30 PM states, Activities of daily living completed by resident with set up and minimal assistance. Feeds himself/herself after set up. Propels himself/herself throughout the facility in wheel chair He/she is incontinent at times and wears a brief for protection. He/she has been very agitated with staff in regards to taking medications. Has refused to take meds and to drink Medpass. Denies pain and no signs or symptoms of distress noted. Will continue to encourage him/her to take meds. Further review on 9/1/2015 at approximately 2:21 PM revealed yet another nurses note dated 7/11/2015 (no time of note written) and states, Resident has been very restless and angry today. He/she has refused to take meds at 1:00 PM. Police called and stated he/she was found out on a heavily traveled commercial intersection. He/she was taken to (hospital) Medical Director and the Director of Nurses (DON) notified. The next nurses note dated 7/11/2015 at 8:00 PM states, Returned to facility. Resident is sleeping at present. Head to toe skin assessment done, reveals no current skin issues. Resident is easily aroused. Follows verbal commands. Resident drifts back off to sleep. Instructed by DON to transfer resident to the (hospital) emergency room for evaluation. Spoke with (hospital) nurse re: as to why this resident was being transported to (hospital ER), due to his wandering off the unit tonight and refusal of medications last night and today. The ambulance service was notified for pick up. A note at 12:30 AM on 7/12/15 states, ambulance here, resident transferred via stretcher to hospital emergency room . Responsible party notified. DON made aware of transfer. Review of a form titled, Resident Incident Report, on 9/1/2015 at approximately 2:30 PM reveals, Resident #153 eloped from the nursing home on 7/11/2015. He/she had no injuries. The report indicated that the medical director and the attorney for the facility were notified. No mention was made that the family or responsible party was notified by the facility that the resident had eloped. The narrative of the incident states, At 6:55 PM the police called, resident was picked up at Anna(NAME)and Highway 17 - took resident to ECMC to be checked out. Patient last seen at the facility at 6:15 PM. He/she had finished his/her dinner. Review of Resident #153's Medication Administration Record (MAR) on 9/1/2015 at approximately 2:45 PM revealed he/she was on a medication regimen of Depakote Extended Release 500 mg (milligrams) 2 tablets at bedtime for a [DIAGNOSES REDACTED]. Cogentin 0.5mg 2 times daily for muscle stiffness. He/she was also on Niacin 250 mg at bedtime for a [DIAGNOSES REDACTED]. Other medications included Zantac 300 mg at bedtime for reflux, Terazosin 1 mg at bedtime for Benign Prostatic Hypertrophy , and Vitamin B-1 and Vitamin E each AM. Based on review of the MAR for Resident #153 the missed doses of medications were as follows: 7/10/2015 - Aspirin 81 mg at 8:00 PM, Cogentin 0.5 mg at 5:00 PM, Depakote 1000 mg at 8:00 PM, Niacin 250 mg at bedtime, Seroquel 400 mg at 8:00 PM, Zantac 300 mg at bedtime, Terazosin 1 mg at bedtime and 4:00 PM and the 8:00 PM dose of Medpass. The 7/11/2015 medications missed were as follows: Norvasc 5 mg the 9:00 AM dose, Aspirin 81 mg the 8:00 PM dose, Cogentin 0.5 mg the 9:00 AM dose, a MultiVitamin at 9:00 AM, Niacin 250 mg at 9:00 PM, Nicotine 14 mg/24 hour patch topical at 9:00 AM, Seroquel 200 mg the 8:00 AM dose and the 12:00 Noon dose. Seroquel 400 mg the 8:00 PM dose. Terazosin 1 mg the 8:00 PM dose and Vitamin B-1 and Vitamin E the 8:00 AM doses. The 8:00 PM and the 9:00 PM doses were not given on 7/11/2015 due to the resident just returning from the hospital after the elopement. An interview on 9/1/2015 at approximately 4:00 PM the DON revealed, the police picked him/her up due to the unsteady gait. The DON stated this resident was sent to the VA emergency room due to refusal of medications and the elopement episode. During an interview on 9/2/2015 at approximately 9:15 AM with Certified Nursing Assistant (CNA) #1, he/she stated, this resident could walk. He/she was flippy. CNA #1 stated this meant that sometimes he/she would be ok one minute and the next minute he/she would flip out, but went on to say that he/she did not work with Resident #153. In an interview with CNA #2 on 9/2/2015 at approximately 9:25 AM, he/she stated, He/she was very nice. Never had any aggressive or combative behavior toward me. CNA #2 stated, Never heard this resident mention going anywhere. He/she was not an exit seeker. He/she would go outside sometimes but would knock on the door and we would let him/her back in. I was not here when he/she walked out but I was very surprised to hear that he/she did that. He/she did love to eat. Very pleasant and nice person. An interview with CNA #3 on 9/2/2015 at approximately 9:30 AM he/she stated, I never saw him/her walking. I did not know he/she could walk. He/she was not aggressive or combative, very pleasant. He/she never attempted to leave the building, not an exit seeker. During an interview on 9/2/2015 with CNA #3, he/she stated, This resident was a very nice person. I did not have any trouble out of him/her. It is my understanding he/she walked out behind a family member and another resident. During an interview on 9/2/2015 at approximately 9:40 AM with Registered Nurse (RN) #2, this surveyor asked, What is the process you follow if a resident refuses medications? RN #2 stated, We should go back and try again to see if the resident will take the medications. We document the behaviors, and the reason why the medications were not given in the medical record and on the nurses notes. We would call the physician if the behaviors are not alleviated and report if the resident has refused any medications. During an interview on 9/2/2015 at approximately 9:45 AM with Licensed Practical Nurse (LPN) #2 he/she stated, I think he/she eloped in the 7p to 7a shift. He/she would refuse care sometimes. He/she never refused to take medications from me. It was probably due to his diagnoses. He/she did not adhere to instructions well. He/she would try to get up unassisted, but I never knew he/she could walk. He/she never mentioned leaving or wanting to go anywhere. An interview on 9/2/2015 at approximately 3:20 PM with the Social Services Director revealed, I guess he/she was sent out for an evaluation due to his/her diagnoses. No documentation could be found in the social service section of the medical record in regards to the elopement and the discharge. No mention of a bed hold or that that the resident would be returning could be found in the medical record for Resident #153. On 9/1/15 at 5:03 pm, during an observation of med pass on the Green Wing, RN #1 checked Resident #101 ' s blood sugar by drawing blood with a lancet. Following the FSBS procedure, RN #1 placed the lancet into Resident #101 ' s trash can. RN#1 was asked if the lancet needed to be put in a sharps container instead of the trash can. RN #1 stated, Yes, I forgot. On 9/1/15 at 8: 00 PM, during an interview with the Director of Nursing (DON), s/he was asked what her/his expectation for disposal of a lancet after a FSBS. The DON stated, It should be placed in the sharps container on the cart. On 9/2/15 at 1:00 PM, a review of the facility policy entitled 5.5 SYRINGE AND NEEDLE DISPOSAL revealed under procedure 2.) Immediately after use, syringes and needles are placed into puncture resistant, one-way containers specifically designed for that purpose. Syringes and needles are never deliberately bent or broken. The facility provided an Allegation of Compliance to the survey team on 9/3/2015. The action plan included the following: I. Corrective Action taken to remove the Immediate Jeopardy; On 9/2/2015 at approximately 2:45pm, the survey team notified the facility that an Immediate Jeopardy situation was present in regards to prior Elopement of resident on 7/11/2015. 1) Corrective Action was accomplished for the resident to have been affected by the deficient practice. Resident was returned to facility and was immediately placed on every 15 minute checks for safety and location. The wander guard was checked for placement and function on 7/11/2015. A body audit and assessment was completed with no signs of injury noted. Vital signs were stable on 7/11/2015. An Elopement Risk Assessment was completed on the resident on 7/11/2015. Code Silver walking rounds were initiated; all residents accounted for on each unit. The physician and legal representative were notified of the incident. An order was received from the Medical Director to send the resident to (the hospital) for psychiatric evaluation and treatment on 7/11/2015. The resident was discharged on [DATE]. 2. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur: Established time line and analysis of root cause. A 100% audit of all wander guards for placement and function was completed on 7/11/2014. Door code was changed. All staff were in-serviced by the Director of Nursing and Assistant Director of Nursing on the new code with instructions not to divulge that code to family, visitors or vendors; completed 7/14/2015. Code Silver Drills will be completed. Door signs posted on Main Entrance and Side Entrance doors warning visitors not to allow any person out of the facility without notification to facility staff on 7/11/2014. All nursing staff were in-serviced by the Assistant Director of Nursing beginning on 7/14/2015 on policy for rounding and location of their residents, all nursing staff were educated by 7/24/2015. Maintenance continues to check all doors for wander guard function once per week. Resident wander guards will continue to be checked daily for placement and function. All findings were presented to the QA Committee for review and recommendation for continued intervention or amendment of plan on 7/17/2015. All ambulatory residents and any resident in a wheelchair who can self-propel, excluding those residents residing in our Secured Unit will have an elopement risk assessment completed by 9/3/2015. Any resident identified as at risk for elopement or wandering will have their care plan updated as appropriate by 9/3/2015. All new employees, including prn staff will be in-serviced/educated by Director of Nursing /Assistant Director of Nursing during orientation and prior to resident assignment on policy regarding rounding and location of their residents and door lock codes will not be divulged to visitors/family or vendors. Licensed nursing staff will complete an Elopement risk assessment for each residents upon admission, quarterly and at significant change. The Assistant Director of Nursing and/or Director of Nursing will in-service all Licensed Nurses on accurate completion of Elopement Risk Assessments, all new licensed nurses will be in-serviced during orientation and prior to resident assignment. Allegation of compliance date- 9/3/2015. Observations, record reviews, and interviews revealed the A[NAME] submitted by the facility on 9?3/2015 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on 9/3/15. The Immediate Jeopardy at F323 was removed with the Scope and Severity of the citation lowered to a D.",2019-04-01
5147,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,329,E,0,1,WIDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Antipsychotic Medication Use and interview, the facility failed to provide evidence that non-pharmacological interventions were attempted prior to administration of an as needed anti-anxiety medication for Resident #108. 1 of 5 residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #108 with [DIAGNOSES REDACTED]. Record review on 9/3/15 revealed Resident #108 had a written physician's order for [MEDICATION NAME] .5 milligrams (mg) every six hours as needed for anxiety. Review of the Medication Administration Record [REDACTED]. Review of the nurse's notes revealed there was no documentation of the resident's behavior nor was there any documentation a non-pharmacological intervention was attempted. Review of the MAR for (MONTH) (YEAR) revealed the resident received [MEDICATION NAME] on 8/4/15, twice on 8/13/15 and on 8/19/15. Review of the nurse's notes and the Behavior/Intervention Monthly Flow Record revealed there was no documentation a non-pharmacological intervention had been attempted. During an interview with the Director of Nursing on 9/4/15, he/she confirmed there were no non-pharmacological interventions documented related to the above referenced dates. He/she continued by stating staff should try an intervention prior to administering the as needed medication. Review of the facility policy on 9/4/15 titled Antipsychotic Medication Use revealed under the Policy Interpretation and Implementation section #6 the following: The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications.",2019-04-01
5148,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,333,D,0,1,WIDK11,"**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, the facility failed to administer [MEDICATION NAME] Purified Protein Derivative (PPD) Mantoux as ordered by the physician for 1 of 1 resident reviewed for PPD administration. Resident #159 received physician ordered PPD during medication administration after the date the medication should have been removed from use based on the date it was originally opened. The findings included: The facility admitted Resident #159 with [DIAGNOSES REDACTED]. On 8/31/15 at 12:19 PM, an observation with Registered Nurse (RN) #2 of the Blue Wing medication storage room refrigerator revealed a one 1 milliliter (ml), 10 test, vial of PPD with (Lot Number ) C4652AA, which was labeled, Opened Date 7/23/15. Also, the vial label states, Discard opened product after 30 days. Following the observation RN #2 stated, The PPD is only good for 30 days after being opened and indicated the PPD should have been removed. On 8/31/15 at approximately 1:00 PM, review of Resident #159 ' s Medication Administration Record [REDACTED]. RN #2 verified Resident #159 received PPD from vial (Lot Number) C4652AAs with an opened date of 7/23/15. On 9/2/15 at 4:30 PM, review of the [MEDICATION NAME] Purified Protein Derivative (PPD) (Mantoux) package insert product information states under Storage: A vial of [MEDICATION NAME] ([MEDICATION NAME] Purified Protein Derivative (Mantoux)) which has been entered and in use for 30 days should be discarded because oxidation and degradation may have reduced the potency.",2019-04-01
5149,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,431,D,0,1,WIDK11,"Based on observations, interview, review of the manufacturer recommendations and facility policy, the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 1 of 3 medication storage rooms. Expired Aplisol, Tuberculin Purified Protein Derivative (PPD) was in the Blue Wing medication storage room. The findings included: On 8/31/15 at 12:19 PM, an observation with RN #2 of the Blue Wing medication storage room refrigerator revealed a one 1 milliliter (ml), 10 test, vial of Aplisol, Tuberculin Purified Protein Derivative (PPD) with Lot Number C4652AA, which was labeled, Opened Date 7/23/15. Also, the vial label states, Discard opened product after 30 days. Following the observation RN #2 stated, The PPD is only good for 30 days after being opened and indicated the PPD should have been removed. RN #2 also stated, It is nursing ' s responsibility to check expiration dates on PPD vials. On 8/31/15 at 12:45 PM, a review of the Aplisol, Tuberculin Purified Protein Derivative (PPD) box insert manufacture recommendations states under Storage: Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. On 9/2/15 at 1:45 PM, a review of the facility policy entitled Medication Storage revealed under procedure 14.) Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock., disposed of according to procedures for medication disposal (Refer to Section 5 Disposal of Medications, Syringes and Needles), and reordered from pharmacy if a current order exists.",2019-04-01
5150,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,441,E,0,1,WIDK11,"Based on observation and interview, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to prevent development and transmission of disease and infection. Observation of the laundry revealed Laundry Worker #1 placed a trash bag on clean folded items with soiled gloved hands, removed soiled gloves and did not wash hands, closed the washer door with a soiled gloved hand, placed an item in the sink and started the faucet with soiled gloved hands. Laundry Worker #2 cut off the water at the faucet using his/her bare hand. Clean items were stored on the soiled side of the laundry. The findings included: Observation of the laundry on 9/4/15 at 8:58 AM revealed Laundry Worker #1 after sorting laundry, placed a trash bag on clean folded items using his/her soiled gloved hand. Laundry Worker #1 removed his/her gloves and gown, exited the room to obtain another gown, donned gown/gloves, loaded the washer and closed the washer door with a soiled gloved hand. No handwashing was observed after removing the gloves and gown and exiting the room. On 9/4/15 at 12:25 PM, Laundry Worker #1 was observed loading a washer. During the observation, an item was placed in the sink and the faucet was turned on using a soiled gloved hand. Laundry Worker #2 was observed to cut the faucet off using his/her bare hands. No handwashing was noted after touching the faucet handles. Further observation of the laundry revealed on the soiled side clean folded spreads used by housekeeping were stored and two covered carts with clean clothes were stored. Barrels for the soiled items were approximately 36 1/2 inches away from the folded spreads and 41 inches from the covered clean carts. One soiled barrel was 4 inches away from a clean covered cart. A folding table was observed 35 inches away from a washer. During an interview with Laundry Worker #1 on 9/4/15, he/she stated the washers were wiped down twice a day using stainless steel cleaner and polish. He/she confirmed the faucet had been turned on with soiled gloves. Review of the facility policy titled Departmental (Environmental Services)-Laundry and Linen revealed the following under #15: Use heavy-duty rubber gloves for sorting laundry. Always wash hands after completing the task and removing gloves.",2019-04-01
5151,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,490,J,0,1,WIDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, review of facility files, and interviews, the facility failed to show that is was administered in a manner to ensure the safety of each and every resident by providing the appropriate supervision for 1 of 6 residents reviewed for behaviors. Resident # 153 eloped from the facility on 7/11/2015. He/she was not missed until the police called to say that they had picked up the resident who was found wandering down the street and had been out of the facility for approximately 45 minutes. Cross refers to F-201 - Transfer and Discharge. The facility failed to ensure Resident #153 was discharged in an appropriate manner. Resident #153 was discharged on [DATE] due to elopement and refusing few medications. Resident #153 was sent out to Veterans Hospital for evaluation and not allowed to return. Cross refers to F-272 Comprehensive Assessments - The facility failed to ensure residents residing in the facility had complete and accurate assessments related to elopement and wandering. Cross refers to F-323 Accidents, Hazards/Supervision. The facility failed to ensure Resident #153 was sufficiently monitored and supervised. The facility failed to completely and accurately assess other residents residing in the facility with the potential for elopement and wandering. Any system in place at the facility failed to ensure cognitively impaired residents did not exit the facility unsupervised without the facility having immediate awareness of the resident's absence. The facility provided an Allegation of Compliance to the survey team on 9/3/2015. The action plan included the following: I. Corrective Action taken to remove the Immediate Jeopardy; On 9/2/2015 at approximately 2:45pm, the survey team notified the facility that an Immediate Jeopardy situation was present in regards to prior Elopement of resident on 7/11/2015. 1) Corrective Action was accomplished for the resident to have been affected by the deficient practice. Resident was returned to facility and was immediately placed on every 15 minute checks for safety and location. The wander guard was checked for placement and function on 7/11/2015. A body audit and assessment was completed with no signs of injury noted. Vital signs were stable on 7/11/2015. An Elopement Risk Assessment was completed on the resident on 7/11/2015. Code Silver walking rounds were initiated; all residents accounted for on each unit. The physician and legal representative were notified of the incident. An order was received from the Medical Director to send the resident to (the hospital) for psychiatric evaluation and treatment on 7/11/2015. The resident was discharged on [DATE]. 2. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur: Established time line and analysis of root cause. A 100% audit of all wander guards for placement and function was completed on 7/11/2014. Door code was changed. All staff were in-serviced by the Director of Nursing and Assistant Director of Nursing on the new code with instructions not to divulge that code to family, visitors or vendors; completed 7/14/2015. Code Silver Drills will be completed. Door signs posted on Main Entrance and Side Entrance doors warning visitors not to allow any person out of the facility without notification to facility staff on 7/11/2014. All nursing staff were in-serviced by the Assistant Director of Nursing beginning on 7/14/2015 on policy for rounding and location of their residents, all nursing staff were educated by 7/24/2015. Maintenance continues to check all doors for wander guard function once per week. Resident wander guards will continue to be checked daily for placement and function. All findings were presented to the QA Committee for review and recommendation for continued intervention or amendment of plan on 7/17/2015. All ambulatory residents and any resident in a wheelchair who can self-propel, excluding those residents residing in our Secured Unit will have an elopement risk assessment completed by 9/3/2015. Any resident identified as at risk for elopement or wandering will have their care plan updated as appropriate by 9/3/2015. All new employees, including prn staff will be in-serviced/educated by Director of Nursing /Assistant Director of Nursing during orientation and prior to resident assignment on policy regarding rounding and location of their residents and door lock codes will not be divulged to visitors/family or vendors. Licensed nursing staff will complete an Elopement risk assessment for each residents upon admission, quarterly and at significant change. The Assistant Director of Nursing and/or Director of Nursing will in-service all Licensed Nurses on accurate completion of Elopement Risk Assessments, all new licensed nurses will be in-serviced during orientation and prior to resident assignment. Allegation of compliance date- 9/3/2015. Observations, record reviews, and interviews revealed the A[NAME] submitted by the facility on 9?3/2015 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. The Administrator was informed of this on 9/3/15. The Immediate Jeopardy at F490 was removed with the Scope and Severity of the citation lowered to a D.",2019-04-01
5152,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-09-17,502,D,0,1,WIDK11,"**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 laboratory supplies were in 1 of 3 medication storage rooms. Expired Vacutainer 's for resident use were in the Gold Wing medication storage room. The finding included: On [DATE] at 12:28 PM, an observation of the Gold Wing medication storage room with LPN #1 revealed, 84 BD Vacutainer's SST REF 8 (Lot Number) ) 23 with expiration dates of ,[DATE]. Following the observation LPN #1 verified the 84 BD Vacutainer's were expired and stated, It is nursing's responsibility to check expiration dates on Vacutainer's.",2019-04-01
5838,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-08-21,157,D,1,0,Z6Z311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility staff failed to notify Resident #2's physician about the resident vomiting, 1 of 3 resident reviewed for notification. Resident #2 recently started on an antibiotic to treat a urinary tract infection had 2 episodes of vomiting and the physician was not notified. The findings included: Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set coded Resident #2 as having a BIMS (brief interview of mental status) of 7. Her/his speech was unclear, s/he was coded as understood and understands. S/he required extensive assistance of one with transfers, dressing, bathing and hygiene; s/he fed him/herself after the meal was setup. Review of the Nurse's Notes contained in the closed medical record revealed that on 07/28/2015 at 6:00 PM Resident#2's Foley Catheter was changed and replaced with a 16 F (French) catheter. The urine was noted to be yellow, cloudy urine and was sent for a urinalysis, culture and sensitivity. At 9:30 PM a note indicated that the physician [MEDICATION NAME] a urinary tract infection after receiving the results of the urinalysis. When the nurse administered [MEDICATION NAME] resident complained of bladder spasms attributed to the placement of the new catheter, the concerns were addressed and the resident was assessed, stating s/he feels better. On 07/29/2015 at 4:00 AM Tylenol was administered for a complaint of bladder pain; at 5:00 AM s/he expressed slight relief. The next note at 4:00 PM stated, Resident has been complaining of discomfort with his/her foley catheter most of the day . The next note dated 07/30/2015 at 4:00 AM indicated the resident continued with an antibiotic for a urinary tract infection with no acute distress noted. Voiced no complaints so far this shift. The charting for the 7A-7P shift, 2:15 PM stated, Resident tolerated all meds well. S/he takes one pill at a time.[MEDICATION NAME] mg (milligrams) given for UTI (urinary tract infection). No adverse reaction noted. One assist with ADL's (activities of daily living) feeds self after tray setup appetite good, foley catheter in place and functioning cloudy yellow urine in leg bag. No c/o (complaints) discomfort or pain at this time. The next note dated 07/31/15 at 4:00 AM stated, resident resting in bed w (with) eyes closed, call bell w/n (within) reach and bed in lowest condition no adverse reaction noted (?) [MEDICATION NAME]. This note was not signed. Review of the 24 hour reports for 07/28-07/31/2015 revealed documentation dated 07/30/2015 that stated Resident #2 vomited x 2. Saw vomit x 1 brown with food. Resident needs to sit up to eat.[MEDICATION NAME] mg BID (twice a day) for UTI. In an interview with the surveyor on 08/18/2015 at approximately 7:30 AM Licensed Practical Nurse (LPN) #1 confirmed that s/he documented the information on the 24 hours report. S/he stated Certified Nurse Aide (CNA) #1 called her/him to Resident #2's room and said s/he vomited, it was supper time, there was food in the vomit. LPN #1 stated it was probably between 5:30 and 5:45 PM. LPN #1 confirmed s/he did not notify the physician about Resident #2 vomiting or document the incident in the nurse's notes.",2018-08-01
5839,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2015-08-21,309,D,1,0,Z6Z311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the necessary care and services to maintain the physical well-being for Resident #2 who was noted with vomiting on [DATE] without physician or family notification; without documentation of the incident or monitoring of the resident regarding his/her vomiting (1 of 3 residents reviewed for a change in condition). The findings included: Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set coded Resident #2 as having a BIMS (brief interview of mental status) of 7. Her/his speech was unclear, s/he was coded as understood and understands. S/he required extensive assistance of one with transfers, dressing, bathing and hygiene. S/he fed her/himself after the meal was setup. Review of the Nurse's Notes contained in the closed medical record revealed that on [DATE] at 6:00 PM Resident #2's Foley Catheter was changed and replaced with a 16 F (French) catheter. The urine was noted to be yellow, cloudy amber and was sent for a urinalysis, culture and sensitivity. At 9:30 PM a note indicated that the physician [MEDICATION NAME] a urinary tract infection after receiving the results of the urinalysis. When the nurse administered [MEDICATION NAME] resident complained of bladder spasms attributed to the placement of the new catheter, the concerns were addressed and the resident was assessed, stating s/he feels better. On [DATE] at 4:00 AM Tylenol was administered for a complaint of bladder pain; at 5:00 AM s/he expressed slight relief. The next note at 4:00 PM stated, Resident has been complaining of discomfort with his/her foley catheter most of the day . The next note dated [DATE] at 4:00 AM indicated the resident continued with an antibiotic for a urinary tract infection with no acute distress noted. Voiced no complaints so far this shift. The charting for the 7A-7P shift, 2:15 PM stated, Resident tolerated all meds well. S/he takes one pill at a time.[MEDICATION NAME] mg (milligrams) given for UTI (urinary tract infection). No adverse reaction noted. One assist with ADL's (activities of daily living) feeds self after tray setup appetite good, foley catheter in place and functioning cloudy yellow urine in leg bag. No c/o (complaints) discomfort or pain at this time. The next note dated [DATE] at 4:00 AM stated, resident resting in bed w (with) eyes closed, call bell w/n (within) reach and bed in lowest condition no adverse reaction noted (?) [MEDICATION NAME]. This note was not signed. The next note untimed and signed by the ([DATE]) 7A-7P nurse documented that the resident was in bed throughout the day with increased weakness. Verbalized not feeling quite right. The nurse practitioner was notified and the residents antibiotic was changed. The next note stated, At approx (approximately) 9:25 PM upon entering residents room to admin (administer) [MEDICATION NAME], resident was nonresponsive, no resp (respirations), no pulse, CPR begun 911 called. CPR continued until 911 arrived. EMS notified their MD of full arrest status and determined that based on lack of VS (vital signs) and resident condition to terminate CPR . Review of the Physician's Progress Notes revealed a note dated [DATE] that stated, Chief complaints/reason for visit: .for f/u (followup) of UTI. Received results of urine C&S (culture and sensitivity); no susceptible to Cipro. On exam s/he is lying in bed and reports not feeling well . Abdomen: soft, nontender, no distended, + bowel sounds . In a face-to-face interview with the surveyor on [DATE] at 6:05 PM Certified Nurse Aide #2 stated that s/he helped Resident #2 wash up on the 7A-3P shift on [DATE]. Nothing unusual that I remember. In a face-to-face interview with the surveyor on [DATE] at 6:15 PM Licensed Practical Nurse (LPN) #1 was asked if Resident #2 had any vomiting from his/her antibiotics? S/he replied, Not sure. The surveyor asked LPN #1 if anything happened on [DATE] during the 7A-7P shift? S/he replied, No, s/he was his/her normal self. In a face-to face interview with the surveyor on [DATE] at 7:40 AM CNA #3 stated s/he was assigned to Resident #3 on [DATE] 3P-11P shift. After supper I went in room, one of the nurses went in with me s/he not look good. Other nurses came in started working on him/her. I went on to take care of other residents. When asked by the surveyor what s/he saw? S/he stated, Head of bed was up, s/he was turned to right, black stuff on the floor. CNA #3 was not sure if the black stuff was wet. S/he stated it was about the diameter of a grapefruit. In a face-to-face interview with the surveyor on [DATE] at 9:20 AM Registered Nurse #1 stated s/he was running late to work on [DATE]. Observation of the timecard report documented that s/he clocked in on [DATE] at 11:28 PM and clocked out at 7:18 AM ([DATE]); RN#1 confirmed this was accurate. RN #1 stated that s/he was not aware if Resident #2 had had vomiting prior to her/him coming to work. RN #1 was asked by the surveyor to provide the 24 hour report for [DATE]. Review of the 24 hour reports for ,[DATE]-[DATE] revealed documentation dated [DATE] that stated, Resident #2 vomited x 2. Saw vomit x 1 brown with food. Resident needs to sit up to eat.[MEDICATION NAME] mg BID (twice a day) for UTI. In a telephone interview with the surveyor on [DATE] at approximately 7:30 AM Licensed Practical Nurse #1 confirmed that s/he documented the information on the 24 hours report. S/he stated Certified Nurse Aide (CNA) #1 called her/him to Resident #2's room and said s/he vomited, it was supper time, there was food in the vomit. LPN #1 stated it was probably between 5:30 and 5:45 PM. LPN #1 confirmed s/he did not notify the physician about Resident #2 vomiting or document the incident in the nurse's notes. In a telephone interview with the surveyor on [DATE] at 9:05 AM CNA #1 confirmed that Resident #2 vomited prior to supper on [DATE]. I took his/her tray back. When asked by the surveyor what time s/he reported to the nurse, s/he stated, 5:30 - 5:45. Only time I saw him/her vomit. When asked by the surveyor where the vomit was, s/he stated, mouth, nose, clothes, bed and floor. When asked to describe the vomit, s/he stated, dark colored. When asked by the surveyor if it looked like blood, s/he stated, Didn't look like blood, not red, lots of liquid. CNA #1 stated that the prior CNA did not report any vomiting during their walking rounds.",2018-08-01
6396,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2014-06-30,155,D,0,1,QRXS11,"**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 policy titled, Do Not Resuscitate , the facility failed to afford 2 of 19 sampled residents reviewed for Code Status the right to formulate their own Advanced Directives. Resident #52 and Resident #76 had not been deemed to lack capacity by 2 Physicians to make their own Advanced Directives/healthcare decisions. The findings included: The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Record review on 06-25-14 at approximately 4:30 PM of the Physician's Telephone Orders dated 04-15-14 revealed the following order, .i.e .Do Not Resuscitate (DNR). Further record review on 06-25-14 of the Medical Decision Capacity for Resident #52 revealed only one Physician had determined Resident #52 to have all medical decisions made by others , not the required 2 Physicians. The resident's daughter had signed the Resuscitation designation form instead of the resident. During an interview on 06-25-14 at approximately 4:37 PM with the Director of Social Services, h/she, after chart review, verified the Medical Decision Capacity for Resident #52 had been signed by 1 Physician, not the required 2 Physicians. Review of the facility policy titled Do Not Resuscitate revealed in Section III. Basic requirements for facility Do Not Resuscitate order policy the following, (f.) Incompetent Patient- An adult who is unable to appreciate the nature and implications of his condition, to make reasoned decisions concerning his care, or to communicate decisions concerning his care. This incapacity must be verified by clinical assessment of the patient by 2 physicians, unless the individual was previously declared legally incompetent by court order. The facility admitted Resident #76 for Short-Term Rehab following hospitalization with [DIAGNOSES REDACTED]. Review of the Advance Directives section of the medical record revealed the resident's daughter signed the Resuscitation Designation form indicating the resident's code status was DNR. The physician had signed this form as well. Review of the Medical Decision Capacity form indicated one physician had signed this form indicating the resident lacked decision-making capacity. The section of the form reserved for a second physician's signature attesting to the resident's capacity contained documentation which stated, See H & P (History and Physical) & D/C (discharge) summary dated 2/18/14. Review of the hospital Discharge Summary indicated that the resident's granddaughter was the Healthcare Power of Attorney. Review of the facility's Social Services Evaluation form upon admission indicated , Resident's daughter is her RP and HCPOA (Healthcare Power of Attorney.) A DNR was signed by daughter and MD. Further record review indicated the resident signed a Durable Power of Attorney prior to admission designating his/her daughter as the Durable Power of Attorney. Review of the document indicated it did not address the right to make health-care decisions for the resident. Additional documentation was requested related to the family member signing the Advance Directive form without two physician's attesting to the resident's capacity to make healthcare decisions. The Director of Nursing reviewed the medical record and confirmed that the record contained only the Durable Power of Attorney.",2018-03-01
6397,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2014-06-30,241,D,0,1,QRXS11,"On the days of the survey, based on observations, interview and review of the policy entitled, Quality of Life - Dignity, the facility failed to promote care for residents in a manner that maintained or enhanced each resident's dignity and respect. Staff did not offer the residents the choice of using or not using clothing protectors in 2 of 3 dining areas observed during meal service. The findings included: An observation of the lunch meal on 6/23/2014 at approximately 12:45 PM revealed staff applying clothing protectors on residents without first asking if they would like to have one applied. An observation on 6/26/2014 at approximately 12:35 PM revealed staff applying clothing protectors on residents without first asking for permission to do so. During an interview on 6/26/14 at approximately 1:20 PM with Certified Nursing Assistant #1, he/she verified and confirmed that clothing protectors were applied without asking the residents if they would like to have one. During a random dining observation on 6/23/14 at 11:50 AM, three CNA's(Certified Nursing Assistants) were observed to place clothing protectors on thirteen residents without affording the residents the opportunity to decline the use of a clothing protector. During a random observation on 06-23-14 at approximately 12:35 PM of the B Wing lunch meal, a Certified Nursing Assistant (CNA) was observed placing clothing protectors on residents without first asking their permission or preference. Review of the facility provided policy entitled, Quality of Life - Dignity stated, 'Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality section #8 stated Procedures shall be explained before they are performed'.",2018-03-01
6398,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2014-06-30,253,F,0,1,QRXS11,"On the days of the survey, based on random observations and interviews, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior on 3 of 3 Units. There were multiple housekeeping/maintenance concerns related to walls and doors, and resident use items. The findings included: On 06-23-14 at approximately 12:50 PM and all days of the survey, random observations revealed the following: Observations of the Unit 1 Day area on 6/23/14 revealed the following concerns: Numerous dark scrapes/marks were observed on the lower half of the walls around the circumference of the room. The windows in the two doors leading onto the porch were observed with smudged, hazy, and white deposits. The two windows between the doors were observed with this same discoloration. The bottom edges of the door frames of the doors leading into the dayroom from the hallways had a build-up of dark-colored substance. These doors frames also had numerous scratches. A build-up of soiling/dust was observed on the area underneath the windows near the floor. Observation on 6/23/14 revealed the Unit 1 and Unit 2 weight scales located in the hallways near the Nurses Stations with numerous areas of missing, black rubberized material covering the base of the scale. The white metal material underneath the rubberized base was exposed. Observation of Room 105 on 6/23/14 revealed the following: The painted, bottom portion of the walls were observed with numerous scratches/scrapes leaving white areas in the dark-colored painted areas. The wallpaper was observed to be pulling away from the window frame The arms of the chair contained numerous scratched areas. The closet doors had patches and numerous scratches. A wire rack in the resident's bathroom was rusted. The wall behind the sink and commode had a build-up of light-colored substance. The bathroom doors had numerous scratches. Observation of Room 106 on 6/23/14 revealed the following: The wallpaper was pulling away from the wall above the head of the bed near the window . The closet doors had numerous scratches and chipped paint. The bathroom baseboard was observed pulling away from the wall behind the commode. The bottom edge of the door frame on both sides of the door leading into the bathroom had large areas of chipped paint. The baseboard in the bathroom had numerous dark, discolored areas. Room #116 P: Edge of the baseboard missing on the left side of the entrance to the room, lower portion of the room door scuffed Room #119 A: Wallpaper noted torn near the right side of the bed Room #119 B: Black marks noted on the wall near the right side of the bathroom door entrance, black marks noted on the right side of the wall upon entrance to the room, scraped paint noted on the wall behind the trash can located to the right side of the bathroom entrance. Room #119: Bathroom: Brown rust colored areas noted on the over the commode chair. Unit 200: Upon entrance to the Nursing Station area the lower portions of the walls and baseboards were noted with scuffed areas. In the Dining Room/Day Area the following concerns were noted: hand rail noted scuffed, a green chair seat noted with a slit at the edge of the chair, paint noted peeling along the edge of the window sill, lower areas of the walls noted with black marks, green couch near the TV noted with stains, torn floor tile noted beside the couch on the right side, wallpaper not repaired where TV had previously been located, smudged/soiled glass on the windows/door glass near the porch, and the lower portions of the Soiled Utility door and the Clean Utility doors noted with scraped marks. Additionally: Room #202 B: Scuffed arms and legs of green back/seat chair at the end of the bed, torn end of arm pad on the left side Room #205 A: Scuffed/torn wallpaper near the head of the bed. Room #206 B: Baseboard noted to the right side of the entrance to the bathroom loose from the wall, wallpaper above the bed unattached near the ceiling. Room #210 A: Baseboard loose beside the bed, torn wallpaper noted. Room #210 B: Wallpaper near the head of the bed noted torn. Observation of the 300 Unit during initial tour on 6/23/14 at 10:57 AM revealed the following: Scratched handrails and scuffed walls throughout the unit; Molding coming away from wall near Room 308; Torn/stained wallpaper near Room 311 and 312 and wallpaper coming away from wall near Room 315/316; Stained ceiling tile near Room 317; Damaged wall near Room 324; Vent near dayroom noted with dust; Damaged wall to day area/dining room; and odors noted throughout unit. Observation of the 200/300 Unit on 6/23/14 revealed the following: Room 214A-floor noted to be soiled; Room 216B-damaged flooring in bathroom and damaged wall in bathroom, dust on vent in bathroom, scuffed closet Room 218-broken commode seat, wall behind sink damaged, dust on vent in bathroom, scuffed bathroom door Room 221B-brown substance noted on commode handle, Room 223B-scuffed bathroom door; Room 324A-damaged walls noted on each side of room; Room 325A-damaged wall behind bed, wheelchair with missing left arm cushion; 300 Shower room noted with dust on vent, shower trolley with debris and care items under mat, soiled floor; odors noted in hallway near rooms 324 and 325. Observation of the 200 unit on 6/26/14 at 2:16 PM revealed the following: Room 201-scuff marks noted on wall nearest door, ceiling tile noted with stain; Room 202-damaged tile beside bed, Room 204-scuffed closet doors; Room 205-damaged wall, scuffed closet doors, black stains noted on ceiling tile Room 206-damaged wall Room 210-damaged wall noted at bed A, stain noted on wall at bed B; Room 211-damaged wall behind bed Room 215-scuffed wall Room 219-damaged wall beside bed at door, loose ceiling tile; Room 224-torn wall behind bed, torn wallpaper bed A; Room 225-scuffed wall beside bed A and behind bed, spill noted on bathroom door; torn seat noted in upright chair at nurse's station. Gold Wing: Resident bath on the Gold Wing smelled strongly of urine and the ceramic tile around the entrance door had broken pieces in 3 areas with sharp edges. Room 301 - The entrance door, walls, closet door and baseboards were scuffed. Bathroom walls scratches, and bathroom floor was soiled. Room 302 - Walls scuffed Room 303 - Call light outside of room was not in place and was over to one side as if broken. Room 304 - All walls scuffed and in need of repair. Room 305 - Walls doors scuffed. Wall above the trash can has yellow substance that has ran down the wall and dried. Room 306 - Walls are scuffed in need of repair. All baseboards at Nurses desk were observed to be soiled. All along the hallways of the unit, the walls and the hand rails are scuffed. Rooms 307 through 315 the walls, doors and baseboards are scuffed, soiled and in need of repair. Hallway around rooms 311-314 smells strongly of urine. On the right side of the exit door at the end of hallway, a portion of the door frame is missing. Room 319 - Closet door is scuffed Room 320 - Room smells strongly of urine. Closet door is scratched. Rust is noted around the base of the commode. Bathroom faucet is leaking. Wall on the left side of the sink has a brown dried substance. Room 321 - Entrance door is scuffed, closet door is scratched Rooms 322-326 all closet doors are scuffed. Walls soiled, scratched and in need of repair. Bathroom between room 324 and 325 the walls are 2 colors in places, floor appears soiled, the pipes under the bathroom sink have black electrical tape noted where the pipes connect. Review of Maintenance work orders on 6/26/2014 at approximately 4:00 PM revealed a Maintenance Work order dated 6/5/2014 at 6:30 PM for room # 325B that states, Air conditioner knobs have a missing cover, holes in the closet door from previous locks, paint is chipped on the door frame in the bathroom and wall paper is torn. Another Maintenance work order dated 6/5/14 written at 6:30 PM for room 325B also included wallpaper in the bathroom is all different colors. Commode plunger in bathroom is gross and needs to be replaced. The writer wrote, I am not sure if it should even be there. Floor is discolored. Adhesive pads on wall and toilet tank. Tape is connecting the pipes under the sink. An observation on 6/26/2014 at approximately 4:45 PM revealed the bathroom walls between room 324 and 325 remain different colors. The commode plunger had been removed. Floor remained discolored. No adhesive pads were found on the wall or the toilet tank. Black electrical tape remained wrapped around the pipes under the sink where the pipes connect together. All of the above findings were observed and confirmed by the facility Maintenance Director during a tour on 6/26/14 at approximately 4:52 PM and on 6/27/14.",2018-03-01
6399,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2014-06-30,309,D,0,1,QRXS11,"**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 residents reviewed for Hospice services. The facility failed to coordinate care with the Hospice provider and failed to have Hospice documentation for Resident #54 in the medical record and/or facility. The findings included: The facility admitted Resident #54 with [DIAGNOSES REDACTED]. Review of the medical record indicated the facility admitted Resident #54 to Hospice services 4/4/14. Review of the medical record on 6/27/14 revealed the care plan section of the record contained the facility's most recent comprehensive care plan. The care plan addressed the fact that the resident was receiving Hospice services. Hospice staff will collaborate/update resident care and care plan to insure quality of care. The care plan did not include documentation related to the services to be provided by the facility and the services to be provided by Hospice, did not indicate how services were to be coordinated with the Hospice provider, and did not indicate Hospice participation in the development/coordination of the care plan. Review of the medical record revealed no documentation of Hospice staff visiting the resident/administering care to the resident. The medical record did not contain documentation of Hospice nursing visits or documentation from other Hospice staff related to the resident. When asked for documentation of care provided by Hospice staff, Licensed Practical Nurse (LPN) #1 was unable to provide this documentation. When asked if the Unit had a Hospice notebook for each resident, he/she was unable to locate additional information. He/she stated that he/she would contact the Hospice provider and request that documentation be faxed to the facility. On 6/27/14 at approximately 7:00 PM, the facility provided Hospice documentation faxed to the facility. According to the Director of Nursing (DON) at that time, the Hospice notebook containing the faxed information had previously been available on the unit. The DON indicated that he/she was unsure of why the notebook and documentation was no longer in the facility.",2018-03-01
6400,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2014-06-30,323,D,0,1,QRXS11,"**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 interventions as ordered for accident prevention for 1 of 4 sampled residents reviewed for fall/accident prevention. Resident #45 sensor alarm was not functioning when tested . In addition, the facility failed to maintain proper water temperatures in 1 of 3 units. The findings included: Record review on 6/26/14 of Resident # 45's medical record revealed a current physician's orders [REDACTED]. Review of the Accu-tech Sensor Function Check List for May and June 2014 revealed verification of the function of the Accu-tech Sensor. Observation of the Accu-Tech Sensor on 6/26/14 at 4:47 PM revealed the Sensor was located on the resident's ankle. LPN (Licensed Practical Nurse) #1 was asked to verify the function of the Sensor and confirmed the Sensor no longer functioned when tested . On 6/23/14 at approximately 2:00 PM, observation of the Blue Wing revealed water temperatures in resident bathrooms above 120 degrees as follows: Room 216-120.3 degrees Room 218P-123.2 degrees Room 220-122 degrees Room 223-120.4 degrees. The temperature in the bathrooms was taken again on 6/24/14 with temperatures as follows: Room 216-119.1 degrees 218P-122.4 degrees 220-122.6 degrees 223-116.6 degrees On 6/26/14 during environmental rounds with the Maintenance Director, the following temperatures were noted: Room 216-119.4 degrees Room 218-123.3 degrees Room 220-111 degrees Review of the Temperature Log for the months of May and June 2014 revealed one temperature on the Blue Wing on 5/19/14 registering 120.3 degrees. All other temperatures taken were within the acceptable range.",2018-03-01
6401,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2014-06-30,325,D,0,1,QRXS11,"**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 ensure that Resident #50 maintained acceptable parameters of nutritional status. Resident #50 did not receive the full amount of tube feeding as ordered. (1 of 4 residents reviewed for nutrition. The findings included: The facility admitted Resident #50 with [DIAGNOSES REDACTED]. Record Review on 6/25/14 revealed a physician's orders [REDACTED]. Review of the resident's care plan revealed two care plans addressing the resident's nutritional status. Two of the approaches listed were to document diet tolerance and administer tube feedings/flushes as ordered. Review of the weight record revealed Resident #50 weighed 133 lbs (pounds) on 12/13 and now weighed 145.5 on 6/2/14. Observation on 6/25/14 of the tube feeding bottle revealed the resident had only received 500 cc of the 900 cc of tube feeding ordered. On 6/25/14 at 3:15 PM, LPN #3 was asked to view the tube feeding bottle with the surveyor. He/she confirmed the resident had not received the ordered amount of tube feeding of 900 cc and had only received approximately 500 cc of tube feeding. He/she continued by stating the resident would stop his/her tube feedings at times. Review of the dietary notes dated 6/13/14 revealed Resident #50 consumed approximately 25% of meals and nutrition was provided primarily via the nocturnal feedings. There was no documentation in the dietary notes related to the resident not receiving all of the recommended tube feeding and/or having a history of stopping the tube feeding at times. LPN #3 confirmed there was no daily documentation as to how much tube feeding the resident received from 7 PM-5 AM. During an interview with the RD(Registered Dietician) on 6/26/14 at 4:15 PM, he/she stated did not think he/she was aware the resident would stop the tube feeding. He/she continued by stating staff should document the times the resident did not get the full amount of tube feeding to ensure an accurate assessment could be done on the resident.",2018-03-01
6402,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2014-06-30,371,E,0,1,QRXS11,"On the days of the survey, based on observations, interview and review of the facility policy, the facility failed to ensure meals were served under sanitary conditions. Certified Nursing Assistants were observed touching Resident's food with their bare hands on 2 of 3 units. The findings included: An observation on 6/23/2014 at approximately 1:00 PM on the Gold Wing revealed Certified Nursing Assistant (CNA) #1 touching residents bread with his/her bare hands while applying butter to the bread. A second observation on 6/23/2014 at approximately 1:15 PM revealed CNA #2 touching residents bread with his/her bare hands during removal of the bread from the wrapper. An observation on 6/26/2014 at approximately 1:00 PM on the Gold Wing revealed CNA #1 touching residents bread with his/her bare hands during removal of the bread from the wrapper. An interview on 6/26/2014 at approximately 1:20 PM CNA #1 confirmed that he/she had touched the resident's bread on both days as observed. CNA #2 was not available for interview. Review of the facility policy entitled, Food Preparation and Service, the section entitled, Food Service/Distribution, #6 states, Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. During meal observation on the 300 Unit on 6/23/14 at 12:00 PM, CNA (Certified Nursing Assistant) #1 and CNA #2 were observed touching the bread on resident trays with bare hands.",2018-03-01
6403,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2014-06-30,441,D,0,1,QRXS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview and review of the facility policy titled Dressings, Dry/Clean and skills check off titled Dressing Change, Clean, 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 pressure ulcer treatment for [REDACTED].(1 of 3 residents reviewed for pressure ulcer treatment and infection control) The findings included: During observation of the pressure ulcer treatment for [REDACTED].#2 was observed to place Santyl ointment on a sacral wound noted with drainage with his/her gloved finger. He/she then continued the treatment, placing Calcium Alginate and a dressing over the area, while continuing to wear contaminated gloves. Review of the facility policy titled Dressings, Dry/Clean revealed there was no information related to applying a medication/ointment to the wound area. Review of the facility skills check off titled Dressing Change, Clean stated 'to apply prescribed medication if ordered'. During an interview with LPN #2 on 6/25/14 at 10:35 AM, he/she confirmed placing the Santyl on the wound and continuing with the treatment without changing his/her gloves or washing hands.",2018-03-01
7607,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2012-10-17,281,E,0,1,JNP611,"**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 meet professional standards of quality related administering medications per the physicians' order. Resident #20 recieved a medication beyond the specified number of days ordered by the physician. (1 if 14 sampled residents reviewed for professional standards related to medication administration per the physicians' orders.) The findings include: The facility admitted Resident #20 with [DIAGNOSES REDACTED]. On 10/17/12 at 11:30 AM, review of the physician's orders [REDACTED]. Further review of the Medication Administration Records (MAR) dated 5/30/12 through 10/14/12 revealed Resident #20 received [MEDICATION NAME] 220 milligrams /5 milliliters 4 times daily from 5/30/12 through 10/14/12. During an interview with Licensed Practical Nurse (LPN) #3, Unit Manager, s/he, after record review of the current physician's orders [REDACTED].",2016-12-01
7608,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2012-10-17,314,D,0,1,JNP611,"**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 appropriate Pressure Ulcer Treatment per the physician's orders [REDACTED]. During observation of Resident #5's Pressure Ulcer Treatment, the facility staff failed to provide the correct treatment. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review on 10/16/12 at 9:30 AM of the physician's orders [REDACTED]. An addditional physician's orders [REDACTED]. On 10/16/12 at 10:00 AM, Licensed Practical Nurse (LPN) #1 entered Resident #5's room to provide Pressure Ulcer Treatment. Observation revealed Licensed Practical Nurse (LPN) #1 failed to apply the [MEDICATION NAME] 2% Cream per the physician's orders [REDACTED].#1, s/he revealed s/he had not been aware of applying the [MEDICATION NAME] 2% Cream but would check the physician's orders [REDACTED].#1, s/he, after record review of the current physician's orders [REDACTED].",2016-12-01
7609,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2012-10-17,328,E,0,1,JNP611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility admitted Resident #1 with [DIAGNOSES REDACTED]. During an observation on 10/15/12 at 4:27pm, the Resident's oxygen concentrator was set at 6 L/M (liters per minute) via N/C (nasal cannula). During an observation and interview on 10/15/12 at 4:52pm the UM (Unit Manager) confirmed the Resident did not have an order for [REDACTED]. During a record review on 10/16/12 at 12pm, the Nurse's Notes stated Resident # 1 was started on oxygen at 6L/M on 10/15/12 at 2am after being noted to have an oxygen saturation level of 49%. After oxygen was applied the resident's saturation level rose to 79%. However, no physician's order was noted in the medical record. The nurses notes stated the physician was notified via service . On 10/15/12 at 4:50PM, a physician's order stated: oxygen via nasal cannula at 2 liters, titrating up to (sic) Keep oxygen saturation level above 92%. Oxygen sats (saturation) (sic) at 4 l/min via nasal cannula. During an observation on 10/16/12 at 10:46am the Resident's oxygen concentrator was set at 6 L/M via N/C. During an observation and interview on 10/16/12 at 12:37pm, Nurse #2 verified the oxygen concentrator was again set at 6 L/M via N/C. The facility admitted Resident #20 with [DIAGNOSES REDACTED]. Record Review on 10/17/12 at 11:10 AM of the Physician's Orders dated 5/24/12 revealed an order to Check Oxygen (02) saturation (SATs) every shift (q shift) and as needed (PRN). Further record review on 10/17/12 at approximately 11:10 AM revealed no documentation available to substantiate the Oxygen (02) saturation (SATs) were done each shift. Record review of the Medication Administration Record [REDACTED]. During an interview on 10/17/12 at approximately 11:20 AM with Licensed Practical Nurse (LPN) #3 Unit Manager, s/he, after chart review, verified the Oxygen (02) saturation (SATs) had not been done per the Physician's Orders.",2016-12-01
7610,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2012-10-17,371,F,0,1,JNP611,"On the days of the survey, based on observation, interviews, and review of the facilities policies, the facility failed to prepare, distribute, and serve food under sanitary conditions. Dietary staff failed to calibrate the Fahrenheit food temperature probe (thermometer) accurately; to reheat foods on the steam table to the recommended temperature; keep the ceiling vents in the kitchen free from dust and remove food /debris from the floor of the dry storage area. A dietary staff member was observed to not use a barrier when turning off the faucet during handwashing. Staff members were observed to touch resident food with their bare hands. The findings included: During initial tour of the kitchen on 10/15/12 at approximately 11:15 AM, a heavy dust build-up on 3 ceiling vents was observed above the tray line and food serving area. Also, 2 boxes of cereal and food debris were observed on the floor of the dry storage area under the right side storage rack. The heavy dust build-up and 2 boxes of cereal were observed again on 10/16/12 at approximately 4:20 PM, and on 10/17/12 at 9:10 AM. During an interview following the 10/17/12 observation , the Dietary Service Director confirmed the finding of the heavy dust build-up and 2 cereal boxes in the dry storage area. S/he stated that employees are assigned to different cleaning tasks and are expected to monitor the tasks daily and clean as needed. S/he also stated there was a cleaning schedule, but it has not been followed recently. On 10/16/12 at approximately 11:30 AM, during an observation of a lunch meal serving line. Dietary Employee #1 calibrated a probe thermometer for monitoring food temperatures to 20 degrees in a cup of ice water and then began to test the temperature of foods on the steam table. The surveyor asked Dietary Aid #1, What is the correct temperature for calibration of a thermometer in ice water? Dietary Aid #1 stated, I don't know. Furthermore, during an observation of the steam table temperatures, a pan of ground pork was 110 degrees Fahrenheit when tested . Dietary Aid #1 then reheated the ground pork and placed it back onto the steam table. The thermometer then read 120 degrees Fahrenheit. Dietary Aid #1 then stated 120 degrees, is that right?. Dietary Aid #1 then confirmed that s/he did not know the correct reheating temperature. On 10/17/12 at 11:55 AM, an observation of the steam table for the lunch meal serving line was conducted. Two thermometer probes were placed in ice water and read 0 degrees Fahrenheit. The surveyor asked Dietary Aid #2, What is the correct temperature for calibrating a thermometer probe in ice water? S/he stated I thought the thermometer should be calibrated to 0 degrees. On 10/17/12 at approximately 4:30 PM, an observations of Dietary Aid #3 was made washing hands and not using a barrier to turn off the water in the food service area. During an interview following the observation, Dietary Aid #3 confirmed not using a barrier to turn off the water. On 10/16/12 at approximately 12:45 PM, review of the facilities policy titled Proper USE of Thermometers, revealed under Procedure: 3.) Thermometers should be calibrated at least monthly and after being dropped. To calibrate a probe thermometer fill a medium- sized glass with ice and then add water. Place the thermometer in ice the water and wait three minutes stirring occasionally. After three minutes the thermometer should read 32 degrees Fahrenheit. If the temperature does not read 32 degrees Fahrenheit leave it in the ice water and use a pair of pliers to turn the adjustable nut on the back of the thermometer until the needle reads 32 degrees Fahrenheit. Wait three more minutes (add ice if needed) and check to make sure temperature reads 32 degrees Fahrenheit. The facility policy titled Reheating Food, revealed under section Temperatures to Remember, and sub-section: 165 degrees for 15 seconds b.) Minimum internal product temperature for reheating foods. Also, the facility policy titled Proper Handwashing Procedure, revealed under 8.) Use towel to turn off water and protect hands from resoiling. On 10/15/12 at 5:50 PM a random observation of the 100 Hall Dining Room during the dinner meal noted a staff member had removed a roll from a wrapping with his/her bare hands and placed it onto the resident's plate. A second random observation on 10/16/12 at 1:00 PM in the 200 Hall Dining Room during the lunch meal revealed a second staff member who removed bread from a wrapping with his/her bare hands and placed it onto the resident's plate.",2016-12-01
7611,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2012-10-17,441,D,0,1,JNP611,"**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 Infection Control Policies and Procedures , the facility failed to remove the trash or bag linen upon exiting the room and failed to wash hands after disposing of linen after completing a pressure ulcer treatment. (1 of 3 pressure ulcer treatments observed for infection control practices) The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 10/16/12 at 10:00 AM, after the completion of Resident #5's Pressure Ulcer Treatment, Licensed Practical Nurse (LPN) #1 failed to bag the trash and remove it from the resident's room. Further observation revealed Licensed Practical Nurse (LPN) #1 exited the resident's room with soiled linen without being bagged, proceeded to the Soiled Utility Room and handed the linen to the Housekeeper to dispose of it. Licensed Practical Nurse (LPN) #1 without washing his/her hands, proceeded to store the Wound Cleanser and Santyl Ointment in the Treatment Cart and charted the pressure ulcer treatment on the Treatment Sheet. During an interview with Licensed Practical Nurse (LPN) #1, on 10/17/12 at 12:40 PM. s/he verified the above concerns. Review of the facility policy for Infection Control titled Laundry and Bedding, Soiled revealed the Policy Statement: Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. Review of the policy titled Hand Washing/Hand Hygiene revealed #2 All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors.",2016-12-01
7612,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2012-10-17,516,D,0,1,JNP611,"On the days of the survey, based on offsite record review, the facility failed to safeguard clinical record information against loss, destruction or unauthorized use. Protected Health Information was mailed to the State Survey Agency without safeguards in place to ensure it goes to the appropriate individual. The findings included: On October 2, 2012, the facility requested information via email on how to have an MDS 3.0 (Minimum Data Set) assessment removed from the National Database. On 10/2/12 at 11:47 AM, an MDS 3.0 Manual Assessment Correction/Deletion Request form was emailed to the facility with the instructions: It must be returned Certified Mail. The form itself, under the space for the Administrator's signature, stated: Submit completed (bold) and signed (bold) form to your State Agency via Certified Mail (bold) through the US Postal Service. The State Agency received the completed form on 10/8/12. However, the envelope containing the form, did not indicate that the request was sent Certified Mail. The form included the resident's full name, date of birth and Social Security Number.",2016-12-01
8722,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2011-09-29,225,D,0,1,QZ8411,"**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 policy entitled Abuse Investigations and Reporting Abuse to State Agencies and Other Entities/Individuals, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source were reported immediately to the administrator of the facility and to other officials in accordance with State law. Resident #5 reported being told by staff to be incontinent rather than being assisted to use the bathroom/bedpan. There was no evidence provided that the allegation was investigated or reported. The findings included: The facility admitted Resident #5 on 8/26/11 with [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set indicated that on 9/2/2011 the resident had a BIMS (Brief interview for mental status) score of 14 and on 9/7/2011 her score was 15 which indicated no cognitive impairment. Nurses' Notes reviewed on 9/27/2011 for 9/13/2011 stated res. (resident) cont (continues) to call for incont (incontinent) care, when asked why not call for the bed pan res (resident) stated I was told to go in my brief, it's easier to change you. Resident could not state who told her this. In an interview with the Green Unit Manager, she verified the note and stated that this was not what happened. She stated that the resident had refused to use a bed pan and stated she would use her brief. However, there was no documentation found nor provided that substantiated that statement. The Unit Manager stated that she had not reported the accusation or started an investigation. On 9/29/2011 at 11:00 AM, in an interview with the Director of Nursing, she stated that the resident was admitted with a [MEDICAL CONDITION] and could not use a bed pan or a lift so she could not be taken to the bathroom. The resident's careplan dated 8/30/11 related to incontinence stated under approaches: :Incontinent care/toilet during rounds as needs Adult briefs while OOB (out of bed) for dignity if indicated 9/6/11 start toileting schedule q (every) 3 hours while awake. On 9/29/2011 at 11:45 AM, in an interview with the resident, the surveyor asked if she had been told to use her brief? The resident stated Yes and it astounded me. The resident also stated They have not corrected that statement. I still have to urinate in my brief but they will take me to the bathroom for a bowel movement. Review of the facility's policy entitled Abuse Investigations stated: Policy Statement; All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by the facility management .Preventing Resident Abuse .q. Encouraging all personnel, residents, family members, visitors, etc to report any signs or suspected incidents of abuse to facility management immediately.",2015-12-01
8723,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2011-09-29,241,D,0,1,QZ8411,"**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 promote care for Residents in a manner and in an environment that maintains or enhances each resident's dignity. Resident # 10's air condition was turned on for staff comfort while providing a treatment without the residents permission. ( One of four residents observed for dignity during treatments.) The findings included: The facility admitted resident # 10 on 5/26/10 with the following Diagnosis: [REDACTED]. On 9/27/11 at 11:20 AM Licensed Practical Nurse (LPN) # 3 entered the residents room to provide wound care and catheter care for the resident. The resident was lying in bed, on her back, with covers pulled up to her chin. The nurse told the resident I'm going put the air on. I know you don't like it but it's really warm in here. She turned the air conditioner on and proceeded to uncover the resident to provide care. When she left the room LPN # 10 left the air condition running. On 9/28/11 at 9:30 AM during a interview with LPN # 3, when questioned about the air conditioner, she stated I should have ask the resident if it was ok.",2015-12-01
8724,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2011-09-29,246,D,0,1,QZ8411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interview and observations the facility failed to reasonably accommodate three residents related to the provision of appropriate call light and/or having the call light within reach for residents # 1, and # 10 . Repeated observations revealed the light switch/chain was not available for use for Resident # 6. (Three of 21 sampled residents reviewed for accomodation of needs.) The findings included: The facility admitted Resident # 10 on 5/26/10 with [DIAGNOSES REDACTED]. On 9/27/11 at 9:40 AM this surveyor entered the residents room for an individual interview. The resident was lying in bed on her back with covers pulled up to her chin. The call light was lying on the bedside table. When ask if she could reach the call light to get help she stated No, you have to put it on my stomach for me to reach it. At 11:20 AM on 9/27/11 Licensed Practical Nurse (LPN) # 3 entered the residents room to provide wound care and catheter care. After the treatments were completed, the LPN left the room and left the call light lying across the residents legs. During two additional observations made at 12:10 PM and 4:30 PM on 9/27/11 the call light was observed lying by the residents leg and once across her leg but not within her reach. On 9/27/11 at 4:40 PM the unit manager ( LPN # 4 ) joined this surveyor in the room of Resident # 10, and when questioned about the call light not being within reach on multiple observations, she stated They (the staff) know she can't reach it if its not on her stomach. On 9/28/11 at 9:30 AM during the interview with LPN #3, when questioned about leaving the resident without the call light after performing treatments, she stated I have no excuse for that. The facility admitted Resident # 1 on 9/1/11 with the following Diagnosis: [REDACTED]. The Resident was listed on the facility list of interviewable residents and was chosen for a sampled resident and individual interview. On 9/27/11 at 9:20 AM the resident was observed lying in bed on her back with the call bell and a desk bell in her lap. The resident had a brace on the left hand and had no voluntary movement in the hand or fingers. The right arm was contracted and the resident was able to move it around her chest and abdominal area. The fingers on the right hand moved very slowly When ask to activate the call bell for a nurse, the resident picked the call light up and pushed the side of the call bell instead of the top. The resident could not pick her head up to see the call light and she could not raise her arm to see the call light button. She was also unable to ring the desk bell. When assisted to push the button on the call light, the call light did work. On 9/27/11 at 10:15 LPN #3 entered the room and provided wound care and catheter care for the resident. When done , the LPN left the room and left the call bell hanging off the bed. Two other observation on 9/27/11 at 11:00 AM and 4:30 PM revealed the call light was either on the side of the bed or tied to the side rail. The resident could not reach the call light during either observation. On 9/27/11 at 4:45 PM the unit manager (LPN # 4) joined this surveyor in the room of Resident # 1. When questioned about the call light not being within reach, she asked the resident to push the call light. The call light was next to the side rail. The resident could not reach it. When she handed the call light to the resident, the resident was unable to push the button. LPN #4 stated She needs one of those flat or special call lights that she can use better. 9/28/11 at 9:30 AM during the interview with LPN #3 when ask about leaving the resident without the call light after treatments, she stated I have no excuse for that. The facility admitted Resident # 6 on 10/11/05 with the following Diagnosis: [REDACTED]. Resident # 6 was noted on the facility list for interviewable residents and was selected as a sampled resident and individual interview. On 9/27/11 at 9:00 AM during the interview, the residents chain for the over the bed light was loose from the light and laying in the floor and tied to the siderail. The chain remained on the floor as noted on 9/27/11 at 4:00 PM, 9/28/11 9:15 AM and 9/29/11 at 10:25 AM. When the resident was questioned as to how long has it been there, he stated Several days. It is broken, they have to turn the light on and off for me.",2015-12-01
8725,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2011-09-29,250,D,0,1,QZ8411,"**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 medically-related social services for one of 14 sampled residents reviewed for the provision of social services. There was no Social Service follow up related to Resident # 5's suicidal comments made during her Psychiatric Evaluation. The findings included: The facility admitted Resident #5 on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 4:55 PM, during review of Resident #5's medical chart, the Daily Skilled Nurses Notes for [DATE] indicated the the resident had a psychiatric consult completed. Review of the Psychiatric Consult notes documented that the resident had stated she had been depressed all her life and stated that she describes overwhelming sadness at times, wishes she had died while at the hospital, worries what's the purpose? The notes also indicated (Passive, not active) . Further review of the record revealed that the Social Service Assessment had been completed on [DATE]. On [DATE] at 4:30 PM, during an interview with the Social Service Assistant, she verified that there was no Social Service follow up after the psychiatric consult and that there was no other documentation by Social Services other that what was located on the chart.",2015-12-01
8726,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2011-09-29,253,E,0,1,QZ8411,"**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. The facility had multiple rooms and hand rails with paint peeling, holes in the walls, peeling sheet rock and wall paper, scuffed paint on doors. laminate loose on television stands, baseboards loose/missing and call light cords broken. The findings included: On 9/27/2011 at 12:35 PM, a tour of the facility was conducted. Room #120 had wallpaper peeling near the doorway and the closet door had areas of scuffed peeling paint. Room #122 was noted to have to have wallpaper peeling above the kick plate behind Bed A and beside the doorway. The base board near the television stand and wall near the doorway was peeling away from the wall. The laminate on the front edge of the television stand was loose and hanging down exposing the wood beneath it. Room #123 had baseboards pulling away from the walls behind the bed and multiple scrapped, chipped areas in the wallpaper near the bathroom and closet. Room #125 had holes in the sheet rock behind Bed A. The wallpaper behind the bed down to the baseboard was wrinkled and the baseboards were pulling away from the walls. Rooms 117, 118, 120, 121 and 122 had multiple chips in the painted door jams. The hand rails outside the dining area and the hallway to the above rooms contained multiple chips in the paint. Rooms 108, 109, 110, 111, 112 and 114 also had multiple areas of scuffed paint on doors, peeling, scuffed wallpaper and loose baseboards. Room 110 had loose flooring at the foot of the bed near the bathroom door. Room 112 had the baseboard missing on the right side of the doorway inside the resident's room. Room 114 had floor tiles separating at the seams in the center of the floor. The shower room doorway had flooring separating at the threshold causing a ridge at the entrance. On 9/29/2011 at 10:25 AM, during a tour with the Nursing Home Administrator, he stated that he could not dispute the surveyors observations and that as they found items they were putting in work orders to fix them. He also stated that they had been working on repairs for two and a half years. The facility admitted Resident # 1 on 9/1/11 with the following Diagnosis: [REDACTED]. Observation of the residents room on 9/27/11 revealed chipped paint on the walls in multiple areas and the closet doors. Wall paper was peeling off the wall in multiple areas around the television area and around the window. The baseboard was coming loose from the walls in multiple areas. The facility admitted Resident # 10 on 5/26/10 with the following Diagnosis: [REDACTED]. Observation of the residents room on 9/27/11 revealed chipped paint on the walls in multiple areas and the closet doors. Wall paper was peeling off the wall in multiple areas around the television area and around the window. The baseboard was coming loose from the walls in multiple areas. Both Residents # 1 and # 10 shared a bathroom (which neither used) that had paint peeling from the door frames, exposing rust. Room 224 had a hole in the wall at the phone jack. The closet doors paint was chipped. The light switch plate in the bathroom did not cover the hole behind it. The doors in the bathroom had paint chipped from the frame and exposing rust. In Room 215 , behind the headboard of both beds there was large areas of torn drywall. The paint on closet doors were chipped and the walls were heavily scuffed. The bathroom had a strong urine odor, the toilet was not flushed (both men used urinals). The door frame in the bathroom was chipped and rusted.",2015-12-01
8727,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2011-09-29,279,D,0,1,QZ8411,"**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 policy entitled Suicide Threats, the facility failed to develop, review and revise the resident's comprehensive plan of care to include suicidal comments expressed by Resident #5, 1 of 1 sampled residents reviewed for Care Plans related to suicidal feelings The findings included: The facility admitted Resident #5 on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 4:55 PM, during review of Resident #5's medical chart, the Daily Skilled Nurses Notes for [DATE] indicated the resident had had a psychiatric consult completed on [DATE]. The Psychiatric Consult notes documented that the resident had stated she wished she had died while at the hospital, worries what's the purpose? The notes also indicated (Passive, not active) . Review of the Resident's Care Plans revealed that the resident did not have a Care Plan related to the suicidal comments/thoughts During an interview with the Green Unit Manager on [DATE], she verified that a Care Plan related to suicide was not on the chart. The Social Service Assistant also verified that Resident #5 did not have a Care Plan related to suicidal comments. Review of the facility's policy entitled Suicide Threats revealed .7 .update care plans accordingly .",2015-12-01
8728,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2011-09-29,314,D,0,1,QZ8411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observation, record review, review of the facility provided policy for wound cleansing and interview, the facility failed to provide necessary treatment and services to promote healing for two sampled residents. During the observation of care for Resident # 1, the Licensed Practical Nurse (LPN) # 3 failed to apply a medicated powder as ordered by the Physician and Resident # 10's wound was not cleaned appropriately. The findings included: The facility admitted Resident # 1 on 9/1/11 with the following Diagnosis: [REDACTED]. During the observation of the wound care on 9/27/11 at 10:15 AM, LPN # 3 removed the soiled dressing and placed it in the trash bag, she then stated: I forgot to get gauze to clean with, and she stepped out of the room. She returned and donned gloves, without washing her hands first. The LPN removed her gloves, washed her hands then placed Calcium Alginate on the wound bed and covered it with a large dressing and taped the sides. She then assisted in repositioning the resident while wearing the same gloves. Review of the medical record revealed an order to cleanse with wound cleanser, apply Collagen Powder to the wound bed, pack with Calcium Alginate and cover. On 9/29/11 at 10:00 AM when LPN # 3 was asked about the powder not being applied she stated I sprinkled it on the Calcium Alginate. When reminded that the powder was not on the dressing table or in the residents room she stated I put it on before I came in. The facility admitted Resident # 10 on 5/26/10 with the following Diagnoses: [REDACTED]. During the wound care observation on 9/27/11 11:20 AM LPN # 3 washed her hands and donned gloves. She cleaned the wound bed in a circular motion going around twice in same area, never moving outward from the center. The facilities Policies and Procedure for Clean Dressing Change stated under Steps of Procedure # 15 stated 'Cleanse wound with prescribed solution in circular outward motion.' The LPN stated, when ask about her cleaning methods, on 9/28/11 at 9:30 AM : I didn't realize I did it that way.",2015-12-01
8729,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2011-09-29,315,D,0,1,QZ8411,"**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 Residents # 1 and 10. (2 of 3 catheter care observations conducted) The findings included: The facility admitted Resident # 1 on 9/1/11 with the following Diagnoses: [REDACTED]. During the observation of the catheter care on 9/27/11 at 10:15 AM Licensed Practical Nurse (LPN) # 3 turned Resident # 1 on her left side. She sprayed a perineal wash on a 4 x 4 gauze and reached her hand through the thighs into the vaginal area and wiped toward the back. She repeated this with a second 4 x 4. Using a clean 4 x 4, she cleaned the catheter tubing, after securing it. With each pass of the 4 x 4, a brownish tinge was noted on the gauze. LPN # 3 then used a dry wash cloth and wiped the vaginal area and down the catheter tube without securing it. During the procedure, the labia and urinary meatus were not exposed. The facility admitted Resident # 10 on 5/26/10 with the following Diagnoses: [REDACTED]. During the observation of catheter care on 9/27/11 at 11:20 AM Licensed Practical Nurse (LPN) # 3 turned the resident ( # 10 ) on her right side. She sprayed a perineal wash on a disposable wipe and pushed her hand between the resident's thighs into the vaginal area and wiped toward the back. She repeated this with a second wipe. She then cleaned the catheter tubing using the same wipe. LPN # 3 then used a dry wash cloth and patted dry only the area that was exposed. During the procedure, the labia and urinary meatus were not exposed. During the interview with LPN # 3 on 9/28/11 at 9:30 AM she stated I always turn them on their side because its hard to spread their legs. The Surveyor questioned using the assistant who was present during the procedure and she stated that's true. She confirmed that she could not visualize the labia's or the meatus.",2015-12-01
8730,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2012-12-18,223,K,1,0,DVUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified on [DATE] at 11:45 AM, related to the failure of the facility to protect Resident #1 from alleged humiliation and harassment. Resident #1 had a hidden camera placed in his/her room on [DATE]. The camera captured Certified Nursing Assistant (CNA) #1 allegedly harassing Resident #1 between ,[DATE] PM on [DATE]. The facility failed to attempt an interview with Resident #2, the roommate of Resident #1 who witnessed the harassment per the video footage. Resident #3 had escalating behaviors; the facility medicated the resident without investigating the cause of the escalating behaviors. The facility failed to investigate and report allegation of abuse/neglect reported by Resident #4. The findings included: On [DATE] Resident #1's family member had a hidden video camera placed at his/her bedside. On [DATE] the surveyor viewed a video at the police department that revealed on [DATE] between 6:00 PM and 7:00 PM Certified Nursing Assistant (CNA) #1 flicked the resident's nostril while the resident appeared to be asleep, then hid behind the curtain so the resident could not see what happened. CNA #1 then pulled the curtain between the two beds and grabbed the resident's arm through the curtain. Resident #1 attempted to grab his/her own hand in an attempt to release the CNA's grasp. The resident poured a glass of water on the CNA, grabbed an electric razor and struck the CNA to release his/her grasp. CNA #1 was observed to roughly clean the resident's arm with a wipe. CNA #1 then walked around the resident's bedside and leaned close to the resident and was observed to yell at the resident (no sound was available on the video at the time of the survey). CNA #1 was observed leaning close to the resident's cheek in what appeared to be an attempt to kiss the resident. On [DATE] the police alerted the facility of CNA #1's alleged behavior and the CNA #1 was escorted from the facility at approximately 6:30 PM. CNA #1 was arrested and charged with abuse of a vulnerable adult on [DATE]. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a 0 on the Brief Interview for Mental Status. The resident was coded with a behavior of rejection of care ,[DATE] days during the assessment period. The resident was also coded as having other behaviors directed towards others ,[DATE] days during the assessment period. Review of the physician's orders [REDACTED]. The [MEDICATION NAME] was discontinued on [DATE]. No other psychoactive medications were ordered. Review of the Nurse's Notes revealed the following: [DATE] the resident was noted to have increased anxiety and an order for [REDACTED]. [DATE] at 3:35 AM, the resident was agitated and was attempting to pull out his/her Foley catheter. Further review revealed the resident would frequently refuse meals and requested staff to leave him alone. [DATE] at 6:30 PM, Body Audit done on res noted scratch to R upper thigh and scratch to L hip area where brief is fastened, no other areas noted. Res (resident) refused supper. Review of additional incidents related to Resident #1 revealed the following incidents. On [DATE], the resident was noted to have a small amount of blood under his/her right eye from a micro skin abrasion . unknown origin . The incident was not investigated or reported to the state agency. On [DATE] the resident was transferred roughly by a CNA that resulted in bruising to the resident's left arm and elbow area. The incident was not reported to the state agency. During an interview on [DATE] at 2:15 PM, the ADON confirmed the three injuries of unknown origin for Resident #1. She/he confirmed that the injuries were not investigated or reported. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a 0 on the Brief Interview for Mental Status. The resident was coded with a behavior of rejection of care ,[DATE] days during the assessment period. The resident was also coded as having other behaviors directed towards others ,[DATE] days during the assessment period. During an interview with the surveyor on [DATE] at 3:15 PM, with the Unit Manager, Resident #2 was interviewed related to the witnessed alleged abuse. Resident #2 was noted to be able to answer yes and no questions. Resident #2 answered yes appropriately three times when questioned by the surveyor if someone hit, yelled and kissed his roommate. Resident #2 was not able to give a name or answer appropriately when given a CNAs name. Resident #2 also answered yes appropriately twice when asked by the surveyor if someone kissed him and was rough with him. Resident #2 was not able to provide a name or answer appropriately when given a CNA's name. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored an 11 on the Brief Interview for Mental Status. No behaviors were coded as occurring during the assessment period. Review of the Care Plan (CP) revealed a problem area related to behaviors and/or [MEDICAL CONDITION] was identified on [DATE] with approaches including labs as ordered c abnormalities reported per protocol, assist up to w/c as needed when restless in bed, Psych consult PRN, Administer meds per MD orders, observe and report any changes to MD, SSD and Nursing staff PRN, remain calm when approaching resident, continue to monitor medications, attempt to contact family and friend if unable to redirect. On ,[DATE] the care plan was updated to include will continue to observe, psych consult will be recommended to MD. On ,[DATE] the CP was updated to include (change) [MEDICATION NAME] 0.5 mg PRN to [MEDICATION NAME] 0.5 mg PO or IM BID PRN severe agitation. On ,[DATE] the CP was updated to include reviewed and updated at this time. Review of the Nurse's Notes from [DATE] through [DATE]/2012 revealed the following documentation: [DATE] at 11 PM, Res agitated earlier during shift attempting to get out of front door brought back to unit by activities. Rec'd order for [MEDICATION NAME] 0.5 mg po x 1 now. Res remains agitated at this time, refusing to go to bed. 2 CNAs placed resident on bed and (changed) brief res very upset stating they were trying to get in bed c her and look at her tootsie. Res placed back in chair p brief (changed) . [DATE] the nurse documented was delusional and paranoid at beginning of shift thinking someone was trying to get her during the night . ,[DATE] at 7:30 AM, In bed anxious, yelling wanting (local police), requesting to go home . On [DATE] at 5:30 AM, resident very resistive and combative during brief change . [DATE] at 9:30 PM, Res also agitated, talking to people not present, saying she has to go to (?) and church. [MEDICATION NAME] 0.5 mg given at 5 P ineff(ective). Cont'd yelling and screaming that your tying to kill me when CNA was providing incont care . [DATE] at 10:30 PM, Res noted yelling and screaming during dinner, given IM [MEDICATION NAME] 0.1 cc for severe agitation rolling throughout hallway from door to door exit seeking. Multiple attempts to calm res unsuccessful. Taken to room approx ,[DATE]:30 P to put to bed and provide incontinent care. Res became combative CNA (2) and myself in room attempting to complete care, res scratching at CNA, 2nd CNA assisting 1st CNA while I observed. Incont care completed and res placed back in w/chair. Cont to exit seek and screaming and yelling in halls and dayroom. DON cam and sat c res for an hour helping to calm resident . [DATE] at 10:45 PM, res cont to become very agitated, [MEDICATION NAME] 0.5 mg given at 5 P . No other behaviors were documented in the nurse's notes. During an observation/interview of the resident on [DATE] at 9 AM revealed the resident was sitting in her/his wheelchair. The resident was lethargic and had a difficult time staying awake during the interview. The resident stated yeah when asked by the surveyor if staff members were rough with her/him. S/he also stated yeah when asked if staff yelled at her/him or teased her/him. During an interview on [DATE] at 2:15 PM, the Assistant Director of Nurses (ADON), Nurse Consultant and Administrator confirmed the resident's behaviors. The Administrator confirmed that no investigation was initiated related to the resident's statements of alleged abuse. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a ,[DATE] on the Brief Interview for Mental Status. The resident was coded to have verbally abusive behaviors ,[DATE] days during the assessment period. During an interview with the surveyor on [DATE] at 3:40 PM, the resident reported CNA #2 and CNA #3 would purposefully ignore him/her, not provide him/her the appropriate care and would say they were too busy to come to his/her room to assist him/her. Resident #4 also stated that CNA #1 would tease him/her. S/he stated that his/her roommate died several months prior and CNA #1 would pretend that s/he was raising from the dead trying to scare the resident. The resident at first stated that s/he did not inform any staff members, but in a later interview, stated that s/he had mentioned the teasing to the Unit Manager. Review of the Social Service Progress notes revealed on [DATE] continues to make allegations that staff are ignoring him, yet retracts statements later. Resident has threatened staff with telling DHEC some lies if staff do not do what (the resident) wants. (Resident #4) continues to make allegations that staff are not taking care of (another resident). When confronted resident admits that s/he doesn't really know. (Resident #4) has a history of attempting to threaten and or intimidate staff with false allegations and accusations. LMSW and Social Service Assistant have discussed this with (Resident #4) today . On [DATE] Resident continues to be alert and oriented to self and surroundings. S/he continues to display verbal aggression towards staff, using threatening language of calling DHEC. This behavior is not new but is manageable. During an interview with the surveyor on [DATE] at 4:30 PM, the LMSW stated that Resident #4 did not have any documented grievances or reportable incidents. S/he stated that Resident #4 had a history of [REDACTED]. The LMSW stated that because of the resident's history, the allegations were false. S/he confirmed her/his note regarding the allegation of abuse/neglect, s/he also confirmed the allegations were not investigated or reported. During an interview on [DATE] at 5 PM, the Administrator was informed of the resident's allegation regarding CNA #2 and #3. S/he also confirmed that Resident #4 did not have his/her allegations investigated or reported based upon the resident's history of false allegations. On [DATE] at 11:45 AM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-223, F-226 and F-490 at a scope and severity of K. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on [DATE] related to Resident #1's alleged abuse. 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 were in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the abuse policy requiring staff to identify inappropriate behavior, report any allegation of potential abuse and thoroughly investigate allegations of abuse. Psychosocial assessments were completed on all residents residing on Unit One with the appropriate actions taken. The Administrator was informed of this on [DATE] at 4:45 PM. The citation at F-223 remained at a lower scope and severity of E. The facility will be in compliance 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.",2015-12-01
8731,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2012-12-18,226,K,1,0,DVUG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record review and interview, Substandard Quality of Care and/or Immediate Jeopardy was identified on [DATE] at 11:45 AM, related to the failure of the facility to implement their Abuse Prohibition policy as evidenced by the absence of a thorough investigation of allegations of abuse, the failure to assess all resident's psychosocial needs, and report all incidents of potential abuse to the appropriate state agency. The facility staff failed to identify a Certified Nursing Assistant's (CNA's) behavior as inappropriate and potentially abusive towards residents. Resident #1 had a hidden camera placed in his/her room on [DATE]. The camera captured CNA #1 allegedly abusing Resident #1 between ,[DATE] PM on [DATE]. The facility investigation was not thorough related to the incident. The facility failed to assess the resident's room mate who was a witness to the abuse per the video footage. The facility failed to assess each resident's psychosocial needs. Resident #3 had escalating behaviors, the facility medicated the resident without investigating her/her allegations of staff abuse. The facility failed to investigate and report allegations of abuse/neglect reported by Resident #4. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a 0 on the Brief Interview for Mental Status. The resident was coded as having rejection of care behaviors ,[DATE] days during the assessment period. The resident was also coded as having other behaviors directed towards others ,[DATE] days during the assessment period. The resident was noted to be under the care of Hospice. Review of the physician's orders [REDACTED]. The [MEDICATION NAME] was discontinued on [DATE]. No other psychoactive medications were ordered. Review of the Nurses Notes revealed on [DATE] the resident was noted to have increased anxiety and an order for [REDACTED]. Further review revealed the resident would frequently refuse meals and requested staff to leave him alone. On [DATE] at 6:30 PM, Body Audit done on res noted scratch to R upper thigh and scratch to L hip area where brief is fastened, no other areas noted. Res refused supper. Review of additional incidents related to Resident #1 revealed the following incidents. On [DATE], the resident was noted to have a small amount of blood under his/her right eye from a micro skin abrasion . unknown origin . The incident was not investigated or reported to the state agency. On [DATE] the resident was transferred roughly by a CNA that resulted in bruising to the resident's left arm and elbow area. The incident was not reported to the state agency. During an interview with the surveyor on [DATE] at 2:15 PM, the Assistant Director of Nurses (ADON) confirmed the three injuries of unknown origin for Resident #1. S/he confirmed that the injuries were not investigated or reported. On [DATE] the resident's family member had a hidden video camera placed at Resident #1's bedside. Review of the video at the police department by the surveyor revealed that on [DATE] between 6:00 PM and 7:00 PM Certified Nursing Assistant (CNA) #1 was observed flicking Resident #1's nostril while the resident appeared to be asleep. CNA #1 then hide behind the curtain so the resident could not see what happened. The CNA was observed in the video pulling the curtain between the beds of Resident #1 and his/her roommate and grabbed Resident #1's arm through the curtain. Resident #1 attempted to grab his/her own hand in an attempt to release the CNA's grasp. The resident poured a glass of water on the CNA, grabbed an electric razor and struck the CNA to release his/her grasp. CNA #1 was observed roughly cleaning the resident's arm with a wipe. CNA #1 then walked around the resident's bedside, leaned close to the resident and was observed to yell at the resident (no sound was available on the video). CNA #1 was also observed leaning down close to the resident's cheek in what appeared to be an attempt to kiss the resident. The police informed the facility of the video and the allegation against CNA #1, s/he was escorted from the property on [DATE] at approximately 6:30 PM. CNA #1 was arrested and charged with abuse of a vulnerable adult on [DATE]. The facility reported the incident to the State Agency in accordance with regulation and started an investigation. The facility did not obtain witness statements from staff or residents in regards to CNA #1's behavior or interactions with residents. Review of the Corrective Action revealed Alert and oriented residents who are typically assigned to the accused CNA were interviewed on [DATE] . No residents responded that they had any concerns or problems with the accused CNA. During the survey the surveyor interviewed three residents who voiced concerns related to staff mistreatment. Per the facility investigation no family member had any concerns related to abuse. The facility investigation did not include psychosocial assessments of any resident. Resident #1's roommate was a direct witness to the abuse per the video, however, the facility's failed to assess the resident or attempt to interview the resident. In addition staff members interviewed by the surveyor on [DATE] stated that CNA #1 teased, joked and kidded with the residents. Staff members did not see CNA #1's behavior with the residents as inappropriate or potentially harmful to any resident. Review of the facility's 5 Day Report revealed the facility's obtained statements from the Assistant Director of Nurses (ADON), CNA #1, CNA #2, CNA #3, the Unit Manager and Licensed Practical Nurse #1 and #2. The staff members interviewed were not questioned related to the alleged abuse of Resident #1 by CNA #1. A statement was provided by the Administrator dated [DATE] that indicated s/he interviewed staff members working the evening shift of [DATE] (the date of the alleged abuse). Per the statement, each person was asked if they had ever seen any abusive behavior by (CNA #1), they indicated they had not. The staff members did not sign the statement and no other statement regarding abuse or mistreatment was obtained. The Director of Nurses (DON) provided a statement dated [DATE] that indicated s/he interviewed two other staff members (CNA #4 and #5) who were working the evening of [DATE], s/he inquired if they had witnessed any abuse of any resident in the facility . both indicated to the (DON) that they had not witnessed any abuse. Again, the interviewed staff did not sign the statement and there were no other statement obtained related to abuse/mistreatment of [REDACTED]. Review of the video at the police department by the surveyor showed CNA #2 entering Resident #1's room during the time the alleged abuse occurred. Review of the facility obtained statement from CNA #2 documented by the ADON and dated [DATE] revealed CNA (#2) agrees s/he worked Magnolia Wing ,[DATE] shift ,[DATE] and ,[DATE]. S/he reports s/he has no knowledge of hearing or seeing anything unusual Thursday ([DATE]). S/he has no concerns to report at this time. The statement was only signed by the ADON. CNA #2 did not provide any other witness statement. Also, the statement was not provided to the state agency in the 5 day report but was provided to the surveyor on [DATE]. During an interview with the surveyor on [DATE] at 3:30 PM, CNA #2, stated that s/he was working the evening shift on [DATE]. S/he also stated that s/he was working the same hallway as CNA #1. CNA #2 stated that s/he heard some bumfumbling around in Resident #1's room. S/he entered the room and saw CNA #1 in the room with both residents. CNA #2 stated that s/he didn't see anything unusual and left the room. During an interview on [DATE] at 3:45 PM, the Unit Manager stated that s/he performed a body audit on Resident #1 on [DATE]. S/he stated that the resident had two what appeared to be fingernail scratches on his/her legs. On the right thigh extending from the mid inner thigh outward towards the hip and on the left thigh in the groin area across the brief line. The Unit Manager stated that the two injuries could not be explained by the resident and the source of the injuries was not investigated. The injuries of unknown origin were not reported to the State Agency and were not investigated. The Unit Manager also stated that CNA #1 always joked and teased with the resident. S/he stated that CNA #1 could always be seen dancing and joking and hugging the residents. During a follow up interview, the Unit Manager stated that s/he had interviewed the interviewable residents related to the abuse allegation. S/he stated that s/he did not believe CNA #1 could have abused the resident and did not think s/he was capable of harming anyone as s/he was one of the best CNAs. The Unit Manager stated that one week after the allegation, s/he watched the video clip and read the news articles related to the allegation. S/he stated that it was not until that moment that s/he allowed her/himself to be open to the possibility that CNA #1 allegedly abused Resident #1. During an interview with the surveyor on [DATE] at 3:50 PM, CNA #3 stated that CNA #1 was the life of the party. S/he stated that CNA #1 liked to kid and tease the residents. During an interview with the surveyor on [DATE] at 3:15 PM, with the Unit Manager, Resident #2 was interviewed related to the alleged abuse. Resident #2, the roommate of Resident #1 was in the room at the time of the alleged abuse. Resident #2 admitted to the facility with [MEDICAL CONDITION] and was heard of hearing s/he most recent Quarterly Minimum Data Set coded him/her as having short and long term memory problems with severely impaired cognitive skills for daily decision making. S/he was noted to be able to answer yes and no questions. Resident #2 answered yes appropriately three times when asked by the surveyor if someone hit, yelled and kissed his/her roommate. Resident #2 was not able to name the perpetrator. Resident #2 answered yes appropriately twice when asked if someone kissed him/her and was rough with him/her; s/he was not able to provide the name of the perpetrator. During an interview on [DATE] at 11:45 AM, the Administrator confirmed staff statements were not obtained related to the alleged abuse. S/he stated that s/he met with the staff members working [DATE] but admitted that their statements were not individually obtained nor were statements obtained related to CNA #1's behavior and practice. S/he also confirmed that no other staff member had viewed the CNA's behavior as inappropriate towards residents. The Administrator confirmed that no residents' psychosocial needs were assessed after the alleged abuse. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the resident scored an 11 on the Brief Interview for Mental Status. No behaviors were coded as occurring during the assessment period. Review of the Care Plan (CP) revealed a problem area related to behaviors and/or [MEDICAL CONDITION] identified on [DATE] with approaches including labs as ordered c (with) abnormalities reported per protocol, assist up to w/c (wheelchair) as needed when restless in bed, Psych consult PRN (as needed), Administer meds per MD (medical doctor) orders, observe and report any changes to MD, SSD (social service director) and Nursing staff PRN, remain calm when approaching resident, continue to monitor medications, attempt to contact family and friend if unable to redirect. On ,[DATE] the care plan was updated to include will continue to observe, psych consult will be recommended to MD. On ,[DATE] the CP was updated to include (change) [MEDICATION NAME] 0.5 mg (milligrams) PRN to [MEDICATION NAME] 0.5 mg PO (by mouth) or IM (intramuscular) BID (twice a day) PRN severe agitation. On ,[DATE] the CP was updated to include reviewed and updated at this time. Review of the Nurse's Notes from [DATE] through [DATE] revealed the following documentation: [DATE] at 11 PM, Res (resident) agitated earlier during shift attempting to get out of front door brought back to unit by activities. Rec'd order for [MEDICATION NAME] 0.5 mg po x 1 now. Res remains agitated at this time, refusing to go to bed. 2 CNAs placed resident on bed and (changed) brief res very upset stating they were trying to get in bed c (with) her and look at her tootsie. Res placed back in chair p (after) brief (changed) . [DATE] the nurse documented was delusional and paranoid at beginning of shift thinking someone was trying to get her during the night . ,[DATE] at 7:30 AM, In bed anxious, yelling wanting (local police), requesting to go home . [DATE] at 5:30 AM, resident very resistive and combative during brief change . [DATE] at 9:30 PM, Res also agitated, talking to people not present, saying she has to go to (?) and church. [MEDICATION NAME] 0.5 mg given at 5 P ineff(ective). Cont'd yelling and screaming that 'your tying to kill me' when CNA was providing incont (incontinent) care . [DATE] at 10:30 PM, Res noted yelling and screaming during dinner, given IM [MEDICATION NAME] 0.1 for severe agitation rolling throughout hallway from door to door exit seeking. Multiple attempts to calm res unsuccessful. Taken to room approx(imately) ,[DATE]:30 P to put to bed and provide incontinent care. Res became combative CNA (2) and myself in room attempting to complete care, res scratching at CNA, 2nd CNA assisting 1st CNA while I observed. Incont care completed and res placed back in w/chair. Cont to exit seek and screaming and yelling in halls and dayroom. DON came and sat c res for an hour helping to calm resident . [DATE] at 10:45 PM, res cont to become very agitated, [MEDICATION NAME] 0.5 mg given at 5 P . During an observation/interview with the resident on [DATE] at 9 AM revealed the resident was sitting in her/his wheelchair. The resident was lethargic and had a difficult time staying awake during the interview. The resident stated yeah when asked by the surveyor if staff members were rough with her/him. S/he also stated yeah when asked if staff yelled at her/him or teased her/him. No other information could be obtained by the surveyor during the interview. During an interview on [DATE] at 2:15 PM, the Assistant Director of Nurses (ADON), Nurse Consultant and Administrator confirmed the resident's behaviors. The Nurse Consultant confirmed that the resident did not have any other documented interventions besides medication. All confirmed that the residents behaviors decreased drastically on [DATE]. The Administrator confirmed that no investigation was initiated related to the resident's statements of alleged abuse. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident scored a ,[DATE] on the Brief Interview for Mental Status. The resident was coded to have verbally abusive behaviors ,[DATE] days during the assessment period. During an interview on [DATE] at 3:40 PM, the resident reported CNA #2 and CNA #3 would purposefully ignore him/her, not provide him/her the appropriate care and would say they were too busy to come to his/her room to assist him/her. Resident #4 also stated that CNA #1 would tease him/her. S/he stated that his/her roommate died several months prior and CNA #1 would pretend that s/he was raising from the dead trying to scare the resident. The resident at first stated that s/he did not inform any staff members, but in a later interview, stated that s/he had mentioned the teasing to the Unit Manager. Review of the Social Service Progress notes revealed on [DATE] continues to make allegations that staff are ignoring him, yet retracts statements later. Resident has threatened staff with telling DHEC some lies if staff do not do what (the resident) wants. (Resident #4) continues to make allegations that staff are not taking care of (another resident). When confronted resident admits that (s/he) doesn't really know. (Resident #4) has a history of attempting to threaten and or intimidate staff with false allegations and accusations. LMSW (Licensed Masters of Social Worker) and Social Service Assistant have discussed this with (Resident #4) today . On [DATE] Resident continues to be alert and oriented to self and surroundings. (S/he) continues to display verbal aggression towards staff, using threatening language of calling DHEC. This behavior is not new but is manageable. During an interview with the surveyor on [DATE] at 4:30 PM, the LMSW stated that Resident #4 did not have any documented grievances or reportable incidents. S/he stated that Resident #4 had a history of [REDACTED]. The LMSW stated that because of the resident's history, the allegations were false. S/he confirmed her/his note regarding the allegation of abuse/neglect, s/he confirmed the allegations were not investigated or reported. During an interview on [DATE] at 5 PM, the Administrator was informed of the resident's allegation regarding CNA #2 and #3. S/he also confirmed that Resident #4 did not have his/her allegations investigated or reported based upon the resident's history of false allegations. Review of the facility's policy on Abuse Prohibition revealed: The Administrator has overall responsibility and accountability for designation of an Abuse Coordinator for the facility and implementing the Resident Abuse Prohibition program . Identification: All employees will be trained to identify potential and/or actual occurrences of abuse, neglect .Training includes: Physical Abuse-hitting, slapping, pinching, kicking and controlling behavior through corporal punishment and non-accidental use of physical force that results in bodily injury, pain or impairment are physically abusive behaviors. Unreasonable confinement or restraint, physical coercion, pushing and shoving are also physically abusive behaviors. Verbal Abuse-The use of oral, written or gestured language that deliberately includes disparaging and derogatory terms within hearing distance of residents and family members .Threats of physical or emotional pain are also examples. Mental Abuse-includes but is not limited to humiliation, harassment, and threats of punishment or deprivation or speaking in a language foreign to a resident in his/her presence. Investigation: The facility will immediately investigate any alleged resident neglect, mistreatment, misappropriation of funds and/or physical, verbal, sexual, emotional/psychological abuse using the resident protection investigation procedure. Investigation Procedures: Regardless of the specific nature of the allegation, the investigation shall consist of interview with: the person reporting the incident, the resident, any witnesses to the incident, staff members having contact with the involved parties during the period of alleged incident, the resident's roommate, family members, visitors or others who were near the incident .This information should be compiled as a complete, written report. The Interview Process: Adhere to the following important guidelines during interviews: The summary statement is signed and dated as accurate by the interviewee and the statement attached to the Investigation Report Form. On [DATE] at 11:45 AM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-223, F-226 and F-490 at a scope and severity of K. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on [DATE]. 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 were in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the abuse policy requiring staff to identify inappropriate behavior, report any allegation of potential abuse and thoroughly investigate allegations of abuse. Psychosocial assessments were completed on all residents residing on Unit One with the appropriate actions taken. The Administrator was informed of this on [DATE] at 4:45 PM. The citation at F-226 remained at a lower scope and severity of E. The facility will be in compliance 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.",2015-12-01
8732,MOUNT PLEASANT MANOR,425110,921 BOWMAN ROAD,MT PLEASANT,SC,29464,2012-12-18,490,K,1,0,DVUG11,"br>On the days of the survey based on observations, record review and interview, Immediate Jeopardy was identified related to the failure of the facility administration to administer the facility in a manner to use its resources effectively and efficiently to maintain the physical, mental and psychosocial well-being of each resident. The Abuse Prohibition Policy was not implemented related to the identification, investigation and reporting of alleged abuse. The findings included: Cross Refer to F-223 as it relates to the failure of the facility to respond appropriately to allegations made by residents of potential abuse. Cross Refer to F-226 as it relates to the failure of the facility to implement the Abuse Prohibition Policy related to investigation, identification and reporting alleged abuse. On 12/6/12 Resident #1's family member had a hidden video camera placed at his/her bedside. On 12/17/12 the surveyor viewed a video at the police department that revealed on 12/6/12 between 6:00 PM and 7:00 PM Certified Nursing Assistant (CNA) #1 flicked the resident's nostril while the resident appeared to be asleep, then hide behind the curtain so the resident could not see what happened. CNA #1 then pulled the curtain between the two beds and grabbed the resident's arm through the curtain. Resident #1 attempted to grab his/her own hand in an attempt to release the CNA's grasp. The resident poured a glass of water on the CNA, grabbed an electric razor and struck the CNA to release his/her grasp. CNA #1 was observed to roughly clean the resident's arm with a wipe. CNA #1 then walked around the resident's bedside and leaned close to the resident and was observed to yell at the resident (no sound was available on the video at the time of the survey). CNA #1 was observed leaning close to the resident's cheek in what appeared to be an attempt to kiss the resident. On 12/7/12 the police alerted the facility of CNA #1's alleged behavior and the CNA #1 was escorted from the facility on 12/7/12 at approximately 6:30 PM. CNA #1 was arrested and charged with abuse of a vulnerable adult on 12/10/12. Review of the facility's policy on Abuse Prohibition revealed: The Administrator has overall responsibility and accountability for designation of an Abuse Coordinator for the facility and implementing the Resident Abuse Prohibition program . During an interview on 12/18/12 at 11:45 AM, the Administrator confirmed staff statements were not obtained related to the alleged abuse. S/he stated that s/he had met with the staff members working 12/6/12 but admitted that their statements were not individually obtained or related to CNA #1's behavior and practice. The Administrator confirmed that CNA #1's behavior with the resident's was inappropriate. S/he also confirmed that no other staff member had viewed the CNA's behavior as inappropriate towards residents. The Administrator also confirmed that no residents' psychosocial needs were assessed after the alleged abuse. On 012/18/2012 at 11:45 AM the Administrator was notified that Substandard Quality of Care and/or Immediate Jeopardy was identified at F-223, F-226 and F-490 at a scope and severity of K. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 12/06/2012. Observations, interviews, and review of policy education and signature sheets on 12/18/12 revealed the Allegation of Compliance submitted by the facility on 12/18/12 had been implemented by the facility and were in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and was knowledgeable of the abuse policy requiring staff to identify inappropriate behavior, report any allegation of potential abuse and thoroughly investigate allegations of abuse. Psychosocial assessments were completed on all residents residing on Unit One with the appropriate actions taken. The Administrator was informed of this on 12/18/12 at 4:45 PM. The citation at F-490 remained at a lower scope and severity of E. The facility will be in compliance 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.",2015-12-01
2077,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2018-02-28,761,D,1,0,IOF011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to store all drugs and biologicals in locked compartments, and permit only authorized personnel to have access to the keys. The facility's treatment cart was noted to be unlocked during two observations by the surveyor. One of one treatment carts. The findings included: The surveyor observed the facility treatment cart on the Azalea unit on the day of the survey at 12:20 PM during initial tour. The cart was checked and noted to be unlocked. The surveyor observed the treatment cart again at 1:30 PM on the Azalea unit near the nurses' station in the same spot it was at 12:20 PM. The treatment cart was again noted to be unlocked. In an interview with the surveyor on 2/28/18 at approximately 1:30 PM, LPN (Licensed Practical Nurse) #1, the Azalea unit manager, stated the treatment cart should be locked. S/he locked the cart and stated RN (Registered Nurse) #1 is the wound care nurse and uses the treatment cart around the facility. In an interview with the surveyor on 2/28/18 at approximately 1:40 PM, RN #1, the wound care nurse, initially stated s/he leaves the cart unlocked so the nurses on the floor can get into it. RN #1 was asked about who has keys to the cart and s/he stated one nurse on each unit has a key to the treatment cart. RN #1 stated s/he has been at the facility for about a month and s/he does not have a key to the treatment cart. When asked about the training s/he received, RN #1 stated the nurses on the unit told him/her the lock would be partially pushed in so no one could get in. RN #1 could pull on the lock to open it, without a key. Review of the contents of the treatment cart revealed the following: dressings/band-aids/ duoderm, [MEDICATION NAME], [DEVICE] sponges, 2 x 2 s, 4 x 4 s, tape, saline, steri-strips, scissors, [MEDICATION NAME] gauze, Dakin's solution, biofreeze, ointments/Tao/[MEDICATION NAME]/[MEDICATION NAME]/capsasin/[MEDICATION NAME], skin prep, hydrogel, providone swabs, barrier cream, applicator/swabs, kerlix, coban, and [MEDICATION NAME].",2020-09-01
2078,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2018-06-11,565,E,1,0,U9B911,"> Based on observation and interview, the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. The surveyor noted concerns from residents related to receiving snacks. Observation of the nourishment rooms revealed there were no snacks stocked in the rooms. 2 of 2 nourishment rooms in the facility. The findings included: Review of the Resident Council Minutes dated 4/19/18 revealed old business not resolved included everyone still not getting evening snack. Review of the Food Council Minutes dated 5/1/18 revealed a concern that snacks are not available to all residents. The CDM (Certified Dietary Manager) stated there is a snack closet on each unit and s/he will be stocking those personally for anyone who would like a snack throughout the day or night. During initial tour of the facility on 5/30/18 at 3:10 PM the surveyor observed the nourishment rooms on both units of the facility. The surveyor noted there were no snacks available in either room. In a telephone interview with the surveyor on 6/11/18 at approximately 10:05 AM, the CDM stated s/he started the Food Council meetings last month. Up until the meeting, they did not have a defined plan for snacks. Now they have a stock list of what snacks they will keep in the nourishment rooms. The CDM stated s/he was out on leave starting 5/25/18 and did not appoint a backup person to stock the nourishment rooms. In an interview with the surveyor on 5/30/18, Resident A stated s/he does not receive snacks from the facility.",2020-09-01
2079,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2018-06-11,812,D,1,0,U9B911,"> Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety. Observation of the nourishment room on the 100 unit revealed the refrigerator had multiple areas that needed to be cleaned and the ice scoop was not stored properly. One of two nourishment rooms reviewed. The findings included: During initial tour of the facility on 5/30/18 at approximately 3:10 PM, the surveyor observed the nourishment room on the 100 unit. The surveyor noted the refrigerator had several areas on each shelf that had spilled food or beverage that needed to be cleaned. The tray under the freezer also had food debris. The surveyor observed the ice scoop in a bin on top of the ice machine. The ice scoop base was lying, uncovered, in standing water in the bin. In an interview with the surveyor on 5/30/18 at approximately 3:15 PM, the DON (Director of Nursing) confirmed the findings and was asked who is responsible for cleaning the nourishment rooms. S/he stated it was a combination of nursing and housekeeping that is responsible for the nourishment rooms. The DON stated the ice scoop should be covered and not stored in standing water. In an interview with the surveyor on 5/30/18 at approximately 3:30 PM, the Cook/Assistant Kitchen Manager stated nursing is responsible for keeping the nourishment rooms clean. The Cook/Assistant Kitchen Manager stated ice scoops should be in plastic wrap and not stored in a plastic container.",2020-09-01
2080,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2017-06-29,155,D,0,1,4QY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure accuracy of medical records for Code Status and the Advance Directives Notification Worksheet in the medical record for 1 of 21 residents reviewed. Resident #141's Advance Directive was not complete in the clinical record and was in conflict with the record maintained by Social Services. The findings included: Resident #141 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 9:09 AM a review of the Advance Directives Section of the Medical Record kept on the nursing unit revealed that the form titled; Advance Directives Notification and Work Sheet was signed by Resident #141 and no date completed. On the same form, the section that states: Please Choose One: ___I do want CPR: Attempt Cardio [MEDICAL CONDITION] Resuscitation (CPR) Choosing CPR means that all medical treatments will be done to prolong life when the heart stops or breathing stops. ___I do not want CPR: Do not Attempt Resuscitation (Allow Natural Death) This means no attempts will be made to restart the heart or breathing if either stops allowing for a natural death. No election was made for CPR as there was no election checked by the resident. The form shows a signature on the Social Service line and dated [DATE]. [DATE] at 2:43 PM, LPN#1 verified that no selection was checked on the Advance Directives Notification Worksheet located in the medical record kept on the nursing unit. On [DATE] at 2:53 PM, Social Worker #2 verified that the date should have been included beside the Resident #141's signature and form should have had an election made for CPR. On [DATE] at 3:30PM Social Worker #2 presented a copy of the Advance Directives Notification Worksheet that h/she keeps in a file in his/her office that has checkmark by I do not want CPR and stated: I keep the original copy in a file in my office. On [DATE] 9:44AM the Administrator verified that the copy of Advance Directives Notification Worksheet in Resident #141's medical record does not match the copy that Social Worker #2 keeps in her office. The Policy and Procedure titled: Social Services Policies and Procedures, Subject: Advance Directives states, Procedures: 4. B. Once it has been determined that the patient/resident wishes to be a DNR patient/resident, the following procedures must be followed IN ADDITION to those outlined in the Policies of Practice for Advance Directives 1) The patient/resident's decision must be CLEARLY AND CONCISELY documented in their chart AND on the patient's/resident's care plan .2) The properly executed Do Not Resuscitate consent from must be provided to the attending physician AND a Do Not Resuscitate order must be provided in the current orders the patient's/resident's medical record.",2020-09-01
2081,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2017-06-29,247,D,0,1,4QY511,"Based on interviews and review of the facility policy Social Services Polices and Procedures-Subject: Room Changes/Transfers Within the Facility, the facility failed to provide advance notice of a room change for 1 of 1 resident reviewed for Admission, Transfer, Discharge.(Resident #75) The findings included: During a Family interview, a family representative of Resident #75 stated that Resident #75 had been moved to a different room, and the family member was given no advance notice prior to the room change. During an interview with Social Services on 6/29/17 at 2:47 PM, he/she stated Resident #75 had been moved to a different room on 11/29/16 due to his/her roommate was actively dying and there were many family members visiting. He/she continued by stating it was the facility policy to notify the resident/family/responsible party prior to the move. During an interview with the Director of Nursing on 6/29/17 at 2:52 PM, he/she stated on the day of the move the family representative was notified and had no problems with the move. He/she continued by stating documentation was not done until the following day on 11/30/16. Review of the facility policy titled Social Services Policies and Procedures-Room Changes/Transfers Within the Facility states the following: 6B-When the patient/resident is moving into another person's room, inform both effected patients/residents and their qualified legal representatives that they are receiving a new roommate and make the appropriate introductions.",2020-09-01
2082,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2017-06-29,280,E,0,1,4QY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review the facility failed to involve all required members to participate in the care plan process for 5 of 21 reviewed for care plan processing. The physician did not attend the care plan meeting.(Resident #75, #9, #35, #8, and #95) In addition, the facility failed to update Resident #23's care plan related to Palliative Services.(1 of 1 reviewed for Palliative Services) The findings included: The facility admitted Resident #75 with [DIAGNOSES REDACTED]. Record review on 6/28/17 of Resident #75's care plan revealed the physician was not involved in the care plan process. No physician signature was observed on the sign in sheet for the care plan dated 5/11/17. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Record review on 6/28/17 revealed the physician was not involved in the care plan process. No physician signature was observed on the sign in sheet for the care plan dated 4/20/17. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Record review on 6/29/17 revealed the physician was not involved in the care plan process. No physician signature was observed on the sign in sheet for the care plan dated 5/4/17. Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 6/29/2017 at approximately 1:15 PM, a review of Resident #9's Care Plan Meeting Attendance Record dated 4/20//2107 shows no signature by the Physician. On 6/29/2017 at approximately 1:30 PM a review of Resident #8's Care Plan Meeting Attendance Record dated 05/25/2017 shows no signature by the Physician. On 06/29/2017 at approximately 2:00 PM an interview with The Care Plan Coordinator said all the physicians are invited to the care plan meetings, and they come to some of them. The facility admitted Resident #23 on 03/09/2017 with [DIAGNOSES REDACTED]. Record review on 06/28/17 at 11:02 AM revealed a Physician's Note dated 03/09/17 stating that the Physician had discussed with Nursing Staff that Palliative Care was to be given to Resident #23. Further review of the record revealed no order was written for Palliative Care between 03/09/17 and Resident #23 being discharged on [DATE] due to his/her death. In an interview on 06/29/17 at 5:42 PM the Director of Nursing and Assistant Director of Nursing stated the facility does not have a formal Palliative Care Program and that there were no changes made to Resident #23's Care Plan due to his/her condition at the time of initial admission. Review of the facilities policy titled Care Plan Process on 06/28/17 at 12:15 PM revealed that the care plan must be reviewed/updated after a change in status and change in condition using the 24 Hour Report process and updates to the Care Plan will be done in Matrix.",2020-09-01
2083,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2017-06-29,309,D,0,1,4QY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility's policy titled Care Plan Process, the facility failed to provide Palliative Care services as per instructions of Physician to Resident Resident #23 . The facility Physician gave instructions for Palliative Care services to be provided to 1 of 1 Sampled Residents reviewed for Palliative Care and those services were not provided. The findings included: The facility admitted Resident #23 on 03/09/2017 with [DIAGNOSES REDACTED]. Record review on 06/28/17 at 11:02 AM revealed a Physician's Note dated 03/09/17 stating that the Physician had discussed with Nursing Staff that Palliative Care was to be given to Resident #23. Further review of the record revealed no order was written for Palliative Care between 03/09/17 and Resident #23 being discharged on [DATE] due to his/her death. In an interview on 06/29/17 at 5:42 PM the Director of Nursing and Assistant Director of Nursing stated the facility does not have a formal Palliative Care Program and that there were no changes made to Resident #23's Care Plan due to his/her condition at the time of initial admission. Review of the facilities policy titled Care Plan Process on 06/28/17 at 12:15 PM revealed that the care plan must be reviewed/updated after a change in status and change in condition using the 24 Hour Report process and updates to the Care Plan will be done in Matrix.",2020-09-01
2084,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2017-06-29,314,D,0,1,4QY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policy titled Wound Care-Performing a Dressing Change, the facility failed to provide adequate care and services for 1 of 3 pressure ulcers reviewed(Resident #142) The findings included: The facility admitted Resident #142 with [DIAGNOSES REDACTED]. Record review on 6/28/17 revealed Resident #142 had an unstageable pressure area to the left and right calf. Further record review revealed a physician's order to cleanse the right and left calf with normal saline or wound cleanser, apply skin prep to the periwound and cover with border foam dressing every day and as needed. Review of the Braden assessment dated [DATE] revealed a score of 9 which indicated the resident was very high risk for development of pressure ulcers. Observation of the pressure ulcer treatment on 6/28/17 at 10:00 AM by Registered Nurse(RN)#1 revealed after washing hands and donning gloves, he/she sanitized the over the bed table; placed a barrier on the over the bed table; obtained dressings from their packaging; opened 4 x 4 packaging touching them with the gloved hand; obtained normal saline packs and skin preps. After the setting up of the items for the pressure sore treatment, RN #1 removed his/her gloves and washed his/her hands. During the treatment of [REDACTED].#1 sprayed the area with normal saline, dried the area, applied skin prep to the periwound and placed the dressing over the wound. RN #1 removed his/her gloves and washed his/her hands. After donning gloves, RN #1 repeated the process on the left calf. During an interview with RN #1 on 6/29/17 at 4:35 PM, he/she confirmed the above findings. Review of the facility policy titled Wound Care-Performing a Dressing Change revealed the following: 1. Don gloves; 2. Remove old dressing and packing(if present). (Change Gloves). 3. Cleanse the wound of drainage, debris, or dressing/filler residue.(Change gloves).",2020-09-01
2085,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2017-06-29,371,F,0,1,4QY511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility policy and procedure, the facility failed to ensure safe food handling practices: Labeling and dating food, Correct storage and/or removal of dented cans, Safe food temperatures for meal service, and to provide sanitary dishware in 1 (one) of 1(one) kitchen and 2 of 2 Food Preparation Areas on the Nursing units. The findings included: During initial tour of the kitchen on 6/26/2017 at approximately 11:00 AM observed one (1) dented can on the shelf in the dry storage room. On 6/26/17 at approximately 11:13 AM, observed in the refrigerator located in the kitchen, 2 separate plastic containers of unlabeled individually wrapped sandwiches and a container of brown substance labeled: Chicken Gravy 7/25/17. The observations were verified by the Dietary Supervisor who said the dented cans should not be stored in the storeroom, and the sandwiches should be labeled on day of preparation and are good for 3 days after preparation. The Dietary Supervisor further said that container of chicken gravy was labeled with the date of 7/25/17 and was made yesterday they accidentally put the wrong date on the gravy yesterday and it should have been labeled 6/25/17 and is good for 3 days from yesterday. Review of the Policy and Procedure titled, Manual: Hospital Nutrition Policies and Procedures Section: [NAME] .12. Refrigerated, read to eat Time Temperature Control for Safety (TCS) foods are properly covered, labeled, dated and refrigerated immediately. The day of preparation or day original container is opened shall be considered day 1. Discard after three days unless otherwise indicated. An observation on 06/28/2017 at 11:00 AM which was verified by the Dietary Supervisor. The Dietary Supervisor said that h/she did not have room for all the dented cans on the labeled shelf Dented Cans. The following dented cans were stored and mixed with the existing inventory of dry stores in the dry store room or in the kitchen: 17 cans of Ensure Plus, 8oz (stored in the kitchen on the shelf above the labeled Dented Cans Shelf) 1 Can Cream of Potato Soup, 50 ounces (in the storeroom) 4 Cans of Manwich 6 pounds, 11 ounces (in the store room) 1 Can of Sliced Apples 6 pounds, 8 ounces (in the store room) 1 Can of Evaporated Milk, 12 ounces (in the store room) 3 Cans of Three Bean Salad, 6 pounds 14 ounces (in the store room) Review of the NUTRITION POLICIES AND PR[NAME]EDURES, SUBJECT: FOOD SAFETY IN RECEIVING AND STORAGE: POLICY: Food will be received and stored by methods to minimize contamination and bacterial growth. PR[NAME]EDURES: 7. Refuse contaminated food and return to the vendor for credit. If the food cannot be returned immediately, store it away for other food and supplies to prevent contamination. Dented cans are stored in a designated location labeled dented cans On 06/28/2017 at 11:20 AM, Dietary Aide #1 was on the serving line and said h/she was not going to calibrate the digital thermometer because h/she said h/she was not aware that h/she could calibrate a digital thermometer and said h/she was unsure of how to clean and sanitize thermometer after placing thermometer in various foods on serving line. On 6/28/2017 at approximately 11:40 AM, Dietary Aide #1 took the temperature of the Puree Bread which was sitting on the counter beside the hot food steamtable and was 110 degrees. When Dietary Aide #1 was questioned regarding safe food temperatures for the hot food steamtable, h/she stated: Should be about 139 to 140 and above. Further the Dietary Aide #1 stated: Puree bread can be served hot or cold or at room temperature. When questioned what to do about puree bread at 110 degrees stated: I guess we will throw away and the puree bread and h/she discarded the puree bread. Review of the Policy and Procedure, [NAME]ina Nutrition Consultants, Section: Food Safety, Policy and Procedure: Safe Food Temperatures, Procedure: 3. After the food has been cooked to the proper temperature it must be held on the steam table at 140 degrees F(Fahrenheit) or higher .All cold items need to be held at 40 degrees F or lower. On 6/29/2017 at 10:50 AM, Diet Aide #1 was loading the dish machine with soiled dishes from breakfast service and was asked to check the sanitizer solution for the low temperature dish machine. H/She obtained the chlorine sanitizer strips for chlorine testing, h/she tested the solution and chlorine and the chlorine test strip did not change colors, the test strip remained white, indicating no sanitizer present in the dish machine. When Dietary Aide #1 was asked how h/she knew if sanitizer solution was going into the dish machine, h/she said they check it every day. Dietary Aide #1 verified that the [MEDICATION NAME] San Liquid Sanitizer bucket was completely empty. On 6/29/2017 at 11:10 verified with the Administrator that the Ultran San Liquid Sanitizer bucket was empty during dish machine operation. The Dietary Supervisor stated: We are out of it. We will have to order some. The Administrator directed staff to use paper products for lunch service. The form posted Temperature Log Dish machine, Facility: Oakbrook, Month of: (MONTH) (YEAR),shows the last recorded date: 6/27, Lunch Wash: 121, Test: 50. The form has no information recorded at Dinner for the entire month and no information recorded on 6/28 and 6/29 for Breakfast Lunch and Dinner. Review of NUTRITION POLICIES AND PR[NAME]EDURES, SUBJECT: WAREWASHING USING DISHWASHING MACHINE, Policy: Utensils and dishes washed by a mechanical dishwasher will be clean and sanitized. The section titled, PR[NAME]EDURES: 1.If using a low temp machine, check the sanitizer level at contact times specified in accord with the product label. Record data on the Temperature and Sanitizer Log Form #CP1906. On 06/28/2017 at 10:45 AM in the Azalea Food Preparation Area, a 4 ounce carton of Sysco Strawberry Shake with no dated label on carton has statement on container, Must be used 14 days after thawing. The Assistant Director of Nursing (ADON) who verified the undated label on the carton, and then removed and discarded. Review of the form titled, Manual: Hospital Nutrition Policies and Procedures Section: E, 12. Refrigerated, read to eat Time Temperature Control for Safety (TCS) foods are properly covered, labeled, dated and refrigerated immediately. The day of preparation or day original container is opened shall be considered day 1. Discard after three days unless otherwise indicated. On 06/28/2017 at 10:50 AM in the Dogwood Food Preparation Area, the interior of the microwave was soiled and was verified with the Unit Manager LPN #1 and the ADON. LPN#1 said she tried to wipe out when she had a chance and the ADON was unsure of who is responsible for cleaning. Review of the Policy and Procedure titled; Nutrition Policies and Procedures, Subject: Cleaning of the Microwave Oven. The Policy states: The microwave oven will be maintained in a clean, odor-free condition. The Procedure states Housekeeping to clean weekly, unit staff to communicate needs for additional cleaning if visibly soiled.",2020-09-01
2086,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2018-08-04,623,C,0,1,0Y0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to assure that the Resident Representative for Resident 15 and Resident #70 and the Ombudsman were notified in writing as to a change in condition that resulted in the resident being hospitalized . One of one resident reviewed for hospitalization . The finding included: On 8/3/18 at approximately 12:50 PM a review of the computerized and paper medical record for Resident 15 failed to show that written notification had been provided to the Resident Representative or Ombudsman for hospitalization due to [MEDICAL CONDITION] on 5/2/18. On 8/3/18 at approximately 1:22 PM a review of the Facility Discharge/Transfer Policy and Procedure failed to show that a written notification to was required. On 8/3/18 at approximately 1:35 PM the Director of Nursing and Medical Records Coordinator confirmed that no written notice had been provided to either the Resident Representative or Ombudsman and stated they were unaware of this requirement. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 8/4/18 at 12:19 PM revealed Resident #70 was admitted to the hospital on [DATE]-7/7/18 and 7/10/18-7/12/18. Further review of the nurse's notes and social services notes did not indicate transfer/discharge information was given to the resident nor the resident representative.",2020-09-01
2087,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2018-08-04,679,D,0,1,0Y0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of activity policy, the facility failed to offer Resident #76 varying activities.(1 of 4 residents reviewed for activities) The findings included: The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 8/4/18 at 8:51 AM revealed the activity assessment dated [DATE] listed sports, education, watching television, watching movies and cooking as activities the resident enjoyed. Review of the Minimum Data Set((MDS) dated [DATE] listed Resident #76's preferences as books, music, pets, and favorite activities. Review of the resident's care plan revealed Resident #76 had complex medical conditions that hindered him/her leisure ability with approaches of 1) appears to accept and at time enjoy passively participating in sensory stimulation activities; offer hand massages and musical interventions and 2) offer 1:1 visits for leisure stimulation and monitoring. Review of the one to one visit sheet revealed Resident #76 was to receive visits 2-3 times weekly. Review of the one to one log for (MONTH) (YEAR) revealed music was played for the resident six times and the resident was read to three times. Review of the individual resident daily participation record for (MONTH) (YEAR) revealed the resident was in bed during activities and the only active activity was television. There was no variation of activities. Review of the activity note dated 2/12/18 revealed one to one visits were in place and interventions included music, reading spiritual passages, hand massages and pet therapy would be offered. Only reading, music and television were offered during the month of (MONTH) (YEAR). During an interview on 8/4/18 at 6:06 PM with the Activity Director, s/he stated resident received visits and activities were conducted with resident. He/she continued by stating from the information gathered, the facility was offering activities the resident enjoyed. The Activity Director was asked would you not want to offer something new to see if the resident enjoyed something different and s/he stated that could certainly be done. During observations throughout the survey process, Resident #76 was observed in bed with no stimulant activity in progress. Review of the facility policy titled Activity/Recreation Program Variations/Categories list the following: 11. The Activity/Recreation Director and/or staff provide small group or individual programming specifically for residents with dementia, e.g. folding sorting, sensory stimulation, reminiscing, personal care of the environment, etc.",2020-09-01
2088,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2018-08-04,686,E,0,1,0Y0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policy titled Dressing, Simple: Application Of, the facility failed to provide the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 3 of 4 residents reviewed for pressure ulcer. Resident #76's specialty mattress was not inflated on two observations. Resident #15 and #30 concerns with the treatment related to the cleaning of the wounds. In addition, Resident #15 with an incomplete order for pressure ulcer treatment. The findings included: The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 8/4/18 revealed the resident was admitted with an inherited Stage II pressure ulcer which was documented as resolved. Further record review revealed an intervention to prevent pressure ulcers was to have an air mattress on the bed and to check the settings every shift. Observation of the Resident #76 on 8/1/18 at 12:40 PM and 4:51 PM revealed the mattress had deflated. At the time of the second observation, Unit Manager#1 confirmed the mattress was not inflated. The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Record review on 8/3/18 at 1:13 PM revealed a current physician's order to cleanse open area on right ischium, pack with 25% Dakin's soaked gauze tape, and cover with absorbent dressing daily and as needed. During observation of wound care on 8/4/18 at 11:38 AM, Registered Nurse(RN) #1 was observed to cleanse the wound with 25% Dakins soaked gauze. During the cleaning of the wound, RN#1 was observed to cleanse the wound several times without obtaining more gauze or changing the portion of the gauze. In addition, the resident was noted to roll back over after the cleaning of the wound while RN#1 washed his/her hands. During an interview with RN#1 on 8/4/18 at 4:40 PM, s/he confirmed the order was incomplete as to what medium should be used to clean the resident's wound. S/he also confirmed the resident had rolled back over while s/he was washing his/her hands and confirmed new gauze or changing the portion of the gauze was not done during the cleaning process of the wound. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Record review on 8/4/18 at 8:48 AM revealed a current physician's order to cleanse the second left toe with normal saline and paint area with [MEDICATION NAME] every day. Observation of wound care on 8/3/18 at 4:07 PM revealed RN#1, during the cleaning of the wound bed, did not change the position of the gauze. S/he was observed to dab and wipe all over the wound bed. During an interview with RN#1 on 8/3/18 at 4:40 PM, s/he stated was taught to clean a wound inside to outside. After informing him/her of the observation, s/he confirmed s/he had not cleaned the wound as s/he was taught. Review of the facility policy titled Dressing, Simple: Application Of did not address preventing residents from rolling over onto the clean wound and cleansing of the wound.",2020-09-01
2089,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2018-08-04,730,E,0,1,0Y0911,"Based on record review and interview, the facility failed to ensure each Certified Nursing Assistant(CNA) received twelve hours of inservice training. The findings included: Record review on 8/3/18 of CNA inservice records revealed multiple CNA's had not received twelve hours of inservice in a twelve month time frame from their date of hire. On 8/4/18 at 7:46 PM, the Minimum Data Set Coordinator confirmed all CNA's had not had the twelve hours of inservice as required.",2020-09-01
2090,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2018-08-04,800,D,0,1,0Y0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policy titled Medical Nutrition therapy for pressure ulcers/wounds the facility failed to reassess Resident #47's nutritional status upon return from a hospital stay related to a prior dietary recommendation. (1 of 4 residents reviewed for nutrition) The findings included: The facility admitted Resident #47 with [DIAGNOSES REDACTED]. Record review on 8/4/18 at 8:50 AM revealed current orders for a CCHO(Controlled Carbohydrate) Mechanical Soft diet. Further review of the medical record revealed the resident was receiving a supplement of Med Pas 120 cc(cubic centimeters) BID(twice a day). Review of laboratory findings revealed the resident's [MEDICATION NAME] level was low with a finding of 2.7 g/dL(grams per deciliter). Review of the Registered Dietician(RD) assessment dated [DATE] revealed a recommendation for double protein portions at meals and to add Critical Care 30 cc TID(three times a day) and Vitamin C 500 mg BID. Further review of the record revealed the recommendation was not carried forward. During an interview with the Director of Nursing(DON) on 8/4/18 at 2:10 PM, s/he stated recommendations come to the DON, then to the Unit Manager, at that time it is the Unit Managers responsibility to ensure the order is carried through. The DON further stated the resident had hospitalization s from 7/3-6/18 and 7/12-17/18 and residents are readmitted with new orders and that would be the reason the recommendation was not implemented. Further review of the medical record revealed there was no RD re-evaluation. Review of the facility policy titled Medical Nutrition Therapy For Pressure Ulcers/Wounds revealed the following under the procedure section: 1. Refer all patients/residents identified with skin breakdown to the RDN(Registered Dietitian Nutritionist) for evaluation and a comprehensive nutrition assessment include assessing the ability to eat independently. 3. Discuss possible interventions with the patient/resident. Recommend interventions to the physician to accomplish nutrition goals. 4. The nutrition services representative to the care plan team will review the RNS's evaluation of the patient/resident with the care plan team so that the patient/resident's nutritional status and interventions re communicated to all disciplines and are addressed on the care plan as needed.",2020-09-01
2091,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2018-08-04,880,E,0,1,0Y0911,"Based on observation, interview and review of facility policy titled Laundry, the facility failed to follow infection control protocols during the handling of soiled linen for one of one observation of the laundry. Laundry Staff was observed to collect soiled laundry with no clothing protection; all soiled laundry was not bagged; staff did not wash hands after collecting soiled laundry; clean linen were stored on soiled side; and contamination of clean linen was observed. The findings included: During observation of the laundry on 8/3/18 at 9:30 AM, Laundry Staff #1 was observed during the collection of the soiled linen without a gown or apron on to protect his/her clothing. Multiple soiled items were observed loose and not contained in a bag. After the collection of the soiled items, Laundry Staff #1 removed his/her gloves and did not wash his/her hands. Upon entering the soiled side of the laundry multiple clean items were observed covered. Entering into the washer room, after Laundry Staff #1 donned personal protective equipment(PPE), s/he removed clean clothes out of the washer and placed them in a basket; removed the lid off the soiled barrel and placed the lid onto the basket of clean clothes. After loading the washer, Laundry Staff #1 removed his/her gloves, closed the washer door and started the machine. S/he removed the PPE and began to push the cart with the contaminated clean clothes into the dryer room. The surveyor stopped the laundry worker and explained due to the placement of the soiled lid onto the clean clothes, the clothes/linens were now contaminated. During an interview with Laundry Staff #1 after the observation, s/he did not disagree with the concerns with infection control practice. Review of the facility policy titled Laundry revealed the following under the procedure section: 5. Personnel in the laundry services are properly garbed at all times. When handling soiled linens, gown and gloves, at a minimum will be donned. Under the Handwashing section: 2. Hands are washed after handling soiled linens even if gloves have been worn.",2020-09-01
2092,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2019-10-18,805,F,0,1,QM2Z11,"Based on observation, interview, and recipe review, the facility failed to adhere to corporate puree recipes in making puree foods for nine (9) of nine (9) residents that received pureed diet. Findings include: Observations made in the kitchen during a follow up on 10/17/19 at approximately 10:14 AM revealed the Cook #1 had just finished making pureed pork to be served for lunch. When asked how she made the puree pork she reported she took the steamed pork and put it in the [NAME]ot Coupe food processor and then added hot water, barbeque sauce, and three (3) cups of powdered thickener. When asked how much pork she used in doing this she was not able to answer. When the cook was asked if she received any training at this facility regarding puree diets and recipes she replied No. Observation of the same Cook on 10/17/19 at 11:27 AM revealed she took seven (7) servings using a #8 (four (4) ounces) scoop of okra and tomatoes including its own liquid out of deep pan and placed it in a six (6) inch () deep stainless-steel steam table pan. She then placed the okra and tomatoes with its own liquid with three (3) cups of powdered thickener into the [NAME]ot Coupe food processor. Once done she placed the mixture in a six (6) deep stainless-steel steam table pan and into the steamer at 11:31 AM. Review of the facility's corporate recipe for Puree Pulled BBQ (Barbeque) Pork Plate revealed the following instructions: Measure desired number of servings of BBQ pork into food processor. Blend until smooth. Add gravy if product need thinning. Add commercial thickener if product need thickening. Review of the facility's Resident Consistency Report provided by the facility on 10/17/19 at 1:23 PM revealed the facility had a total of nine (9) residents receiving diets in puree consistency. Kitchen observations made on 10/18/19 at 11:11 AM revealed the Assistant Dietary Manager (ADM) put about two (2) tablespoons of powdered chicken broth into a four (4) deep stainless-steel steam table pan. She then added hot water into the pan and mixed together. She then proceeded to use a #10 scoop (three (3) ounces) to obtain nine (9) servings of boiled diced chicken into a pan. At 11:14 AM the ADM placed the diced boiled chicken into the [NAME]ot Coupe food processor. She then added the previously mixed chicken broth, and one 6-ounce spoon of powdered thickener and turned the food processor on. She then said it needed to be mashed potato consistency and stopped the food processor. Using a plastic spatula, the ADM scooped out some of the chicken in the processor. She said it was not quite mashed potato consistency and then added another three quarters of 6-ounce spoon full of powdered thickener to the chicken in the processor. At 11:28 AM the ADM placed the pureed chicken in the steamer. When the ADM asked why diced boiled chicken was used instead of fried chicken, she indicated they always used diced boiled chicken for the puree, and because it had no flavor she used the broth. Interview with the Dietary Manager on 10/18/19 at approximately 11:30 AM revealed the food service staff had been trained on diets including pureed textures in (MONTH) 2019, and as needed training was provided on the spot when needed. She reported when on the spot training was done no record was kept. She reported the recipes used at the facility were provided by corporate. Observations in the kitchen on 10/18/19 at approximately 11:33 AM revealed the ADM used an eight (8)-quart square food container and filled it with three (3) liters of cooked collard greens and liquid. She then placed the liquid and collard greens into the food processor with two (2) 6-ounce spoon full of powdered thickener. At 11:53 AM the ADM dished out nine (9) servings using a #8 scoop (4 ounces) of cooked macaroni and cheese from a lunch pan on the steam table into a four (4) deep stainless-steel steam table pan. She then placed the macaroni and cheese into the food processor and used the same pan to fill with hot water without measuring amount used. The ADM then placed the hot water into the food processor and then added two (2) 6-ounce spoons full of powdered thickener. At 11:58 AM she stopped the food processor and used a plastic spatula to scoop out some of the mixture. She reported it was still a little runny and added one third (1/3) of 6-ounce spoon full of powdered thickener into the food processor. At 12 noon she stopped the food processor and transferred what appeared to be a smooth pasty pureed macaroni and cheese into a 1/3 Size 4 Deep Anti-Jam Stainless Steel Steam Table Pan and placed it on the lunch steam table already in progress. Review of the week I day 6 Diet Guide Sheet for Friday 10/18/19 revealed residents were to receive fried chicken, seasoned greens, macaroni and cheese. Review of the puree recipes revealed the following instructions: Fried Chicken: Measure desired # of servings into food processor. Blend until smooth. Add broth or gravy if product needs thinning. Add commercial thickener if product needs thickener. Seasoned Greens: (portion size = #8 dipper/scoop) measure 1/2 cup cooked vegetable, 1 tablespoon water for each serving needed into food processor. Blend until smooth. Macaroni and Cheese: (portion size = #8 dipper/scoop) measure #8 dipper and 1 tablespoon water for each serving needed. Using food processor, blend until smooth.",2020-09-01
4554,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2016-09-09,155,D,0,1,706J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the Adult Care Consent Act, Section [DATE] of the South [NAME]ina Code of Laws, the facility failed to afford 2 of 25 residents the opportunity to formulate their own Advance Directives. (Resident #59 and Resident #113.) The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Advance Directives Notification & Work Sheet signed by the resident's family member indicating the resident's code status was Do Not Resuscitate. The Physician Certification of Inability to Consent form was signed by the resident's physician and indicated the resident was unable to make his/her own healthcare decisions. Further review of this form indicated a second physician did not sign the form indicating the resident lacked the ability to make his/her own healthcare decisions until more than one month after the resident expired. During an interview on [DATE] at approximately 11:30 AM, the facility's Social Worker stated that the medical director first signs the Physician Certification of Inability to Consent forms. The Social Worker stated that he/she reviews the forms for those needing a second physician's signature. The Social Worker stated that this form was overlooked. Review of the Adult Health Care Consent Act, Section [DATE] of the South [NAME]ina Code of Laws, indicates: (8) 'Unable to consent' means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner .A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient . Resident #59 was admitted on [DATE] with a [DIAGNOSES REDACTED]. (The Advance Directives Notification & Worksheet) states Full Code and was signed by Easther Billy(NAME)( the residents niece) on [DATE] although the (Physicians Certification Of Inability to Consent) form states Resident able to make healthcare decisions. During an interview with the Social Worker on [DATE] at 1:10 PM, when asked if s/he could find paperwork where two doctors deemed the resident as unable to make her/his own healthcare decisions the Social Worker stated there is no documentation deeming Resident #59 as not capable of making her/his own decisions. The Social Worker stated, The resident was drowsy from the hospital and was unable to sign on [DATE] so his/her niece signed his/her advance directives.",2019-11-01
4555,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2016-09-09,156,B,0,1,706J11,"Based on record review and interview, the facility failed to provide the required CMS Form -NOMNC notice to 1 of 3 sampled residents who had been discharged from Medicare Part A services with days of eligibility remaining. (Resident #45.) The findings included: A review of Liability and Appeal Notices with the Social Services Director on 9/9/16 revealed that Resident #45 had been discharged from Medicare Part A services with Medicare eligibility days remaining, and Resident #45 remained in the facility. The surveyor requested to review the required CMS Form for Resident #45. At that time, the Social Services Director informed the surveyor that he/she did not issue CMS Form .",2019-11-01
4556,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2016-09-09,431,E,0,1,706J11,"Based on observations, record reviews, interviews and manufacturer package inserts the facility failed to assure that it was free of expired medications in 1 of 2 medication rooms and that medications were correctly labeled in 1 of 4 medication carts. The findings include: -Inspection of the Hall 200 (Dogwood) medication room refrigerator on 9/6/16 at approximately 11:30 AM revealed a 1 ml (milliliter) vial (approximately 1/10 full) of Tuberculin Purified Protein Derivative, Diluted Aplisol by PAR Pharmaceuticals, Lot # 0 which had been labeled by the facility with an expiration date of 8/6/16. This finding was verified by Licensed Practical Nurse # 1 on 9/6/16 at approximately 11:36 AM. The manufacturer package insert states: Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. -Inspection of the Hall 100 (Azalea) front medication cart on 09/6/2016 at approximately 3:08 PM revealed one opened vial of Humulin 70/30 Insulin by Lilly belonging to Resident # 24 which had been dated by the facility as opened on 9/1/16. The insulin had been labeled by the Pharmacy: DISCARD 42 DAYS AFTER OPENING. This finding was verified by Registered Nurse # 1 on 9/6/16 at approximately 3:12 PM. The manufacturer's (Lilly) package insert states for in-use (opened) Humulin 70/30 vials: If stored at room temperature, below 86 degree F (Fahrenheit) (30 degrees C (centigrade) the vial must be discarded after 31 days, even if the vial still contains HUMULIN 70/30. The pharmacy labeling was verified by the Consultant Pharmacist on 9/8/16 at approximately 2:27 PM who stated that according to the manufacturer the insulin should have been labeled to expires 31 days after opening.",2019-11-01
5702,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2015-05-15,282,E,0,1,XS4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of forms titled,[MEDICAL TREATMENT] Communication Records, the facility failed to ensure coordination of care was provided per written plan of care for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. A [MEDICAL TREATMENT] Communication Record was not completed and returned to the facility after each [MEDICAL TREATMENT] treatment for [REDACTED]. The findings included: The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Review on 5/14/2015 at approximately 5:26 PM of Resident #35's medical record revealed a physician's orders [REDACTED]. Further review of Resident #35's medical record revealed, [MEDICAL TREATMENT] Communication Records were placed in the resident's clinical record after each treatment. No [MEDICAL TREATMENT] Communication Records were found in resident #35's medical record for the following dates of treatment: 2/24/2015, 3/10/2015, 3/12/2015, 3/14/2015, 3/17/2015, 3/19/2015, 3/21/2015, 3/24/2015, 3/26/2015. 3/29/2015, 3/31/2015, 4/2/2015, 4/4/2015, 4/7/2015, 4/16/2015, 4/21/2015, 4/30/2015. 5/2/2015, 5/7/2015, 5/11/2015 and 5/14/2015. Further review of the [MEDICAL TREATMENT] Communication Record on 5/14/2015 at approximately 7:30 PM revealed a section on the form titled, Information to be Completed by the [MEDICAL TREATMENT] Center. This section contained a pre-weight and the post weight. It also contained lab work if any was completed, any problems that may have occurred while at the [MEDICAL TREATMENT] center, and any medications given at that time. The form also contained vital signs after the [MEDICAL TREATMENT] treatment and any recommendations and or follow ups for this resident by the physician. Review on 5/14/2015 at approximately 7:17 PM of Resident #35's Comprehensive Plan of Care dated 2/25/2015 revealed a problem which stated, Resident has a potential for multiple problems related to End Stage [MEDICAL CONDITION] requiring [MEDICAL TREATMENT]. The goal read, Resident will have no complications related to End Stage [MEDICAL CONDITION] or [MEDICAL TREATMENT]. Included in the approaches were, Send a communication sheet with resident to [MEDICAL TREATMENT] to be notified of any changes. Monitor for changes in resident upon return to the facility. And, Obtain labs from [MEDICAL TREATMENT]. During an interview on 5/14/2015 at approximately 7:30 PM with Registered Nurse (RN) #1, Unit Manager of the Dogwood Hall, confirmed that the [MEDICAL TREATMENT] Communication Records were not in the medical record and the resident's care plan had not been followed. The facility did not provide a policy for [MEDICAL TREATMENT]. The Administrator stated, there is no [MEDICAL TREATMENT] policy.",2018-10-01
5703,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2015-05-15,309,E,0,1,XS4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of forms titled,[MEDICAL TREATMENT] Communication Records, and the Nursing Home Outpatient [MEDICAL TREATMENT] Agreement, the facility failed to ensure coordination of care was conveyed between the facility and the [MEDICAL TREATMENT] center for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. A [MEDICAL TREATMENT] Communication Record was not completed and returned to the facility after each [MEDICAL TREATMENT] treatment for [REDACTED]. The findings included: The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Review on 5/14/2015 at approximately 5:26 PM of Resident #35's medical record revealed a physician's orders [REDACTED]. Further review of Resident #35's medical record revealed, [MEDICAL TREATMENT] Communication Records were placed in the resident's clinical record after each treatment. No [MEDICAL TREATMENT] Communication Records were found in resident #35's medical record for the following dates of treatment: 2/24/2015, 3/10/2015, 3/12/2015, 3/14/2015, 3/17/2015, 3/19/2015, 3/21/2015, 3/24/2015, 3/26/2015. 3/29/2015, 3/31/2015, 4/2/2015, 4/4/2015, 4/7/2015, 4/16/2015, 4/21/2015, 4/30/2015. 5/2/2015, 5/7/2015, 5/11/2015 and 5/14/2015. Further review of the [MEDICAL TREATMENT] Communication Record on 5/14/2015 at approximately 7:30 PM revealed a section on the form titled, Information to be Completed by the [MEDICAL TREATMENT] Center. This section contained a pre-weight and the post weight. It also contained lab work, if drawn/ordered, any problems that may have occurred while at the [MEDICAL TREATMENT] center, and any medications given at that time. The form also contained vital signs after the [MEDICAL TREATMENT] treatment and any recommendations and or follow ups for this resident by the physician. During an interview on 5/14/2015 at approximately 7:30 PM with Registered Nurse (RN) #1, Unit Manager for the Dogwood Hall, he/she confirmed the communication sheets were not in the facility. He/she went on to say that the nurse is suppose to call the [MEDICAL TREATMENT] center if the resident comes back to the facility without it. This surveyor asked, How would the nurse know if resident #35 had new orders from the nephrologist, had received medications, or had labs drawn at the [MEDICAL TREATMENT] center? He/she stated, we wouldn't. Review on 5/15/2015 at approximately 3:51 PM of a document titled, Nursing Home Outpatient [MEDICAL TREATMENT] Agreement, paragraph 4 states, Whereas, Nursing Home and RAI deem it to their mutual interest to enter into this agreement, pursuant to which they will provide effective coordination of medical care for residents who will be receiving care from both parties.",2018-10-01
5704,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2015-05-15,332,D,0,1,XS4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy titled General Dose Preparation and Medication Administration and interview, the facility failed to ensure it was free of medication errors of greater than 5%. The facility medication error rate was 6.89% as a result of 2 errors out of 29 opportunities. The findings included: Error #1 and #2-During medication reconciliation record review on 5/15/15 at 2:00 PM, the physician's order dated 5/13/15 stated [MEDICATION NAME] 400 milligrams(mgs) by mouth three times a day for seven days. Further review of the physician orders revealed an order for [REDACTED].#110. On 5/15/15 at 3:00 PM, during an interview with Licensed Practical Nurse #2, he/she stated the [MEDICATION NAME] was given at a later time. No further explanation was given by LPN #2 as to why the [MEDICATION NAME] was given later nor did he/she explain why the [MEDICATION NAME] had not been given during the observation of the medication pass. Review of the facility policy titled General Dose Preparation and Medication Administration revealed under item 3.1 the following: 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.",2018-10-01
5705,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2015-05-15,431,E,0,1,XS4J11,"Based on observation, interview, review of Medication Storage Audits and review of the facility policy titled Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles, the facility failed to ensure expired medications were not stored with other medications for resident use, failed to place open dates on items, and the pharmacy failed to place an expiration date on a medication in 4 of 4 medication carts reviewed. The findings included: Observation of the Azalea Front Hall Medication Cart on 5/15/15 revealed (1) 30 fluid(fl) ounces(oz) UTI Stat bottle with no open date. Observation of the Azalea Back Hall Medication Cart on 5/15/15 at 1:49 PM revealed (1) 30 fl oz Pro-stat SF AWC with no open date; (1) box of Zantac 75 with a lot # 1 and expiration date of 10/14; (1) bottle of Cyanocobalamin 1000 micrograms(mcg's)/1 milliliter(ml) lot # 36 with no open date; (1) Advair HFA 230-21 mcg lot #5ZP8221 with no open date; (1) 4 fl oz Epi-Clenz lot # with an expiration date of 4/15. Observation of the Dogwood Front Hall Medication Cart on 5/15/15 at 3:36 PM revealed (2) 600 ml bottles of Valproic Acid 250 mg/5 ml with no expiration date. Observation of the Dogwood Back Hall Medication Cart on 5/15/15 at approximately 3:50 PM revealed (1) Advair 250/50 with an expiration date of 5/12/15. During an interview with Registered Nurse(RN) #2 on 5/15/15 at approximately 1:50 PM, he/she confirmed the findings on the Azalea Unit and stated once an item is opened it should be dated. He/she further stated prior to giving a medication the expiration date should be checked. During an interview with RN #3 on 5/15/15 at approximately 3:50 PM, he/she confirmed the expiration date of the Advair. During an interview with the Unit Manager of the Dogwood Unit, he she stated the pharmacy had been contacted related to the Valproic Acid and he/she had been informed by pharmacy the medication did not expire until 1/17. Review of the Medication Storage Audits by the pharmacy revealed the Azalea and Dogwood medication carts had been checked on 5/6/15. Review of the facility policy titled Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles states under section 3 the following: The Facility should ensure that drugs and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; Section 3.1 states Once any drug or biological package is opened, the Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications.",2018-10-01
5706,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2015-05-15,456,F,0,1,XS4J11,"Based on observations, interview and review of the facility policy titled, Laundry Area Practices, the facility failed to ensure the lint traps were free of a heavy build up lint for 3 of 3 clothes dryers observed. And further failed to ensure the area behind the dryers was free of lint build up for 1 of 2 areas observed. The findings included: An observation on 5/14/2015 at approximately 8:30 AM revealed a heavy build up of lint behind the clothes dryers. An interview on 5/14/2015 at approximately 8:30 AM with the Laundry Supervisor, he/she confirmed the heavy build up of lint behind the clothes dryers and went on to say,maintenance cleans the lint from behind the clothes dryers. An observation on 5/14/2015 at approximately 2:30 PM revealed a heavy build up of lint on the clothes dryer lint traps, above the traps and on the floor of 3 of 3 clothes dryers. An interview on 5/14/2015 at approximately 2:30 PM with the Laundry Supervisor verified the heavy build up of lint on the lint traps, above the lint traps and on the floor of 3 of 3 clothes dryers. He/she stated, I will take care of this right away. Then he/she called to a laundry worker and asked, When was the lint removed from the lint traps? The laundry worker stated,I just cleaned those out. Review on 5/15/2015 at approximately 3:20 PM of the facility policy titled, Laundry Area Practices, with the Purpose: To conduct laundry operations in a clean, safe environment. Under, Procedure. Cleaning Schedule states, CAUTION: Clean the dryer lint traps after each load!",2018-10-01
5707,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2015-05-15,502,D,0,1,XS4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an ordered laboratory test, LFT (Liver Function Test) was drawn for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. Resident #35. The findings included: The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Review of Resident #35's medical record on 5/15/2015 at approximately 7:25 AM revealed monthly physicians orders for LFT's to be drawn every 6 weeks. The order remained on the monthly physician orders [REDACTED]. No results could be found that the LFTs had been drawn since 12/11/2014. Further review of the medical record for Resident #35 on 5/15/2015 at approximately 8:20 AM revealed a telephone order dated 11/14/2014 which stated, Obtain LFT's every 6 weeks (to begin 6 weeks from now on 12/26/2014) related to elevated LFT's. During an interview on 5/15/2015 at approximately 8:30 AM with Registered Nurse (RN) #1, Unit Manager of the Dogwood Hall, he/she stated, the [MEDICAL TREATMENT] Center draws his/her labs and then send a copy of the results to us for the medical record. No orders could be found to confirm that the LFT's were to be drawn at the [MEDICAL TREATMENT] Center. RN #1 then went to medical records to find copies of the LFT results. Upon return, he/she stated the LFT's were to be drawn here in the facility every 6 months. Then confirmed that the labs should have been drawn every 6 weeks as ordered by the physician. No lab results could be found in medical records to confirm the LFT's had been drawn.",2018-10-01
6892,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2013-12-20,371,E,0,1,K2HX11,"On the days of the Recertification Survey, based on observation, interviews and review of the facility policy entitled Food Storage Principles with the release date of 4/15/01 the facility failed to store and prepare food under sanitary conditions as evidenced by: failure to remove expired products from refrigerated/freezer storage and failure to seal ice cream after opening in 1 of 3 resident refrigerators. In addition, a microwave was observed with dried food particles, splatters, rust and peeling plastic on the inside. (1 of 3 resident microwaves) The identified concerns had the potential to affect multiple residents. The findings included: Review of the facility policy entitled Food Storage Principles dated 4/15/01 recorded in part Label each package, box, can, etc. with the expiration date, date of receipt, or when the item was stored after preparation Discard foods that have exceeded their expiration date. On 12/19/13 at approximately 10:18 AM, the surveyor had observed the following in the Activity refrigerator for the residents: 1-half gallon strawberry ice cream with expiration date of 11/18/13, 1-gallon of Blue Bell ice cream in the freezer not completely sealed, 1-1/2 pint fat free skim milk with the expiration date of December 9, 2013, 1-19 ounce (oz) Chocolate syrup with expiration date of 9/1/13, 1-17 oz strawberry syrup with the expiration date of August 2013 and 1-7.3 oz cinnamon roll raw dough with the expiration date of 11/2/13. Further review of the Restorative dining room on 12/19/13 at approximately 10:30 AM revealed food particles and splatters on the sides and top on the inside of the microwave. The microwave also had rust stains on the inside and peeling plastic on the bottom. During an interview with Restorative Aide #1 on 12/19/13 at approximately 10:32 AM, he/she confirmed the surveyor's findings and stated that it is the Activity Directors responsibility for checking the dates and monitoring food storage. He/she further stated that housekeeping was responsible for cleaning the microwave in the Restorative Dining room. The Activity Assistant on 12/19/13 at approximately 11:16 AM confirmed the food in the refrigerator was used for residents in the facility. The Activity Assistant further stated The Activity Director has been out since October and I did not know that I would have been responsible for monitoring the food storage. The Activity Assistant stated there were no logs or documentation of monitoring the refrigerator for expired items.",2017-08-01
6893,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2013-12-20,372,E,0,1,K2HX11,"On the days of the survey, based on repeated observations, review of the facility provided policy titled Food Handling Practices and interview, the facility failed to maintain garbage dumpsters in a sanitary manner. The Facility dumpster was observed with the doors open, loose debris and spillage on the ground. (1 of 1 dumpster area observed with multiple concerns) The findings included: On 12/17/13 at 12:10 PM, observation of the facility dumpster revealed the dumpster door had been left open, There were two trash receptacles without lids containing loose and bagged garbage. The grease trap lid was observed open and a large amount of spillage and debris was observed on the ground. On 12/19/13 at 11:30 AM, a repeat observation with the CDM (Certified Dietary Manager) present, revealed the dumper lid and side door was open. The dumpster appeared filled to capacity. There were two additional receptacles without lids containing both bagged and loose garbage. The grease trap remained opened and spillage was evident. On 12/19/12 review of the facility provided policy entitled Food Handling Practices revealed : Keep all garbage and food wastes in leak-proof, non-absorbant containers. Cover trash containers when not in continuous use Empty containers twice daily or more often, if necessary. Keep outside dumpster areas clean. Keep lids/doors to dumpsters closed when not dumping garbage. On 12/19/13 at 12:10 PM, the CDM was unable to provide evidence of a cleaning or maintenance schedule for the dumpster/grease traps.",2017-08-01
7778,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2012-09-27,156,D,0,1,77HO11,"On the days of the survey, based on review of Advanced Beneficiary and Liability Notices and staff interview, the facility failed to notify 2 of 3 sampled residents reviewed of non-coverage under Medicare prior to their first non-covered day as required. The findings included: An interview and review of Advanced Beneficiary and Liability Notices was conducted on 9-25-12 at 1:40 PM with the Business Office Manager (BOM). Resident #39 was denied Medicare coverage with beneficiary days remaining. His/her first non-covered day was 6-27-12. No Advanced Beneficiary and Liability Notices were located for this resident. The BOM verified none had been completed. Resident #40 was also denied Medicare coverage with beneficiary days remaining. His/her first non-covered day was 5-15-12. No Advanced Beneficiary and Liability Notices were located for this resident. The BOM verified none had been completed.",2016-11-01
7779,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2012-09-27,279,D,0,1,77HO11,"On the days of the survey, based on interview, observation and record review, the facility failed to develop a plan of care for 1 of 3 residents reviewed for (Range of Motion (ROM). There was no plan of care developed to address Resident #54's known flexion contractures and the resident's resistance to intervention. The findings included: During an interview with Licensed Practical Nurse (LPN) # 2 on 9/24/12 at approximately 11 am, it was revealed Resident # 54 had a known contracture of the hand. The nurse stated the resident used to wear a palm protector but it was discontinued due to the resident's noncompliance. Record review on 9/26/12 at 12:30 pm revealed a palm protector had been ordered in 2009 for right hand flexion contractures. The treatment/intervention was discontinued related to the resident's refusal to wear, removal of the protector and being uncooperative with the intervention. Following the completion of the record review, an Interview with LPN # 2, the Unit Manager, and the Director of Nursing verified the findings and confirmed the intervention had been discontinued related to the residents refusal to cooperate. During an interview with the Occupational Therapist on 9/26/12 at 1:26 pm, s/he stated the resident was due for a contracture screen this month. The therapist provided the most recent contracture screen done (January 2012) at which time the resident had refused to allow the assessment of the contractures of the hand, therefore it was not measured and no intervention had been ordered. Resident # 54 was observed and interviewed at 1:35 pm on 9/26/12. Three ( 3) fingers (middle, ring and pinky) on the right hand were observed to be held in a flexed position. The resident was unable to extend the fingers that were positioned snugly together. The nail tips were in close proximity of the palm of the resident's hand. The inner side of the fingers/inner palm was slightly white and slightly moist in appearance. The Occupational Therapist then provided a contracture screen that s/he had just completed. The screen stated the resident demonstrated limited PROM (passive range of motion) at (R) right hand - c/o (complained of ) pain during PROM Resident will benefit with skilled OT (occupational therapy) to prevent developing further flexion contracture.Resident is very sensitive with right hand care- keeps ring and middle finger flexed. During an interview with the Resident Assessment Coordinator (RAC) on 9/26/12 at approximately 3PM, s/he confirmed the Minimum Data Set ( MDS) did not reflect a contracture because the resident was functional despite the contracture. The RAC verified no plan of care had been developed related to the identified contracture because the resident was functional and because s/he was known to have been noncompliant with past interventions. It was not disputed that having a plan of care that addressed the awareness of the contracture, the resident's noncompliance with an appropriate intervention and the need to monitor for further decline and or necessary intervention would be appropriate.",2016-11-01
7780,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2012-09-27,431,D,0,1,77HO11,"On the days of the survey, based on observation and interview, the facility failed to date one vial of tuberculin solution when punctured to assure proper storage. (One of two medication rooms observed for medication storage.) The findings included: During observation of the Dogwood Medication Storage Unit on 9/24/12 (one) bottle of Apisol (5 milliliters) was punctured but not dated when opened. The finding was verified at 9:35 AM by the Unit Manager who was present when the concern was identified. The Unit Manager stated it was facility policy to date the solution when the vial was punctured.",2016-11-01
8131,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2013-08-15,241,D,1,0,WRJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations and interviews, the facility failed to promote care in a manner and in an environment that enhances each resident's dignity and respect for 1 of 3 sampled residents. Resident #1 was observed multiple times with a soiled garment protector on after meals and riding a urinal on the side of his/her electric wheelchair throughout the building, without a privacy bag. The findings included: The facility admitted Resident #1 on 11/9/12 with [DIAGNOSES REDACTED]. The Quarterly MDS (minimum data set) assessment dated [DATE], revealed that Resident #1 had a BIMS (brief interview of mental status) score of 10 and was alert with confusion. S/he required assistance of 1-2 persons for ADL (activity of daily living) care. The resident had an electric wheelchair and was observed transporting him/herself throughout the facility. During the survey on 8/14/13 at 12:05 PM, Resident #1 was observed in his/her electric wheelchair in the Dogwood hallway. A soiled, garment protector remained around his/her neck after lunch and on the side of the electric wheelchair was a urinal container, which was empty at the time. A second observation was made on 8/15/13 at 1:15 PM, as Resident # 1 was returning to the nurse's station on Dogwood hall from the main dinning room, a garment protector remained around his/her neck as well as a urinal was noted on the side of the wheelchair. An observation was made as a CNA (certified nurse aide) asked if s/he could remove the garment protector. Resident #1 stated clearly NO. The CNA moved away and continued to assist other residents who had needs. An interview on 8/15/13 at 1:55 PM with the ADON (assistant director of nursing), revealed that Resident #1 liked to wear his/her garment protector at times. S/he sometimes will let you take it and sometimes not. S/he also likes to carry his/her urinal on the wheelchair. We have tried to put it in a privacy bag, but s/he refuses. The Unit Manager for Dogwood stated that Resident #1 will use the garment protector as a shield while he uses his urinal in public.",2016-07-01
8132,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2013-08-15,281,D,1,0,WRJU11,"**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 provide services which meet professional standards for 1 of 3 sampled residents. Resident # 3 did not have daily documentation regarding behaviors as required by the facility. The findings included: The facility admitted Resident #3 on 5/1/13 with [DIAGNOSES REDACTED]. The admission MDS (material data set) for 5/8/13 revealed a BIMS (brief interview of mental status) score of 3 and required assistance of 1-2 persons for all ADLs (activity of daily living). During the record review on 8/15/13 at 10:15 AM, it was noted that the Behavior/Intervention Monthly Flow Record for Resident # 3 for the months of June, July and August were not filled in completely. There were days that the nursing staff did not document the residents behavior as required. A pharmacy Consultation Report from 7/3/13 documented under Recommendation: Please consider decreasing [MEDICATION NAME] to 500 mg three times daily at this time and see if the tremor improves. The physician responded with a decline regarding the recommendation stating, benefits outweigh the risks. The physician did agree to have a [MEDICATION NAME] Acid level drawn on the next lab day. The [MEDICATION NAME] Acid level was drawn on 6/27/13 with a reading of 69. A review of the Behavior Monitoring Log for June revealed 4 evening shifts which were not documented. The resident was sent to hospital in June, but there were 12 days which were not marked if he/she were out of the facility. The month of July revealed 14 evening shifts that were not documented and the month of August revealed 1 day shift and 2 evening shifts thus far this month. A review of Resident # 3's physician orders [REDACTED]. A review of the care plan for Resident #3 on 8/15/13 at 11:15 AM, revealed that the facility did identify the risks associated with [MEDICAL CONDITION] medications and there was an approach for nursing to Monitor for adverse reactions or unusual symptoms and update the physician. A note was hand written under the Care Plan Reviewed dated 7/18/13 documenting-[MEDICATION NAME] at bedtime with no signs or symptoms of adverse reaction. Prescription review indicated that tremors were from [MEDICATION NAME]. The physician is aware and notes that benefit outweighs the risks. [MEDICATION NAME] for mood stabilization-Next GDR (gradual dose reduction) due for [MEDICATION NAME] is 12/17/13. A review of the policy for [MEDICAL CONDITION] Medication Assessment and Monitoring provided by the Interim DON (director of nursing) states under, Documentation-4. Record behavior, interventions, and the effectiveness of the interventions taken in the behavior monitoring record. An interview with the Interim DON on 8/15/13 at 1:30 PM, revealed that the ADON (assistant director of nursing) did the training for the nursing staff regarding documenting and each department head comes and in-services staff as well. The staff have to chart what the residents behavior is and try to re direct when they can. The nursing staff are expected to chart the behavior every shift. When the Interim DON was shown the behavioral monitoring logs for Resident #3, he/she stated, I would say yes that is a concern when they do not chart on the residents behavior log.",2016-07-01
8133,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2013-08-15,441,D,1,0,WRJU11,"**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 a safe sanitary and comfortable environment to help prevent the transmission of disease and infection for 1 of 3 sampled residents. Resident #1 was noted to keep his/her urinal on the side of his/her electric wheelchair without utilizing a privacy bag. The findings included: The facility admitted Resident #1 on 11/9/12 with [DIAGNOSES REDACTED]. The Quarterly MDS (minimum data set) assessment dated [DATE], revealed that Resident #1 had a BIMS (brief interview of mental status) score of 10 and was alert with confusion. S/he required assistance of 1-2 persons for ADL (activity of daily living) care. The resident had an electric wheelchair and was observed transporting him/herself throughout the facility. During the survey on 8/14/13 at 12:05 PM, Resident #1 was observed in his/her electric wheelchair in the Dogwood hallway. A soiled, garment protector remained around his/her neck after lunch and on the side of the electric wheelchair was a urinal container, which was empty at the time. A second observation was made on 8/15/13 at 1:15 PM, as Resident # 1 was returning to the nurses station on Dogwood hall from the main dinning room, a garment protector remained around his/her neck as well as a urinal was noted on the side of the wheelchair. An interview on 8/15/13 at 1:55 PM with the ADON (assistant director of nursing), revealed that Resident #1 likes to wear his/her garment protector at times. S/he sometimes will let you take it and sometimes not. S/he also likes to carry his/her urinal on the wheelchair. We have tried to put it in a privacy bag, but s/he refuses. Upon review of the Care Plan for Resident #1 under -Potential for altered dignity related to: Care Plan Reviewed dated 4/22/13 it was noted Uses urinal and is only occasional incontinent with bladder. Frequently incontinent of bowel. Continue with plan of care. The Unit Manager for Dogwood stated that Resident #1 will use the garment protector as a shield while he uses his urinal in public.",2016-07-01
8963,OAKBROOK HEALTH AND REHABILITATION CENTER,425156,920 TRAVELERS BOULEVARD,SUMMERVILLE,SC,29485,2015-05-15,364,E,0,1,XS4J11,"Based on interview, record review, and observation, the facility failed to serve meals at the proper temperature. The findings included: During individual interviews, four residents described the food as sometimes cold, always cold, lukewarm, or that the eggs were served cold. Review of the Resident Council Minutes for 12/18/14 revealed on the week-ends the breakfast is cold and on 3/19/15 the residents stated the food is cold when it comes out. On 5/15/15 at 8:25 AM, a breakfast test tray was observed with oatmeal, eggs, link sausage, sweet roll, milk, and juice. Upon tasting the items by two surveyors, the eggs, sweet roll and link sausage were not hot.",2015-09-01
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
1792,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-02-27,584,E,1,0,WVW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure each resident had a safe, clean, comfortable, and homelike environment. The surveyor noted several areas in the facility that had been patched and not repainted to match the paint color of the room. The surveyor also noted a door on the 200 unit that had a large crack in the glass. Two of two units reviewed for environment. The findings included: During initial tour of the facility on 2/26/18 at approximately 10:45 AM, the surveyor noted multiple resident rooms that had white patch repairs that had not been painted to match the paint color of the rooms. The surveyor also noted walls in the main dining room had white patch repairs that had not been painted to match the paint color of the room. The surveyor also noted an exterior glass door near room [ROOM NUMBER] that had blue tape on the lower portion covering a crack in the glass. The Maintenance Director provided a copy of a work order from a glass repair company dated 2/20/18 to measure broken door glass. The Maintenance Director stated s/he called the glass repair company and the work order was created on the date the door crack was identified. The Maintenance Director stated s/he had been at the facility for 3 years and the door glass had not been cracked before to their knowledge. Review of the complaint information received by the State Agency revealed the complainant stated the exit door near room [ROOM NUMBER] had a huge crack in the glass across the bottom of the door and a piece of blue tape was used to cover the crack. The observation was made by the complainant on 1/19/18. In an interview with the surveyor on 2/27/18 at approximately 11:30 AM, the Maintenance Director stated s/he called the glass company about a week ago. The glass company is out of Columbia and they are going to send someone out to replace it. The Maintenance Director stated the facility just got new dispensers in the residents' rooms and that is where a lot of the patches have come from. When the old dispensers were removed they had to patch the walls. There is a plan to repaint the entire building. They have started the work and are painting the main hallway. The Maintenance Director and his/her assistant are the ones doing the painting. The Maintenance Director provided a copy of the (MONTH) (YEAR) QAPI that indicted the maintenance department had started painting different areas of the building. They will start on the front hall and then move on around the building. The maintenance department will paint until all hallways and rooms are complete. The QAPI contained no information about when the work was to be finished. In an interview with the surveyor on 2/27/18 at approximately 12:20 PM, the administrator stated they have identified the building needs painting in (MONTH) (YEAR). The administrator just started at the facility about a month ago. They have started painting, but don't have a formal plan in place. It will be ongoing, there is no set time for when the project will be finished. They had a paint day a couple of weeks ago, and instead of having a morning stand up they painted. Then had lunch and stand up meeting around noon. The surveyor asked for any information on a plan of when the painting project would be completed. The administrator stated there was no set time for when the project will be completed.",2020-09-01
1793,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-02-27,867,D,1,0,WVW611,"> Based on observation and interview, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. The surveyor noted several areas in the facility that had been patched and not repainted to match the paint color of the room. During interviews, the surveyor learned that the facility had identified the problem and noted it during the QAPI meeting, but did not develop an appropriate plan of action to correct the problem. One of one problems reviewed for quality assurance. The findings included: During initial tour of the facility on 2/26/18 at approximately 10:45 AM, the surveyor noted multiple resident rooms that had white patch repairs that had not been painted to match the paint color of the rooms. The surveyor also noted walls in the main dining room had white patch repairs that had not been painted to match the paint color of the room. In an interview with the surveyor on 2/27/18 at approximately 11:30 AM, the Maintenance Director stated the facility just got new dispensers in the residents' rooms and that is where a lot of the patches have come from. When the old dispensers were removed they had to patch the walls. There is a plan to repaint the entire building. They have started the work. The Maintenance Director and his/her assistant are the ones doing the painting. The Maintenance Director provided a copy of the (MONTH) (YEAR) QAPI that indicted the maintenance department had started painting different areas of the building. They will start on the front hall and then move on around the building. The maintenance department will paint until all hallways and rooms are complete. The QAPI contained no information about when the work was to be finished. In an interview with the surveyor on 2/27/18 at approximately 12:20 PM, the administrator stated they have identified the building needs painting in (MONTH) (YEAR). The administrator just started at the facility about a month ago. They have started painting, but don't have a formal plan in place. It will be ongoing, there is no set time for when the project will be finished. They had a paint day a couple of weeks ago, and instead of having a morning stand up they painted. Then had lunch and stand up meeting around noon. The surveyor asked for any information on a plan of when the painting project would be completed. The administrator stated there was no set time for when the project will be completed.",2020-09-01
1794,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-07-11,692,D,1,0,D3N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Resident #1 was noted to have a tube feeding order on admission with no documentation on the MAR (Medication Administration Record) that the tube feeding was administered. Resident #1's MAR was updated with new tube feeding orders on 5/11/18 and there were five entries not signed as administered during the month of May. The resident was not weighed per facility policy to monitor weights. Resident #3 was admitted with tube feeding orders and was not weighed per facility policy/physician order [REDACTED]. The findings included: Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE]. Review of the Resident's Progress Notes revealed an entry by the Registered Dietitian on 5/9/18 at 4:03 PM indicated resident's current diet order is pureed pleasure snacks TID (three times daily) and Ensure TID via feeding tube related to swallowing difficulty and [MEDICAL CONDITION] stricture. Recommended to change tube feeding to [MEDICATION NAME] 1.5 QID (four times daily). Review of the physician's orders [REDACTED]. Times noted as 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Review of the resident's May 2018 MAR (Medication Administration Record) revealed [MEDICATION NAME] 1.5 QID was ordered 5/11/18 and first administered on 5/11/18 at 8:00 PM. The 4:00 PM feeding was held per the physician due to resident vomiting. There was no order on the MAR for Ensure. [MEDICATION NAME] 1.5 was not signed as administered on 5/21/18 at 8:00 AM, 12:00 PM, or 4:00 PM. The order was also not signed as administered on 5/25/18 at 8:00 AM and 4:00 PM. There were no comments on the MAR and no documentation in the Nursing Progress Notes to indicate why the tube feeding was not signed as administered. Review of the Nursing Progress Note dated 5/10/18 at 3:51 PM revealed one can of Ensure was administered to Resident #1 via peg tube at 8:00 AM and 2:00 PM. There were no additional Progress Notes that indicated the resident's Ensure was administered via PEG. The facility was unable to provide a Nursing Admission Assessment for the resident. The facility was able to provide the resident's orders that indicated Ensure 1 can TID ordered 5/8/18. The order was noted as open ended and there was no discharge date . The facility was unable to provide a MAR to show where the tube feeding was documented as administered. Resident had an order for [REDACTED]. Reviewed the resident's Oral Intake documentation and the information provided revealed the documentation started 5/16/18. There were no entries prior to that date. Review of Resident #1's documentation revealed a weight was obtained on 5/9/18 and recorded as 93.9#. The next weights recorded were on 5/12/18 as 99.4#, on 5/13/18 as 100.6#, and on 5/14/18 as 91.2#. The next weight recorded was on 5/24/18 as 93#. On 6/27/18 at 5:55 PM, the administrator stated the nurse will usually call the nurse practitioner or physician on call and review the medications the day a resident is admitted . The nurse will then put the orders in the system. Once in the system the MAR is generated from the orders and the nurses use that to administer medications to residents. Review of the Performance Feedback form dated 5/22/18 revealed RN #1's medications were not administered in a timely manner and nursing documentation was incomplete in MAR. A Corrective Action Form dated 5/26/18 indicated the nurse was discharged because bolus gastrostomy tube feedings were not administered as prescribed. 8:00 AM and 12:00 PM feedings were not given. The nurse noted it was an unintentional omission. Review of the facility's Weight Management policy revealed weigh and obtain height on each resident within 24 hours of admission and re-admission. Weigh newly admitted residents: daily x 3 days, then weekly x 3 weeks, and then monthly and/or per physician's orders [REDACTED]. Review of Resident #3's Admission Documentation dated 4/19/18 revealed no documentation of the resident's admission weight. The resident was noted as having a feeding tube and no oral intake. There was a physician's orders [REDACTED]. Review of the resident's record revealed the following weights: 4/24/18 - 218.1# - noted as admission weight 5/8/18 - 211.5# 5/23/18 - 211.5# 5/29/18 - 213.5# 6/14/18 - 215.8# 6/19/18 - 215.8# In an interview with the surveyor on 6/27/18 at approximately 5:27 PM, the Director of Nursing stated that the first weight recorded for the resident was on 4/24/18, 5 days after admission. At 5:32 PM, the DON confirmed there were no weekly weights done as ordered.",2020-09-01
1795,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-07-11,711,F,1,0,D3N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure the physician reviewed the resident's total program of care and signed/dated all orders at each visit. The facility had a physician who was unable to access residents' electronic medical records. The physician was unable to sign orders and view information in the new electronic medical records since the facility changed Matrix system access on May 8, 2018. Three of three residents reviewed for physician services. Resident's #5, #6, and #7. The findings included: The surveyor reviewed the electronic medical records for Resident #5, #6, and #7 and noted the residents had physician orders [REDACTED]. Further review of the residents' medical records revealed there was no physician documentation in the Fundamental Matrix system used for the electronic medical record. The surveyor requested access to the facility's previous electronic medical record system, the PALM Matrix system. Review of Resident #5, #6, and #7's electronic medical records in the PALM Matrix system revealed physician documentation from May 2018, June 2018 and July 2018. The physician progress notes [REDACTED]. health related documents since the facility had changed new Matrix Care website. Interviews with the Administrator and Director of Nursing revealed the facility transitioned from the PALM Matrix system to the Fundamental Matrix system on May 8, 2018. In an interview with the surveyor on 7/10/18 at approximately 4:40 PM, the administrator and Director of Nursing (DON) asked to speak with the surveyor. They stated they have a physician that has been resistant to using the new system and is still documenting in the PALM Matrix system. The system changed from PALM to Fundamental on 5/8/18. The physician has been seeing patients every week and documenting the information in the PALM Matrix system. The administrator stated s/he has called and emailed the physician about using the Fundamental Matrix system. The physician works out of another facility owned by the same corporation and they have Fundamental matrix. The administrator stated their IT department says there is an option for the physician to choose facilities when s/he logs into the Matrix system. The administrator stated s/he did not realize the physician was not using the new system until s/he saw the progress notes dated 7/4/18 that were requested by the surveyor today. The administrator stated the physician uses the new user ID for the other facility, but will not use it for St. George. The physician has not signed orders since the Matrix system changed on 5/8/18. They did not know the physician was not signing orders until today when they saw the note for the residents from 7/4/18. The orders are in place and being administered, but are not signed off on by a physician. Both the DON and administrator were not sure if there was a system in place to flag orders that need to be signed by the physician in the electronic medical record. In an interview with the surveyor on 7/11/18 at approximately 10:25 AM, LPN (Licensed Practical Nurse) #1, the day shift supervisor, stated the physician comes in between 4:00 and 5:00 AM to do rounds on his/her residents. The physician told LPN #1 that the administrator knows s/he still does not have access to the Fundamental Matrix system to see medical records. The physician said not to worry about it, s/he would take care of it. Right after they changed the Matrix system from PALM to Fundamental, the physician started saying s/he couldn't get into the new system. The physician talked with LPN #1 about his/her residents and asked about any changes. LPN #1 stated the nurses enter the orders into the Matrix system and then the physician will go in and electronically sign the orders. LPN #1 stated when the new system was put in place the employees received new log-ins for the Fundamental Matrix system. A mobile DON and IT person from corporate were at the facility to help with the transition. They were at the facility about 1 to 2 weeks. LPN #1 stated s/he had a couple of times that s/he had problems logging in the new system when they first transitioned. That is one of the reasons the mobile DON and IT person were at the facility, they worked on the issues and they were resolved. In a telephone interview with the surveyor on 7/11/18 at approximately 10:55 AM, the physician stated s/he has not had access to the electronic medical record system since May. S/he called and talked with the facility administrator and also called the IT department. The IT department told the physician to call the facility and have the super user at the facility call them. They could not verify his/her identity, anyone could call and say they were him/her. The IT department told the physician the administrator would have to call about his/her log-in. The physician stated IT has his/her information, they just need to call him/her to set up an account. They also have his/her email address and could email the new access information. The physician stated s/he has been asking for access to the system and no one has given him/her a new username and password since the system changed in May. The physician stated s/he does not have a problem accessing records in sister facilities but cannot pull up electronic medical records for St. George. In an interview with the surveyor on 7/11/18 at approximately 11:20 AM, medical records staff stated the PALM and Fundamental Matrix systems are the same type of system. You have to use a different password and username to get into the new Fundamental Matrix system. The physician mentioned to him/her that s/he could not get into the new system because s/he did not have a new password. The physician said s/he had called the IT department to try and get access to the new system. S/he was told by IT that whoever at this facility that was in charge needed to be the one to do that. Anyone could call and say they were the physician. The physician does document in the old Matrix system. The physician will not sign care plan meeting sheets because s/he cannot see the care plan in the new system and cannot justify signing them. The medical records staff asked the physician about how s/he gets into the systems in sister facilities. The physician said they have not changed systems so s/he can still get in. In an interview with the surveyor on 7/11/18 at approximately 1:20 PM, the administrator stated s/he called the sister facility where the physician is based to make sure they were documenting in the Fundamental system. The administrator stated s/he got some mixed information from IT about the system. The other facility was supposed to change to the Fundamental system about the same time as St. George. They delayed the transition because they wanted one system fully implemented before doing another facility's system. The information that s/he was sending to the physician had the same username that IT told him/her. Come to find out they are using the PALM system, so the log-in information would not be the same. IT is now mailing him/her the new user name/password for the physician. The administrator stated s/he is not sure the physician was given the new URL for the database to get to the system log in. IT has been telling him/her the physician's username is the exact same as what s/he is using at the other facility. Legal found out today that the other facility might still be using the PALM system. The administrator stated medical records at the other facility stated they are still documenting in the PALMS Matrix system and have not converted to the Fundamental Matrix system. The administrator talked with the administrator and medical records staff at the other facility today. The administrator stated there was someone from IT who was at the facility to meet with each nurse and CNA individually to go over documenting when they transitioned from the PALMS system to the Fundamental system. They also trained medical records staff at that time. The physicians were not necessarily in the building when IT was here. The administrator stated there is a report that can be pulled to let them know if there are any unsigned physician orders. They have not been pulling the report.",2020-09-01
1796,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-07-11,835,F,1,0,D3N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to be administered in a manner that enabled it to use it resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. A physician was unable to access the new electronic medical record to view resident information and sign orders. The physician communicated to the facility that s/he was not able to access the new electronic medical record system. The facility failed to ensure the physician had access to medical records when the system was transitioned. One of one reviewed for administration. The findings included: The surveyor reviewed the medical records for Resident #5, #6, and #7 and noted the residents had physician orders [REDACTED]. Further review of the residents' medical records revealed there was no physician documentation in the Fundamental Matrix system used for the electronic medical record. The surveyor requested access to the facility's previous electronic medical record system, the PALM Matrix system. Review of Resident #5, #6, and #7's electronic medical records in the PALM Matrix system revealed physician documentation from May 2018, June 2018 and July 2018. The physician progress notes [REDACTED]. health related documents since the facility has changed new Matrix Care website. Interviews with the Administrator and Director of Nursing revealed the facility transitioned from the PALM Matrix system to the Fundamental Matrix system on May 8, 2018. Review of facility emails revealed the problem with the physician's log in was first sent to the IT department on 6/7/18 and they responded by email to the facility administrator on 6/8/18. The facility administrator did not respond to the physician until 6/21/18 regarding the information from IT. The next documented communication was a letter to the physician dated 7/6/18. In an interview with the surveyor on 7/10/18 at approximately 4:40 PM, the administrator and Director of Nursing (DON) asked to speak with the surveyor. They stated they have a physician that has been resistant to using the new system and is still documenting in the PALM Matrix system. The system changed from PALM to Fundamental on 5/8/18. The physician has been seeing patients every week and documenting the information in the PALM Matrix system. The administrator stated s/he has called and emailed the physician about using the Fundamental Matrix system. The physician works out of another facility owned by the same corporation and they have Fundamental matrix. The administrator stated their IT department says there is an option for the physician to choose facilities when s/he logs in to the Matrix system. The administrator stated s/he did not realize the physician was not using the new system until s/he saw the progress notes dated 7/4/18 that were requested by the surveyor today. The administrator stated the physician uses the new user ID for the other facility, but will not use it for St. George. The physician has not signed orders since the Matrix system changed. They did not know the physician was not signing orders until today when they saw the note for the residents from 7/4/18. The orders are in place and being administered, but are not signed off on by a physician. Both the current DON and administrator were not sure if there was a system in place to flag orders that need to be signed by the physician in the electronic medical record. In an interview with the surveyor on 7/11/18 at approximately 10:25 AM, LPN (Licensed Practical Nurse) #1, the day shift supervisor, stated the physician comes in between 4:00 and 5:00 AM to do rounds on his/her residents. The physician had told LPN #1 that the administrator knows s/he still does not have access to the Fundamental Matrix system to see medical records. They said not to worry about it, s/he would take care of it. Right after they changed the Matrix system from PALM to Fundamental, the physician started saying s/he couldn't get into the new system. The physician talked with LPN #1 about his/her residents and asked about any changes. LPN #1 stated the nurses enter the orders into the Matrix system and then the physician will go in and electronically sign the orders. LPN #1 stated when the new system was put in place the employees received new log-ins for the Fundamental Matrix system. A mobile DON and IT person from corporate were at the facility to help with the transition. They were at the facility about 1 to 2 weeks. LPN #1 stated s/he cannot log into the old PALM Matrix system. When they transitioned to the new system, it was supposed to be where they could log in to look at the old system. Certain people were supposed to have access so they could view the medical records. LPN #1 stated s/he had a couple of times that s/he had problems logging in when the new system when they first transitioned. That is one of the reasons the mobile DON and IT person were at the facility, they worked on the issues and they were resolved. In a telephone interview with the surveyor on 7/11/18 at approximately 10:55 AM, the physician stated s/he has not had access to the electronic medical record system since May. S/he called and talked with the facility administrator and also called the IT department. The IT told the physician to call the facility and have the super user at the facility call them. They could not verify his/her identity, anyone could call and say they were him/her. The IT department told the physician the administrator would have to call about his/her log-in. The physician stated IT has his/her information, they just need to call him/her to set up an account. They also have his/her email address and could email the new access information. The physician stated s/he has been asking for access to the system and no one has given him/her a new username and password since the system changed in May. The physician stated s/he does not have a problem accessing records in sister facilities but cannot pull up electronic medical records for St. George. In an interview with the surveyor on 7/11/18 at approximately 11:20 AM, medical records staff stated the PALM and Fundamental Matrix systems are the same system. You have to use a different password and username to get into the new Fundamental Matrix system. The physician mentioned to him/her that s/he could not get into the new system because s/he did not have a new password. The physician said s/he had called the IT department to try and get access to the new system. S/he was told by IT that whoever at this facility that was in charge needed to be the one to do that. Anyone could call and say they were the physician. The physician does document in the old Matrix system. The physician will not sign care plan meeting sheets because s/he cannot see the care plan in the new system and cannot justify signing them. The medical records staff asked the physician about how s/he gets into the systems in other sister facilities. The physician said they have not changed systems so s/he can still get in. In an interview with the surveyor on 7/11/18 at approximately 1:20 PM, the administrator stated s/he call the sister facility where they physician is based to make sure they were documenting in the Fundamental system. The administrator stated s/he got some mixed information from IT about the system. The other facility was supposed to change to the Fundamental system about the same time as St. George. They delayed the transition because they wanted one system fully implemented before doing another facility's system. The information that s/he was sending to the physician had the same username that IT told him/her. Come to find out they are using the PALM system, so the log-in information would not be the same. IT is now mailing him/her the new user name/password for the physician. The administrator stated s/he is not sure the physician was given the new URL for the database to get to the system log in. IT has been telling him/her the physician's username is the exact same as what s/he is using at the other facility. Legal found out today that the other facility might still be using the PALM system. The administrator stated medical records at the other facility stated they are still documenting in the PALMS Matrix system and have not converted to the Fundamental Matrix system. The administrator talked with the administrator and medical records staff at the other facility today. The administrator stated there was someone from IT who was at the facility to meet with each nurse and CNA individually to go over documenting. They also trained medical records staff at that time. The physicians were not necessarily in the building when IT was here. The administrator stated there is a report that can be pulled to let them know if there are any unsigned physician orders. They have not been pulling the report.",2020-09-01
1797,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-07-11,842,F,1,0,D3N711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to maintain medical records on each resident that are complete, accurately documented, and readily accessible. Residents #1, #2, and #3 were noted to have documentation errors related to medication administration. The facility changed computer systems on 5/8/18 and were unable to provide documentation from the old system to provide the surveyor with information related to the residents' condition. Facility medical records were not accessible by physician for Resident's #5, #6, and #7. Six of six residents reviewed for medical records. The findings included: Review of Resident #1's electronic medical record revealed there was information related to the resident's care that could not be located. Resident #1 was admitted to the facility on [DATE] with an order to receive Ensure three times daily via feeding tube. The facility was not able to provide the resident's Nursing Admission Assessment. The facility was able to provide a copy of the resident's admission tube feeding order which was in place 5/8/18-5/11/18. The facility was unable to provide documentation that showed where the tube feeding was administered to the resident. The surveyor reviewed the resident's May Medication Administration Record and the tube feeding order for Ensure was not listed. Reviewed May and June 2018 MAR and note multiple entries with late administration. There were more than 50 entries in May 2018 and more than 50 entries in June 2018 that were flagged as late administration per the computer system. In an interview with the surveyor on 6/27/18 at approximately 6:25 PM, DON (Director of Nursing) stated the computer system was changed with a go live date of 5/8/18. The DON stated there is a report that can be viewed that will show the late administrations. S/he does not review the report daily, but she has looked at the report. Review of Resident #2's electronic medical record revealed more than 50 entries in May 2018 and more than 50 entries in June 2018 that were flagged as late administration per the computer system. Review of Resident #3's electronic medical record revealed more than 50 entries in May 2018 and more than 50 entries in June 2018 that were flagged as late administration per the computer system. Review of the facility's Medication Management Program revealed medications are to be administered 1 hour before or 1 hour after the designated medication pass time. The steps for administering the medication pass included the licensed staff member documents that the medication is given in the correct slot of the MAR, before going to the next resident. During the survey the surveyor requested multiple documents that could not be found in the residents' electronic medical records. The facility was able to provide some of the documentation by contacting their corporate office, which has access to the facility's previous electronic medical record system. The facility was unable to provide some of the requested information. The administrator, DON, and unit manager all stated that they did not have access to the facility's previous electronic medical record system that was replaced with a new electronic system on 5/8/18. The surveyor reviewed the medical records for Resident #5, #6, and #7 and noted the residents had physician orders [REDACTED]. Further review of the residents' medical records revealed there was no physician documentation in the Fundamental Matrix system used for the electronic medical record. The surveyor requested access to the facility's previous electronic medical record system, the PALM Matrix system. Review of Resident #5, #6, and #7's electronic medical records in the PALM Matrix system revealed physician documentation from May 2018, June 2018 and July 2018. The physician progress notes [REDACTED]. health related documents since the facility has changed new MatrixCare website.",2020-09-01
1798,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,156,B,1,1,EIV311,"> Based on record review and interviews, the facility failed to follow guidelines for issuance of the Center for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (CMS -NOMNC) to Resident #4. Timely notice was not given to 1 of 3 residents reviewed for Liability Notices. The findings include: Record review on 07/13/17 at 3:46 pm revealed that the facility provided less than the required two day notice to Resident #4 for the Notice of Medicare Non-coverage. Further review of the file revealed that Resident #4's benefit period was due to end on 01/25/17. The notice provided by the facility was dated 01/24/17. In an interview on 07/13/17 at 4:11 pm the Social Worker stated that the notice should have been done on 01/23/17 to meet the two day requirement.",2020-09-01
1799,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,167,B,1,1,EIV311,"> Based on observation and interview the facility failed to post signage indicating the location of past survey results and making them readily accessible to both residents and visitors. The findings included: On 07/14/2017 11:42 AM this surveyor along with the Administrator observed placement of the facility's mandatory posting of contact information for state regulatory agencies, the Ombudsman and other advocacy groups. In an interview on 07/14/17 at 11:42 AM the Administrator confirmed that the board contained out-of-date and repetitive information. The Administrator stated that a resident would need to ask for assistance to select the proper contact information. Further observation revealed the facility's past survey results to be placed in a notebook in a mail bin on the left wall of the entrance hall to the dining room. In an interview on 07/14/17 at 11:42 AM, the Administrator was asked, how would a person entering the front door of the facility know where to find the survey results without asking for assistance. The Administrator stated there should be a sign to tell them.",2020-09-01
1800,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,244,E,1,1,EIV311,"> Based on record review and interview the facility failed to act upon grievances and requests submitted by the Resident Council. The findings included: Record review on 07/13/17 at 1:31 PM revealed that during Resident Council meetings from January through June of 2017, the council made repeated requests for specific activities, meal changes and outings. Requests included, starting vegetable and flower gardens, trips to Walmart and for fresh fruits and vegetables to be served at meal times. Review of the June 27, 2017 minutes indicated that after requests for fresh fruit and vegetables at both the April 18, 2017 and May 23, 2017 meetings. The June 27, 2017 minutes revealed that the Dietary Manager had attended and presented a Summer Menu that would be served for 5 weeks and included the requested items. In an interview with the Resident Council President, it was revealed that when the council brings up items to the facility nothing happens. It was stated that the reason given to the council for not carrying out requests is they only have so much money or they do the best they can. In an interview on 0713/17 at 3:34 PM the Activities Director stated that when concerns are raised in the Resident Council meetings the information is reported to the department head in the morning meetings. The Activities Director stated the requests are not logged and there is not follow up system to track whether the concerns are addressed. In an interview on 07/13/17 at 3:13 PM, the Dietary Manager stated the Summer Menu was not scheduled for implementation as the items had not been ordered from the food supplier. The Dietary Manager stated there was no target date for the menu to be implemented. The Dietary Manager did acknowledge that fresh fruits and vegetables could be obtained locally.",2020-09-01
1801,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,274,D,1,1,EIV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to conduct a significant change for Resident #44 who had a decline in activities of daily living.(1 of 3 residents reviewed for activities of daily living) The findings included: The facility admitted Resident #44 with [DIAGNOSES REDACTED]. Record review on 7/13/17 of the Annual Minimum Data Set((MDS) dated [DATE] revealed Resident #44 was coded for limited assist/one person physical assistance in the areas of bed mobility, transfer and walking in room; supervision/one person physical assist in the area of walking in corridor and supervision/setup help only in the areas of locomotion on and off the unit and eating. Resident #44 had no functional limitation in range of motion. Resident #44 fell on [DATE] and sustained a fracture. A quarterly MDS dated [DATE] revealed Resident #44 was coded for extensive assistance/one person physical assist in the areas of bed mobility and eating; extensive assistance/two person physical assist in the areas of transfer, locomotion on/off unit; walk in room/corridor did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period. Lower extremity on one side was documented as having function limitation in range of motion. Review of the two assessments revealed Resident #44 had a decline in two or more areas. During an interview with the Interim MDS Consultant on 7/14/17, he/she stated a significant change assessment should have been completed on the resident due to the changes. Review of the Resident Assessment Instrument Version 3.0 Manual states a significant change is a decline or improvement in a resident's status that impacts more than one area of the resident's health status.",2020-09-01
1802,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,276,B,1,1,EIV311,"> Based on record review and interview, the facility failed to submit a Minimum Data Set (MDS) OBRA quarterly assessment in a timely manner for 4 of 4 residents reviewed for MDS transmission of records. (Residents #96, #80, #69, and #12) The findings included: Review of the facility's MDS 3.0 Missing OBRA Assessment report revealed Resident's #96, #80, #69, and #12 were listed on the report. During an interview on 7/14/17 at approximately 9:45 AM, the facility's Regional MDS Coordinator reviewed the report. The MDS Coordinator later provided a report indicating the missing quarterly assessments had been submitted. The MDS Coordinator confirmed that the quarterly assessments were not submitted within the required timeframe.",2020-09-01
1803,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,280,E,1,1,EIV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to ensure that a Certified Nurse Aide (CNA), physician, and other required members of the Interdisciplinary Team developed the care plans for 14 of 18 residents reviewed for care plans. (Residents #44, #43, #5, #46, #96, #65, #53, #94, #24, #32, #91, #17, #79, and #104) The findings included: The facility admitted Resident #24 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Care Plan Conference Summary sheet dated 2/15/17 included a space for signatures of staff attending the care plan meeting. Further review of the form revealed no signature of a CNA or physician to indicate they participated in the Interdisciplinary Team that developed the care plan. Review of the Care Plan Conference Summary sheet dated 5/15/17 revealed no member of the dietary staff signed the form to indicate participation on the Interdisciplinary Team. During an interview on 7/14/17 at approximately 9:45 AM, the facility's Regional MDS Coordinator reviewed the above attendance forms for Resident #24 and confirmed these findings. The facility admitted Resident #32 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Care Plan Conference Summary sheet dated 5/2/17 indicated the Director of Nursing and Social Worker were the only staff members who signed the attendance sheet to indicate participation in the Interdisciplinary Team. Review of the Care Plan Conference Summary sheet dated 6/28/17 revealed no signature of a CNA or physician to indicate participation in the Interdisciplinary Team. During an interview on Interview on 7/14/17 at approximately 9:45 AM, the facility's Regional MDS Coordinator reviewed the above attendance forms for Resident #32 and confirmed these findings. The facility admitted Resident #53 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Care Plan Conference Summary sheet dated 2/15/17 indicated no CNA or physician signature to indicate they participated in the Interdisciplinary Team that developed the care plan. Review of the Care Plan Conference Summary sheet dated 5/8/17 indicated the Social Worker was the only staff member that signed the attendance sheet to indicate participation in the Interdisciplinary Team. During an interview on Interview on 7/14/17 at approximately 9:45 AM, the facility's Regional MDS Coordinator reviewed the above attendance forms for Resident #53 and confirmed these findings. The facility admitted Resident #44 with [DIAGNOSES REDACTED]. Review of the Care Plan Summary Sheets on 7/13/17 revealed the 2/15/17 Care Plan Conference did not include participation in the planning process of the Certified Nursing Assistant or the Physician. The facility admitted Resident #65 with [DIAGNOSES REDACTED]. Review on 7/12/2017 at approximately 9:42 AM of the form titled, Care Plan Conference Summary, dated 2/22/2017 revealed no participation in the care planning process by the Certified Nursing Assistant (CNA) or the Registered Nurse (RN) involved in the care for Resident #65 nor the Certified Dietary Manager (CDM) or the Physician. The facility admitted Resident #104 wish [DIAGNOSES REDACTED]. Review on 7/12/2017 at approximately 4:04 PM of the form titled, Care Plan Conference Summary, dated 2/8/2017 revealed no participation in the care planning process by the CNA and RN involved in the care for Resident #104. According to the signatures on the form the CDM nor the Physician had input into the care planning process for Resident #104. The facility admitted Resident #96 with [DIAGNOSES REDACTED]. Review on 7/13/2017 at approximately 3:01 PM of the medical record for Resident #96 revealed a form titled, Care Plan Conference Summary, dated 2/22/2017 contained no documentation of the participation in the care planning process for Resident #96 by the CNA nor the RN involved in the care for this resident nor the Physician. Further review of the, Care Plan Conference Summary, sheets for Resident #96 revealed a summary sheet dated 5/25/2017 and indicated that the RN involved in the care for this resident and the Physician were not involved in the care planning process for Resident #96. The facility admitted Resident #94 with [DIAGNOSES REDACTED]. Review on 7/13/2017 at approximately 4:09 PM of the form titled, Care Plan Conference Summary, dated 2/8/2017 revealed that the CNA nor the RN involved in the care for Resident #94 had any input into the care planning process for Resident #94. Further review of the form revealed that he CDM and Physician also had not had any input into the care planning for Resident #94. The facility admitted Resident #79 with [DIAGNOSES REDACTED]. Review on 7/13/2017 at approximately 4:52 PM of the medical record for Resident #79 revealed a form titled, Care Plan Conference Summary, dated 3/22/2017 revealed that the CNA and the RN involved in Resident #79's had not been involved in the care planning process for Resident #79. Further review of the form dated 3/22/2017 revealed no participation in the care planning process for this resident by the CDM or the Physician. Addition review on 7//13/2017 at approximately 5:00 PM of the medical record for Resident #79 revealed yet another form titled, Care Plan Conference Summary, dated 6/21/2017 and contained no input into the care planning process for Resident #79 by the RN involved in his/her care. The facility admitted Resident #91 with [DIAGNOSES REDACTED]. Review on 7/14/2017 at approximately 11:09 AM of the medical record for Resident #91 revealed a form titled, Care Plan Conference Summary, dated 6/28/2017 and indicated that the RN involved in the care for Resident #91 had not attended the care plan conference and had no input into planning the care for Resident #91. Further review of the form revealed no input from the Physician for planning the care for Resident #91. Resident #46 was admitted with [DIAGNOSES REDACTED]. Record review on 7/12/17 at 9:26 AM revealed the Care Plan Conference Summary dated 4/27/17 has no signatures or evidence of participation by the Certified Nurse Assistant (CNA), the Physician and the Dietitian/and or Certified Dietary Manager. Resident #43 was admitted with [DIAGNOSES REDACTED]. Record review on 7/13/2017 at 2:34 PM revealed the Care Plan Conference Summary dated 6/7/2017 has no signature or evidence of participation by the Physician. Resident #22 was admitted with [DIAGNOSES REDACTED]. Record Review on 7/14/2017 revealed the Care Plan Conference Summary dated 6/14/17 has no signature or evidence of participation by the Physician. Resident #86 was admitted with [DIAGNOSES REDACTED]. Record review on 7/14/2017 at 11:51 AM revealed no signature or evidence of participation by the Physician. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review on 07/14/17 at 1:37 PM revealed that the Care Plan signature sheets dated 02/22/17 and 05/24/17 did not include signatures verifying attendance by a Certified Nursing Assistant(CNA) and/or a Physician. The signature sheet from the 05/24/17 Care Plan conference also did not include a signature to verify attendance of the Dietary Manager. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review on 07/12/17 at 1:43 PM revealed that the Care Plan signature sheets dated 03/01/17 and 06/07/17 did not include signatures verifying attendance by a a CNA and or Physician.",2020-09-01
1804,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,314,D,1,1,EIV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility policy, the facility failed to ensure Pressure ulcers were assessed on admission and and staged by a Registered Nurse for Resident #44 for 1 of 3 residents reviewed for Pressure Ulcers. The findings included: The facility admitted Resident #44 with [DIAGNOSES REDACTED]. Record review on 7/12/17 of the Wound Treatment & Progress Record revealed Resident #44 developed a suspected deep tissue injury of the right heel. On 5/16/17, the resident's wound was classified as unstageable due to thick eschar. Further review of the weekly measurements and staging from 5/3/17-7/11/17 revealed the Licensed Practical Nurse signed for the staging. Review of the back of the Wound Treatment & Progress Record revealed a Registered Nurse signed one time. During an interview in 7/12/17 with the Nurse Consultant, he/she stated the Director of Nursing(DON) went with the nurse weekly and staged the resident's wound and signs on the back of the form. Review of the weekly staging and measuring forms revealed there was no documented evidence the DON staged the wounds weekly.",2020-09-01
1805,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,323,D,1,1,EIV311,"> Based on observations, interviews and review of the facility policy titled, Maintenance/Housekeeping Policies and Procedures - General Cleaning, the facility failed to ensure chemicals were stored securely in a janitor's closet on the 100 Hall, and further failed to ensure throat lozenges and denture tablets were stored and out of reach for potential wandering residents on 1 of 2 units. The finding included: An observation during the initial tour on 7/10/2017 at approximately 10:40 AM of the 100 Hall revealed an unlocked Housekeeping Closet with unsecured chemicals. Further observation on 7/10/2017 at approximately 10:40 AM revealed tissue paper stuck into the opening where the latch would lock the door once closed. The door would not completely close due to the tissue paper in the opening. An interview on 7/10/2017 at approximately 10:45 AM with a Laundry Worker and the Maintenance Technician confirmed the door was unlocked and the closet contained unsecured chemicals. The laundry worker removed the tissue paper from the latch opening and stated the closet is usually locked. The maintenance technician, verified the closet was not locked and also stated it is usually locked and went on to confirm that housekeeping staff had access to a key to unlock the closet if needed. Review on 7/13/2017 at approximately 2:08 PM of the facility policy titled, Maintenance/Housekeeping Policies and Procedures - General Cleaning, under Procedure Description states, This is a routine procedure that is used to maintain our janitor's closets in a clean, neat, orderly and secure manner. Under Procedure number 7. states, Doors should be kept locked at all times when not in use. During room rounds on 7/10/17 at approximately 3:20 PM, the following were observed: Room 202A- (1) box of Menthol Lozenges and (1) box of denture tablets; Room 205 restroom- Polident Denture tablets located on the sink. Each item had a warning to keep out of reach of children. Mobile, cognitively impaired residents were observed on the hall where the items were observed. The Director of Nursing was notified of the above findings on 7/10/17. The facility provided a handout of Important Reminders which indicated items that were strictly prohibited such as medications from outside the facility.",2020-09-01
1806,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,329,E,1,1,EIV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to implement non-pharmacological interventions prior to administering a [MEDICAL CONDITION] medication for Resident #14.(1 of 5 reviewed for unnecessary medications) The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review on 7/14/17 of the physician orders [REDACTED]. Further record of the Medication Administration Record and the Nurse's Notes review revealed Resident #14 received [MEDICATION NAME] on the following dates without non-pharmacological interventions attempted prior to the administration of the medication: 4/25/17, 4/27/17, 5/2/17, 5/4-7/2017, 5/9-10/17, 5/15/17, 5/19/17, 5/22-24/17, 5/27-28/17, 5/31/17, 6/3-10/17, 6/13-15/17, 6/17-18/17, 6/21-26/17, 6/30/17, 7/1-2/17, 7/4/17, 7/6-11/17. During the review of the administration of the [MEDICATION NAME], on 5/8/17, 5/26/17, 6/3/17, 6/4/17 and 7/11/17, documentation [MEDICATION NAME] was given was noted in the nurse's notes but not documented on the Medication Administration Record. During an interview with the Director of Nursing on 7/14/17, he/she stated the expectation of the staff would be to attempt non-pharmacological interventions prior to administering the [MEDICATION NAME]. No facility policy related to administering as needed [MEDICAL CONDITION] medications and attempting non-pharmacological interventions was provided during the survey process.",2020-09-01
1807,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,354,F,1,1,EIV311,"> Based on record reviews, interviews and review of the facility policy titled, Human Resources Planning - Staffing, the facility failed to ensure the Director of Nursing (DON) served as a charge nurse only when the facility had an average occupancy of 60 or fewer residents for 30 of 100 days reviewed for staffing on 2 of 2 units. The findings included: Review on 7/14/2017 at approximately 4:37 AM of the staffing for Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs) from 4/1/2017 through 7/9/2017 revealed the DON as the charge nurse/supervisor on 29 of 100 days. The days documented that the DON was charge nurse/supervisor are as follows: April 6, 2017, 4/7/2017, 4/10/2017, 4/11/2017, 4/12/2017, 4/14/2017, 4/15/2017 and 4/16/2017. The days in May 2017 include, 5/22/2017, 5/23/2017, 5/24/2017, 5/25/2017, 5/26/2017, 5/30/2017 and 5/31/2017. The days documented in June 2017 for the DON as charge nurse/supervisor are 6/1/2017, 6/2/2017, 6/9/2017, 6/12/2017, 6/13/2017, 6/16/2017, 6/23/2017, 6/26/2017, 6/27/2017, 6/29/2017 and 6/30/2017. The dates for July 2017 that the DON served as charge nurse/supervisor included, 7/3/2017, 7/5/2017, 7/6/2017, 7/7/2017. Further review of the staffing from 4/1/2017 through 7/9/2017 revealed the MDS (Minimum Data Set) assessment consultant as charge nurse/supervisor on 6/5/2017, 6/6/2017, 6/7/2017 and 6/8/2017. Further review on 7/14/2017 at approximately 9:00 AM of the form 671 titled Long Term Care Facility Application for Medicare and Medicaid, filled out by the facility, section F29 is coded with an, NA, to indicate the facility does not have a nurse waiver. During an interview on 7/14/2017 at approximately 9:00 AM with the Director of Nursing (DON) confirmed that he/she was the only RN in the building on the days listed and the weekends and served as charge nurse/supervisor on those days. An interview on 7/14/2017 at approximately 9:20 AM with the CNA scheduler confirmed that the DON had served as charge nurse/supervisor on the above mentioned dates. During an interview on 7/14/2017 at approximately 3:00 PM with the MDS consultant, he/she stated, I come in and help out with the MDS but I have not been the charge nurse/supervisor for the halls. Review on 7/14/2017 at approximately 3:15 PM of a list of RNs employed by the facility which included 3 and 2 of those are prn (as needed) and the third is a weekend supervisor only. No other RNs were listed except the DON. Review on 7/14/2017 at approximately 3:30 PM of the facility policy titled, Human Resources Planning - Staffing, under Procedures, A1 states, Care needs are consistent with patient/resident needs, provides sufficient numbers of licensed nurses and other nursing staff (RN's, LPNs/LVNs, Nurse Aides) on a 24-hour basis. And 2A states under, Nursing: #2.Designates a RN to serve as a full-time director of nursing, who may serve as charge nurse only when the facility has an average daily occupancy of 60 or fewer patients/residents.",2020-09-01
1808,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,371,F,1,1,EIV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of facility policy and procedures the facility failed to ensure: Out of date lettuce and cheese discarded when expired, safe food service distribution of food for a [MEDICAL TREATMENT] resident, adequate supply of food for emergency/disaster, dishmachine detergent in dishmachine during operation of dishmachine for appropriate washing and sanitizing of dishware, food not handled with bare hands, that the foodservice staff are educated on safe food temperatures and correct temperature for thermometer calibration, and the staff is wearing beard restraints while working in the kitchen in 1 of 1 kitchen and 1 of 2 dining rooms. The findings include: During initial tour on 7/10/2017 at 10:45 AM, observed in the walk-in refrigeration unit, 2 plastic bags with iceberg lettuce with browning on lettuce leaves. One bag contained 4 heads of lettuce and the bag had been opened and a white label which stated Date Received 6/27. The second, unopened plastic bag contained 6 heads of lettuce which had label from the vendor with date of 6/27. The Certified Dietary Manager (CDM) said, We keep foods three days from the day we opened it and verified that both bags had exceeded the 3 day limit and h/she removed and discarded. On 7/12/2017 at 10:02 AM observed in the walk-in refrigeration unit, 1 partial bag of shredded cheddar cheese labeled 6/30. The CDM verified the date and no presence of expiration date and stated, the cheese is good for a month. Review of the NUTRITION POLICIES AND PROCEDURES, SUBJECT: General Food Storage Guidelines, Refrigerated Storage Guidelines, 12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use by date and refrigerated immediately. Mark them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Discard after three days unless otherwise indicated. On 7/10/2017 at approximately 11:00 AM an observation in the Dry Storage room, the Emergency Supply Shelf had 2 cases of canned soup. The CDM said, we will use all the food we have in coolers and storeroom if we have an emergency and further said that we don't have room for any other food. The CDM verified there was no emergency supply of canned puree for residents with Physician order [REDACTED]. An observation on 07/10/2017 at 12:50 PM, while on the 200 Unit, revealed a plastic Ziploc bag which contained a sandwich and a container of applesauce which was sitting on the Nurse's desk at room temperature. LPN #4 said, This is for the resident going to [MEDICAL TREATMENT] and will h/she will picked up by the transport unit at 1:00 PM. LPN#4 took the plastic Ziploc bag to Resident #44's room. 07/11/2017 at 9:40 AM an interview with the CDM regarding transportation of snacks and meals for [MEDICAL TREATMENT] patients. The CDM said, The food, sandwich and yogurt for example are placed in Ziploc bag. The Ziploc bag containing the food goes with the resident to the [MEDICAL TREATMENT] center and then the [MEDICAL TREATMENT] center puts the food in the Ziploc container in the refrigerator at the [MEDICAL TREATMENT] center. The CDM said the food is transported with the resident to the [MEDICAL TREATMENT] center in the Ziploc bag and stated did not have insulated bags/cold packs to transport the food with the residents going to the [MEDICAL TREATMENT] centers. Review of the NUTRITION POLICIES AND PROCEDURES, SUBJECT: SAFE FOOD HANDLING,POLICY:Food acquisition, storage, and distribution will comply accepted food handling practices. Proper food handling is essential in preventing foodborne illness. PROCEDURES: Food/Beverages Prepared and Served by Facility Staff for Patients/Residents: 4. All foods are stored, prepared, and served at temperatures that prevent bacterial growth .cold foods are maintained at 40 degrees F (Fahrenheit) or below at point of service. At point of delivery, .cold foods 41-45 degrees F or per state regulations. On 07/12/17 at 4:45 PM during an observation of the high temperature dishmachince operation revealed that there was no dishmachine soap in dispenser during the operation of the dishmachine, the soap dispenser held an empty canister labeled Solid Power XL, 9 LB and was verified with Dishroom Staff #1. When he/she was questioned on when the canister needs to be replenished, h/she said when it is out of soap, the dishmachine makes a beeping noise and said that h/she checked this morning and there was soap in the dispenser. The NUTRITION POLICIES AND PROCEDURES, SUBJECT: WAREWASHING USING DISHWASHING MACHINE, POLICY: Utensils and dishes washed by a mechanical dishwasher will be clean and sanitized. Under Procedures: handwritten on the form, Check soap dispenser if low replace. On 7/12/17 at approximately 4:35 PM during food temperature checks for the dinner line, the foodservice staff and the CDM were unable to accurately answer questions about the correct temperature for thermometer calibration, safe hot food held on the steamtable and safe cold food temperatures. On 07/13/2017 at 10:21 AM verified with CDM that the foodservice staff were unable to accurately answer questions about safe food temperatures. H/She then showed the July Food Temperature Log and stated that h/she tells the foodservice staff temperatures should be greater than 165 so they will get the food cooked to the correct temperature. Review of the NUTRITION POLICIES AND PROCEDURES, SUBJECT: SAFE FOOD HANDLING,POLICY:Food acquisition, storage, and distribution will comply accepted food handling practices. Proper food handling is essential in preventing foodborne illness. PROCEDURES: Food/Beverages Prepared and Served by Facility Staff for Patients/Residents: 4. All foods are stored, prepared, and served at temperatures that prevent bacterial growth .cold foods are maintained at 40 degrees F (Fahrenheit) or below at point of service. At point of delivery, .cold foods 41-45 degrees F or per state regulations. On 7/13/2017, the Registered Dietitian Consultant provided a 30 minute inservice for the foodservice staff on the following topics: Cooking and Holding Food Temperatures, Thermometer Calibration and Dishmachine procedures. On 07/14/20 at 1:44 PM Observed Dishroom staff #2 working in dishroom and handling dishes with no beard protector on. When Dishroom Staff #2 was asked, Are you supposed to have a beard protector on? H/She stated: Oh yes, then and then left the dishroom, obtained a beard protector and put it on, covering the beard on his face. The NUTRITION POLICIES AND PROCEDURES, SUBJECT: SAFE FOOD HANDLING,POLICY: PROCEDURES: General statements: 8. Anyone working in the kitchen during normal food production hours is expected to wear hair restraints (such as hats, hair covers or nets, beard restraints). The NUTRITION POLICIES AND PROCEDURES, SUBJECT: DRESS CODE, POLICY: The Nutrition/Culinary Services Department employees will adhere to a facility dress code that facilitates safe, sanitary meal production and service, and will present a professional appearance. PROCEDURES: Culinary staff involved in food production adheres to the department dress code that includes: 6. Appropriate hair restraints (such as hats, hair covers or nets, beard restraints) while involved in food production activities. An observation on 7/10/2017 at approximately 12:50 PM, during the lunch service on the 200 Hall, revealed Certified Nursing Assistant (CNA) #1 reaching into a plastic wrapper from a resident's meal tray, and removing a slice of bread using his/her bare hands. During an interview on 7/13/2017 at approximately 1:40 PM CNA #1 confirmed that he/she had touched a resident's bread, during the lunch meal service on 7/10/2017, with his/her bare hands. Review on 7/14/2017 at approximately 9:00 PM of the facility policy titled, Meal Delivery, under Procedure, #17 states, When serving the meal, tell the patient/resident what is being served, open and unwrap food items, butter bread, cut meat and add seasoning if patient/resident desires or is unable to perform these tasks. Perform these tasks avoiding bare hand contact with the food.",2020-09-01
1809,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,431,E,1,1,EIV311,"> Based on observations, interviews and review of the facility policy titled, Storage and Expiration of Medications, Biological's, Syringes and Needles, the facility failed to ensure opened sterile dressings and expired medications and biological's were stored on 2 of 2 treatment carts. The facility further failed to ensure expired medications were removed from 1 of 4 medication carts and not stored with other medications for resident use. The findings included: An observation on 7/13/2017 at approximately 9:30 AM of treatment care on the 200 Unit revealed an Alginate Wound Dressing that was opened and partially used. The package indicated the dressing was a sterile, 4 X 4 , Maxorb with Lot # and will expire on 11/2018. Further observation of the treatment carts contents on the 200 Unit revealed a the biological, Super-Sani Cloth Germicidal, 20 individual wrapped disposable pads had expired on 9/2016. During an interview on 7/13/2017 at approximately 9:30 AM with the Director of Nursing (DON) confirmed the findings and removed the items from the treatment cart on the 200 Unit. An observation on 7/13/2017 at approximately 9:45 AM of the 100 Hall treatment cart revealed, an 8 ounce bottle of Hibiclens (Chlorhexidine Gluconate Solution 4.0% with Lot #HAOZ had expired on 2/2017 and 2 bottles of Curad Iodoform Packing Strip with Lot # , Mfg. Medline had expired on 3/2017. Further observation of the 100 Hall treatment cart on 7/13/2017 at approximately 9:45 AM revealed Carrasyn V Hydrogel Wound Dressing, 3 ounces with Lot # , Mfg. Medline had expired on 3/2017 and Lotrimin Antifungal Foot Powder with Lot #4M14FU had expired on 10/2016. A sterile dressing, Alginate Wound Dressing, Rope Maxorb with Lot # was partially used and left on the treatment cart to reuse. An interview on 7/13/2017 at approximately 10:00 AM with the DON, he/she confirmed the findings. An observation on on 7/13/2017 at approximately 11:41 AM of medication cart #1 on the 200 Unit revealed, 20 tablets of Allopurinol 100 mgs (milligrams) with Lot #C 16A had expired 3/2017. During an interview on 7/13/2017 at approximately 11:41 AM, Licensed Practical Nurse (LPN) #1 confirmed the findings and removed the medication from the medication cart. Review on 7/14/2017 at approximately 2:15 PM of the facility policy titled, Storage and Expiration of Medications, Biological's, Syringes and Needles, states under, Procedure: #4. Facility should ensure that medications and biological's: 4.1 Have an Expiration Date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines; or 4.3 Have not been contaminated, deteriorated, and stored separate from other medications until destroyed or returned to the pharmacy or supplier. Number 16 states, Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biological's in accordance with Pharmacy return/destruction guidelines and other Applicable Law, and in accordance with Policy 8.2 (Disposal /Destruction of Expired or Discontinued Medication).",2020-09-01
1810,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,441,E,1,1,EIV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to establish an effective Infection Control Program. Observation of the Laundry revealed there was close proximity of soiled to clean linen/personal clothing and during room observations, personal care equipment was observed uncovered or unlabeled in residents restrooms.(1 of 1 laundry observed and 1 of 2 units observed) The findings included: During room observations on 7/10/17 the following was observed: room [ROOM NUMBER]- uncovered bedpan in restroom; room [ROOM NUMBER]-uncovered bedpan, uncovered urine collection hat and an unlabeled/uncovered toothbrush in the restroom; room [ROOM NUMBER] -uncovered urine collection hat. On 7/12/17 at 2:27 PM, observation of the laundry revealed, during the sorting of the soiled linen, the barrel for the soiled linen was in very close proximity to the barrel for the clean linen. The barrels were within an approximate 2-3 inches of each other. During environmental rounds with the Administrator and Maintenance Director on 7/14/17 at 11:00 AM, only one partially covered bedpan was observed. The Administrator observed the Laundry area with the surveyor and the concern related to the close proximity of soiled to clean was explained. The Administrator at that time confirmed the finding of close proximity of soiled to clean during the sorting of the linen. On 7/14/17, the Maintenance Director was asked to take measurements in the laundry which are as follows: clean carts measured 32 1/2 inches x 20 1/4 inch and 37 1/2 inch by 27 1/4 inch. The cart for the soiled items measured 37 1/2 inch by 27 1/4 inch. The distance between the dryers to the washers was 105 1/4 inches. No policy was provided during the survey process related to proper storage of personal items.",2020-09-01
1811,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,507,D,1,1,EIV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the the facility policy titled, Laboratory Testing, the facility failed to ensure labs results were in the medical record for Resident #65 for the physician to view for 1 of 1 resident reviewed on [MEDICATION NAME] with pressure ulcers. The findings included: The facility admitted Resident #65, with [DIAGNOSES REDACTED]. Review on 7/12/2017 at approximately 9:42 AM of the medical record for Resident #65 revealed a physician order [REDACTED]. Further review on 7/12/2017 at approximately 9:48 AM of the lab results for Resident #65 revealed a PT/INR drawn on 2/6/2017 and 2/16/2017. No other results for the PT/INRs were found in the medical record. There should have been PT/INR results for 2/9/2017, 2/13/2017 and 2/20/2017. During an interview on 7/12/2017 at approximately 5:45 PM, the Registered Nurse (RN) Consultant verified the findings and called the lab and had the results faxed to the facility. The RN could not verify that the physician had viewed the results due to the fact they were not in the facility nor Resident #65's medical record. Review on 7/12/2017 at approximately 6:30 PM of the facility policy titled, Laboratory Testing, states, POLICY: To provide services that are accurate and timely, ensuring the utility of laboratory testing for diagnosis, treatment, prevention or assessment is maximized. Under, BLOOD TEST, #1. states, Should the attending physician order [REDACTED]. Critical STAT test results shall be reported to the physician as soon as the results are obtained. The section titled, LAB TEST RESULTS, states, #1. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility via fax or electronic reporting. #2. The attending physician shall be promptly notified of abnormal/stat test results. #4. Signed and dated reports of all diagnostic services shall be made a part of the resident's medical record.",2020-09-01
1812,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2017-07-14,514,D,1,1,EIV311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews the facility failed to ensure complete and accurate medical records for Resident #65 and Resident #104. Resident #65 had discrepancy in code status listed on physician orders [REDACTED]. Resident #104 has discrepancy in documentation related to urinary incontinence for 1 of 1 residents reviewed for urinary incontinence. The findings included: The facility admitted Resident #65, with [DIAGNOSES REDACTED]. Review on 7/12/2017 at approximately 9:42 AM of the medical record for Resident #65 revealed a code status election of DNR (Do Not Resuscitate) signed by Resident #65. Further on 7/12/2017 at approximately 9:45 AM of the physician orders [REDACTED].#65 was a Full Code status. The physician orders [REDACTED]. The facility admitted Resident #104 with [DIAGNOSES REDACTED]. Review on 7/12/2017 at approximately 4:04 PM of the medical record for Resident #104 revealed a care plan dated 5/15/2017 that states, Resident experiences occasional incontinence of bladder related to decreased mobility, [DIAGNOSES REDACTED]. No interventions were in place to improve any bladder incontinence. Further review on 7/12/2017 at approximately 4:05 PM of the medical record for Resident #104 revealed a MDS (Minimum Data Set) assessment dated [DATE] and Section H for Bowel and Bladder is coded a 1 for occasionally incontinent of bladder and 3 for always incontinent of bowels. Review of the quarterly MDS dated [DATE] has coded for Section H, Bowel and Bladder as frequently incontinent of bowel and bladder. No toileting programs were attempted even though Resident #104 has a BIMS (Brief Interview for Mental Status) of 15 out of 15 as indicated and coded on both MDS assessments. Review on 7/12/2017 at approximately 4:44 PM of the Bowel and Bladder admission assessment dated [DATE] has Resident #104 assessed as usually continent of bladder and frequently incontinent of bowel. Review on 7/12/2017 at approximately 4:50 PM of the nurses notes dated 1/25/2017 through 5/1/2017 has documentation daily which indicated Resident #104 is continent of bladder and uses a urinal independently. Review on 7/12/2017 at approximately 5:10 PM of the Certified Nursing Assistant (CNA) documentation indicated Resident #104 is frequently incontinent of bowel and bladder. During an interview on 7/12/2017 at approximately 5:30 PM with the Registered Nurse (RN) Consultant verified the findings.",2020-09-01
1813,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,550,D,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, and record and facility policy reviews, the facility failed to provide care in a manner that promoted the resident's dignity for resident (R) #283 (1 of 38 sampled residents). The findings included: Review of an undated Face Sheet found in the electronic medical record (EMR) revealed R283 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R283's only Minimum Data Set (MDS) assessment with an Assessment Reference Date, (ARD) dated 08/16/19, revealed the assessment was incomplete and included minimal information (name and admitted only). See F636. Review of an acute hospital discharge summary dated 08/14/19 revealed R283 was cognitively intact and could be reliably interviewed about his/her care. The resident was admitted to the facility to continue antibiotic therapy and wound care for a wound to the left lower extremity (LLE) that was surgically debrided in the hospital. Review of R283's admission physician's orders [REDACTED]. The resident was receiving Physical Therapy and Occupational Therapy for strengthening, therapeutic exercises, and ADLs. During an interview with R283 on 09/11/19 at 10:30 AM the resident voiced issues about the care s/he received. S/he was complimentary of the facility staff but described an incident with a named Certified Nurse Aide (CNA) 1 that occurred on the night shift on 09/09/19. R283 stated that at about 9:00 PM she let CNA1 know that she needed assistance with toileting, and she requested a bedpan. The CNA told the resident that there were no bedpans available, they (bedpans) were kept in the shed, and s/he could not access the shed. R283 said CNA1 called for assistance and another CNA came in to assist with positioning R283 for toileting. The resident said they rolled him/her from side to side and s/he expected to be on a bedpan, but the CNA reached between his/her legs and pulled up a diaper, and told the resident, you will just have to use this. The resident said, I can't - I need a bedpan. R283 said (named CNA) replied, if you need to go, you will have to go in the diaper. The resident relented because s/he was offered no other choice .but I was embarrassed and didn't like it, and I told them so. R283 said that s/he waited an hour for someone to come in and change his/her brief after s/he had soiled it, even after requesting that CNA 1 come right back because I have a wound and I don't want that on my skin. Staff interviews were conducted randomly on 09/11/19, regarding maintaining/accessing supplies for resident care. Two CNA's (CNAs 1 and 2) and three Licensed Practical Nurses (LPNs 1, 2 and 4) were interviewed. Each stated the staff have a small supply room on each hall that should be stocked with necessary supplies for resident care including cups, briefs, bedpans, etc. Additionally, there is a Central Supply room in the facility, and the nurse on each hall has a key to that room when it is locked at night and on weekends. The staff confirmed there is a shed with additional supplies, but no one had ever had to go to the shed to restock. LPN4 said she was aware the facility was out of the large cups they (residents) like on the night shift 09/09/19 but they had plenty of regular cups for residents .and there were bedpans available, if not on the floor, then in Central Supply .the keys are on med cart keys. In an interview with the Director of Nursing (DON) on 9/11/19 at 4:30 PM, s/he confirmed the information received from the other staff members. There is a supply room and it is accessible to staff if needed. When told about the incident reported by R283, the DON stated, that's not OK. In an interview with the Administrator on 09/12/19 at 9:10 AM, the Administrator confirmed that staff forcing a continent resident to wear an adult brief rather than assist with toileting was unacceptable and would be addressed promptly. When asked, the Administrator provided a copy of the facility's Patient/Resident Rights policy, revised 05/2015. The policy specified: The facility will ensure that the patient's/resident's personal dignity, well-being, and self-determination will be maintained .and will be recognized and supported by all Facility staff members at all times .The Facility must treat each resident with respect and dignity and care for each resident in a manner that promotes, maintains, or enhances his or her quality of life.",2020-09-01
1814,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,623,D,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide appropriate written Notice of Transfer to the resident and/or Resident Representative for Resident #64 (1 of 2 sampled residents reviewed for hospitalization ). The findings included: Record review on 09/12/19 at approximately 4:00 PM revealed the facility admitted Resident #64 with [DIAGNOSES REDACTED]. In a family interview on 09/11/19 at approximately 10:36 AM, Resident #64's relative reported the resident had been sent out to the hospital related to a fall. Further review of the electronic health record revealed Resident #64 was transferred to the hospital on [DATE]. In an interview on 09/13/19 at approximately 12:02 PM the Administrator confirmed that a transfer notice was not provided to the Resident Representative or to Resident #64.",2020-09-01
1815,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,625,D,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide appropriate written Notice of Bedhold to the resident and/or Resident Representative for Resident #64 (1 of 2 sampled residents reviewed for hospitalization ). The findings included: Record review on 09/12/19 at approximately 4:00 PM revealed the facility admitted Resident #64 with [DIAGNOSES REDACTED]. In a family interview on 09/11/19 at approximately 10:36 AM, Resident #64's relative reported s/he had been sent out to the hospital related to a fall. Further review of the electronic health record revealed Resident #64 was transferred to the hospital on [DATE]. The resident was not admitted and returned to the facility. In an interview on 09/13/19 at approximately 12:02 PM, the Administrator confirmed that a bed hold notice was not provided to the Resident Representative or to Resident #64.",2020-09-01
1816,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,636,E,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and facility policy reviews, and staff interviews the facility failed to provide federally mandated comprehensive resident assessments, Minimum Data Set (MDS) assessments, within required timeframes, to identify the resident's functional capacity and to assist with care planning for three of five residents reviewed for MDS accuracy and timeliness. (Residents (R) 283, 384 and 385). Additionally, the facility failed to ensure timely assessments completed in the absence of the MDS office staff. This had the potential to affect all 90 residents residing in the facility. The findings included: 1. Review of an undated Face Sheet found in the electronic medical record (EMR) revealed Resident (R) 283 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R283's only MDS assessment dated [DATE], revealed the assessment was incomplete and included minimal information (name and admitted ). There was no full admission assessment, nor was there a 14-day (required) assessment. The resident did have a nursing care plan dated 08/16/19. The Director of Nursing (DON) reviewed the issue concerning absent MDS information on 09/11/19 at 11:50 AM. S/he stated the full time MDS nurse, Registered Nurse (RN) 2, had been on bereavement leave for several weeks. The Administrator was present and joined the conversation to say, the facility had a new part time MDS RN3 and had tried to fill the void with 'mobile' (corporate) staff to help out. The DON verified R283 did not have a complete 14 day admission MDS. An interview conducted with both facility MDS RN's on 09/12/19 at 2:25 PM to locate any additional assessment information. RN2 and RN3 both stated, They were trying hard to get things caught up, but they had a long way to go. What's there (indicating the MDS data found in the electronic charting system) is what we have. Review of the facility's policy titled Nursing Policies and Procedures - Minimum Data Set (MDS) revised 7/1/2016, revealed, .Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, and preferences, and offer guidance for further assessments when problems are identified. The comprehensive assessments are completed initially and periodically .assessments require completion within the required timeframes according to applicable law and regulations .13. Facilities are required to complete a comprehensive assessment for each resident within 14-days of admission to the facility, when there is a significant change in the resident's status and not less than once within 366 days. 14. A quarterly review is completed no less than every three months between comprehensive assessments . In an interview with the Administrator on 09/12/19 at 8:15 AM the Administrator confirmed there had been a staffing issue in the MDS office, but that did not relieve the facility's responsibility to conduct timely and accurate resident assessments to identify resident's needs and assist with care planning. Resident #384 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 9/10/2019 at approximately 10:00 AM revealed the Quarterly MDS was conducted on 05/10/2019. Further review revealed no other MDS Assessments had been conducted as of 9/13/2019. Resident #385 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 9/10/2019 at approximately 4:30 PM revealed the Comprehensive Admission Assessment not been completed. Interview with the MDS Coordinator, RN #3, on 9/11/2019 at approximately 2:00 PM revealed he/she works at the facility part time and has a full-time job elsewhere. Further interview revealed the full time coordinator has been out of the office the past several months and the part time coordinator has been filling in as he/she could. Continued interview verified several MDS assessments were not completed within the specified time frames or were not completed at all. In an interview on 09/13/19 at approximately 2:34 PM the MDS nurse reviewed the Missing Assessments report for the facility and confirmed that the required assessments for Residents #384 and #385 had not been completed nor transmitted timely.",2020-09-01
1817,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,641,D,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, facility policy review, and staff interviews the facility failed to ensure Minimum Data Set (MDS) assessments (federally mandated assessments used to assist in care planning) were accurate and completed by qualified staff who are knowledgeable about the resident's status, needs, strengths, and areas of decline. This failure affected two of four residents reviewed for MDS accuracy. (Resident (R) 42 and 57). The findings included: Review of the facility's policy titled Minimum Data Set (MDS) revised 7/1/2016, revealed, assessments are completed within required timeframes according to applicable law and federal regulations .The facility is responsible for addressing all needs and strengths of each resident .each assessment must represent an accurate picture of the resident's status. 1. Review of an undated Face Sheet, found in the electronic medical record (EMR) revealed R42 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Hospice consultation order revealed R42 and his/her Power of Attorney (POA) had elected to initiate hospice services on 05/10/18. The resident was admitted to a (named) Hospice agency on 05/11/18. Review of R42's current physician's orders [REDACTED]. Review of R42's two most recent Quarterly MDS assessments dated 04/10/19 and 07/10/19 revealed the MDS assessments failed to capture R42's need for oxygen therapy and his/her hospice services. 2. Review of an undated Face Sheet, found in the EMR, revealed R57 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R57 had a behavior of wandering and was identified to be an elopement risk by the facility. After an attempt to leave the facility unsupervised R57 was placed on 1:1 supervision by the facility to ensure his/her safety. Continued record review revealed R57's care plan captured the wandering behavior and safety risk, but his/her most recent Quarterly MDS assessments dated 04/25/19 and 07/25/19 failed to capture that R57 had exhibited a behavior of wandering daily. This behavior was a primary reason the resident was admitted to the facility. S/he could no longer be adequately supervised in the Assisted Living Facility s/he resided in prior to his/her admission to this facility. An interview was conducted with both facility MDS Registered Nurses (RNs) on 09/12/19 at 2:25 PM in an attempt to locate any additional assessment information. RN2 and RN3 both stated, They were trying hard to get things caught up, but they had a long way to go. What's there (indicating the MDS data found in the electronic charting system) is what we have. In an interview with the Administrator on 09/12/19 at 8:15 AM, the Administrator confirmed there had been a staffing issue in the MDS office, but that did not relieve the facility's responsibility to conduct timely and accurate resident assessments to identify resident's needs and assist with care planning.",2020-09-01
1818,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,656,D,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure each resident received a person centered comprehensive care plan developed and implemented to meet his/her needs for 1 of 3 residents reviewed for position/mobility (Resident #384). The findings included: Resident #384 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of Resident #384 during the days of the survey revealed him/her lying in bed with his/her legs hanging out off of the bed. Observation on 09/11/19 11:43 AM revealed resident observed in bed with leg hanging out of bed; however, when Resident #384 was asked, he/she was not able to put legs back in bed him/herself. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 384 requires extensive assistance and one-person physical assist for bed mobility. Further review revealed Resident #384 requires extensive assistance and one-person physical assist for bed mobility. Review of the Care Plan updated 08/06/2019 revealed no plan of care to address assisting resident with positioning/bed mobility/transfers. Further review of the plan of care revealed turn and reposition resident frequently. Continued review of the MDS (Section M0150) and the Care plan (Pressure Ulcer) revealed Resident #384 is at risk for skin breakdown. Interview with Certified Nursing Assistant (CNA) #4 on 9-12-2019 at approximately 9:30 AM revealed information related to a residents care to include positioning was listed in the kiosk posted on the unit ([NAME]) hallway get up list. When CNA #4 was asked to demonstrate how this information was accessed at that time, review of the information in the kiosk revealed there was documentation related to a residents level of supervision and staff assistance, but there was no information in the kiosk related to when to turn/reposition residents. This was confirmed by CNA #4 at the time of discovery. Review on 9-13-2019 at approximately 2:00 PM of facility policy Wound Care Policies and Procedures revealed: Procedures- 1. Any turning/repositioning program includes a consistent plan for changing the resident's position and realigning the body.",2020-09-01
1819,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,661,D,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a discharge summary for one resident (Resident (R)233 of three residents selected for closed record reviews. The findings included: Review of an undated Face Sheet found in the electronic medical record (EMR) revealed R233 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Physician's (MD) Progress Note in the EMR revealed on 12/28/18 the MD was notified R233 had a decreased L[NAME] (Level of Consciousness). The MD examined the resident and ordered an emergent (EMS) transfer to the acute care hospital for further evaluation. Review of the Discharge Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) dated 12/28/18 indicated admission to the hospital with urosepsis [MEDICAL CONDITION]. The record was randomly selected for the closed record review portion of the survey. R233's EMR did not contain a discharge summary that recapitulated the resident's treatment and stay in the facility. On 09/13/19 at approximately 10:00 AM the Administrator was asked if the summary could be located elsewhere, and s/he stated s/he would look into it. At 10:30 AM on 09/13/19, the Administrator returned with a reply. S/he had spoken with the MD about the discharge summary and s/he told him/her it wasn't done because s/he expected the resident to return. The Administrator acknowledged the deficient practice.",2020-09-01
1820,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,684,D,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to follow accepted Standards of Practice as related to neurological checks and monitoring after a fall for Resident #64 (1 of 5 sampled residents reviewed for unnecessary medications). The findings included: The facility admitted Resident #64 with [DIAGNOSES REDACTED]. Record review on 09/12/19 at approximately 4:00 PM revealed a Nurses Note dated 06/06/19 which documented Resident #64 fell on buttocks and sustained a puncture wound to right side of head with minimal bleeding but stopped. Resident #64 was very talkative at that time. After speaking with Hospice and the Director of Nursing (DON) neurological checks were to be completed. Further review revealed a partially completed Neurological Evaluation Flow Sheet for the date of 06/06/19. A second incomplete neuro check flow sheet related to a fall on 07/27/19 was also contained in the electronic health record. The resident was noted with chronic decline with increased confusion and trying to walk. Review of the falls care plan interventions revealed the plan was revised in (MONTH) 2019 and updated again in 07/2019. In an an interview on 09/13/19 at approximately 12:12 PM the DON reviewed the neuro check flow sheets for 06/06/19 and 07/27/19 and confirmed they were not completed as would be expected and according to facility policy. Review of the facility policy entitled Neurological Checks revealed the following: 1. Neurological checks are performed following an actual or suspected head injury or change in level of consciousness per physician ordered frequency OR: [NAME] Initially, then B. Every 15 minutes for 1 hour, then C. Every 30 minutes for 2 hours, then D. Every 1 hour for 2 hours, then E. Every shift for 72 hours. Also, documentation is completed on the Neurological Evaluation Flow Sheet.",2020-09-01
1821,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,725,E,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record and facility policy reviews, the facility failed to provide sufficient nursing staff to ensure residents were cared for in a manner that attained or maintained the resident's highest practicable physical, mental and psychosocial well-being; and failed to ensure that nursing services were provided timely, and without excessive waits for care. This failure had the potential to affect all 90 of the residents residing in the facility at the time of the recertification survey. Additionally, the facility failed to adjust staffing assignments for acuity when one resident (R) 57) was determined to require one to one supervision to ensure his/her safety. The findings included: Review of the facility's policy titled Human Resources Planning: Staffing revised 11/1/17, revealed: The facility Leadership will provide a sufficient number of staff to successfully implement resident focused functions .2. The adequacy and competency of staff is determined by the facility's assessment of the resident population .includes resident's care needs .considering the number, acuity, and [DIAGNOSES REDACTED]. 1. During the initial pool screening portion of the recertification survey, resident interviews were conducted with residents that were determined to be cognitively intact and interviewable regarding their care. In separate interviews (and with different surveyors) Residents (R)31, R82, R84, and R57 each stated they felt the staff treated them well but there just weren't enough of them (staff). Each stated that on more than one occasion they had to wait for more than a reasonable amount of time for their call light to be answered or for personal care. 2. During the initial pool screening portion of the recertification survey, resident representatives (RR) of residents with cognitive deficits were interviewed regarding the care their family member received in the facility. In two of four family interviews conducted, (family members of R34 & R55) the RRs were complimentary of the staff and care; however, two of the resident representatives stated (in separate interviews) that they felt the facility was short staffed and that it seemed to be worse on the night shifts. When probed the RR's could not recall any specific incident or event related to insufficient staffing; but stated their family members had to wait for call lights to be answered or for care to be provided on different occasions. 3. Observation of and interview with resident Resident (R) 283 on 09/11/19 at 10:30 AM, revealed the resident had admitted to the facility for wound care and antibiotic therapy for a wound to her left calf. R283 was alert and oriented, was cognitively intact, and could be reliably interviewed about her care. R283 was largely independent in his/her ADLs (Activities of Daily Living) but did require two staff members and a mechanical lift for transfers. S/he was ambulatory by way of his/her wheelchair. When asked about the timeliness of his/her care, the resident was complimentary of both staff and the facility overall, but s/he did state there were times that they work short, and you have to wait to get changed, or get help to the bathroom, and sometimes you just can't wait as long as it takes. R283 did name a specific incident on 09/09/19 at 9:00 when the Certified Nurses Aid (CNA) 1 forced her to use an adult brief instead of using the bedpan or bedside commode. S/he stated, s/he told them (CNAs) over and over that s/he needed them to stay close so they could change him/her and get that off her skin. R283 stated s/he sat in the soiled brief and used the call light repetitively (without response) for over an hour before the CNAs returned to change him/her. 4. Review of an undated face sheet found in the record revealed R57 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R57 had a target behavior of wandering and was identified to be an elopement risk by the facility. After an attempt to leave the facility, by way of following staff and visitors out the door, to avoid setting off the door alarm, R57 was placed on 1:1 supervision by the facility. This meant that one staff member was assigned solely to R57 on a 24/7 basis. The staffing schedules were reviewed but there was no evidence of a specific staff member had been specifically assigned to R57 for constant supervision. Interviews were conducted with random staff members from different shifts, during the course of the four-day survey. The staff interviews included three CNAs (CNA 1, CNA 2, and CNA 3) and with four licensed nurses that routinely provide resident care (LPN 1, LPN 2, LPN 4, and Registered Nurse (RN) 1). Each of the staff members admitted they had worked short staffed. The staff members stated that it was not an everyday occurrence, and that it was usually the result of call-ins or increased resident acuity for one reason or another. The staff members also stated that the air conditioning (ac) in the halls and common areas had been broken for a couple of weeks and the heat was another hardship for the staff. (The resident rooms had separate units and were more comfortable than the hallways). In an interview with the Director of Nursing (DON) on 09/12/19 at 8:20 AM s/he stated that staff should be able to provide care timely and without excessive waits for call lights to be answered or care provided. S/he stated that call-ins or changes in acuity, such as having a resident that requires 1:1 care, do put an additional strain on the staff. When asked about assigning a specific staff member to R55 for 1:1 supervision, the DON stated s/he would look for the documentation of how that was provided. There was no 1:1 scheduling information provided. During an interview with the Administrator on 09/12/19 at 1:00 PM, the staff concerns about staffing ratios and the broken air conditioning (AC) unit reported to the Administrator. S/he stated the AC was being fixed but it was an older unit and had to be replaced. The new AC unit ordered and should be delivered and installed soon. S/he also stated that call-ins and acuity can make staffing challenging. When questioned about R55 and his/her need for 1:1 supervision, the Administrator stated that during the days when additional staff (admin/support staff) were in house they would take turns with R55. The Administrator stated they are in the process of installing a wander guard system (personal alarms) to enhance resident safety. S/he said R55 was more confused and unsettled when s/he was first admitted a few months ago, but s/he is getting better as s/he adjusts to his/her new home. His/her medical record reflects a decrease in attempts to leave the facility unattended. S/he now has certain staff members that s/he seeks out (examples: the Business Office Manager and the Maintenance Director) and s/he visits with them during the day. The Administrator stated, they are usually adequately staffed, but that staffing issues are a concern in most facilities, and this one is no different.",2020-09-01
1822,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,732,E,0,1,T56Z11,"Based on observations, staffing data reviews, and staff interviews, the facility failed to post daily nurse staffing data in a clear and readable format as required. This failure had the potential to affect all 90 residents residing in the facility. The findings included: Observation on each day of the four-day survey revealed the nurse staffing information was posted near the front entrance and was in a prominent place accessible to the residents and visitors. The postings are required to include the actual hours worked by licensed and non-licensed staff responsible for resident care on each shift. Staff postings for the 30-days prior to survey entrance on 09/10/19 were requested for review and were provided by the Administrator on 09/12/19. It was noted that on five (of thirty) of the staff posting sheets the information had been altered by the use of correction fluid (white out). There were no initials nor date to indicate when the numbers had been changed and made it impossible to validate the accuracy of the documents. The sheets/dates that had altered data were: 08/30/19, 09/05/19, 09/09/19, 09/10/19, and 09/12/19. An interview with the Administrator was conducted, with a review of the staffing data on 09/12/19 at approximately 4:00 PM. The Administrator confirmed these were the posted staff documents and they were official documents retained by the facility for a minimum of 18 months, and the documents should not have been altered by the use of correction fluid.",2020-09-01
1823,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,755,D,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's pharmacy policy, the facility failed to ensure medications were available for residents as ordered for 1 of 4 residents reviewed for pain. Resident #74's pain medication was not available in the facility for several hours. The findings included: Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 9-13-2019 at approximately 9:30 AM revealed the Quarterly Minimum Data Set assessment dated [DATE] revealed section J0400 coded Resident #74 as having occasional pain and J0600 coded Resident #74 having pain intensity of 5 on a numeric pain rating scale of 0-10. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed most of the assessment had not been completed. Further review revealed section J0100C was coded to indicate Resident #74 received as needed pain medication. Continued review revealed section J0600 was not coded for pain intensity numeric rating scale. Review of the Care Plan edited 9-4-2019 revealed Problem-resident is at risk for generalized pain r/t (related to) bladder spasm. Approaches included Administer medications as ordered PRN. Review of Nurses Notes on 9-13-2019 at approximately 10:00 AM revealed a note dated 3/3/19 06:45 AM stating, 4:00 AM resident hit call bell complaining of pain from suprapubic catheter site. Position changed several times/reassurance offered with no relief for pain. 4:15 am [MEDICATION NAME] given with effectiveness for pain. Urine leaking from catheter site. Slight odor noted. Stoma red. MD (physician) called. New order [MEDICATION NAME] 5 mg Bid. Further review revealed Nurses Note dated 3/3/2019 12:58 PM Res [MEDICATION NAME] 5 mg did not come in Omnicare has been called. Awaiting response. ER box has been checked as well. Review of the Medication Administration Record [REDACTED]. In addition, the MAR indicated [REDACTED]. Review on 9-13-2019 at approximately 2:30 PM of Pharmacy Services Policies and Procedures Section 7-Medication Procurement- &.1.3 Emergency Boxes and On-Site Stores revealed The facility shall have on hand an Emergency Box and other On-Site Stores of medications to be utilized in the case of new admissions, new orders unable to be received before the next scheduled pharmacy delivery, or when immediate medication administration is required. Interview with Charge Nurse on 9-13-2019 at approximately 11:00 AM verified Resident #74 had not received the [MEDICATION NAME] timely. Interview with the Administrator on 9-13-2019 at approximately 2:00 PM revealed the facility has a contract with CVS to provide emergency medications but provided no explanation as to why Resident #74's pain medication was not received by the facility timely.",2020-09-01
1824,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,758,E,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, facility policy reviews, and staff interviews the medical staff failed to provide an appropriate clinical indication for the long-term use of antipsychotic medications and failed to attempt Gradual Dose Reductions (GDRs) of anti-psychotics unless clinical contraindications were documented. Additionally, the facility failed to provide 14-day stop dates for PRN (as needed) antipsychotic medication use. These failures affected three of five residents reviewed for the use of [MEDICAL CONDITION] medications. (Resident (R) #31, #35, and #64). The findings included: Review of the facility's policy titled Medication Management - 6.6 [MEDICAL CONDITION] Drugs - Use of dated 11/1/17 revealed: A [MEDICAL CONDITION] drug is any drug that affects brain activities associated with mental processes and behavior. [NAME] Residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific diagnosed condition documented in the medical record; B. Residents who use [MEDICAL CONDITION] medications receive GDRs and behavioral interventions .in an effort to discontinue these drugs .1.) The facility will ensure each resident's drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being .4.) The facility will not use [MEDICAL CONDITION] medications for the purpose of discipline or convenience .13.) [NAME]) The facility will only order PRN [MEDICAL CONDITION] medications to treat a specific diagnosed condition and the prescribing physician must document the diagnosed specific condition and the indication for the PRN .and (PRNs) should be ordered for no more than 14 days .At the time a PRN is administered, documentation must be present to justify the need for the medication, the nonpharmacological interventions attempted, and that monitoring has occurred .14.) [NAME]) The facility will only order PRN antipsychotic drugs for up to 14 day duration .B.) The required evaluation of a resident before writing a new PRN order .entails the prescribing practitioner directly examine the resident and assess the resident's current condition to determine if the PRN medication is still needed .the prescribing practitioner should, at a minimum, determine and document the following in the resident's medical record: 1.) Is the antipsychotic medication still needed? 2.) What is the benefit of the medication to the resident? 3.) Have the resident's expressions or indications of distress improved as a result of the PRN medication? 1. Review of an undated Face Sheet found in the electronic medical record (EMR) revealed Resident (R) 31 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no diagnostic information that the resident suffered from any major mental illness. Record review of R31's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/18/19, revealed the resident had a Brief Interview for Mental Status (BIMS) score of six (of a possible 15 points) which indicated severe cognitive impairment. The MDS indicated R31 did not exhibit any indicators of [MEDICAL CONDITION], such as hallucinations or delusions and had exhibited no behaviors during the assessment period. According to the MDS, an antipsychotic medication ([MEDICATION NAME]) received routinely since the resident's admission. The MDS indicated a gradual dose reduction (GDR) declined by the physician on 04/30/19 stating the GDR was clinically contraindicated. The MDS did not include any active [DIAGNOSES REDACTED]. [MEDICATION NAME] is an antipsychotic medication used in the treatment of [REDACTED]. Antipsychotic use in the elderly should be avoided except for treating [MEDICAL CONDITION] or [MEDICAL CONDITION] disorder ([MEDICAL CONDITION]). There is an increased risk of cognitive decline (problems with memory, language, thinking and judgement), morbidity (disease), and mortality (death) in elderly patients treated with antipsychotics for dementia-related [MEDICAL CONDITION] (hallucinations and/or delusions) (PDR.net). Random observations of R31 conducted throughout the survey revealed the resident was frequently observed in a geri-chair at the nurse's station. S/he was confused at baseline and could not be reliably interviewed about his/her care. Interview of his/her spouse/resident representative (RR) for R31 during the initial screening portion of the survey denied R31 had any major mental illness diagnoses, but stated, s/he does act out sometimes. Review of the pharmacy Consultation Report dated 03/19/19 and noted to be a repeated recommendation from 02/18/19 revealed, (R31) receives [MEDICATION NAME] but does not have a supporting indication for use documented .If current therapy is to continue please update the resident's chart to include: 1.) the specific diagnosis .and 2.) a list of target behaviors .CMS guidance requires that antipsychotics only be used in accordance with current standards of practice The physician noted on the same consult report, Will document and signed the report on 03/22/19. No new [DIAGNOSES REDACTED]. Review of a pharmacy Consultation Report dated 04/24/19 revealed, (R31) has received [MEDICATION NAME] 12.5 mg(milligrams) every evening since 01/13/19 .A GDR should be attempted in 2 separate quarters with a month between attempts, with in the first year in which an individual is admitted on a [MEDICAL CONDITION] medication If this therapy is to continue it is recommended that: a.) the prescriber documents an assessment of risk vs benefit .b.) the record contains specific target behaviors, desired outcomes, and the effectiveness of nonpharmacological approaches. The physician's response (MD1) documented on the consult report: a box checked next to: I decline the recommendations because GDR is clinically contraindicated .GDR attempt is likely to impair function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder documented below. The MD replied with a handwritten note on 04/30/19 that stated, still has episodes of agitated behavior intermittently. The MD failed to provide a [DIAGNOSES REDACTED]. MD1 present in the facility on 09/13/19 at 12:40 PM. A review of R31 medical record with MD1 revealed the use of an antipsychotic medication and the lack of a psychiatric diagnosis. The MD stated, S/he has [MEDICAL CONDITION] due to his/her [MEDICAL CONDITION] and diabetes. The MD was aware that the resident did not have a [DIAGNOSES REDACTED]. MD1 stated I take care of my patients and bureaucrats aren't going to tell me how to do that. The Administrator was present during the interview with MD1 on 09/13/19. S/he acknowledged the deficient practice but had nothing to add. On 9/12/19 at approximately 2:33 PM the medical record review for Resident #35 revealed an open ended physician order [REDACTED]. [MEDICATION NAME] is a [MEDICAL CONDITION] medication. Further record review of the medication administration records from (MONTH) 12, 2019 to September, 2019 revealed that the medication had been administered multiple times without non-pharmacological interventions. On 9/12/19 at approximately 4:10 PM review of the facility's Pharmacy Services P&P (policy and procedure) on [MEDICAL CONDITION] Drugs Section 6, Subject 6.6 revealed the following: 2. D. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days. Except as provided in 483.45 (e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the residents medical record and indicate the duration for the PRN order. These findings were verified by the Director of Nursing (DON) on 9/13/19 at approximately 10:09 AM. The facility admitted Resident #64 with [DIAGNOSES REDACTED]. Record review on 09/12/19 at approximately 4:00 PM revealed a current physician's orders [REDACTED].#64 to be administered on a PRN basis. Further review revealed the order had been in place for greater that 14 days and did not have a stop date. Review of the Medical Administration Record (MAR) revealed the medication was given on 06/28/19 , 07/02/19, 07/08/19, 07/13/19, 07/19/19, and 07/21/19. In an interview on 09/12/19 at approximately 4:23 PM the DON confirmed the PRN anxiolytic had been ordered on [DATE] with no stop date and had not been discontinued.",2020-09-01
1825,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,761,F,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and manufacturing labeling and USP (United States Pharmacoepia) requirements, the facility failed to assure that it was free of expired medications in 2 of 2 medication rooms and that medications were stored at correct temperature in 1 of 2 medication rooms. The findings included: On 09/10/19 at approximately 9:51 AM inspection of the [NAME] Hall Medication Room revealed one bag of Sodium Chloride Injection, USP (United Sates Pharmacopoeia) 0.45% (percent) 1,000 ml (milliliter) Lot Y 6 with an expiration date of (MONTH) 2019. This finding was verified on 09/10/19 at approximately 9:56 AM by LPN (Licensed Practical Nurse) # 3 who stated that it is the nurses responsibility to check for out of date medication. On 09/10/19 at approximately 10:06 AM inspection of the Rogers Hall Medication Room revealed five vials of [MEDICAL CONDITION] Vaccine (Recombinant) ([MEDICATION NAME]-B) 20 mcg (microgram)/ml (1 dose) Lot with expiration dates of 6/2/19 (House Stock). This finding was verified on 9/10/19 at approximately 10:10 AM by LPN # 4 who stated that it is the nurses responsibility to check for out dates. On 9/10/19 at approximately 10:12 AM the Rogers Hall Medication Room temperature was noted to be uncomfortably hot by the Surveyor and LPN # 4. LPN # 4 stated that the medication room been very hot for several days. Further inspection of the Rogers Hall Medication Room revealed within a metal storage cabinet approximately 22 different o-t-c (over the counter) medications stored on the first shelf, 29 on the second shelf, 19 on the 3rd shelf, and 11 on the 4th shelf. This finding was verified by LPN # 4 on 9/10/19 at approximately 10:18 AM. All of these medications were labeled by the manufacturer to be stored as room temperature which is defined by the USP as being between 68-77 degrees F (Fahrenheit). LPN # 4 stated that temperatures in the medication room had been a problem for at least a week and that he/she did not think the air conditioner could be fixed. He/she stated the o-t-c medications in the cabinet were for use on the Rogers Wing only. On 09/10/19 at approximately 10:17 AM, the Surveyor recorded a room temperature of 83.4 degrees F (Fahrenheit) using a calibrated thermometer and asked the facility Maintenance Director to check the room temperature with a facility thermometer which had been calibrated. On 9/10/19 at approximately 10: 23 AM, he/she recorded a reading of 82.4 degrees F and stated that he/she knew that the temperature was too high as of 9/3/19 and was in process of getting a bid to have the air conditioner fixed. He/she was unable to state how often the room temperature is normally checked in the medication room. 09/11/19 at approximately 9:30 AM the Administrator stated that one bid had been received and that he/she was having all of the o-t-c medications in the Rogers Hall Medication room moved to the [NAME] Hall Medication Room until the air conditioning for the Roger Hall Medication Room could be repaired or replaced.",2020-09-01
1826,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,812,F,0,1,T56Z11,"Based on observation, record review, and interview, the facility failed to store foods in accordance with food safety guidelines and to follow three sink sanitizer instructions for 1 of 1 kitchens. The inside temperature of the refrigerator was unavailable, the freezer temp was not accurate, debris was observed on the floor in the refrigerator, grease was observed on the stove and oven, and the sanitizer in the three compartment sink was outside of the manufacturer's instructions. The findings included: Initial tour of the kitchen on 9/10/2019 at 9:31 AM revealed the outside thermometer of the freezer read 12 degrees. The thermometer inside the freezer read 30 degrees. The Dietary Manager stated at that time it feels like it's in defrost. The thermometer outside the refrigerator read 32 degrees and the inside temperature was not available as there was no thermometer inside the unit. Review of the temperature logs for the refrigerator for the month of (MONTH) revealed temperatures had been recorded for 9/10/2019 AM and PM readings. Final observation of the kitchen on 9/13/2010 at 9:18 AM revealed the dish rack noted with buildup of food particles and rust, the refrigerator had debris on the floor and the stove and oven contained heavy grease build up. Further observation revealed the three compartment sink sanitizer solution read 500 ppm (parts per million). Review of the Ecolab OASIS 146 Multi Quat Sanitizer instructions revealed the sanitizer solution should read between 150 - 400 ppm. Interview with the Dietary Manager on 9/13/2019 at approximately 10:00 AM verified the above findings and included him/her proceeding to add more water to the three compartment sanitizer sink.",2020-09-01
1827,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,842,D,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure that physician's orders for Resident #17 were accurately transcribed into the computerized medical record system. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The findings included: On 9/12/19 at approximately 11:08 AM a review of the computerized medical record for Resident #17 revealed a physician's order dated 9/9/19 for [MEDICATION NAME] ([MEDICATION NAME]) - Schedule IV tablet; 1 mg (milligram); amt (amount) 1 mg; oral as needed with an open ended end date. Based on this record review the Surveyor initially determined that this was an incomplete order since it did not state the frequency for administration and that there was no 14-day limit placed on the order as required for a [MEDICAL CONDITION] medication. This finding was confirmed by the Director of Nursing (DON) on 9/12/19 at approximately 11:20 AM. He/she was asked by the Surveyor to provide hard copies of the physician's order and medication administration record. A review of the hard copy of the physician's order on 9/12/19 by the Surveyor and the DON at approximately 2:43 PM revealed that the physician had written [MEDICATION NAME] 1 mg qhs (every bedtime) PRN (as needed) x 14 days dispense 14 tabs (tablets) with no refills which was a complete order related to PRN frequency and had specified a 14-day limit on the medication. On 9/13/19 at approximately 3:06 PM, the DON confirmed that the physician's order had been entered incorrectly into the computerized medical record system.",2020-09-01
1828,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2019-09-13,880,D,0,1,T56Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement an ongoing infection control prevention program for 1 of 2 residents reviewed for catheter care. Resident #74 was observed with catheter bag uncovered and tubing on the floor. The findings included: Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation during initial tour on 9-10-2019 at approximately 10:30 AM revealed Resident #74 lying in bed with his/her catheter bag and tubing uncovered and on the floor. Random observation on 9-11-2019 at approximately 12:09 PM revealed Resident #74 lying in bed with his/her catheter bag and tubing uncovered and on the floor. Review of the medical record for Resident #74 on 9-13-2019 at approximately 9:30 AM revealed he/she has [DIAGNOSES REDACTED]. Review of the Care Pan last edited 9-4-2019 revealed: Problem-Urinary Incontinence with Approaches to include: encourage resident to keep urine bag below level of bladder for proper draining, avoid kinks to tubing, keep tubing and bag off floor. Interview with Charge Nurse on 9-13-2019 at approximately 11:00 AM revealed catheter bags and tubing should be kept off of the floor at all times.",2020-09-01
1829,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,578,D,0,1,HBGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were afforded the opportunity to formulate their own advance directives for 1 of 4 residents reviewed for advance directives. (Resident #66) The findings included: The facility admitted Resident #66 on 10/11/16 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident's Representative signed the Advance Directive Notification & Work Sheet dated 10/11/16. Further record review revealed the Resident's Brief Interview Mental Status (BIMS) score was 15 which indicated the resident was alert and oriented. Record review revealed there was no form in the record with 2 physician's signatures attesting that the resident was not capable to making his/her own healthcare decisions. There was no documentation in the record to indicate Resident #66 was afforded the opportunity to formulate his/her own advance directive. The documentation was reviewed and findings confirmed by the Administrator on 9/27/18 at approximately 8:30 AM.",2020-09-01
1830,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,623,C,0,1,HBGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to provide written Notice of Transfer upon occurrence to 4 of 4 sampled residents reviewed for hospitalization . The notification process was not followed for Residents #66, #45, #9 and #58 and/or their Resident Representatives. The findings include: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 09/27/18 at approximately 2:09 PM revealed that Resident #9 was transferred to the hospital on [DATE] and 06/10/18. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Record review on 09/26/18 at approximately 2:27 PM revealed Resident #45 was transferred to the hospital on [DATE], 07/10/18, 05/25/18 and 05/18/18. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. The facility admitted Resident #58 with [DIAGNOSES REDACTED]. Record review on 09/28/18 at approximately 11:57 AM revealed that Resident #58 was transferred to the hospital on [DATE]. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. In an interview on 09/27/18 at approximately 9:45 AM the facility's Administrator stated no written Notice of Transfer or Notice of Bed Hold Policy was being provided to the Resident and/ or his/her Representative. The Administrator also stated there was no documentation of the notice to the Ombudsman retained at the facility and was unable to obtain any verification. The report sent to the Ombudsman regarding transfers was based on the midnight census and did not include reporting for residents who were transferred out and returned the same day. On 09/27/18 at approximately 11:00 the Administrator provided copies of facility policies entitled Bed Hold Policy and Transfer and Discharge. The policy on Transfer and Discharge stated [NAME] Before a facility transfers or discharges a resident, the facility must: 1) Notify the resident and the resident's representative (s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. 2) Send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and documentation to reflect in the resident's medical record. 3) Document reasons for the transfer or discharge in the residents medical record . The Bed Hold Policy stated Facility's staff will provide each patient/resident or their qualified legal representative with Facility's written bed-hold policy at teatime of admission and each time the patient/ resident leaves the facility for hospitalization or therapeutic leave. The facility admitted Resident #66 on 10/11/16 with [DIAGNOSES REDACTED]. Review of the Progress Notes dated 8/25/18 indicated Resident #66 was sent to the emergency room and admitted to the hospital. The facility readmitted Resident #66 on 8/29/18. There was no documentation in the medical record to indicate the facility sent a written Notice of Transfer with the resident or mailed a written notification for the reason for the transfer to the resident's representative.",2020-09-01
1831,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,625,C,0,1,HBGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on record review, observation and interview the facility failed to provide written Notice of Bed Hold upon occurrence to 4 of 4 sampled residents reviewed for hospitalization . The notification process was not followed for Residents #66, #45, #9 and #58 and/or their Resident Representatives. The findings include: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 09/27/18 at approximately 2:09 PM revealed that Resident #9 was transferred to the hospital on [DATE] and 06/10/18. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. The facility admitted Resident #45 with [DIAGNOSES REDACTED]. Record review on 09/26/18 at approximately 2:27 PM revealed Resident #45 was transferred to the hospital on [DATE], 07/10/18, 05/25/18 and 05/18/18. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. The facility admitted Resident #58 with [DIAGNOSES REDACTED]. Record review on 09/28/18 at approximately 11:57 AM revealed that Resident #58 was transferred to the hospital on [DATE]. No documentation that written Notice of Transfer or Notice of Bed Hold being provided to the resident and/ or resident representative was located in the record. In an interview on 09/27/18 at approximately 9:45 AM the facility's Administrator stated no written Notice of Transfer or Notice of Bed Hold Policy was being provided to the Resident and/ or his/her Representative. The Administrator also stated there was no documentation of the notice to the Ombudsman retained at the facility and was unable to obtain any verification. The report sent to the Ombudsman regarding transfers was based on the midnight census and did not include reporting for residents who were transferred out and returned the same day. On 09/27/18 at approximately 11:00 the Administrator provided copies of facility policies entitled Bed Hold Policy and Transfer and Discharge. The policy on Transfer and Discharge stated [NAME] Before a facility transfers or discharges a resident, the facility must: 1) Notify the resident and the resident's representative (s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. 2) Send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman and documentation to reflect in the resident's medical record. 3) Document reasons for the transfer or discharge in the residents medical record . The Bed Hold Policy stated Facility's staff will provide each patient/resident or their qualified legal representative with Facility's written bed-hold policy at teatime of admission and each time the patient/ resident leaves the facility for hospitalization or therapeutic leave. The facility admitted Resident #66 on 10/11/16 with [DIAGNOSES REDACTED]. Review of the Progress Notes dated 8/25/18 indicated Resident #66 was sent to the emergency room and admitted to the hospital. The facility readmitted Resident #66 on 8/29/18. Further record review revealed there was no documentation in the medical record to indicate the resident and/or resident's representative was provided with written information related to the facility's bedhold policy upon transfer to the hospital.",2020-09-01
1832,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,657,D,0,1,HBGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the care plan was reviewed and revised related to Restorative Services for 1 of 2 residents reviewed for care plan revision. (Resident #4). In addition, the facility failed to ensure 1 of 1 resident reviewed for care plan participation was afforded the opportunity to participate in development of their care plan. (Resident #49) The findings included: The facility admitted Resident #49 on 5/8/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Care Plan Conference Summary form dated 9/12/18 contained a space to document participation in the care plan conference of the resident and family members. Further review of the form revealed the resident's representative signed the form to indicate attendance at the care plan conference. There was no signature or notation to indicate the resident attended or participated in the care plan meeting. During an interview on 9/27/18 at approximately 5:00 PM, the Social Worker provided a copy of the letter sent to the resident's representative about the meeting. At that time, the Social Worker indicated that residents are informed of / invited to the care plan meetings by word of mouth. The Social Worker reviewed the attendance sheet and confirmed there was no documentation that the resident participated. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review on 09/25/18 at approximately 4:29 PM revealed the care plan included interventions to reduce and/ or prevent decline in Activities of Daily Living (ADL) and Range of Motion (ROM). Those interventions included: Restorative Nursing to provide passive/active ROM to extremity as ordered days per week. Record minutes ROM performed in Plan of Care. In an interview on 09/26/18 at approximately 12:18 PM the Director of Nursing stated Resident #4 was not receiving the ROM services because the facility does not have a Restorative Nursing Program. In a subsequent interview, the facility's Administrator stated, the expectation would be for the therapist to develop an alternative recommendation and the care plan should have been updated accordingly.",2020-09-01
1833,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,676,D,0,1,HBGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide services to prevent decline in Activities of Daily Living and Range of Motion for 1 of 2 sampled residents reviewed for Activities of Daily Living. Resident #4 did not receive recommended Restorative Nursing services. The findings include: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review on 09/25/18 at approximately 4:29 PM revealed the care plan included interventions to reduce and/ or prevent decline in Activities of Daily Living (ADL) and Range of Motion (ROM). Those interventions included: Restorative Nursing to provide passive/active ROM to extremity as ordered days per week. Record minutes ROM performed in Plan of Care. In an interview on 09/26/18 at approximately 12:18 PM the Director of Nursing stated Resident #4 was not receiving the ROM services because the facility does not have a Restorative Nursing Program. In a subsequent interview, the facility's Administrator stated, the expectation would be for the therapist to develop an alternative recommendation and the care plan should have been updated accordingly.",2020-09-01
1834,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,686,E,0,1,HBGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of the facility policy titled Hand Hygiene/Hand Washingand Performing a Dressing Change, the facility failed to ensure residents received necessary treatment and services to promote healing of pressure ulcers for 3 of 3 residents reviewed for pressure ulcers.(Resident #59, #57, & #76) Staff member was observed not following infection control practices during wound care. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Record review on 9/25/18 at 5:20 PM revealed Resident #59 had a pressure ulcer area to his/her right lateral foot. Further review revealed a current physician's order to use wound cleanser to clean the foot, dry the foot, apply [MEDICATION NAME] and cover with border gauze every day. Observation of wound care on 9/27/18 at 10:20 AM revealed Licensed Practical Nurse(LPN)#1, after washing hands and donning gloves, cleaned the resident's wound, dried the wound, applied [MEDICATION NAME], and placed a dressing to the wound. LPN #1 did not wash his/her hands after cleaning the wound. The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review on 9/25/18 at 5:19 PM revealed Resident #67 had pressure ulcers on the right foot and lower right buttocks. Further review revealed physician orders to clean the areas with wound cleanser, pat dry, apply a nickel thick layer of Santyl on the right foot, cover with a non-adherent dressing and wrap with kerlix daily and to apply collagen to the wound bed on the lower right buttocks and cover with border gauze. Observation of wound care on 9/27/18 at 2:50 PM revealed LPN #1 reached into his/her pocket and removed scissors and cut hypofix. After washing his/her hands and donning gloves, LPN #1 was observed to clean the wound to the right lower buttock, dry the wound, place collagen and place the dressing. S/he removed the gloves and washed his/her hands. After donning gloves, LPN #1 cleansed the area to the foot, dried the area, applied santyl, placed a non-adherent dressing, applied kerlix, and hypofix was applied. S/he then removed his/her gloves. LPN #1 did not wash his/her hands after cleaning the wound. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Record review on 9/25/18 at 5:20 PM revealed Resident #76 had a wound to the right heel. Further review revealed a physician's order to cleanse the wound with wound cleanser, pat dry, apply santyl and apply dakin's wet to dry, cover with dressing and wrap with kerlix. Observation of wound care on 9/26/18 at 3:00 PM, revealed LPN #1 reached into his/her pocket and used scissors from the pocket to cut hypofix. After washing his/her hands and donning gloves, LPN cut the dressing off the resident's foot and placed the scissors on the over the bed table. After washing his/her hands and donning gloves, LPN #1 cleansed the wound, dried the wound, applied santyl with a q-tip applicator, applied Dakins .5% soaked 4 x 4's, applied dry gauze, dressing and placed hypofix. LPN #1 did not wash his/her hands after cleaning the wound. Review of the facility policy titled Hand Hygiene/Hand Washing revealed the following under the Procedure section: 2. Wash hands . K. After contact with an object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds . Review of the facility policy titled Performing A Dressing Change revealed under the Procedure section the following: Note: (Wash hands before and after donning glove) and 3. Cleanse the wound of drainage, debris, or dressing/filler residue.(Change gloves) During an interview with LPN #1 on 9/28/18, after sharing concerns related to wound care, s/he did not dispute the findings.",2020-09-01
1835,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,690,E,0,1,HBGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policy titled Perineal Care/Incontinent Care, the facility failed to provide appropriate treatment and services during incontinent care for 2 of 2 residents reviewed.(Resident #4 and #59) During incontinent care, staff were observed retracting the foreskin and not replacing the foreskin in its proper position. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review on 9/26/18 at 4:51 PM revealed a physician's order to document episodes of urine continence and incontinence every shift. Further record review revealed documentation in the record. Observation of incontinent care on 9/25/18 at 10:09 AM revealed Certified Nursing Assistant(CNA)#1 retracted the foreskin and after care did not replace the foreskin. During an interview with CNA #1 on 9/27/18 at 2:25 PM, s/he confirmed s/he did not replace the foreskin during incontinent care. The facility admitted Resident #59 with [DIAGNOSES REDACTED]. During observation of incontinent care on 9/27/18 at 11:00 AM, CNA #2 was observed to retract the foreskin and after providing incontinent care did not replace the foreskin. During an interview with CNA #2 on 9/27/18 at 2:35 PM, s/he confirmed the foreskin was not replaced after care and continued by stating s/he was nervous. Review of the facility policy titled Perineal Care/Incontinent Care revealed the following: 9.[NAME] 1) .If patent/resident is uncircumcised, retract foreskin .3) Return foreskin to its natural position.",2020-09-01
1836,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,730,E,0,1,HBGF11,"Based on record review and interview, the facility failed to ensure the adequacy of the Certified Nurse Aide (CNA) in-service education program for all employed CNAs. The facility failed to track and ensure the in-service training for nurse aides included the 12 hours per year as required. The findings included: During a review of CNA inservice training, the Human Resource department staff provided reports for CNA inservice courses. Record review indicated the reports did not calculate the total number of yearly inservice hours for the CNAs based on the hire date. When further information was requested, the Human Resource staff informed the surveyor that no other reports were available. The staff member stated that some inservice hours are done in-house with sign-in sheets but indicated that those hours are not tracked.",2020-09-01
1837,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,732,C,0,1,HBGF11,"Based on record review and interview, the facility failed to post nurse staffing information that included all the required information. The total number of hours worked by various categories of licensed and unlicensed nursing staff was not included on the postings. The findings included: A review of the staff postings for the past 30 days revealed the total number of hours worked by registered nurses, licensed practical nurses, and certified nurse aides per shift was not documented on the forms. On 9/28/18 at approximately 10:45 AM, the Director of Nursing reviewed the forms and confirmed the finding at that time.",2020-09-01
1838,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,761,E,0,1,HBGF11,"Based on observations, records reviews and interviews the facility failed to assure that medications had been stored properly in 1 of 2 treatment carts and 1 of 2 medication rooms. The findings include: On 9/24/18 at approximately 12:25 PM inspection of the Hall 100 Treatment Cart bottom drawer revealed the following: -one opened bottle of Medline RD 6 Sterile 0.9% (percent) Normal Saline, USP (United States Pharmacopoeia) 100 ml (milliliter), dated as opened 8/22/18 with approximately 10 ml left of liquid left in the bottle -one opened bottle of Medline RD 6 Sterile 0.9% Normal Saline, USP 100 ml, not dated as opened with approximately 20 ml of liquid left in the bottle The manufacturer label states: Caution: No antimicrobial or other substance added. and Contents sterile unless container is opened or damaged. This finding was verified by LPN (Licensed Practical Nurse) # 1 on 9/24/18 at approximately 12:33 PM. On 9/25/18 at approximately 9:48 AM inspection of the Hall 200 Medication Room Refrigerator revealed the following: The thermometer inside the refrigerator indicated a temperature of 35 degrees Fahrenheit and a frosted over freezer compartment with no door. The freezer compartment contained 10 unfrozen vials of Amniotic Cytokine Extract /PGE Lot: OSPGE2, Exp (expires) 09/27/18 Qty (quantity): 0.4 ml labeled Freeze and Protect from Light. These vials were inside a dispensing box which was labeled as follows: Pinnacle Compounding [PHONE NUMBER] 1120 Kensington Ave., Suite E Missoula, MT Rx (prescription) 0 Dr . 8/15/18 Resident # 4 (name) and DOB (date of birth) OS PGE2-PROSTAGLANDIN E2 DROP Thaw one bottle until liquid and instill 1 drop to each eye in the am. refrigerate during the day. instill 1 drop to each eye in the pm. discard bottle at end of day. Qty (quantity): 12 Lot #: 8OSPGE2 Drug exp (expires) 9/27/18 3 refills before 7/13/2019 RPH AF /LS An additional label read: Genesis Amniotic Cytokine Extract Dry Eye Drops (directions for use) 1. After removing the Genesis box from the shipping container (Mw/dry ice) immediately store the Genesis box of unopened bottles in your freezer. 2. Remove only one bottle from your freezer per day. 3. Defrost the bottle for approximately 5 minutes on your counter top or approximately 3 minutes in the palm of your hand. 4. After the fluid has completely defrosted/thawed, apply one drop in each eye and the place/store the remaining Genesis product/vial in your refrigerator. 5. At night remove this vial from your refrigerator and apply another drop in each eye and then discard the vial. 6. Make sure to discard opened bottle at the end of each day. For any further questions please call Pharmacy at 1--------. To order refills please call Compounding Pharmacy at 1--------. This finding was verified on 9/25/18 at approximately 9:56 AM by LPN # 3 and was confirmed with the Director of Nursing on 9/25/18 at approximately 10:23 AM.",2020-09-01
1839,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,880,E,0,1,HBGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy titled Hand Hygiene/Hand Washing the facility failed to follow infection control practices after performing pressure ulcer care, incontinent care and after sorting of linen in the laundry. After pressure ulcer care, staff was observed to deposit soiled items in the soiled utility, exit and enter into the nutrition room to wash hands. After incontinent care, staff was observed to touch items in room with soiled gloved hands. In addition, after staff sorted linen, removed personal protective equipment and transferred clean linen from washer to dryer without washing hands after removing soiled gloves. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. After performing incontinent care on 9/28/18 at 11:40 AM, Certified Nursing Assistant(CNA)#1 removed covering on resident, pulled shirt down, pulled bedspread up, placed items in drawer of bedside table, and shut the drawer using his/her soiled gloved hands. During an interview with CNA #1 on 9/27/18 at 2:25 PM, s/he confirmed items in the resident's room were touched with soiled gloves. The facility admitted Resident #59 with [DIAGNOSES REDACTED]. After performing incontinent care on 9/27/18 at 11:00 AM, CNA #2 was observed to obtain a brief out of the resident's closet, wiped buttocks again, and placed new, clean brief while wearing soiled gloves. During an interview with CNA #2 on 9/27/18 at 2:35 PM, s/he stated thought the gloves had been removed when s/he obtained the brief. S/he continued by stating s/he was nervous. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. After performing pressure ulcer care on Resident #76 on 9/26/18 at 3:00 PM, Licensed Practical Nurse(LPN)#1 exited the resident's room, entered into the soiled utility room, exited the soiled utility room without washing hands and entered into the nutrition room to wash hands. During an interview with LPN#1 on 9/28/18, LPN #1 did not dispute the finding. During observation of the laundry on 9/26/18 at 10:55 AM, Laundry Worker #1 was observed after sorting the linen, to remove protective personal equipment(PPE), enter into the clean area, unload the washer, place the clean linens into a cart, and cover the cart. Laundry Worker #1 did not wash his/her hands after removal of the PPE. During an interview immediately after the observation, Laundry Worker #1 confirmed s/he did not wash hands after the removal of the PPE. Review of the facility policy titled Hand Hygiene/Hand Washing, revealed the following under the Procedures section: 2. Wash hands: .C. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves .F. Before and after patient/resident contact .[NAME] After contact with soiled or contaminated articles .K. After contact with an object or source where there is a concentration of microorganisms .",2020-09-01
1840,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2018-09-27,883,D,0,1,HBGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policies titled Pneumococcal Disease: Prevention and Control and Use of Pneumococcal [MEDICATION NAME] Vaccine and Influenza Vaccine Administration and Disease Control, the facility failed to offer all residents the vaccines as required for 1 of 5 residents reviewed. Resident #9 was not offered the Pneumococcal [MEDICATION NAME] Vaccine or the Influenza Vaccine. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on 9/28/18 revealed there was no documentation Resident #9 was offered and had received the Influenza and Pneumococcal [MEDICATION NAME] Vaccines. During an interview with the Administrator on 9/28/18, s/he stated documentation could not be found the resident had been offered or received vaccines. Review of the facility policy titled Pneumococcal Disease: Prevention and Control and Use of Pneumococcal [MEDICATION NAME] Vaccine revealed the following under the Procedure section: 2. Pneumococcal vaccine will be offered to all new patients/residents upon admission after determining whether they have previously received the vaccine or if they have a medical contraindication. Review of the facility policy titled Influenza Vaccine Administration and Disease Control revealed under the Procedure section the following: 1. Influenza vaccine will be administered to all patients/residents unless medically contraindicated, or refused. 2. All Patients/Residents will be offered influenza vaccine when it becomes available upon admission during the vaccine season, (MONTH) 1 through (MONTH) 31 and each year thereafter.",2020-09-01
4548,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2016-09-09,279,D,0,1,GIVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop comprehensive care plans for 2 of 25 sampled residents (R46 and R95) whose care plans were reviewed. Specifically, the bathing needs identified in the comprehensive assessment for R46 were not addressed in the care plan; and the pain management needs identified in the comprehensive assessment for R95 were not addressed in the care plan. The Stage 2 census sample was 37 and the facility census was 74 at the time of the survey. Findings include: 1. A review of R95's clinical record revealed a Face Sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) which indicated the resident was admitted to the facility on [DATE]. A review of R95's Resident Progress Note dated 9/8/16 revealed R95 had [DIAGNOSES REDACTED]. A review of R95's Medication Administration Record [REDACTED]. No breakthrough or as needed pain relief medication was noted. A review of R95's quarterly Minimum Data Set (MDS) assessment (a standardized assessment form required for all long term care residents), dated 6/24/16 revealed R95 received scheduled pain medication. The MDS also coded the resident as having almost constant pain, that limited his day to day activities and on a 1-10 scale of pain, ten being the worst, the resident was coded as having pain at an 8 over the last 5 days of the assessment look back period. A review of the facility's Pain Management policy and procedure last revised 7/1/16, stated Obtain information from the evaluation process to determine at what level pain will interfere with the resident's quality of life and prohibit them from carrying out normal life activities. This information should be incorporated into the development of the resident's pain management care plan. A review of R95's care plan dated 7/6/16 for the problem of resident has complaints of chronic pain due to decreased mobility,[MEDICAL CONDITION] with left sided [MEDICAL CONDITIONS]([MEDICAL CONDITION] reflux disease) revealed the following approaches: administer medications as ordered, educate resident on requesting pain meds before pain is too unbearable, evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge, monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factor. Use non-medicated pain relief measures: (e.g. bio-feedback, application of heat/cold, massage, physical therapy, stretching and strengthening exercises, acupuncture, etc.). Monitor effectiveness. No evidence could be found the facility implemented their policy and procedure for Pain Management. The care plan did not include information as to what level of pain interfered with R95's quality of life and prohibited him from carrying out normal life activities. An interview with Registered Nurse (RN1) MDS coordinator, on 9/9/16 at 10:40 a.m., confirmed the care plan did not address what level of pain would interfere with R95's quality of life, did not address what staff were to do if the scheduled pain medication was ineffective and included educate resident on requesting pain meds before pain is too unbearable when the resident has no as needed pain medication. 2. A review of R46's Face Sheet in the clinical record, revealed the resident was admitted to the facility 6/14/13. A review of R46's annual MDS, dated [DATE] revealed it was very important for the resident to choose between a bed bath, tub bath, shower or sponge bath. The MDS further revealed the resident required physical help in bathing. R46's quarterly MDS dated [DATE], coded the resident as being totally dependent on one person for bathing. A review of R46 s care plan last revised 8/17/16, revealed a care plan for Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by: becoming combative (hitting.) R46's care plan for self-care performance deficit last revised 8/17/16, had the following approaches: M rails to aid with independent bed mobility. Assist oral/denture care daily and as needed. Assist with ADLs as needed. Assist with dressing per resident's comfort level. Encourage maximum independence. Explain all procedures prior to initiating. Provide privacy during all care. The care plan did not address R46 being combative at shower time. The care plan did not address the medication [MEDICATION NAME] being given prior to showers. The care plan did state R46 refuses showers at time-prefers baths. The care plan did not include interventions on what to do if the resident refused a shower. A review of physician's orders [REDACTED]. During an interview with Licensed Practical Nurse (LPN) 1 on 9/8/16 at 5:14 p.m., she stated (R46) can become aggressive and combative refusing showers. She (R46) is given [MEDICATION NAME] (an anti-anxiety medication) to reduce anxiety and makes it easier to shower her. On 9/9/16 at 9:03 a.m., during an interview with Certified Nursing Assistant (CNA) 1, R46's normally assigned CNA, she stated (R46) frequently gets agitated when asked to take a shower. She was unaware of why showers agitated the resident. On 9/9/16 at 9:59 a.m., during an interview with the Activity Director, who completed the resident preferences section in the MDS, she stated (R46) did not like showers and preferred sponge baths. During an interview with CNA2, on 9/9/16 at 10:05 a.m. she stated (R46) did not like showers and could become combative. She stated (R46) preferred bed baths. During an interview with LPN3, on 9/9/16 10:27 a.m. she stated (R46) did not like showers and that R46's daughter informed her the resident had never liked showers. During an interview with CNA3 on 9/9/16 at 10:29 a.m., she stated (R46) did not like showers and was much less combative when offered a sponge bath or bed bath. She further stated R46's scheduled shower time was at 9:00 a.m. on Tuesday and Friday. An interview with Registered Nurse (RN1) MDS coordinator, on 9/9/16 at 10:40 a.m., confirmed the care plan was not sufficient to address R46's needs for bathing.",2019-11-01
4549,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2016-09-09,285,D,0,1,GIVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 1 sampled resident (R28), with a significant mental illness, was assessed for a Level II Pre-admission Screening and Resident Review (PASRR) according to the facility policy at admission or readmission to the facility. The stage two sample size was 37 and the facility census at time of survey was 74. Findings include: A review of R28's Face Sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) revealed R28 was admitted to the facility 11/09/09 with a re-admission date of [DATE]. A review of the [DIAGNOSES REDACTED]. A review of the PASRR located in R28's medical record revealed a Date of Review of 5/21/09. In section II Screening for Mental Illness Indicators the [DIAGNOSES REDACTED]. A review of the Report of Consultation dated 5/24/11 by R28's physician, revealed a handwritten [DIAGNOSES REDACTED]. In an interview on 9/8/16 at 11:15 a.m. a Social Service Employee (SSE1) stated the PASRR form reviewed was the only form for R28. In an interview on 9/9/16 at 9:33 a.m. SSE2 stated the PASRR should have been updated when R28 was readmitted . At 9:35 a.m. SSE1 stated the schizophreniform noted should have been checked as a mental illness, but did not know the person who had signed the form. In an interview on 9/9/16 at 9:45 a.m. the Regional Account Manager stated the signature on the 5/21/09 PASRR was that of the facility Social Services employee at the time. A review of the facility policy Subject: PASRR Documentation Policy section General Guidelines for PASRR: . 2. If the PASRR Level 1 screen indicates the individual may have an ID (intellectual disability), DD (developmental disability), or MI (mental illness) diagnosis, follow the state-specific process for completion of the Level II evaluation.",2019-11-01
4550,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2016-09-09,309,D,0,1,GIVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to consistently assess, monitor and provide interventions for pain relief for 1 of 25 sampled residents (R95) who suffered from chronic pain, and failed to provide interventions for 1 of 25 sampled residents (R46) who resisted showers based on her preference for sponge baths or bed baths. These deficient practices had the potential to affect the residents' highest practicable well-being and quality of life. Findings include: 1. A review of R95's clinical record revealed a Face Sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) which indicated the resident was admitted to the facility on [DATE]. A review of R95's quarterly Minimum Data Set (MDS) assessment (a standardized assessment form required for all long term care residents), dated 6/24/16 revealed R95 received scheduled pain medication. The MDS also coded the resident as having almost constant pain, that limited his day to day activities and on a 1-10 scale of pain, ten being the worst, the resident was coded as having pain at an 8 over the last 5 days of the assessment look back period. A review of the facility's Pain Management policy and procedure last revised 7/1/16, stated Obtain information from the evaluation process to determine at what level pain will interfere with the resident's quality of life and prohibit them from carrying out normal life activities. This information should be incorporated into the development of the resident's pain management care plan. A review of R95's care plan dated 7/6/16 for the problem resident has complaints of chronic pain due to decreased mobility,[MEDICAL CONDITION] with left sided [MEDICAL CONDITIONS]([MEDICAL CONDITION] reflux disease) revealed the following approaches: administer medications as ordered, educate resident on requesting pain meds before pain is too unbearable, evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge, monitor and record any complaints of pain: location, frequency, effect on function, intensity, alleviating factors, aggravating factor. Use non-medicated pain relief measures: (e.g. bio-feedback, application of heat/cold, massage, physical therapy, stretching and strengthening exercises, acupuncture, etc.). Monitor effectiveness. No evidence or documentation could be found the facility determined at what level pain would interfere with the resident's quality of life or prohibit him from carrying out normal life activities per the facility's policy and procedure for Pain Management. A review of R95's Pain Management-[MEDICATION NAME] Weekly Pain Monitoring dated 7/31/16 at 2:55 a.m., revealed the resident had moderate pain but rarely. The Pain Management-[MEDICATION NAME] Weekly Pain Monitoring dated 8/28/16 at 3:52 a.m., revealed the resident had occasional pain that was mild. Weekly pain monitoring was done on all four forms provided by the facility during resident sleeping hours. A review of R95's Medication Administration History: 8/1/16-8/31/16 revealed nursing coded the resident as having a pain score of 5 on 8/9/16 at 9:00 a.m., and as mild on 8/20/16 at 9:00 p.m. There was no evidence the facility documented the pain was relieved with the scheduled pain medications. A review of R95's Medication Administration Record [REDACTED]. No breakthrough or as needed pain relief medication was noted. R95 was unable to use words to communicate, however, during an interview with R95 on 9/6/16 at 3:54 p.m., he nodded his head yes when asked if he had pain without relief. When asked if his pain interfered with his daily living, he again nodded yes. During an interview with R95 on 9/8/16 at 4:40 p.m., when asked if nursing ever used bio-feedback, application of heat/cold, massage, physical therapy, stretching or strengthening exercises or acupuncture to alleviate his pain, he replied by nodding his head negatively (meaning no). A review of R95's Resident Progress Note dated 9/8/16 revealed R95 had [DIAGNOSES REDACTED]. During an interview with Licensed Practical Nurse (LPN) 1, on 9/8/16 at 6:56 p.m., she confirmed there were no instructions for unrelieved pain but, if the pain was severe she would call the physician. LPN1 also confirmed the facility did not determine what level of pain interfered with R95 carrying out normal life activities. During an interview with LPN2, on 9/8/16 at 7:29 p.m., she stated she did not document when the pain medication was ineffective in relieving (R95's) pain and on rare occasions it had been ineffective. 2. A review of R46's Face Sheet in the clinical record, revealed the resident was admitted to the facility 6/14/13. A review of R46's annual MDS, dated [DATE] revealed it was very important for the resident to choose between a bed bath, tub bath, shower or sponge bath. The MDS further revealed the resident required physical help in bathing. R46's quarterly MDS dated [DATE] coded the resident as being totally dependent on one person for bathing. A review of R46's care plan last revised 8/17/16, revealed a care plan for Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by: becoming combative (hitting). The care plan did not address the resident's combativeness at shower time. The care plan did state R46 refuses showers at time-prefers baths. A review of the facility's Point of Care History for showers, for (MONTH) (YEAR) and (MONTH) (YEAR), indicated R46 refused/was combative for 6 of 11 shower opportunities. During an interview with Licensed Practical Nurse (LPN) 1 on 9/8/16 at 5:14 p.m., she stated R46 could become aggressive and combative refusing showers. She stated (R46) was given [MEDICATION NAME] (an anti-anxiety medication) to reduce anxiety and makes it easier to shower her. On 9/9/16 at 9:03 a.m., during an interview with Certified Nursing Assistant (CNA) 1, R46's normally assigned CNA, she stated (R46) frequently gets agitated when asked to take a shower. She was unaware of why showers agitated the resident. During an interview with CNA2, on 9/9/16 at 10:05 a.m. she stated (R46) did not like showers and could become combative. She stated R46 preferred bed baths. During an interview with CNA3 on 9/9/16 at 10:29 a.m., she stated (R46) did not like showers and was much less combative when offered a sponge bath or bed bath. She further stated R46's scheduled shower time was at 9:00 a.m. on Tuesday and Friday. A review of physician's orders [REDACTED]. During an interview with the Director of Nursing (DON) on 9/9/16 at 10:36 a.m. she could not explain why R46 was medicated prior to her scheduled shower time to facilitate showering, when the resident preferred sponge/bed baths and disliked showers.",2019-11-01
4551,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2016-09-09,312,D,0,1,GIVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure 1 of 25 sampled residents ((R) 73) observed for grooming, received necessary assistance to keep his fingernails clean and trimmed. Findings include: A review of R73's quarterly Minimum Data Set (MDS) assessment, dated 8/17/16, revealed R73 was coded as needing extensive assistance, by one person, for his grooming. A review of the resident's care plan, last updated 8/17/16, revealed R73 required the assistance of one staff to assist with his activities of daily living, which included grooming. During an observation on 9/6/16 at 4:07 p.m., R73 was observed in a hallway in his wheelchair. He was observed to have long broken nails with black substances under his fingernails. During an observation on 9/7/16 at 2:31 p.m., R73 was observed in his room in his bed. He was observed to have long broken fingernails with black substances under his fingernails. An interview with the Administrator on 9/7/16 at 3:16 p.m. revealed nurses were to trim residents' fingernails each weekend. On 9/7/16 at 3:18 p.m., an interview with LPN1, the floor nurse responsible for R73, confirmed R73's fingernails were not trimmed or clean. A review of R73's Resident Progress Note dated 9/8/16 revealed a section entitled Medical Problem List which included the following:[MEDICAL CONDITION](cardiovascular accident) late effects, Right [MEDICAL CONDITION], Partial Motor [MEDICAL CONDITION], Extremities Contractures and [MEDICAL CONDITION].",2019-11-01
4552,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2016-09-09,329,E,0,1,GIVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident (R) 11 was monitored for the efficacy of psychoactive medications; that a clinical rationale was provided for the use of two antipsychotic medications for R28; and that R46 was free from pre-medication for a type of bathing not of his/her preference. The stage 2 sample size was 37 and the facility census at time of survey was 74. Findings include: [NAME] A review of R11's Face Sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) revealed the resident was admitted to the facility on [DATE] with a readmission date of [DATE]. A review of the [DIAGNOSES REDACTED]. A review of R11's physician orders in the Electronic Health Record (EHR) revealed an order for [REDACTED]. A review of R11's EHR Medication Administration Record [REDACTED]. A review of R11's EHR Care Plan noted a Problem of Resident is at risk for adverse consequences R/T (related to) receiving antidepressant and prn antianxiety medication for treatment of [REDACTED]. Monitor and report signs of sedation, [MEDICATION NAME] (dry mouth and related dental problems, blurred vision, tendency toward overheating (hyperpyrexia), and in some cases, dementia-like symptoms) and extrapyramidal (restlessness, tremor, difficulty speaking, uncontrollable facial movements or involuntary muscle contractions) symptoms. Monitor resident's mood and response to medication. The care plan noted a Problem of Resident has verbal behavioral symptoms directed toward others, s/he can become verbally aggressive, resistive to care at times, has Dx (diagnosis) Dementia, Depression, Anxiety D/O (disorder). The first Approach for this problem was Report adverse side effects. The care plan for these problems was initiated on 7/18/16. A review of the facility policy Subject: [MEDICAL CONDITION]/Psychoactive Drugs - Use of, with a Complete Revision: 7/1/2016 revealed . Procedures: .2. Complete and sign, each shift, side 1 of the Behavior/Side Effect Tracking Record to identify and document number of episodes, interventions, and outcomes of targeted behaviors, e.g.: continuous screaming, yelling, and pacing, if functional capacity impaired or experiencing psychotic symptoms, i.e., hallucinations, paranoid delusions that cause distress or impair functional capacity. NOTE: Supporting Nursing note documentation is completed when resident behavior escalates, or a new behavior occurs, or for an unusual occurrence. In an interview on 9/9/16 at 8:54 a.m. the Director of Nurses (DON) stated there was no behavior or side effect tracking record for R11. B. A review of R28's Face Sheet revealed R28 was admitted to the facility 11/09/09 with a re-admission date of [DATE]. A review of the [DIAGNOSES REDACTED]. A review of the physician's orders located in R28's EHR revealed orders for [MEDICATION NAME] (brand name: [MEDICATION NAME]; an atypical antipsychotic medication) 5 mg total (two orders, one for 2mg and one for 3 mg) to be administered daily at supper; and quetiapine (brand name: [MEDICATION NAME]; an atypical anti-psychotic medication) 300mg daily at bedtime. Both medications were ordered on [DATE]. R28 also had a physician's order for [MEDICATION NAME] ER (extended release; generic name: [MEDICATION NAME]; an antiepileptic drug is used to treat a variety of [MEDICAL CONDITIONS] types as well as acute manic symptoms in patients with [MEDICAL CONDITION] disorder) 500mg daily at 9:00 a.m. and 1000mg daily at bedtime. A review of R28's EHR did not reveal a clinical rationale from R28's physician for the use of two antipsychotic medications. A review of the facility policy Subject: [MEDICAL CONDITION]/Psychoactive Drugs - Use of, with a Complete Revision: 7/1/2016 revealed . Policy: 1.The facility will use [MEDICAL CONDITION] drug therapy only when appropriate to enhance the quality of life, while maximizing functional potential and well-being of the patient/resident. Procedures: . 7. Both the consulting pharmacist and the physician review the progress of the patient/resident and advise the nursing staff in the development of goals and a plan to maintain the patient/resident at the lowest possible dose necessary to control symptoms. 8. Update the [MEDICAL CONDITION] medication list at least annually with input from the consulting pharmacist. 9. Document justification in the medical record for dosages that exceed the recommended ranges for [MEDICAL CONDITION]. In an interview on 9/9/16 at 12:36 p.m. the DON stated a review of the R28's record revealed no history of a gradual dose reduction attempt or a clinical rationale for the two antipsychotics. C. A review of R46's Face Sheet in the clinical record, revealed the resident was admitted to the facility on [DATE]. A review of R46's annual MDS, dated [DATE] revealed it was very important for the resident to choose between a bed bath, tub bath, shower or sponge bath. The MDS further revealed the resident required physical help in bathing. Review of the Consultant Pharmacist Drug Regimen Review dated 2/16/16, revealed the Pharmacist recommended a reduction of [MEDICATION NAME] (brand name [MEDICATION NAME]; an anti-anxiety medication) which the resident received 0.5 mg at bedtime and 0.5 mg twice weekly on Tuesday and Friday prior to her shower. The Physician responded to the Consultant Pharmacist review on 2/22/16 by making an X for The resident's target symptoms returned or worsened after the most recent GDR (gradual dose reduction) attempt within the facility and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder AS D[NAME]UMENTED BELOW. The space for documenting below was blank. A review of Physician's orders for (MONTH) (YEAR), revealed R46 was to receive [MEDICATION NAME] 0.5 mg give one hour prior to shower on Tues and Friday. R46's quarterly MDS dated [DATE] coded the resident as being totally dependent on one person for bathing. A review of R46's care plan last revised 8/17/16, revealed a care plan for Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by: becoming combative (hitting.) The care plan did not address the resident's combativeness at shower time. The care plan did state R46, refuses showers at time-prefers baths. A review of the facility's Point of Care History for showers, for (MONTH) (YEAR) and (MONTH) (YEAR), indicated R46 refused/was combative for 6 of 11 shower opportunities. During an interview with Licensed Practical Nurse (LPN) 1 on 9/8/16 at 5:14 p.m., she stated (R46) could become aggressive and combative refusing showers. She stated (R46) was given [MEDICATION NAME] to reduce anxiety and makes it easier to shower her. On 9/9/16 at 9:03 a.m., during an interview with Certified Nursing Assistant (CNA) 1, R46's normally assigned CNA, she stated (R46) frequently gets agitated when asked to take a shower. She was unaware of why showers agitated the resident. On 9/9/16 at 9:59 a.m., during an interview with the Activity Director, who completed the resident preferences section in the MDS, she stated (R46) did not like showers and preferred sponge baths. During an interview with CNA2, on 9/9/16 at 10:05 a.m. she stated (R46) did not like showers and could become combative. She stated (R46) preferred bed baths. During an interview with LPN3, on 9/9/16 10:27 a.m. she stated (R46) did not like showers and that (R46's) daughter informed her the resident had never liked showers. During an interview with CNA3 on 9/9/16 at 10:29 a.m., she stated R46 did not like showers and was much less combative when offered a sponge bath or bed bath. She further stated (R46's) scheduled shower time was at 9:00 a.m. on Tuesday and Friday. During an interview with the Director of Nursing (DON) on 9/9/16 at 10:36 a.m. she could not explain why R46 was medicated prior to her scheduled shower time to facilitate showering, when the resident preferred sponge/bed baths and disliked showers. An interview with the DON on 9/9/16 at 12:30 p.m. revealed the facility had no evidence a gradual dose reduction of [MEDICATION NAME] was ever attempted for R46 prior to the Consultant Pharmacist recommendation of 2/16/16 or since that time.",2019-11-01
4553,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2016-09-09,428,D,0,1,GIVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Consulting Pharmacist identified there was no monitoring for the efficacy of an anti-anxiety medication for 1 of 37 sampled residents (R) 11; and, that a clinical rationale for the duplicative use of antipsychotics was requested of the physician for 1 of 37 sampled residents (R28). The facility census at time of survey was 74. Findings include: [NAME] A review of R11's Face Sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) revealed the resident was admitted to the facility on [DATE] with a readmission date of [DATE]. A review of the [DIAGNOSES REDACTED]. A review of R11's physician orders in the Electronic Health Record (EHR) revealed an order for [REDACTED]. A review of R11's EHR Medication Administration Record [REDACTED]. A review of R11's EHR Care Plan noted a Problem of Resident is at risk for adverse consequences R/T (related to) receiving antidepressant and prn antianxiety medication for treatment of [REDACTED]. Monitor and report signs of sedation, anticholinergic (dry mouth and related dental problems, blurred vision, tendency toward overheating (hyperpyrexia), and in some cases, dementia-like symptoms) and extrapyramidal (restlessness, tremor, difficulty speaking, uncontrollable facial movements or involuntary muscle contractions) symptoms. Monitor resident ' s mood and response to medication. Thecare plan noted a Problem of Resident has verbal behavioral symptoms directed toward others, s/he can become verbally aggressive, resistive to care at times, has Dx (diagnosis) Dementia, Depression, Anxiety D/O (disorder). The first Approach for this problem was Report adverse side effects. The care plan was initiated on 7/18/16. A review of the facility policy Subject: Psychotropic/Psychoactive Drugs - Use of revealed . 2. Complete and sign, each shift, side 1 of the Behavior/Side Effect Tracking Record to identify and document number of episodes, interventions, and outcomes of targeted behaviors, e.g.: continuous screaming, yelling, and pacing, if functional capacity impaired or experiencing psychotic symptoms, i.e., hallucinations, paranoid delusions that cause distress or impair functional capacity. NOTE: Supporting Nursing note documentation is completed when resident behavior escalates, or a new behavior occurs, or for an unusual occurrence. In an interview on 9/9/16 at 8:54 a.m. the Director of Nurses (DON) stated there was no behavior or side effect tracking record for R11. Review of a document provided by the facility titled Required Consultant Services documented on page 14, 12. Consultant shall conduct a medication regiment review (MRR) for each facility resident at least once a month. 13. Consultant shall identify any irregularities as defined in the State Operations Manual. In an interview on 9/9/16 at 11:23 a.m. the Consulting Pharmacist (CP) stated the staff should be monitoring for efficacy of the medications by a behavior monitor on the EMAR (electronic medication administration record). When asked if the CP looked for those monitors, she stated Yes and if she identified when one was not there, she would notify the DON via a recommendation. B. A review of the physician's orders located in R28's EHR revealed orders for risperidone (brand name: Risperdal; an atypical antipsychotic medication) 5 mg total (two orders, one for 2mg and one for 3 mg) to be administered daily at supper; and quetiapine (brand name: Seroquel; an atypical anti-psychotic medication) 300mg daily at bedtime. Both medications were ordered on [DATE]. A review of R28's EHR did not reveal a clinical rationale from R28's physician for the use of two antipsychotic medications. A review of the Consulting Pharmacist's recommendations for R28, dated 7/18/16, revealed the CP identified the two antipsychotic medications and recommended a gradual dose reduction (GDR) that stated: Recommendation: Please consider a gradual dose reduction of Risperdal and/or Seroquel at this time, while monitoring for re-emergence of target and/or withdrawal symptoms. For antipsychotic therapy, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensure that the care plan includes: ongoing monitoring of specific target behaviors; documentation of 1) a DANGER to self or others 2) desired outcome(s) 3) the efficacy of individualized, non-pharmacological approaches and 4) potential adverse consequences. Update and adapt the care plan as needed to provide person-centered care. Detailed documentation beyond this form is required to support appropriate use, including but not limited to, evaluation for potentially reversible/remediable causes of behavioral or psychological symptoms and assessment of alternative interventions. Rationale for Recommendation: Federal regulations require that antipsychotics being used to treat a psychiatric disorder (i.e., schizophrenia, bipolar mania, or depression with psychotic features) undergo gradual dose reduction (GDR) attempts in 2 separate quarters within the first year in which a resident is admitted or after the facility has initiated the medication, then annually UNLESS CLINICALLY CONTRAINDICATED. The physician responded on 7/28/16 by declining the recommendation with the rationale of (R28) occasionally still has some symptoms on current meds though not severe, reduction would likely worsen. In an interview on 9/9/16 at 1:17 p.m. the Consulting Pharmacist stated that duplicative therapy was not uncommon with a bipolar diagnosis. She stated she did request a clinical rationale for the duplicative therapy in (MONTH) 2010 but did not receive a response from the physician. In (MONTH) of 2010, she requested it again and the physician responded Just because. The CP stated after that, she no longer did a request for clinical rationale.",2019-11-01
5568,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2015-09-25,156,D,0,1,IXD811,"Based on record review and interview, the facility failed to provide the appropriate Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (CMS Form ) and/or Denial Letter to 1 of 3 sampled residents discharged from Medicare Part A services with benefit days remaining and who remained in the facility. (Resident #29) The findings included: Review of Liability Notices on 9/25/15 at approximately 9:30 am revealed that Medicare Part A services for Resident #29 ended 6/14/15. Further review indicated that Resident #29 had Medicare benefit days remaining and stayed in the facility following termination of Medicare Part A services. Additional review revealed that Resident #29 and/or the resident's Representative was not issued SNFABN Form informing the resident and/or Representative of the costs of services and an opportunity to choose whether or not to continue the services following termination of Medicare Part A coverage. On 9/25/15 at approximately 9:30 AM, the facility's Social Worker provided the above referenced forms. At that time, the Social Worker confirmed that SNFABN Form was not issued. The Social Worker stated that the form should have been provided; however, it was not done as required.",2018-11-01
5569,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2015-09-25,274,D,0,1,IXD811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to perform a significant change assessment for 1 of 3 residents reviewed for Activities of Daily Living. Resident #39 with a decline in two or more areas. The findings included: The facility admitted Resident #39 with [DIAGNOSES REDACTED]. Record review on 9/24/15 of the Annual Minimum Data Set((MDS) dated [DATE] revealed Resident #39 was coded as limited assistance/one person physical assist in the area of transfer. He/she was coded as independent with no physical assist from staff in the areas of walk in room/ corridor and locomotion on and off unit. In the area of Urinary and Bowel Continence, Resident #39 was coded as occasional incontinent. Review of the Quarterly MDS dated [DATE] revealed Resident #39 had a decline and was coded as extensive assistance with one person physical assist in the areas of transfer, walk in room and locomotion on/off unit. In the area of walking in the corridor, the resident was coded as activity occurred only once or twice with one person physical assist. In the area of Urinary and Bowel Continence, Resident #39 was coded as always incontinent. During an interview with the Minimum Data Set Coordinator on 9/24/15 at 5:55 PM, he/she confirmed Resident #39 should have had a significant change assessment due to a decline in two or more areas.",2018-11-01
5570,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2015-09-25,280,D,0,1,IXD811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled Goals and Objectives, Care Plans, the facility failed to review and revise the Care Plan for 1 of 3 residents reviewed for Pressure Ulcer. Resident #35's Care Plan had not been updated to reflect a healed sacral pressure ulcer. The findings included: The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Record review on 9/24/15 of Resident #35's Care Plan revealed a problem area r/t a pressure ulcer to the sacral area with a start date of 3/19/15 with revision/edited dates of 7/24/15 and 9/9/15. Further review of the resident's record revealed Resident #35 currently did not have a sacral pressure ulcer. During an interview with the Director of Nursing on 9/25/15 at approximately 10:21 AM, he/she stated the resident did not have a sacral pressure ulcer and it was healed as of 2/2/15. During an interview with the Care Plan Coordinator on 9/25/15 at 11:00 AM, he/she confirmed the care plan had not been updated to reflect the healed sacral pressure ulcer. Review of the facility policy titled Goals and Objectives, Care Plans revealed under the section of Policy Interpretation and implementation #5 the following: Goals and objectives are reviewed and/or revised: a. When there has been a significant change in the resident's condition; b. When the desired outcome has not been achieved; c. When the resident has been readmitted to the facility from a hospital/rehabilitation stay; and d. At least quarterly.",2018-11-01
5571,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2015-09-25,314,D,0,1,IXD811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide necessary treatment and services to promote healing and prevent new sores from developing for 1 of 3 residents reviewed with pressure sores. The physician's orders [REDACTED].#35. The findings included: The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Record review on 9/23/15 revealed Resident #31 had an unstagaeable pressure ulcer to his/her left heel. Further record review revealed a physician's orders [REDACTED]. Observation of the pressure ulcer treatment on 9/23/15 at 11:50 AM revealed after the treatment was given, Licensed Practical Nurse #4 was observed to place a sock on the resident's left foot. During an interview with the Director of Nursing on 9/24/15 at approximately 4:30 PM, he/she stated placing a sock over the resident's foot was not open to air.",2018-11-01
5572,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2015-09-25,329,D,0,1,IXD811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of physician's orders and record review, the facility failed to implement behavioral interventions with a resident prescribed antipsychotic medication in an effort to reduce or discontinue utilization of the drug. Resident #39 was 1 of 5 residents sampled prescribed antipsychotic medication. The findings included: The facility admitted Resident #39 with [DIAGNOSES REDACTED]. Record review on 9/24/15 revealed Resident #39 had a current physician order for [REDACTED]. Review of the Medication Administration Records(MAR's) revealed during (MONTH) (YEAR) the resident received twenty-four doses of [MEDICATION NAME] due to anxiety, restlessness or agitation. Review of the nurse's notes revealed on 8/20, 21, 22, and 23, (YEAR) redirection was attempted. No specific or consistent interventions were documented prior to administration of the anti-anxiety medication.",2018-11-01
5573,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2015-09-25,431,D,0,1,IXD811,"Based on observations, record reviews, interviews and manufacturer labeling the facility failed to assure that medications were stored under proper temperature controls in 2 of 4 medication carts. The findings include: 09/21/2015 at approximately 1:55 PM inspection of the(NAME)Wing Front Medication Cart revealed the following: -One opened and unrefrigerated floor stock bottle of Acidophilus with Pectin by Ondra Pharmaceuticals labeled by the manufacturer Refrigerate after opening. This finding was verified by Registered Nurse # 1 on 9/21/15 at approximately 2:02 PM. 09/21/2015 at approximately 2:08 PM inspection of the(NAME)Wing Back Medication Cart revealed the following: -One opened and unrefrigerated floor stock bottle of Acidophilus with Pectin by Ondra Pharmaceuticals labeled by the manufacturer Refrigerate after opening. This finding was verified by Licensed Practical Nurse # 1 on 9/21/15 at approximately 2:13 PM",2018-11-01
5574,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2015-09-25,514,D,0,1,IXD811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to ensure records were accurately documented and documentation related to resident treatment was readily accessible. Resident #35 had a dietary order incorrectly entered and Resident #33 had pharmacy recommendations acted upon but not readily available for review to ensure accuracy. Resident #33 and #35 were 2 of 35 clinical records reviewed. The findings included: The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Record review on 9/24/15 revealed a Registered Dietary recommendation dated 8/18/15 for Sugar Free Prostat 30 cubic centimeters(cc) every day. Review of the physician's orders [REDACTED]. During an interview on 9/25/15 at 10:21 AM with the Director of Nursing, he/she stated the order had been incorrectly entered into the system. The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Review of the medical record on 9/24/15 revealed that the monthly pharmacist Medication Regimen Reviews dated 6/18/15 and 7/15/15 included a report of irregularities and/or recommendations. Further record review of the Medication Administration Record [REDACTED]. The surveyor requested a copy of the 6/18/15 and 7/15/15 pharmacist's Consultation Reports and physician's response to these reports. On 9/24/15 at approximately 5:40 PM, the Director of Nursing (DON) stated that copies of these Consultation Reports with physician's response were not available. The DON indicated that these reports could not be located and were not maintained as part of the resident's medical record.",2018-11-01
6734,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,157,E,0,1,80UC11,"**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 the residents attending Physician and responsible party (RP) were notified of a change of condition for 5 of 27 residents reviewed for evidence of physician notification. Resident #5 was noted to have a low blood sugar and was exhibiting symptomatic signs of [DIAGNOSES REDACTED] and there was no documentation, Residents #66, #93 and #67 had a change in condition and the physician had not been notified and Resident #39 refused medication and [MEDICAL TREATMENT] treatments without physician notification. The findings included: The facility admitted Resident #5 with the [DIAGNOSES REDACTED]. Record review on 7/9/14 at approximately 3:36 PM revealed Physicians orders that stated [MEDICATION NAME] Emergency 1 miligram (mg) kit: Finger Stick Blood Sugar (FSBS) Review of the nurses notes dated 6/24/14 on 7/9/13 at approximately 3:36 PM revealed: Certified Nursing Assistant (CNA) asked nurse to assess resident. Entering the room resident is drenched in sweat .is also cold to touch and chill bumps and disoriented, unable to answer questions. Resident gazes like s/he is thinking of answers. Gave one pack glucoburst in juice. Blood sugar (bs) went from 44 to 46 in 15 min. On call service contacted s/he suggested Intravenous (IV) [MEDICATION NAME]. I told her/him we had Intramuscular (IM) [MEDICATION NAME]. S/he said to send him/her out, EMS (Emergency Medical Services) arrived and bs (blood sugar) results 81 EMS said whatever I did fixed the problem and they would not give him/her IV [MEDICATION NAME] because (b/c) s/he is now asymptomatic and blood sugar is increasing. During an interview with the Assistant Director of Nursing (ADON) on 7/10/14 at approximately 9:01 AM, s/he stated a resident's family/RP (responsible party) should be notified when there have been medication changes and or changes in the resident's condition. The ADON further stated: If a resident is about to go out to the hospital for a condition, we would notify the resident's RP. After reviewing the nurses notes, the ADON verified there was no evidence Resident #5's RP had been notified of the low blood sugar/ change in condition or the projected transfer. The Facility admitted Resident #66 with the [DIAGNOSES REDACTED]. Review of the document titled Activity of Daily Living (ADL) Flow Record on 7/10/14 at approximately 2:04 PM revealed the resident had no documented bowel movements from April 20, 2014 until April 26, 2014. Record review on 7/10/14 at approximately 9:21 AM revealed a nurses note dated 4/27/14 that noted Contacted on call Medical Director (MD) regarding res(ident) with no Bowel Movement (bm) indicated since the 19th. No pain, no nausea/vomiting abd(abdomen) soft non distended, fecal matter around rectum. New order (n. o.) Milk of Magnesia 30 milliliter (ml) via peg tube as needed (prn) for constipation. Further review of the nurses notes did not reveal that the facility had notified the resident's responsible party that the resident had not had a bowel movement in 7 days. Review of Resident #66's standing orders on 7/10/14 at approximately 2:30 PM revealed Constipation: check for fecal impaction. milk of magnesia 30 ml by mouth (po) every day (qd) prn (as needed) for constipation, if no improvement in 48 hrs give [MEDICATION NAME] suppository qd prn for constipation, notify MD if no improvement . During an interview with the ADON (Assistant Director of Nursing) on 7/10/14 at approximately 3 PM, s/he stated the the nurses should have known to notify the physician if the resident had not had a bowel movement after 3 days. The ADON confirmed that the physician had not been notified timely, which resulted in a delay in treatment. The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review and interview revealed that a physician's Diabetes Protocol was not followed and the physician was not notified of a significantly low BS (blood sugar) results for this short-term resident. Review of physician's orders [REDACTED]. The blood sugar (BS) was monitored twice daily at 6 AM and 4 PM. On 2-7-14 at 4:30 AM, the resident's BS was 20. [MEDICATION NAME] was administered and the BS was rechecked at 4:35 PM. The BS was LO. Apple juice and sugar were given. At 4:40 PM, the BS was still LO. Transport was called and the physician and family were notified. During an interview on 7-9-14 at 4:53 PM, the Assistant Director of Nurses (ADON) and Administrator reviewed the record. The ADON stated the nurses should follow the protocol. None were located in the chart. When asked, the ADON stated that when the standing orders were implemented, They should write a physician's orders [REDACTED].>The physician's Diabetes Protocol provided by the DON stated: FSBS (Finger Stick Blood Sugar) The facility admitted Resident #93 with [DIAGNOSES REDACTED]. Based on record review and interview the facility failed to notify the family of multiple significant changes in Resident #93's condition requiring physician intervention. Review of the 3-26-14 Admission and 4-17-14 Discharge Minimum Data Set (MDS) Assessments on 7-8-14 at 10:05 PM revealed that the resident had Brief Interview for Mental Status (BIMs) scores of 14-15, indicating s/he was cognitively intact. The Discharge MDS noted that the resident had developed verbal and other behaviors not directed at others as well as rejection of care. Review of Nurse's Notes on 7-9-14 at 10:59 AM revealed that Resident #93 was sent to the hospital on 3-20-14 and treated for [REDACTED]. There was no evidence in the record that the family was notified. On 4-9-14, a culture was done of the resident's toe wound. The resident was placed on Bactrim and contact precautions for a [MEDICAL CONDITION] (MRSA) wound infection on 4-15-14. There was no evidence in the record that the family was notified. On 4-10-14, Physical therapy was discontinued due to the resident's refusal to participate and on 4-11-14 Occupational therapy was discontinued due to the resident's refusal to participate. There was no evidence in the record that the family was notified. On 4-11-14 at 3 PM Resident was throwing feces into the hallway. Res(ident) also C/0 (complained of) chest pain. Requesting to be sent to hospital . There was no evidence in the record that the family was notified. On 4-12-14, the resident was documented as again throwing feces into the hallway when unable to obtain pain medication and/or ice cream. There was no evidence in the record that the family or physician was notified. On 4-13-14, the resident was sent to the hospital for complaints of chest pain. S/he returned on 4-14-14 at 3 PM with a [DIAGNOSES REDACTED]. At 3:30 PM, Resident #93 Ref(used) VS (vital signs)- threatened to hit nurse. At 8:45 PM, the resident insisted on being sent back to the hospital. S/he refused a nursing assessment; stated, I'm psychotic and pulled the call light out of the wall. The physician was notified and [MEDICATION NAME] was administered intramuscularly. There was no evidence in the record that the family was notified. Review of Treatment Administration Records on 7-9-14 at 11:39 AM revealed that the resident refused all wound treatments 50% of the time from 4-1-14 through 4-14-14 (4-1-14, 4-3-14, 4-7-14, 4-8-14, 4-11-14, 4-12-14, 4-13-13). There was no evidence that the physician or family was notified. During an interview on 7-9-14 at I:l0 PM, the Director of Nurses and ADON reviewed the resident's record. The ADON reviewed the Nurse's Notes and physician's orders [REDACTED]. On 7-9-14 at 2:30 PM, the ADON stated s/he was unable to locate any additional information. The facility admitted Resident #39 with [DIAGNOSES REDACTED]. Review of Resident #39's medical record on 7/9/2014 at approximately 8:19 AM revealed he/she refused medications from 4/4/2014 through 4/8/2014. Resident #39 also refused medications on 4/10/2014, 4/17/2014, 4/20/2014, 4/23/2014, 4/24/2014, 4/28/2014, 5/3/2014, 5/6/2014, 5/8/2014, 5/9/2014, 5/10/2014, 5/12/2014, 5/13/2014, 5/16/2014, 5/24/2014, 5/27/2014, 5/28/2014, 5/30/2014, 5/31/2014. He/she also refused medications on 6/2/2014 through 6/6/2014 and 6/13/2014 through 6/16/2013; and 6/18/2014, 6/19/2014, 6/23/2014, 6/24/2014, 6/27/2014, 7/02/2014, 7/3/2014 and 7/06/2014. There was no evidence the physician was notified on any of the above days of Resident #39 refusing medications. The medications the resident refused included but was not limited to: Levimir (insulin), Nepro, Humalog (insulin), Sliding scale Insulin, Welchel, Questran, [MEDICATION NAME]. Further review of Resident #39's medical record on 7/9/2014 at approximately 8:19 AM revealed documentation in nurses notes of this resident refusing wound care, bathing and [MEDICAL TREATMENT] without documentation of physician notification. During an interview on 7/9/2014, the Director of Nurses (DON) confirmed that Resident #39 refused medications, wound care, [MEDICAL TREATMENT], and daily care and there was not consistent documentation of physician notification.",2017-10-01
6735,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,241,E,0,1,80UC11,"**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 titled Resident Dignity & Personal Privacy, the facility failed to provide an environment to promote dignity of residents during the dining experience. During random observations of meal times, staff were observed placing clothing protectors on residents without asking residents permission. and Resident #17 was not served a dinner tray in a timely manner. In addition, a staff member was observed moving Resident #17 without addressing the resident. (1 of 1 sampled residents reviewed for Dignity with additional random observations) The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. On 7/9/14 at approximately 4:15 PM, the Activity Director was observed to approach the resident and move Resident #17 without addressing the resident and explaining to the resident what he/she was doing. During an interview with the Activity Director on 7/10/14 at 4:44 PM, he/she confirmed moving Resident #17 without explaining what he/she was doing. On 7/9/14 at approximately 5:45 PM, during observation of the dinner meal on the Stone Wing, Resident #17 was observed sitting in his/her wheelchair for thirty-five minutes waiting to be fed as other residents were being fed. During meal observation in the main dining room beginning at 12 PM on 7-7-14, two staff members failed to offer clothing protectors before placing them on the residents. At 12:05 PM, Certified Nursing Assistant (CNA) #2 approached Resident #A and said, Hello, how are you? while applying a clothing protector, then walked away. At 12:07 PM, CNA #2 approached a second resident Resident #81 at the same table and stated, I'm going to put your clothing protector on. S/he did not ask the resident if s/he wanted it. CNA #2 then placed a clothing protector on a third resident in a highback wheelchair at a nearby table without speaking to the resident. At 12:13 PM, Registered Nurse/MDS Coordinator placed a clothing protector on Resident #106 without asking or speaking to her/him, while, at the same time, a CNA placed a tray down on the table in front of her/him. At 12:14 PM, CNA #2 placed a clothing protector on Resident # B without asking if s/he wanted one. During an interview on 7-9-14 at 6 PM, RN #5 stated, after being informed of the observations, They know better. An observation during the lunch meal service on 7/7/2014 at approximately 12:20 PM revealed Certified Nursing Assistant (CNA) #1 applying clothing protectors on residents without first asking if they would like to have one applied. An additional observation during the lunch meal service on 7/8/2014 at approximately 12:45 PM revealed CNA #6 applying clothing protectors on residents without first asking if they would like to have one applied. An interview on 7/8/2014 at approximately 2:45 PM with CNA #6 confirmed that clothing protectors were applied to residents without first asking if the residents would like to have one applied. S/he stated: We should first ask the residents if they would like to have one applied. During random observations on 07-07-14 and 07-08-14 of the lunch meal distribution, staff placed clothing protectors on residents without asking if was the resident's preference. On 07-07-14 at approximately 12:30 PM during the lunch meal distribution on the Rogers Unit, Certified Nursing Assistant (CNA) #6 was observed placing clothing protectors on two residents without asking permission and CNA #3 was observed placing a clothing protector on one resident without asking permission. During a second random lunch observation on 07-08-14 at approximately 12:12 PM in the Rehab Dining Room, CNA #4 was observed placing a clothing protector on 2 residents without asking the residents preference. During an interview on 07-09-14 at approximately 10:00 AM with CNA #4, s/he stated, Okay, when informed of the surveyor's observation of clothing protectors placed on the residents without asking permission. During an interview on 07-10-14 at approximately 2:27 PM with CNA #3, s/he responded, It's not enough if I say to the resident I have your clothing protector? Review on 07-10-14 at approximately 11:15 AM of the South Carolina Code of Laws, Section 44-81-20: Resident's Bill of Rights, revealed in the section of Personal Treatment the following, Be treated with respect and dignity. Review on 07-10-14 at approximately 11:15 AM of the facility's policy titled, Resident Dignity and Personal Privacy revealed in the section Fundamental Information the following, i.e Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth.",2017-10-01
6736,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,246,D,0,1,80UC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on random observations and interview, the facility failed to ensure that call lights were readily accessible to multple residents to call for needed assistance during random observations on one of two units. The findings included: During the Initial Tour on the 100 Hall on 7-7-14 beginning at 10:36 AM, five residents were observed without call lights accessible. The resident in room [ROOM NUMBER]A was observed in bed with a flat touch-type call light on the right side of her/his pillow. The resident was tilted to the left and her/his right upper extremity was contracted. In room [ROOM NUMBER]A, the call light was tied to the bottom of the half rail near the bed frame. When asked, the resident, who was in bed, was unable to locate or reach the call light to call for assistance if needed. The resident in room [ROOM NUMBER]B was positioned in bed on his/her right side with the call light behind the resident, hanging down below the half rail. The resident in room [ROOM NUMBER]B was observed in a wheelchair in front of the closet, across the room from the call light. The resident had oxygen on and was moaning repeatedly. The resident in room [ROOM NUMBER]B was positioned in bed on her/his left side. The call light was behind the resident, hanging below the bed frame. At 3 PM on 7-7-14, the resident in room [ROOM NUMBER]B had the call light positioned where s/he was unable to reach, hanging down by bed frame. The resident in room [ROOM NUMBER]B was positioned in bed on her/his right side. The call light was attached to the bottom rail of the half siderail, hanging below the frame of the bed. On 7-9-14 at 6:05 AM, the resident in 107A was observed sleeping positioned on her/his left side. A flat touch-type call light was behind the resident on the right side of her/his pillow. The resident's right upper extremity was splinted. During an interview on 7-9-14 at approximately 6 pm, when advised of call lights not being within residents' reach, Registered Nurse #5 shook her/his head and stated, They know better than that.",2017-10-01
6737,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,253,E,0,1,80UC11,"On the days of the survey, based on observation and interview, the facility failed to provide effective housekeeping and/or maintenance services on two of two units. The findings included but were not limited to: Bedrails with torn padding; odors were evident; privacy curtains were soiled; chair arms torn; walls and surfaces were observed with scuffs/scratches. The findings included: During the Initial Tour beginning at 10:36 on 7-7-14, the following housekeeping/maintenance concerns were noted: 100 Hall -Room 104-Bedrails had torn black padding/covering. -Room 106-Bedrails had torn black padding/covering. There was a strong urine/body odor/stale smell in the room at 10:36 AM. -The hallway near Rooms 106-107 had a lingering urine odor at 10:57 AM. -Room 109-Bedrails had torn black padding/covering. -Room # 116-Bedrails had torn black padding/covering. -Room 123-Bedrails had torn black padding/covering. The privacy curtain between the beds was soiled with multiple brown spots. There was a stale body odor smell in the room which was also present at 3 PM on 7-7-14. 200 Hall -Room 205 A-seven long scratches on the wall at the head of the bed (up to/greater than I foot long) -205 B-Bedrails had torn black padding/covering. The wall was scraped on both the right and left sides at the head of the bed. The gerichair had a torn armpad. The baseboard was loose from the wall near the bathroom door. There was torn wall plaster to the left side of the commode. -Room 205-The bathroom had a urine odor. -Room 206-The bathroom had a urine odor and rust color buildup around the base of the commode. -Hallway near Room 207 had scraped lower wall. -Dayroom- Baseboards to right and left of the entrance had black marks. -Room 212-The bathroom door had multiple scuffs/scrapes. -Hallway near Rooms 214-218 had strong urine odor (also present on 7-9-14 at 6 AM) -Room 214-The room door was scuffed/scraped and there was wall damage behind the bed. -Room 215 had a strong urine odor in the room & bathroom. Corners and edges of baseboards in the bathroom had brown buildup. There was dark brown substance around the base of the toilet. This observation was unchanged as of 6:23 AM on 7-9-14.",2017-10-01
6738,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,281,D,0,1,80UC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, review of Clinical Nursing Skills & Techniques, 7th Edition, and review of the South Carolina State Board of Nursing Advisory Opinion # 46 (reviewed May, 2014), the facility failed to assure that services being provided met professional standards of clinical practice for 2 of 27 sampled residents reviewed for adherence to standards of practice. Nurses failed to reduce standing orders for treatment of [REDACTED].#67. Resident #93 had documented pressure ulcer assessments completed by a Licensed Practical Nurse. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. The BS was monitored twice daily at 6 AM and 4 PM with orders to Notify MD if greater than 250 mg/dL. Review of the Nurse's Notes on 7-9-14 at 4:23 PM revealed an entry at 6 AM on 1-27-14: .Res(ident's) BS checked @ 42 given apple juice with added sugar. No orders could be located for the intervention. Review of the 2-14 Medication Administration Record [REDACTED]. Nurse's Notes at 6:30 AM on 2-2-14 stated: BS check @ 56. Resident alert & oriented. Responds to verbal stimulation . Res(ident) given apple juice c (with) added sugar x 2 packs . There was no evidence found in the record that the physician was notified. No orders could be located for the intervention. Continued review revealed that on 2-7-14 at 4:30 AM, the residents BS was 20. [MEDICATION NAME] was administered and the BS was rechecked at 4:35 PM. The BS was LO. Apple juice and sugar were given. At 4:40 PM, the BS was still LO. Transport was called and the physician and family were notified. No orders could be located for the intervention. During an interview on 7-9-14 at 4:53 PM, the Assistant Director of Nurses (ADON) and Administrator reviewed the record. When advised that no orders could be found for the interventions administered for low BS, the ADON stated the nurses should follow the protocol. This was clarified to mean standing orders. None were located in the chart. When asked, the ADON stated that when the standing orders were implemented, They should write a physician's orders [REDACTED]. I did not realize they had to be written on the chart. The DON provided a copy of the Diabetes Protocol for one staff physician. The Protocol was signed by the physician but there was no effective date noted. The DON reviewed the record and was unable to find where the physician had been notified of the low BS on 2-2-14. During an interview on 7-9-14 at approximately 6 PM, Registered Nurse #5 stated that when standing orders were implemented, a physician's orders [REDACTED]. Clinical Nursing Skills & Techniques, 7th Edition, page 515 states: A medication order is required for any drug you administer to a patient . Types of orders include standing or routine orders . Each order needs to include the patient's name, .date the order is written . Based on record review and interview, a Licensed Practical Nurse (LPN) was conducting on-going assessments of residents with pressure and/or diabetic ulcers in the facility. The facility admitted Resident #93 with [DIAGNOSES REDACTED]. Review of the 3-19-14 Nursing Admission Evaluation on 7-8-14 at 1:25 PM revealed that the resident Has wound on R(ight) great toe & R lower leg. Both of these had dr(es)s(in)g upon admission. Further review on 7-9-14 at 11:55 AM revealed Nurse's Notes for 4-10-14 at 2 PM entitled w(ee)kly wound assessment which was signed by an LPN. All Nurse's Notes regarding wounds (3-19-14, 3-27-14, 4-8-14, 4-10-14, 4-14-14) were entered by an LPN. Review of two Weekly Wound Documentation forms revealed all five entries were completed by an LPN. Two of the five entries were staged. During an interview on 7-9-14 at I:l0 PM, the Assistant Director of Nurses verified that all weekly documentation including measuring and staging was routinely done by an LPN. Assessments were not completed by Registered Nurses. During an interview on 7-9-14 at approximately 6 PM in the Administrator's office, the DON and RN #5 stated that an interdisciplinary team did weekly rounds but they could not verify that an RN was present for every assessment. The South Carolina State Board of Nursing Advisory Opinion # 46 (reviewed May, 2014) states: The Board of Nursing for South Carolina recognizes that it is NOT within the role and scope of the licensed practical nurse (LPN) to evaluate and/or stage vascular, diabetic/neuropathic or pressure ulcers.",2017-10-01
6739,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,309,E,0,1,80UC11,"**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 appropriate care and services for resident's with End Stage [MEDICAL CONDITIONS] receiving [MEDICAL TREATMENT]. The facility failed to routinely assess Resident #39's [MEDICAL TREATMENT]. The facility failed to communicate changes in Resident #98's condition with the [MEDICAL TREATMENT] provider and failed to evaluate her/his drug regimen to accommodate [MEDICAL TREATMENT]. (2 of 2 sampled resident's reviewed for [MEDICAL TREATMENT].) The facility also failed to have results of pacemaker checks available for review of the interdisciplinary team for one of two sampled residents reviewed with pacemakers (Resident #88). The findings included: The facility admitted Resident #98 with [DIAGNOSES REDACTED]. Review of the 2-17-14 Admission Minimum Data Set (MDS) Assessment on 7-8-14 at 8 PM revealed that the resident's Brief Interview for Mental Status (BIMS) score was 10, indicating a moderate level of cognitive impairment. Her/his PHQ-9 (mood) score was 0 and s/he was on daily antipsychotic medication. The 14-Day MDS, completed 7 days later, noted the PHQ-9 score had increased to 11 indicating moderate depression. In addition, the resident stated s/he had thoughts that s/he would be better off dead or of hurting her/himself in some way nearly every day. Review of the Nurse's Notes on 7-9-14 at 9:04 AM revealed that the physician was notified of the resident's statement that s/he would be better off dead by Social Services on 2-24-14 at 5:30 PM. An antidepressant was ordered. Review of all [MEDICAL TREATMENT] Communication Records provided by the Director of Nurses on 7-9-14 at 1:05 PM revealed no evidence of notification to the [MEDICAL TREATMENT] clinic of this change in the resident's condition and threat of self-harm. Although record review revealed physician's orders [REDACTED]. None were provided for 2-12-14, 2-14-14, 2-28-14 or 3-3-14. The resident was admitted to the hospital from [MEDICAL TREATMENT] on 3-5-14. Further review of Nurses Notes and [MEDICAL TREATMENT] Communication Records revealed that on 2-24-14 at 9 AM, Resident #98 was nauseated and was given [MEDICATION NAME] prior to transport to [MEDICAL TREATMENT]. There was no evidence of notification to the [MEDICAL TREATMENT] clinic of this change in the resident's condition. The [MEDICAL TREATMENT] Communication Record noted, Condition Alert: A/O (Alert/Oriented) X 2. No complaint voiced. No acute distress noted. At 6 PM on 2-24-14, the resident suffered severe vomiting. The physician was notified, [MEDICATION NAME] was given intramuscularly, and [MEDICATION NAME] was ordered as needed. Phoslo was discontinued and [MEDICATION NAME] was decreased. There was no evidence that the [MEDICAL TREATMENT] clinic was notified of the medication changes. On 2-26-14, an entry in the Nurses Notes revealed that the resident had a poor appetite. S/he was also medicated for hip and back pain prior to transport to [MEDICAL TREATMENT]. There was no evidence that the [MEDICAL TREATMENT] clinic was notified. The 2-26-14 [MEDICAL TREATMENT] Communication Record noted Medications Administered: 6 A(M) meds [MEDICATION NAME] . Condition Alert: Alert. HoH (hard of hearing). On 3-1-14 and 3-3-14, the resident suffered many episodes of nausea/vomiting and [MEDICATION NAME] was administered. There was no evidence that there was communication with the [MEDICAL TREATMENT] clinic regarding the resident's condition. Continued review of the medical record revealed no evidence of evaluation of the drug regimen and/or adjustment of administration times to accommodate [MEDICAL TREATMENT]. Daily morning medications given prior to [MEDICAL TREATMENT] included: [MEDICATION NAME], Aspirin, [MEDICATION NAME], Nephro-vite, [MEDICATION NAME] XL, and Phoslo. Review of the Care Plan at 10:16 AM on 7-9-14 revealed no reference to coordination of care and services with the [MEDICAL TREATMENT] center for this resident. The plan did not include communication with [MEDICAL TREATMENT] related to changes in the resident's condition or evaluation of the drug regimen and adjustment in administration times to accommodate [MEDICAL TREATMENT]. During an interview at 10:30 Am on 7-9-14, the Director of Nurses (DON) reviewed and verified the care plan. S/he also confirmed that medication administration times had not been adjusted for [MEDICAL TREATMENT]. The DON stated that the facility had a plan of action in place for [MEDICAL TREATMENT]. Information regarding the plan was requested but not provided. During an interview at I:l0 PM on 7-9-14, the Assistant Director of Nursing reviewed the [MEDICAL TREATMENT] Communication Record and stated that the facility did not send information to the clinic on new orders. S/he verified the resident's statements that s/he would be better off dead but verified that the [MEDICAL TREATMENT] center had not been informed. The Facility admitted Resident #66 with the [DIAGNOSES REDACTED]. Resident #66's Quarterly Minimum Data Set assessment dated [DATE] noted the resident is incontinent of bowel and bladder and had no constipation noted during the assessment period. The Cumulative Physicians order form for April 2014 noted Monitor Bowel Movement (BM) every shift. Review of the document titled Activity of Daily Living (ADL) Flow Record on 7/10/14 at approximately 2:04 PM revealed the resident had no bowel movements from April 20, 2014 until April 26, 2014. Record review on 7/10/14 at approximately 9:21 AM revealed a nurses note dated 4/27/14 stating Contacted on call Medical Director (MD) regarding res(ident) with no Bowel Movement (BM) since the 19th. No pain, no nausea/vomiting abd(abdomen) soft, non distended, fecal matter around rectum. New order (n. o.) Milk of Magnesia 30 mililiter (ml) via peg tube as needed (prn) for constipation. Review of Resident #66's standing orders on 7/10/14 at approximately 2:30 PM revealed Constipation: check for fecal impaction; Milk of Magnesia 30 ml by mouth (po) every day (qd) prn for constipation, if no improvement in 48 hrs give [MEDICATION NAME] supposittory qd prn for constipation; notify MD if no improvement or bowel regiment is needed. During an interview with the ADON on 7/10/14 at approximately 3PM, s/he stated the the nurses should have followed the resident's standing orders after the resident was identified as not having a bowel movement. The facility admitted Resident #39 with [DIAGNOSES REDACTED]. An observation on 7/9/2014 at approximately 8:00 AM revealed a graft in Resident #39's right arm for [MEDICAL TREATMENT]. Review of Resident #39's medical record on 7/9/2014 at approximately 8:19 AM revealed a form dated 3/20/2014 from the [MEDICAL TREATMENT] Center which verified Resident #39 had received a straight graft, (new access) in his/her right upper arm on this date. No documentation could be found in Resident #39's medical record by this surveyor to verify an assessment of his/her [MEDICAL TREATMENT] access graft for thrill and bruit. During an interview on 7/9/2014 at approximately 9:35 AM with Licensed Practical Nurse (LPN) #3 (Unit Manager for 200 Hall), when asked what type of [MEDICAL TREATMENT] access Resident #39 had, s/he stated, I will have to go check. After confirming the access site, s/he stated that s/he thought Resident #39 had the right upper arm graft for a couple of months. When asked if there was documentation in Resident #39's medical for assessment of the thrill and bruit, he/she stated, I am not sure. After reviewing the medical record, s/he found no documentation for assessment of the graft nor evidence of checking for thrill and bruit. LPN # 3stated the access site should be assessed every shift and then wrote a physician's orders [REDACTED]. The facility admitted Resident # 88 with [DIAGNOSES REDACTED]. Review of Resident #88's medical record on 7/10/ at approximately 3:18 PM revealed a physician's orders [REDACTED]. No pacemaker report could be found in Resident #88's medical record by the Unit Manager. During an interview on 7/10/2014 at approximately 3:18 PM with Registered Nurse (RN) #1 Unit Manager for the 100 Hall s/he stated: Since the pacemaker results are not in the medical record, I will call the company and get a copy faxed for the medical record. Copies of the pacemaker check results were then faxed to the facility on [DATE] at 3:51 PM for December 12/2/2013, March 19/2014, May 15/2014 and July 10/2014. No results were found or faxed to the facility for January 2014.",2017-10-01
6740,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,314,D,0,1,80UC11,"**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 information from the Agency for Health Care Policy and Research Clinical Practice Guideline related to Pressure Sores and the facility policy titled Pressure Ulcer & Skin Care Management, the facility failed to provide necessary treatment and services to promote healing of the resident's pressure sore. Resident #17 was observed positioned in the same way for extended amounts of time. During the pressure ulcer treatment, Resident 17's wound did not have a dressing. (1 of 3 residents reviewed for pressure ulcers) The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review on 7/7/14 at 12:22 PM revealed Resident #17 developed a Stage II pressure ulcer to the sacrum On 5/27/14 the measurements were 2.5 x 1.5 x .7, with 100% granular tissue with a small amount of sero-sanguineous drainage. On 5/27/14, the resident was sent to the hospital. On 6/3/14 after hospitalization , wound measurements were 3 x 2 cm with 85% granular tissue and 15% slough. Review of the physician's orders revealed an order to cleanse the sacrum with wound cleanser and to apply a collegan dressing, cover with boarder foam gauze every shift until resolved. Further review of the medical record revealed the resident was incontinent of bowel and bladder and was coded as requiring total care. On 7/8/14, Resident #17 was observed in the dayroom at 10:43 AM and 12:56 PM in the same area of the dayroom. Resident #17 was brought into the dayroom on 7/9/14 at 1:05 PM and was observed being fed by a family member. At 2:20 PM, the resident was noted sitting in the wheelchair on the front porch with a family member. At approximately 4:00 PM, Resident #17 was placed in the dayroom by the family member. At approximately 4:15 PM, the Activity Director placed the resident in an activity. Resident #17 was again observed in the dining room at 5:45 PM. On 7/10/14 at 9:15 AM, 11:18 AM, and 12:47 PM, Resident #17 was observed lying on his/her left side without evidence of having been repositioned. During observation of the resident's pressure sore on 7/9/14 at 11:44 AM, the sacral wound was observed without a dressing. RN (Registered Nurse) #2 stated that the dressing probably came off during the care. During an interview with CNA (Certified Nursing Assistant) #2 on 7/10/14 at 2:18 PM, who was assigned to the resident on the day of the pressure sore treatment, he/she stated could not remember if the resident's dressing was in place or not. During an interview with LPN (Licensed Practical Nurse) #1 on 7/10/14 at 12:26 PM, he/she stated a CNA should notify the nurse if a dressing has come off of a wound. During an interview with the ADON(Assistant Director of Nursing) on 7/10/14 at 1:07 PM, he/she stated CNA's are expected to notify the nurse if a dressing has come off of a wound. Review of the facility policy titled Pressure ulcer & Skin Care Management did not list any information related to moving/repositioning a resident frequently when in a sitting position nor did it list direction for staff if a resident was discovered without a dressing to a pressure area. Review of the Agency for Health Care Policy and Research Clinical Practice Guideline related to Pressure Sores, under the section Tissue Load Management, states Move a sitting patient at least once an hour. :",2017-10-01
6741,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,325,D,0,1,80UC11,"**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 implement interventions to prevent or correct significant weight loss for 1 of 6 sampled residents reviewed for weight loss. Resident # 88 experienced a 33 pound weight loss that was not identified or addressed for the need of possible intervention. The findings included: The facility admitted Resident #88 with [DIAGNOSES REDACTED]. Record review on 7/10/2014 at approximately 3:08 PM revealed a significant weight loss off 33 pounds that occurred from January 2014 to July 2014. Review of the facility form entitled,Monthly Weight and Vital Signs Record, that listed a January 2014 weight of 224 pounds, February 2014 weight of 222 pounds, March 2014 weight of 218 pounds, April 2014 weight of 211 pounds, May 2014 weight of 216 pounds, June 2014 weight of 214 pounds and July 2014 weight of 185 pounds and another weight on 7/8/2014 of 191 pounds. Cumulatively the resident lost 33 pounds during this time period Review of the Nutritional Risk Assessment by the Certified Dietary Manager (CDM) on 7/10/2014 at approximately 3:08 PM revealed an assessment date of 7/8/2014, but it did not include the July 2014 weight of 185 pounds. Review of the, Dietary Progress Notes, dated 7/8/2014 at 10:45 AM stated, Resident on 6/1/2014 weighed 214.1 pounds. His/her weight is stable at 30 and 180 day look back. 5/1/2014 weight is 216 pounds, on 12/1/2013 weight is 224 pounds. He/she feeds himself/herself and consumes 50-75% of a Carbohydrate Controlled No Added Salt regular consistency diet. He/she is allergic to shrimp. Receives Prostat 30 milligrams 2 times daily and Hydration 4 times daily. He/she has a [DIAGNOSES REDACTED]. Will continue plan of care. During an interview on 7/10/2014 at approximately 5:00 PM the CDM confirmed the significant weight loss and he/she stated: The documentation on the Dietary Progress Notes is incorrect. S/he stated s/he had failed to identify and address Resident #88's weight loss and incorporate interventions to maintain a stable weight.",2017-10-01
6742,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,329,D,0,1,80UC11,"**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 Resident #21 and Resident #55 received [MEDICAL CONDITION] medications related to an appropriate diagnoses. Resident #21 received [MEDICATION NAME] for a [DIAGNOSES REDACTED].#55 received [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The findings included: Record review on 7/7/2014 at approximately 4:12 PM for Resident # 21, revealed a physician's orders [REDACTED]. Review of Resident #21's Comprehensive Care Plan on 7/7/2014 at approximately 4:12 PM dated 10/30/2013 revealed a problem of Alzheimer related dementia and an intervention to administer [MEDICATION NAME] as ordered. There was no documentation noted or provided that other interventions were attempted prior to prescribing a [MEDICAL CONDITION] medication. An interview on 7/10/2014 at approximately 9:05 AM with the Unit Manager for the 100 Hall confirmed and verified the [MEDICATION NAME] was ordered for Dementia. The facility admitted Resident # 55 with [DIAGNOSES REDACTED]. Record review on 7/10/2014 at approximately 11:00 AM revealed a physician's orders [REDACTED]. Review of Resident #55's Comprehensive Care Plan on 7/10/2014 at approximately 11:00 AM revealed a problem of dementia and an intervention to administer [MEDICATION NAME] as ordered. There was no documentation noted or provided that other interventions were attempted prior to prescribing a [MEDICAL CONDITION] medication. An interview on 7/10/2014 at approximately 4:24 PM with Licensed Practical Nurse (LPN) #1 verified the [MEDICATION NAME] was ordered for a [DIAGNOSES REDACTED].",2017-10-01
6743,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,366,E,0,1,80UC11,"On the days of the survey, based on observation and interview, staff in one of three dining rooms failed to offer alternates for uneaten food items. Two residents in the main dining room were not offered a substitute for squash left on their plates. One of the two residents was not offered a substitute for beans during a second meal observation. The findings included: During meal observation in the main dining room at approximately 12:25 PM on 7-7-14, three residents at the first table, just inside the entrance to the dining room, left their squash (zucchini) untouched on their plates. At 12:28 PM, Resident #57 took a bite of the squash and spit it out. Certified Nursing Assistant (CNA) #7 took ice cream off the tray, placed it in front of the resident and told her/him to eat it. S/he then removed the resident's tray from the table. No alternate vegetable was offered. At 12:31 PM, Resident # C got up and left the dining room with her/his walker without eating the vegeble or being offered a substitute. CNA #2 asked, Are you finished? and removed Resident tray without offering an alternate. During an interview immediately following the meal, the Certified Dietary Manager stated that substitutes were available for meals if the resident requested them. S/he referred to a posting in the corridor just outside the main dining room that included substitutes available daily upon request. During observation of the noon meal on 7-9-14, Resident #C again left a food item (beans) untouched. S/he left the dining area without being offered an alternate.",2017-10-01
6744,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,371,F,0,1,80UC11,"On the days of the survey, based on observation and interview, the facility failed to store and prepare food under sanitary conditions. Dietary staff stored clean dishes stacked wet and inappropriately air dried glasses. The Convection oven door had dried spills and baked-on food particles. Hand sanitizer was being used in the kitchen. These breaches in sanitation had the potential to affect all residents in the facility not fed via Gastrostomy tubes. The findings included: During the Initial Tour of the kitchen on 7-7-14 at 10:10 AM Hand Sanitizer was noted in a dispenser on the wall by the handwashing sink. The convection oven door was noted dried spills and baked-on food particles. A tray of plastic dessert bowls (approximately 30) were stacked open side up and wet. This was verified by Dietary Staff #1 and the Certified Dietary Manager (CDM) who then restacked the wet dessert bowls. A tray of approximately 30 3-4 ounce glasses were set to dry on tray, open side up, uncovered, with moisture pooling in the bottoms. When asked how glasses were dried, the CDM said, This is the way they do it, then stack the glasses when dry. When the surveyor asked the Dietary Aide if this was the way they did it normally, s/he said, Yes. At 11:58 AM on 7-8-14, food temperatures were taken by the cook with the CDM present after the thermometer was calibrated. At least five trays had already been plated and placed on the tray rack for delivery to the residents. The Pudding temperature read 48 degrees. Food items continued to be plated for serving. The surveyor asked if they were going to cool down the pudding and the CDM told dietary staff to put the pudding in the freezer, after checking an unopened can of pudding. Instructions on the can stated it was a milk product and was to be refrigerated after opening. Upon return to the kitchen at 12:20 PM, dietary staff were observed serving the pudding at 50 degrees. Six trays were on the cart ready to be served. When asked if they had cooled down the pudding in the freezer, a tray of pudding was taken out of the freezer and measured at 41 degrees. At 2:15 PM on 7-9-14, the convection oven had dried spills and food particles remaining on the door. This was verified by Dietary Staff #2. The cleaning schedule was requested and reviewed. No ovens were listed on the schedule for routine cleaning which was verified by Dietary Staff #2. The surveyor questioned Dietary Staff #3 in the presence of the CDM as to how often staff used the Purell Hand Sanitizer on the wall. S/he responded,Every time we wash our hands. The 2013 Food Code page 149 Chapter 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles states: (B) Clean EQUIPMENT and UTENSILS shall be stored . (1) In a self-draining position that allows air drying; and (2) Covered or inverted. Page 48 Chapter 2-301.16 Hand Antiseptics states: (A) A hand antiseptic used as a topical application .shall be: (1) Followed by thorough hand rinsing in clean water before hand contact with food or by the use of gloves; or (2) Limited to situations that involve no direct contact with food by the bare hands.",2017-10-01
6745,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,372,F,0,1,80UC11,"On the days of the survey, based on observation and interview, the facility failed to store the grease container on a solid surface as required. This has the potential to affect all residents of the facility. The findings included: During a tour with the Certified Dietary Manager on 7-8-14 at 12:10 PM, the grease container was observed next to a storage building on the ground, not stored on a solid/firm surface as required. The 2013 Food Code page 167 Chapter 5-501.11 Outdoor Storage Surface states: An outdoor storage surface for refuse, recyclables, and returnables shall be constructed of nonabsorbent material such as concrete or asphalt and shall be smooth, durable, and sloped to drain.",2017-10-01
6746,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,431,D,0,1,80UC11,"**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 titled Drug and Biological Storage, the facility failed to ensure a container of expired sterile water for inhalation was not stored with other supplies available for resident use on 1 of 2 units. The findings included: On [DATE] at approximately 11:30 AM, observation of the Stone Wing Clean Utility Room revealed one container of 1000 milliliters (ml) Airlife Sterile Water for Inhalation, USP: Cardinal Health, McGaw Park, Illinois , USA, Lot # G 5 with an expiration date of [DATE] in a storage bin. During an interview on [DATE] at approximately 11:30 AM with Licensed Practical Nurse (LPN) #3, h/she, after observation of the expired item, stated, The oxygen supplies are checked by the staff in Central Supply. I will discard this. On [DATE] at approximately 3:13 PM, review of the facility policy titled Drug and Biological Storage revealed in the section Procedure the following: 4. Store drugs in an orderly manner in cabinets, drawers, or carts. a.) No discontinued, outdated, or deteriorated drugs or biological's may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with the procedure governing the destruction of medication.",2017-10-01
6747,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-07-18,441,F,0,1,80UC11,"**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 accurate system of data retrieval and tracking of infections to enable evaluation of trending of infections within the facility. This lack of accuracy of data collection and limited frequency of data review has the potential to affect all residents in the facility with regard to prevention and transmission of infections. The findings included: The facility admitted Resident #93 with [DIAGNOSES REDACTED]. Record review on 7-9-14 at 10:59 AM revealed that a physician's orders [REDACTED]. Dx. (diagnosis): Diabetic ulcer with purulent drainage. The culture was obtained on 4-9-14. The results were reported on 4-14-14 at 7:02 AM. The physician was notified on 4-15-14 and ordered Bactrim DS one PO (by mouth) BID (twice daily) x 10 days. Dx : MRSA (Methacillin Resistant Staphylococcus Aureus) wound great R(ight) toe. Contact Precautions . An X-ray was done on 4-10-14 to rule out [DIAGNOSES REDACTED]. Review of the Infection Control Logs for the month of April, 2014 revealed no entry for Resident #93. During an interview on 7-9-14 at I:l0 PM, the Assistant Director of Nurses, who was identified as the Infection Preventionist, reviewed the resident's record and verified that the required information had not been entered into the log. When queried about infection surveillance data gathering, s/he stated that the Unit Managers on each hall were responsible for completing and submitting infection data on a monthly basis. S/he would then compile the data to determine trends. S/he had no way to verify the accuracy or completion of the data and did not keep the originally submitted information. S/he did not review all residents on antibiotics or review lab reports of infections until submitted by the Unit Managers.",2017-10-01
6802,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2014-09-23,205,D,1,0,5V1Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Resident #1 received the 10 day bed hold information at time of discharge to the hospital, and was not allowed readmission into the facility after a brief hospital stay for 1 of 4 residents reviewed for discharge. The findings include: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record on 9/23/2014 at approximately 9:30 AM revealed a physician's orders [REDACTED].#1 to the hospital for a psychiatric evaluation. Resident #1 agreed to go, but did not receive the 10 day bed hold information. After the resident was out of the facility, the facility refused to accept the readmission of the resident; s/he was within the 10 day bed hold at time of the anticipated discharge from the hospital. An interview with the Administrator and Consultant on 9/23/2014 at approximately 11:20 AM confirmed the findings and both verbalized the lack of documentation in Resident #1's medical record concerning his/her discharge to the hospital and/or his/her return. An interview on 9/23/2014 at approximately 11:30 AM with a Consultant, s/he stated the administrator repeatedly told hospital staff that this resident would not be returning to the facility upon discharge from the hospital.",2017-09-01
7775,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,360,D,0,1,Q5B511,"**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 residents received a diet to meet their special nutritional needs for 1 of 1 resident who showed a significant weight loss and whose dietary recommendations were not implemented in a timely manner. ( Resident #9). The findings included: Resident #9 with [DIAGNOSES REDACTED]. The resident displayed continued and significant weight loss since admission in May 2012. On 11/27/12, the Registered Dietitian evaluated the resident again. Assessment notes showed the resident lost 17 pounds in 12 days, representing a 12.3 % weight loss. The resident's overall weight loss was 28 pounds, a 20 % loss over 180 days. According to the assessment, the resident was not eating enough to meet her estimated nutritional needs to prevent weight loss. The following nutrition interventions were recommended by the dietician on 11/27/12: 1. appetite stimulant not eating & taking little fluids; 2. fortified juice at breakfast; 3. Magic cup at dinner daily; 4. continue shakes four times a day; and 5. ProStat 101, 30 milliliters twice a day. Observations of the resident during the survey revealed the resident had little interest in eating. Interviews with the staff revealed the resident did like soup, otherwise intake was poor. Record review on 12/4/12 failed to show that the facility implemented the dietary recommendations. An interview with the Assistant Director of Nursing (ADON) on 12/5/12 at approximately 10:30 AM revealed dietary recommendations were submitted to the Director of Nursing/ADON. The recommendations were then placed into the physician's folder to be addressed. A search of the the physician's folder for this resident revealed the physician signed the recommendation form but did not date it or designate approved or I do not approve. Staff members stated the physician was in the facility earlier that day. After the interview, the ADON called the physician and obtained the orders to institute the recommendations.",2016-11-01
7776,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,365,D,0,1,Q5B511,"On the days of the survey, based on observations, record review, and interview, the facility failed to provide food in a form designed to meet individual resident needs for 1 of 9 residents observed during meals (#5). The findings included: Resident #5 had a regular diet with chopped meats ordered. An observation of the noon meal on 12/4/12 revealed the resident was given two slices of roast pork with gravy on top. At the supper meal on 12/4/12 the resident was given a boneless chicken breast that appeared to be cut into large chunks. At the supper meal, the Dietary Manager was asked about the consistency of the meat served and verified that the chicken was not chopped. The Dietary Manager also confirmed that the resident received sliced pork instead of chopped pork at the noon meal.",2016-11-01
7777,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,502,D,0,1,Q5B511,"**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 laboratory tests were done as ordered for 2 of 10 residents reviewed for lab services (Residents #6 and #10). The findings included: Resident #10 arrived at the facility on 11/2/12 following hospitalization for metabolic acidosis. Review of the medical record revealed a physician's orders [REDACTED]. Do STAT (immediately) if not done yet. Review of the resident's admission orders [REDACTED]f/u (follow-up) BMP 11/5/12. That notation had not been transcribed as an order and the lab was not done on 11/5/12. Review of the laboratory results in the medical record revealed the BMP ordered STAT on 11/8/12 was not drawn until 11/9/12 and the results were not reported until 11/12/12, indicating that the test was not done STAT as ordered. Resident # 6 was admitted to the facility with [DIAGNOSES REDACTED]. On 12/04/2012 at 2:30 PM review of the Physician's Telephone Orders for Resident # 6, dated 11/20/2012 stated H&H (Hemoglobin and Hematacrit), BMP (Basic Metabolic Panel), Fe (Iron) on 26 Nov(ember) Review of the laboratory reports revealed that there were no laboratory results for the H&H, BMP, and Fe as ordered by the physician. On 12/05/2012 at 3:00 PM, the ADON reviewed and verified that there were no laboratory results for the physician ordered lab tests.",2016-11-01
8129,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2013-07-11,309,D,1,0,JNYK11,"**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 the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. Sliding scale insulin was not administered as ordered for two residents reviewed (Resident's #1 and #7). The findings included: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED].#1's care plan revealed at risk for hypo or [MEDICAL CONDITION] related to [DIAGNOSES REDACTED]. Interventions and approaches to this problem area were documented on the care plan and included finger stick blood sugars as ordered. Review of Resident #1's June 2013 Medication Administration Record [REDACTED] 201 - 250 = 2 units 251 - 300 = 4 units 301 - 350 = 6 units 351 - 400 = 8 units BS > 400 give 12 units and call MD The MAR indicated [REDACTED]. Resident #1 also had a Finger Stick Blood Sugar of 260 on 6/27/13 at 6:00 AM and no insulin was administered. Resident #7 was admitted to the facility with [DIAGNOSES REDACTED].#7's care plan revealed at risk for hypo or [MEDICAL CONDITION] related to [DIAGNOSES REDACTED]. Interventions and approaches to this problem area were documented on the care plan and included insulin per orders. Review of Resident #7's May and June 2013 Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. 5/8/13 at 12:00 AM Fingerstick Blood Sugar (FSBS) 200 = 0 insulin given 5/9/13 at 12:00 PM FSBS 200 = 0 insulin given 5/10/13 at 6:00 PM FSBS 200 = 0 insulin given 5/20/13 at 12:00 PM FSBS 200 = 0 insulin given 5/20/13 at 6:00 PM FSBS 222 = 0 insulin given 5/21/13 at 6:00 PM FSBS 200 = 0 insulin given 6/20/13 at 9:00 AM FSBS 227 = 0 insulin given During an interview with the Director of Nursing (DON) on 7/11/13 s/he stated that nurse's use the Physician's Standing Orders for Sliding Scale Insulin. The Standing Orders are located in a notebook at the nurse's station. Review of Physician's Standing Orders, provided by the Director of Nursing, revealed Sliding Scale Insulin should be administered as follows: 200 - 250 = 2 units 251 - 300 = 4 units 301 - 350 = 6 units 351 - 400 = 8 units BS > 400 give 12 units and call MD",2016-07-01
8130,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2013-08-20,280,D,1,0,D3YT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review and interviews, the facility failed to revise/update the comprehensive and CNA (certified nurse aide) care plan for 1 of 3 residents sampled. Resident #1 did not have his/her comprehensive or CNA care plan updated to reflect a new intervention implemented by staff on 7/29/13. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. The resident's completed quarterly MDS (minimum data set) dated 7/3/13 coded the resident with a BIMS (brief interview of mental status) of 14 and requiring the assistance of 1 person for ADL (activity of daily living) care. The resident was coded as continent of bowel and bladder. A record review conducted on 8/20/13 at 11:05 AM revealed that Resident #1 experienced a fall with injury on 7/25/13 at 3:00 AM, when s/he removed the bed alarm and toileted him/herself without assistance from the staff. Continued review of the nurse's notes revealed on 7/29/13 at 7:15 PM, the resident's son requested that the resident have a brief on for night time. The nurse explained that Resident #1 was continent and the staff would take her to the bathroom when s/he asks. The DON (director of nursing) and the ADON (assistant director of nursing) were notified and informed the son that Resident #1 would be toileted every 2 hours. A review of the care plan initiated on 11/14/12 revealed that the resident had several interventions in place to prevent falls. The care plan had the following approaches in place for falls: 1) Encourage and remind resident to call for needed assist with transfers. 2) Remind resident to call for staff to pick up anything that has fallen to the floor. 3) Review any falls that occur for needed change in care plan. 4) Inform therapy of any falls for assessment. 5) Give needed assist with transfers and ambulation. 6) Therapy as directed. 7) Call light within reach at all times when in room. 8) Alarms as indicated to bed and chairs.---Pressure Pad alarm bed-7/25 9) Anti-rollback brakes to w/c (wheelchair). 10) RW (rolling walker) with supervision for ambulation. 11) Inservicing of staff prn (as needed). 12) Falling star program -11/27/12 discontinued on 2/5/13. Add Non skid strips beside bed and in front of toilet/sink/recliner chair 2/14/13. 1/13/13-Resident remain on falling star program. 12/12/12-IDT (interdisciplinary team) Continues to be at risk for falls. Falling star program continues. 2/5/13-Resident remains on [MEDICATION NAME] and [MEDICATION NAME]-has pressure pad to sitting chair, to wheelchair and alarm to bed. 4/19/13-Continues to be at risk for falls, no recent falls noted. 7/4/13-Remains free from falls. 7/25/13-Resident self removed alarm and was unassisted to bathroom, fell . Pressure pad alarm to bed. 8/8/13-IDT (interdisciplinary team) risk related to fall-continue plan of care. The intervention to toilet the resident every 2 hours from 7/29/13 had not been added to the comprehensive care plan nor had it been added to the CNA Care Cardex Worksheet. An interview was conducted on 8/20/13 at 4:40 PM with the MDS (material data set) Coordinator who stated that when a resident has a fall the care plans are updated the next day when they find out about them. The MDS Coordinator stated s/he was not familiar with any interventions related to the last fall for Resident #1. To my knowledge I don't remember it coming up (toileting every 2 hours). After the MDS Coordinator review the current care plan, s/he stated, I don't remember it coming up in morning meeting.",2016-07-01
8670,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2013-01-22,323,G,1,0,OTMU11,"**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 facility files, the facility failed to provide appropriate supervision to prevent falls for 1 of 4 residents with a history of seizures. Resident # 1 was left unattended in the bathroom, had a seizure and fell from the toilet, which resulted in a cervical fracture. The findings included: Resident #1 sampled as a result of a facility reported incident that alleged s/he was a fall risk who sustained a cervical fracture when left unattended in the bathroom. Review of Resident #1's current medical record and the facility investigation revealed that the facility failed to provide adequate interventions to prevent injury when the resident was left in the bathroom unattended on 12/14/2012. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed notes written on 12/14/12 that documented, 10:30 AM: Resident was participating in PT (Physical Therapy) Began to have seizure activity. Lasted for about 5 (five) sec. (seconds). Placed in the bed . 1:40 PM: Res. (resident) was discovered in floor in his/her room by his/her nurse. S/he was lying parallel to the left side of the bed . A&O (alert and oriented) X 3. 4:15 PM: Res. transported to _____(Hospital) d/t (due to) fall and laceration to left side of head. Res. was discovered by this nurse in the restroom; seizing on his/her left side. Blood was noted coming from his/her left side of his/her head . Nurse's Note of 12/20/12, 5:15 PM : Resident returned to facility from hospital via w/c (wheel chair) . Has [DIAGNOSES REDACTED]. Has neck brace in place. Seven stitches noted to L side of forehead. Bruise noted to R forearm. Three scabs noted to top of right hand . Review of the Hospital Discharge Summary dated 12/20/12 revealed a Discharge [DIAGNOSES REDACTED]. Generalized tonic-clonic seizures. 2. Fall with resultant cervical fractures at C 1 and C 5. 3. Urinary Tract Infection . History of Present Illness: .Today at the nursing home, the patient was noted to have a seizure followed by loss of consciousness and hit his head with lacerations on his forehead . CT spine did show nondisplaced acute fracture of anterior and inferior endplate of C 5 with minimally displaced acute fractures in the right lateral mass of C 1. In an interview with the surveyor on 1/15/2013 at approximately 5:30 PM, the Occupational Therapist (OT) confirmed the resident had a seizure earlier in the day of 12/14/12 while in therapy. S/he stated the resident slid from the bed while eating lunch earlier in the day. We gave him the pressure pad at the time and put the strips down. S/he had problems with voiding before. S/he was acting like s/he did when s/he had a urinary tract infection. The nurse was aware of the behaviors. In a telephone interview with the surveyor on 1/22/13 at approximately 11:15 AM, Registered Nurse #1, stated the resident had a seizure in therapy during the morning. S/he stated s/he had a history of [REDACTED]. Around lunch the resident slipped off the bed. Later in the day OT (occupational therapy) was working with the resident and assisted him with the urinal. S/he did not want anyone around when s/he was using bathroom . After 3, I was in the room with connecting bathroom. I heard a crash and went into bathroom and s/he was lying on the floor seizing. I opened the door to yell for assistance. The 3-11 CNA (#1), said s/he was trying to find me because s/he was yelling at her/him to get out of bathroom. S/he had been left in bathroom alone before. S/he was alert and knew how to use the call light. The nurse was not aware if the CNA knew the resident had a seizure and a fall earlier in the day. Certified Nursing Assistant (CNA) #1 was interviewed by the surveyor on 1/16/13 at approximately 11:10 AM. The CNA stated, I came on duty at 3:00 PM . I took Resident #1 to the bathroom s/he stood up and pulled his/her clothes down and told her/him to shut the door. I went to find the nurse because s/he was upset, s/he didn't want the alarms. S/he was not his/her normal self . The nurse was in the room next door to the resident's, s/he heard him/her when he/she had the fall. S/he went in the bathroom and saw him/her on the floor . The nurse said s/he had a seizure . I didn't know s/he had a seizure earlier or that s/he had fallen prior to that incident. Normally the CNA who has them on day shift gives report on the residents. That CNA was already gone that day . I normally wouldn't leave the room, I would do something in room. I left that day to get the nurse cause s/he was so upset. Review of the care plan in use at the time of the fall dated 10/2/2012 and last updated 12/12/2012 revealed the resident was at risk for falls. Interventions included, alarm to bed and chair, resident education for safety issues, and falling star program. On 12/14/2012 the care plan was updated related to the resident's preference for privacy when using the restroom. Interventions included .2. If resident is in the restroom staff is not to leave the room. 3. Staff is to stand beside door while resident is in the restroom. Seizure Disorder was care planned on 10/3/2012 and last updated 12/12/2012. Interventions included 1. Monitor for signs and symptoms of seizures .; 2. If seizure occurs, provide safety as able . 5. Provide safe environment per policy. 6. M-side rails . Review of the CNA (Certified Nursing Assistant) Care Cardex Worksheet revealed the resident was to have M rails, alarm to bed and chair, Non skid strips at bedside. C-Collar at all times remove during care. Do not leave in bathroom unattended. There was nothing documented regarding the resident's seizure activity or history. The entries were not dated when added to the Worksheet.",2016-01-01
8752,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,157,D,0,1,DFWX11,"**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 of changes in the resident's blood pressure potentially requiring physician intervention for one of fifteen sampled residents reviewed for medication assessment. Resident #7 was on multiple antihypertensive medications with deviations from normal blood pressures recorded without physician notification. The findings included: The facility admitted Resident #7 on 7/1/10 with [DIAGNOSES REDACTED]. Record Review on 11/8/11 at 11:15 AM revealed physician's orders [REDACTED].[MEDICATION NAME] 100 mg one tablet by mouth two times a day. On 11/8/11 at 9:30 AM, review of the Medication Administration Record [REDACTED] On 11/8/11 at 2:00 PM, review of the Nurse's Notes and Stone Wing V/S (Vital Signs) forms, the following blood pressures were recorded without evidence of physician notification: 9/8/11=91/60; 9/9/11=96/56; 9/10/11=96/56; 9/11/11=98/60; 9/12/11=96/58; 9/15/11=88/50; 9/19/11=98/60; 9/20/11=97/65; 9/20/11=99/60; 9/22/11=96/55; 9/23/11=96/55; 9/29/11=96/55; 9/30/11=96/55; 10/13/11=96/50; undated=97/50; 10/20/11=96/52; 10/21/11=96/52; 10/27/11=96/54; 10/30/11=99/56; 11/3/11=161/109; 11/7/11=97/58; 11/8/11=97/58. During an interview on 11/8/11 at 2:45 PM, Nurse Consultant #1 reviewed the recorded blood pressures and stated I would have notified the Doctor of blood pressures with a systolic of less than 100 and diastolic greater than 100. Review of the Physician's Progress Notes on 11/10/11 at 4:00 PM, revealed no evidence that the physician was aware of irregularities in the blood pressure.",2015-12-01
8753,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,281,E,0,1,DFWX11,"**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 15 residents reviewed for acceptable standards of practice (Resident #1, #5, #21). Transcription errors regarding the medication [MEDICATION NAME] were made on the Physician's admission orders [REDACTED]. The facility staff failed to administer medication as prescribed for Resident #5 and Resident #21. The facility staff further failed to document the correct administration time on the Medication Administration Record [REDACTED]. The findings included: The facility admitted Resident #5 on 08-31-11 with [DIAGNOSES REDACTED]. Record review on 11-08-11 at approximately 4:15 PM of the Physician's Orders dated 10-01-11 through 10-31-11 and 11-01-11 through 11-30-11 for Resident #5 revealed an order of Glimepiride (for [MEDICATION NAME]) 4 milligram (mg) tablet: 1 tab via Gastrostomy (G) Tube every day with Hour of 9:30 AM. Record review on 11-09-11 of the Medication Administration Record [REDACTED] 10-03-11 through 10-06-11: Glimepiride not documented as administered. 10-08-11 through 10-11-11: Glimepiride not documented as administered. 10-13-11 through 10-30-11: Glimepiride not documented as administered. Record review on 11-09-11 of the Medication Administration Record [REDACTED] 11-08-11: Glimepiride not documented as administered. Review on 11-09-11 at approximately 9:20 AM of the Pill Call and Treatment Schedule St. George HealthCare revealed in section Gastric Tube Pill Call Schedule: This pill call schedule supersedes the pill call schedules set up per resident rooms. All residents who receive their medications via gastric tube will follow this pill call schedule: Time of day - Every Day (QD) 12 AM. During an interview on 11-09-11 at approximately 11:20 AM with Licensed Practical Nurse (LPN) #3, she, after chart review, verified the medications had not been documented as administered. The facility admitted Resident #21 on 05-30-09 with [DIAGNOSES REDACTED]. Record review on 11-09-11 at approximately 4:50 PM of the admission orders [REDACTED]. Record review of the Physician's Orders dated 08-01-11 through 08-31-11, 07-01-11 through 07-31-11, and 05-01-11 through 05-31-11 revealed an order of [MEDICATION NAME] 100 mcg/1 milliliter (ml) Vial: Inject 1 ml (100 mcg) subcutaneous (subq) once weekly. Further record review on 11-09-11 of the admission orders [REDACTED] 04-14-11: [MEDICATION NAME] 100 mcg not documented as administered. Record review of the Medication Administration Record [REDACTED] 05-05-11, 05-12-11, and 05-26-11: [MEDICATION NAME] 100 mcg not documented as administered Record review of the Medication Administration Record [REDACTED] 07-01-11 through 07-31-11: [MEDICATION NAME] not documented as administered Record review of the Medication Administration Record [REDACTED] 08-02-11: [MEDICATION NAME] 100 mcg not documented as administered During an interview on 11-10-11 with Nurse Consultant #1, she, after Medication Administration Record [REDACTED] The facility admitted Resident #1 on 10/3/07 with [DIAGNOSES REDACTED]. Record review on 11/8/11 revealed a physician's order dated 9/7/11 for [MEDICATION NAME] 15 milligrams(mgs) q(every) 8 hours. Review of the monthly printed physician orders for the months of October and November 2011 revealed the order as [MEDICATION NAME] 15 mg three times daily as needed. Review of the Medication Administration Records for the months of September, October, and November 2011 revealed the order as transcribed as [MEDICATION NAME] 15 mg every 8 hours as needed. Review of the MAR's revealed the resident had only received the medication one time since the medication was ordered on [DATE]. On 11/19/11, during an interview with Nurse Consultant #1, she confirmed that the order had not been transcribed as ordered. Readmission orders [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the record with Nurse Consultant #1 on 11/19/11 confirmed these two drugs had not been transcribed. Review of the facility policy titled Medication Pass Guidelines revealed under the section of Fundamental Information - Physician's Orders the following: Medications are administered in accordance with written orders of the attending physician. The nurse who receives the order is responsible for transcribing to the chart.",2015-12-01
8754,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,314,D,0,1,DFWX11,"**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 who enter the facility without pressure ulcers do not develop pressure ulcers and that residents with pressure ulcers receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for three of seven sampled residents. Residents #1did not receive accurate comprehensive skin assessments in order to identify a pressure ulcer. The findings included: The facility admitted Resident #1 on 10/3/07 with [DIAGNOSES REDACTED]. Record review on 11/8/11 revealed a nurse's note dated 9/29/11 stating .while changing dressing to left lower extremity noted a necrotic area on left lateral foot 6.3 x 6.2 area goes onto 5th digit. Weekly skin assessments from 6/4/11 - 8/20/11 did not identify any area to the left foot. On 8/25/11, a body audit was completed by the Nurse Consultant in which a 3 x 2.5 area was observed on the left outer foot by little toe. Resident #1 was admitted to the hospital on [DATE] and readmitted on [DATE]. Nursing admission assessment on 8/30/11 did not identify the area on the left foot. The area was not identified again until 9/29/11. During an interview with Nurse Consultant #1 and #2 on 11/9/11, no explanation was given as to why the area was not identified upon readmission.",2015-12-01
8755,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,323,D,0,1,DFWX11,"On the days of the survey, based on observations and interviews, the facility failed to ensure the safety of residents by not securing 2 of 2 restrooms which were accessible to residents and had no call light system in place for resident use. The findings included: During the initial tour on 11/8/11 and throughout the days of the survey, observations were made of 2 restrooms that were unlocked with no call system in place for residents. The restrooms were located on the opening of the hallway across from the nursing stations near resident rooms. The facility had cognitively impaired residents who can ambulate throughout the facility. During an interview on 11/9/11 at 11:30 AM, the Maintenance Director and Environmental Consultant verified there was no call system in place and agreed that this was a potential safety hazard for residents.",2015-12-01
8756,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,333,E,0,1,DFWX11,"**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 15 sampled residents reviewed for medication administration were free of any significant medication errors. There was no documentation that Resident #5, with [DIAGNOSES REDACTED]. Resident #21, with [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #5 on 08-31-11 with [DIAGNOSES REDACTED]. Record review on 11-08-11 at approximately 4:15 PM of the physician's orders [REDACTED].#5 revealed an order of Glimepiride (for [MEDICATION NAME]) 4 milligram (mg) tablet: 1 tab via Gastrostomy (G) Tube every day. Record review on 11-09-11 of the Medication Administration Record [REDACTED] 10-03-11 through 10-06-11: Glimepiride at 9:30 AM 10-08-11 through 10-11-11: Glimepiride at 9:30 AM 10-13-11 through 10-30-11: Glimepiride at 9:30 AM 11-08-11: Glimepiride at 9:30 AM During an interview on 11-09-11 at approximately 11:20 AM with Licensed Practical Nurse (LPN) #3, she, after chart review, verified there was no documentation that the medications had been administered as ordered. The facility admitted Resident #21 on 05-30-09 with [DIAGNOSES REDACTED]. Record review on 11-09-11 at approximately 4:50 PM of the admission orders [REDACTED]. Record review of the physician's orders [REDACTED]. Further record review on 11-09-11 of the Administration Record for Resident #21 dated 04-07-11 revealed no documentation the medication was administered per the physicians orders for the following dates: 04-14-11, 05-05-11, 05-12-11, 05-26-11, 07-01-11 through 07-31-11 and 8-02-11: During an interview on 11-10-11 at approximately 10:15 AM with Nurse Consultant #1, she, after chart review, confirmed the above findings.",2015-12-01
8757,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,367,D,0,1,DFWX11,"**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 serve diets as ordered by the physician for two of five sampled residents reviewed with orders for therapeutic diets. Resident #8 and Resident #10 did not receive therapeutic diets as ordered by the physician for two days of the survey. The findings included: The facility admitted Resident #10 on 9/23/2011 with [DIAGNOSES REDACTED]. Review of the medical record on 11/08/2011 at 4:30 PM revealed a Physician's Telephone Order for Controlled Carbohydrate Heart Healthy Regular Texture dated 10/13/2011. Observation of the lunch meal on 11/08/2011 at 1:08 PM revealed the resident received roast turkey, green beans, stuffing with gravy, white roll, sweet potato pie, and 8 ounces (oz ) 2% milk. Review of the planned menu revealed the resident should have received a wheat dinner roll, 8 oz skim milk and stuffing with no gravy. Observation of the evening meal tray on 11/08/2011 at 6:00 PM revealed the resident received fried okra, corn bread, salmon patty, blackeye peas, 8 oz skim milk, and citrus fruit salad. Review of the planned menu revealed the resident should have received baked fish with dill sauce, vegetarian lackey peas, one half (1/2) cup steamed okra, and a wheat dinner roll. Observation of the lunch meal tray on 11/09/2011 at 12:35 PM revealed the resident received 3 oz baked meatloaf with gravy, 1/2 cup mashed potatoes, steamed greens, 1/2 cup cinnamon pears, white roll, and 4 oz 2% milk. Review of the planned menu revealed the resident should have received 8 oz skim milk and baked meatloaf with no gravy. During the interview on 11/10/2011 at 11:00 AM, the Dietary Manager verified the diet ordered by the physician, reviewed the planned menu and verified what the resident should have received. The Dietary Manager was unable to verify if the vegetarian lackey peas had been prepared because the temperature log only showed the temperature of two unidentified vegetables, while the planned menu called for preparation of five vegetables in regular consistency. The facility admitted Resident #8 on 10/16/11 with [DIAGNOSES REDACTED]. Record review on 11/8/11 revealed the diet ordered for the resident was a Renal, No Added Salt, CCHO.(Carbohydrate Controlled) Observation of the dinner meal on 11/8/11 at 6:10 PM revealed the resident's tray card listed the diet as Renal, CCHO, No added salt diet. The resident was served Baked fish, black-eyed peas, fried okra, fruit slices, milk, and water. Per the planned/approved menu, the resident should have received steamed okra. Observation of the dinner meal on 11/9/11 at 6:15 PM revealed the resident received sausage, cabbage, carrots, a cookie, slice of bread, 2% milk, brown rice, and water. Per the planned/approved menu, the resident should have received roast pork and a dinner roll.",2015-12-01
8758,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,371,D,0,1,DFWX11,"**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 food transport equipment for [MEDICAL TREATMENT] residents. The findings included: During an interview on 11/09/11 at approximately 9:00 AM, Dietary Staff #1 was asked to explain the process for transporting bagged lunches sent out of the facility with residents attending [MEDICAL TREATMENT]. Dietary Staff #1 stated that the prepared lunch was placed in a zip lock plastic bag labeled with the resident's name and placed in the cooler until the resident left for [MEDICAL TREATMENT]. Dietary Staff #1 showed the surveyor a heavy-duty plastic zip lock bag which was used for this purpose. When asked if the plastic bag was placed into another food transport container when the resident went out of the facility, Dietary Staff #1 confirmed that there was no other container used. The facility admitted Resident #8 on 10/16/11 with [DIAGNOSES REDACTED]. During an interview with Resident #8 on 11/8/11 at 5:45 PM, she stated that when going to [MEDICAL TREATMENT], she carried her lunch in a white paper bag. She continued by stating that lunch composed of items such as a ham sandwich, fruit cocktail, cookies, and a soda. During an interview with LPN(Licensed Practical Nurse)#4 on 11/9/11, she stated that the resident had left early that day and had a sandwich in a zip-lock bag. On 11/9/11, the Dietary Manager was asked to show the surveyor how lunches were stored for [MEDICAL TREATMENT] residents. After going to the kitchen and searching, the Dietary Manager could not find any insulated containers. She then stated that she had received them from Admissions and would ask them if they had any insulated containers. After inquiring with Admissions, the Dietary Manager stated that there were no insulated containers available.",2015-12-01
8759,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,425,D,0,1,DFWX11,"On the days of the survey, based on observation, interview and the Drug Facts and Comparisons book (updated monthly) 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 11/8/11 at approximately 8:40 AM, inspection of the Stone Medication Room refrigerator revealed the following: -One opened floor stock vial of Tuberculin PPD (purified protein derivative), Diluted, Aplisol 10 test, 5 TU (test units)/0.1 ml (milliliter) was not labelled as to date opened. The vial was labelled as dispensed by the pharmacy on 7/15/11 and was labelled by the manufacturer (JHP Pharmaceutical) with lot number 1 and expiration date 01/13. According to the manufacturer package insert and Facts and Comparisons, Tuberculin PPD must be used within 30 days of opening. This finding was verified by LPN (Licensed Practical Nurse) # 1 on 11-8-11 at approximately 11:10 AM.",2015-12-01
8760,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,428,E,0,1,DFWX11,"**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 entitled Medication Regimen Review (May 2010), the Consultant Registered Pharmacist failed to identify drug regimen irregularities were for four of fifteen sampled residents reviewed for medication assessment. The Pharmacist did not identify irregularities in readmission orders [REDACTED]. The Pharmacist did not identify administration omissions for Residents #5 and #21. The Pharmacist failed to identify labs not completed to monitor the medication regimen for Resident #21. The Pharmacist also failed to report that Resident #7 was on four antihypertensive medications with documented irregularities in the blood pressure. The findings included: The facility admitted Resident #7 on 7/1/10 with [DIAGNOSES REDACTED]. Record Review on 11/8/11 at 11:15 AM revealed Physician's Orders for four antihypertensive medications including Norvasc, Diovan, Aldactazide and Lopressor. On 11/8/11 at 2:00 PM, review of the Nurse's Notes and Stone Wing V/S (Vital Signs) forms, the following blood pressures were recorded: 9/8/11=91/60; 9/9/11=96/56; 9/10/11=96/56; 9/11/11=98/60; 9/12/11=96/58; 9/15/11=88/50; 9/19/11=98/60; 9/20/11=97/65; 9/20/11=99/60; 9/22/11=96/55; 9/23/11=96/55; 9/29/11=96/55; 9/30/11=96/55; 10/13/11=96/50; undated=97/50; 10/20/11=96/52; 10/21/11=96/52; 10/27/11=96/54; 10/30/11=99/56; 11/7/11=97/58; 11/8/11=97/58. On 11/8/11 at 2:45 PM, review of the Pharmacy Consultation Report recommendation form, for Resident #7, dated 10/26/2011 revealed that at such time, the residents' medication regimens contained no new irregularities. During an interview on 11/8/2011 at 3:30 PM, Nurse Consultant #1 stated, No pharmacy recommendations were made related to low blood pressures and duplicate (antihypertensive) therapy. The Medication Regimen Review policy reviewed on 11/9/11 at 3:30 PM stated The facility should ensure that the Consultant Pharmacist has access to . 2.4 Physician/Prescriber progress notes, nurses' notes, and other documents which may assist the Consultant Pharmacist in making a professional judgment as to whether or not irregularities exist in the medication regimen; and 2.5 Any other necessary information, in accordance with Applicable Law. The facility admitted Resident #1 on 10/3/07 with [DIAGNOSES REDACTED]. Record review on 11/8/11 revealed a physician's order dated 9/7/11 for Serax 15 milligrams(mgs) q(every) 8 hours. Review of the monthly printed physician orders for the months of October and November 2011 revealed the order as Serax 15 mg three times daily as needed. Review of the Medication Administration Records for the months of September, October, and November 2011 revealed the order as transcribed as Serax 15 mg every 8 hours as needed. Review of the MAR's revealed the resident had only received the medication one time since the medication was ordered on [DATE]. Readmission orders [REDACTED]. Review of the MAR indicated [REDACTED]. Review of the record with Nurse Consultant #1 on 11/19/11 confirmed these two drugs had not been transcribed. Review of the monthly pharmacy reviews for September and October revealed that the pharmacist had not identified the discrepancies. On 11/19/11, during an interview with Nurse Consultant #1, she confirmed that the orders had not been transcribed as ordered and the pharmacist had not identified the discrepancies. The facility admitted Resident #21 on 05-30-09 with [DIAGNOSES REDACTED]. Record review on 11-09-11 at approximately 4:50 PM of Resident #21's revised Care Plan dated 06-14-11 and updated 09-11-11 revealed the following: Problem/Strength/ Need -Chronic anemia related to (r/t) renal disease and Approaches: Monitor ordered labs and update Medical Doctor (MD) as needed. Further record review on 11-09-11 at approximately 4:50 PM of the Medication Regimen Review for Resident #21 revealed no documentation of Hgb and Hct for the month of April 2011, May 2011, and July 2011. Additional record review on 11-10-11 at approximately 8:45 AM of the Pharmacy Consultation Report of April 2011, May 2011, June 2011, and July 2011 for Resident #21 revealed there were no laboratory omissions for weekly Hemoglobin (Hgb) and Hematocrit (Hct) documented. During an interview on 11-10-11 at approximately 10:15 AM with Nurse Consultant #1, no additional information could be provided. The facility admitted Resident #5 on 08-31-11 with [DIAGNOSES REDACTED]. Record review on 11-08-11 at approximately 4:15 PM of the Physician's Orders dated 10-01-11 through 10-31-11 for Resident #5 revealed an order of Glimepiride (for Amaryl) 4 milligram (mg) tablet: 1 tab via Gastrostomy (G) Tube every day. Record review on 11-09-11 of the Medication Administration Record [REDACTED] 10-03-11 through 10-06-11;10-08-11 through 10-11-11; 10-13-11 through 10-30-11: During an interview on 11-09-11 at approximately 11:20 AM with Licensed Practical Nurse (LPN) #3, she, after chart review, verified there was no documentation that the medications had not been administered. Further record review on 11-10-11 at approximately 10:20 AM of the Medication Regimen Review for Resident #5 revealed no irregularities noted for October 2011. Additional record review on 11-10-11 at approximately 10:25 AM of the Pharmacy Consultation Report of October 2011 revealed no concerns. Review on 11-10-11 at approximately 10:35 AM of the facility policy titled Medication Regimen Review stated Procedure: The Consultant Pharmacist will conduct Medication Regimen Reviews (MRRs) if required under a Pharmacy Consultant Agreement .",2015-12-01
8761,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,441,F,0,1,DFWX11,"**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 Infection Control Policies for the Terminal Cleaning of Isolation Room (11-15-02),Transmission Precautions: Contact (11-15-02), and Methicillin Resistant Staphylococcus Aureus (3-04), the facility failed to ensure that 2 of 2 soiled utility rooms were equipped with Personal Protective Equipment (PPE) for staff use in rinsing soiled linen. In addition, the facility failed to use an appropriate disinfectant to clean isolation rooms for Clostridium difficile (C-diff). The facility also failed to have a method in place to sanitize residents' personal laundry. Further, the facility failed to implement transmission based precautions in a timely manner and track infections to identify trends to help prevent the spread of infections within the facility for 2 of 2 residents (Resident #8 and Resident #10) with[DIAGNOSES REDACTED]. Resident # 10 was not placed in contact isolation in a timely manner. Random observations during the survey revealed Resident #14 dipping a drinking cup into a hydration cart. The findings included: During observation of the laundry process on 11/8/11 at approximately 12 PM, the Laundry Assistant stated that heavily soiled linen with feces was bagged and returned to the soiled utility rooms on the unit for rinsing prior to washing. On 11/8/11 at 12:15 PM, the Laundry Assistant stated all cycles have .125 Parts Per Million (PPM) bleach. On 11/8/11 at 12:30 PM, review of Laundry Contract book, recorded temperatures were greater than 160 degrees for all monthly checks. The Laundry aide also stated that maintenance checked the hot water temperatures. Further review of the Hot Water Temperature Log tracked by maintenance, revealed no greater temperature than 150 degrees. Observation of the boiler room with the Maintenance Director, his assistant, and the Environmental Consultant on 11/8/11 at 4 PM revealed the water temperature to be set at 140 degrees. During an interview on 11/9/11 at 11:25 AM, with the Laundry Contract Company representative who stated resident personal clothing was washed with detergent and no bleach. He stated personal clothing was sanitized through the temperature of the water. After being informed of the current water temperature, he agreed residents' personal clothing was not being sanitized properly. Observation on 11/8/11 at approximately 12:40 PM, 2 of 2 soiled utility rooms were found with no PPE to protect staff. There were no gloves or gowns available for staff members to use to clean residents' linen or clothing that had been returned by laundry. During an interview on 11/8/11 at 12:45 PM, 100 hall unit manager verified this and stated there should have been PPE in the soiled linen room. The facility admitted Resident #14 on 9/21/11 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #14 received a regular/mechanical soft diet with regular liquids and was able to self-feed. During a random observation on 11/08/11 at approximately 2:40 PM, Resident #14 was observed sitting in his wheelchair in front of the Hydration Cart in the hallway leading to the Stone Unit. Resident #14 had a Styrofoam cup in his hand, opened the ice chest on the cart, and dipped the cup into the ice chest. Resident #14 then pushed the button on the beverage container on the cart labeled fruit punch while holding the cup under the dispenser and placed the cup to his mouth. A staff member passing in the hallway retrieved the cup after Resident #14 attempted to place the cup on the hand rail. The facility admitted Resident #8 on 10/16/11 with [DIAGNOSES REDACTED]. Record review of nurse's notes on 11/8/11 revealed the following: 10/21/11 at 7:30 AM - resident having 2 episodes of loose stool, MD(medical doctor) called new order for [MEDICATION NAME]. 10/21/11 11:30 PM - .Loose stool throughout the night. Foul odor and slimy 10/22/11 2:00 AM - Resident has been given [MEDICATION NAME] for loose stool s(without) success 10/22/11 9:00 PM - Dr. called regarding resident loose stools and the foul odor from resident stools stated to monitor. 10/22/11 11:50 PM - MD called at 11:20 PM order to send resident to ER(emergency room ) for tx(treatment) & eval(evaluation). Review of laboratory findings dated 10/23/11 revealed the resident was positive for Clostridium Difficile Toxin(C-Diff). Review of the Infection Control log revealed the resident was not listed for C - Diff. At 1:30 PM on 11/8/11, review of the Infection Control Policy Terminal Cleaning of Isolation Room it stated to use Fresh disinfecting solution, diluted per manufacturers specifications on label. In addition, the procedure stated to Wash any special equipment with disinfecting solution and return it to the proper area. No type of disinfectant was specified. At 1:45 PM, review of the Disinfectant cleaner-RTU revealed the disinfectant is not effective against[DIAGNOSES REDACTED]. During an interview on 11/8/11 at 2 PM, Housekeeper #3 stated they used Virex to clean resident rooms and rooms that were on isolation precautions. On 11/8/11 at 2:45 PM, review of the Virex 256 reference sheet revealed that it was not effective against[DIAGNOSES REDACTED]. The facility admitted Resident #10 on 9/23/2011 with [DIAGNOSES REDACTED]. Review of the 9/23/2011 hospital discharge summary on 11/10/2011 at 11:20 AM revealed that on 9/14/2011 the urine culture demonstrated Extended Spectrum Beta-Lactamase (ESBL), and positive for Escherichia coli (E. Coli). On 09/17/2011, the repeat urine culture in the hospital demonstrated Pseudomonas as well as Methicillin Resistance Staphylococcus Aureus (MRSA) for which [MEDICATION NAME] was ordered on [DATE]. This was three days prior to discharge. Further review of the discharge summary revealed transfer orders for [MEDICATION NAME] be continued for seven days after admission to the Skilled Nursing Facility (SNF). There was no evidence in the transfer information that the[DIAGNOSES REDACTED], ESBL, or MRSA was cleared/negative at the time of transfer. Review of 9/23/2011 Nurse's Notes revealed no mention of contact precautions implemented at the time of admission. The first mention of contact precautions in the Nurse's Notes was on 9/29/2011 when the resident complained of loose stools. The same day, a Physician's Telephone Order was written for Contact Precautions Dx (Diagnosis):[DIAGNOSES REDACTED]. Review of the Certified Nurse Aide's Activities of Daily Living (ADL) Flow Record revealed bowel movements were recorded without consistency identified. Review of the 10/06/2011 Nurse's Notes revealed a physician's request for the last two[DIAGNOSES REDACTED] stool results from the hospital. One positive toxin result was noted as faxed to the facility on the same date. Review of the Infection Control Log revealed no documentation of[DIAGNOSES REDACTED], MRSA or ESBL for Resident #10. During an interview on 11/10/2011 at 2:45 PM, the Assisted Director of Nursing (ADON) stated she was not familiar with ESBL. No reference to ESBL could be found in the Infection Control Policy and Procedures. When asked about resident screening prior to admission, the ADON stated that the Director of Nursing (DON) reviewed the paperwork for new admissions. Readmissions came directly to the unit with the Unit Manager or Charge Nurse reviewing the hospital transfer information and they reported infection concerns to the ADON. The ADON stated that she was unaware if the MRSA or[DIAGNOSES REDACTED] had been cleared prior to admission. After review of the record, she stated the resident should had been placed on contact precautions upon admission. On 11/10/2011 at 3:00 PM, review of the Infection Control Policy entitled Transmission Precautions:Contact revealed In addition to Standard Precautions, Contact Precautions may be indicated for residents known or suspected to be infected or colonized with epidemiologically important microorganism that can be transmitted by direct contact with the resident, or indirect contact (touching) with environmental surfaces or resident care items in the resident's environment. Review of the policy entitled Methicillin Resistant Staphylococcus Aureus (3-2004) revealed that a resident infected with MRSA should be placed on contact isolation precautions or cohorted with a like resident. The resident should remain on contact isolation until MRSA is documented as colonized or a negative culture is obtained.",2015-12-01
8762,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,502,D,0,1,DFWX11,"**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 services in a timely manner as ordered by the physician for 1 of 12 sampled residents. physician's orders [REDACTED].#21. The findings included: The facility admitted Resident #21 on 05-30-09 with [DIAGNOSES REDACTED]. Record review on 11-09-11 at approximately 4:50 PM of the physician's orders [REDACTED]. Record review on 11-09-11 of the Physician's Telephone Orders dated 05-28-11 revealed an order of Clarification Order - Hgb and Hct weekly prior to [MEDICATION NAME]. Additional record review on 11-09-11 at approximately 4:50 PM of the admission orders [REDACTED]. Review of the laboratory reports for the month of April 2011, May 2011, and July 2011 revealed Hgb and Hct laboratory reports for the the week of 04-25-11, the week of 05-09-11, and the week of 07-25-11 could not be located. During an interview on 11-10-11 at approximately 10:15 AM with Nurse Consultant #1, no additional information could be provided regarding the missing laboratory reports.",2015-12-01
8763,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,514,D,0,1,DFWX11,"**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 which were accurately documented for 2 of 10 resident records reviewed. The medical records for Resident #6 and Resident #9 contained conflicting documentation related to the residents' capacity for making healthcare decisions. The findings included: The facility admitted Resident #9 on 8/01/11 with diagnosed including: [DIAGNOSES REDACTED]. Review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] indicated Resident #9 scored 15 on the Brief Interview for Mental Status (BIMS). The BIMS score indicated that Resident #9 had no short-term or long-term memory problem and had independent cognitive skills for daily decision-making. Further record review revealed Resident #9 was listed as his own responsible party and signed the admission papers including the Advance Directives Flash Sheet indicating preference for Code Status. Review of the form labeled Cognitive ability to consent regarding health care revealed two physicians signed the form indicating Resident #9 is not able to provide consent regarding health care decisions . The physician signatures were dated 8/08/11 and 8/22/11. During an interview on 11/10/11 at approximately 2:00 PM, the surveyor asked the Administrator and Director of Nursing (DON) to review the above documentation related to Resident #9's cognitive status and ability to make health care decisions. After reviewing the documentation, the Administrator and DON confirmed that the medical record contained conflicting documentation related to the resident's ability to make health care decisions. Resident #6 was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Resident #6 had no diagnoses of Dementia and it was noted that she was oriented and can voice her needs. Review of the form entitled Cognitive Ability to Consent Regarding Health Care on 11/8/11 at approximately 12 PM revealed Resident #6 was documented as unable to make health care decisions. Review of the 5/3/11 Admission and 8/23/11 Quarterly Minimum Data Set assessment revealed Resident #6 scored 15 on the Brief Interview Mental Status (BIMS). A score of 13-15 indicated the resident was cognitive intact. The BIMS score also indicated that Resident #6 had no short-term or long-term memory problems and had independent cognitive skills for daily decision making. On 11/8/11 at 12:30 PM, review of the Social Progress Notes dated 5/20/11 revealed she is alert and oriented to self and family, she is able to voice her needs. Further record review of Resident #6 Initial Care Plan completed on 5-20-11 and subsequent Interdisciplinary Care Plan noted no reference to cognitive impairment.",2015-12-01
8764,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,516,E,0,1,DFWX11,"On the days of the survey, based on observation, interview and review of the facility policy entitled Security of Clinical Records (1-98), the facility failed to safeguard clinical record information from destruction or unauthorized use. The findings included: On 11/8/11 at approximately 12:40 PM, a box of pharmacy orders and physician orders for residents was found stored in lower cabinets near a sink in the soiled utility room on the 100 hall. The cabinets did not have locks on them and the information was readily accessible to unauthorized persons. The Unit Manager for the 100 hall verified this and stated that resident records should not have been stored in the soiled utility room. Review of the facility policy entitled Security of Clinical Records (1-98) on 11/8/11 at approximately 2 PM revealed, Clinical records cannot be taken from any of the various files to other parts of the nursing center except as it is necessary in the transaction of the routine business and properly signed out, .Records are stored in an environment protected from loss, damage, and unauthorized use.",2015-12-01
8765,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2011-11-10,520,D,0,1,DFWX11,"On the days of the survey, based on record review and interview, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. A quality assurance action plan for pressure ulcers lacked measurable goals, lacked follow through of approaches and no definitive time frame for evaluation was established. The findings included: On 11/9/11, during an interview with Nurse Consultant #2, she stated that concerns with pressure sores had been identified and had been QA'ed(reviewed by quality assurance) in August 2011. Materials presented during the survey process, did not list measurable goals, all staff had not been inserviced on wound care, all skills validation had not been updated, and there was no definitive time frame for re-evaluation of pressure sore concerns. During an interview on 11/10/11 with Nurse Consultant #2, when a time frame was asked for, she stated one week(11/17/11). No documentation was provided to indicate the re-evaluation date. .",2015-12-01
8766,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,281,L,1,0,Q5B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey and Complaint Inspection, the facility failed to provide services that meet professional standards of practice. Licensed Practical Nurse (LPN) #1 left her/his assigned unit, Stone Unit, multiple times during her/his shifts from 7:00 PM on 11/9/12 through 7:00 AM on 11/12/12 leaving the residents unattended, sometimes for extended periods. Certified Nursing Assistants (CNA) were unable to locate the nurse assigned to the unit when Resident #18 was found unresponsive requiring LPN #2 from Rogers Unit to leave her/his unit unattended for a period of 1 hour to respond to the emergency on Stone Unit. On 12-18-12 at 10:35 AM the Administrator was notified that Immediate Jeopardy was Identified at F-281. Immediate Jeopardy existed in the facility on 11-11-12 related to the actions of facility staff as noted above. The findings included: On 12/4/12 at approximately 3:15 PM review of the Five-Day Follow-up related to a Facility Reported Incident received by this office revealed the facility had reported to the State agency that LPN #1 had been absent from her assigned unit multiple times during her shifts from 7:00 PM on 11/09/12 to 7:00 AM on 11/12/12. The report revealed the facility had camera videos and a time line was developed for LPN #1 during that time period and included a copy of the time line. Review of the time line revealed LPN #1 left the building 9 times between 7:00 PM and 7:25 AM on 11/09/12: 8:17 PM, 8:35 PM, 9:31 PM, 9:33 PM, 10:25 PM, 1:15 AM, 2:35 AM, 3:21 AM, and 5:09 AM. In addition, LPN #1 was seen coming back into the building at 4:30 AM but the facility was unable to determine when s/he exited. On 11/10/12, s/he exited the building 12 times that the exit and entrance times could be determined: 7:07 PM, 8:02 PM, 9:10 PM, 10:09 PM, 10:45 PM, 11:03 PM, 11:57 PM, 1:21 AM, 2:08 AM, 3:20 AM, 3:55 AM,and 6:49 AM. Additionally, at 4:59 LPN #1 was seen exiting the building. LPN #1 was not seen re-entering the building and was visualized at the dumpster at 6:08 AM and 6:20 AM and re-entered the building at 6:31 AM. On 11/11/12, LPN #1 did not clock in or out per the facility's time line. LPN #1 exited the building at 8:40 PM, 10:19 PM, 11:14 PM, 12:41 PM, 1:28 AM, 1:58 AM, 2:13 AM, 5:41 AM, and 6:20 AM. In addition, LPN #1 was seen on the video entering the building at 6:55 AM but the facility was unable to determine when she exited. Further review of the Follow-up Report indicated that Resident #10 voiced a complaint to the facility on [DATE] that he/she did not see the nurse, LPN #1, all night. The facility's report indicated the nurse asked if the resident was ready for his/her medication at 11:10 PM on 11/11/12 but the resident did not receive them until the following morning at approximately 6:15 AM The report further indicated that Resident #10 stated that LPN#1 sent CNA #1 in the room with the medications. The facility's investigation indicated that the CNA told Resident #10 that the nurse was not in the building. Resident #10 could not be interviewed during the Survey as s/he was transferred to the hospital at 8:00 AM on 12/4/12. Review of CNA #1's facility-obtained statement indicated that LPN#1 was outside most of the night. CNA #1 revealed in his/her statement I had residents yelling for their meds.Resident in room (number) was yelling repeatly (sic) yelling I am in pain my body feel like it's cracking in half please can I have my meds (and) tell the nurse to please come and please bring my meds (medications). CNA #1 stated s/he located LPN #1 outside but was told by the LPN that s/he couldn't come in right then. The CNA's statement indicated LPN #1 said s/he already had the medications ready and would the CNA please take them to Resident #10. CNA #1 also indicated in her/his statement that s/he had called the Nurse from Rogers Unit to assist with an emergency with a resident. During an interview on 12/5/12 at 7:35 AM, CNA #1 confirmed the accuracy of her/his statement and added that LPN #1 did take a lot of cigarette breaks. CNA #1 also stated that when s/he gave Resident #10's medications, there were 3 or 4 pills in the medicine cup and s/he did not know what they were. CNA #4 also gave a written statement to the facility that stated s/he had worked on Rogers Unit on 11/10-11/11/12 on the 11:00 PM to 7:00 AM shift. S/he indicated that the Stone Unit CNAs kept coming over on Rogers to get the nurse to come over there because they couldn't find their nurse.' S/he further stated that caused LPN#2 to get behind in (her/his) work. Further review of the Reportable file revealed a statement from LPN #3 that sometime after 7:00 PM on 11/10/12, LPN #1 texted LPN #3 to bring the medication cart keys outside to her/him so that LPN #3 could leave. LPN #3 refused and instructed LPN #1 to come to the unit to count the narcotics and to receive report. In an interview on 12/4/12 at 4:25 PM LPN #3 confirmed the accuracy of his/her statement and had no other information to offer. Additional review of the Reportable file indicated a statement had been obtained from Registered Nurse (RN) #1 who had worked 7:00 PM to 7:00 AM on 11/10/12. RN #1's statement indicated the CNAs on Stone Unit had voiced concerns about finding the nurse on that side. RN #1 indicated that s/he texted the on-call nurse between 2:00 and 3:00 AM about the CNAs concerns and that numerous times throughout the night the CNAs were searching for the nurse. During an interview on 12/5/12 at 10:05 AM, the Interim Director of Nursing (IDON) confirmed that s/he had been on call the week-end of 11/9 through 11/11/12. S/he stated s/he had received a text stating the CNAs were having trouble finding the nurse on the Stone Unit. The IDON stated that s/he texted LPN #1 and asked where s/he was. LPN #1 texted the IDON that s/he was in the bathroom. S/he also stated that s/he received a call when a resident was transferred out of the facility and called back to the facility but did not get an answer. S/he texted LPN #1 who texted back and said that s/he had been busy with the resident who had been sent out and had not been able to answer the phone when the IDON called. The IDON also stated that when s/he asked LPN #2 what had happened over the weekend, LPN #2 informed her/him that s/he had already reported everything to either the Administrator or the DON at that time, but s/he could not recall to whom s/he had reported. An Allegation of Compliance (AOC) was submitted by the facility. The AOC was accepted on 12/18/12 and after verification that the plan was implemented, the Immediate Jeopardy was removed and the Scope and Severity of F-281 was lowered to a Scope and Severity of F.",2015-12-01
8767,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,309,L,1,0,Q5B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey and Complaint Inspection, based on record review, interviews, and review of the facility's files made in reference to a complaint received by this office, the facility failed to provide care and services in a manner that reduced the residents' risk for harm. Licensed Practical Nurse (LPN) #1 left her/his assigned unit, Stone Unit, multiple times during her/his shifts from 7:00 PM on 11/9/12 through 7:00 AM on 11/12/12 leaving the residents on that unit unattended. Certified Nursing Assistants (CNA) were unable to locate the nurse assigned to the unit when Resident #18 was found unresponsive requiring LPN #2 from Rogers Unit to leave her/his unit unattended for a period of 1 hour to respond to the emergency on Stone Unit. In addition, a Reportable Incident was received by this office that unidentified medications were administered to Resident #10 by a Certified Nursing Assistant (CNA), not the staff nurse, following the residents repeated request for pain medications. On 12-18-12 at 10:35 AM the Administrator was notified that Substandard Quality of Care and Immediate Jeopardy was Identified at F-309. The Substandard Quality of Care and Immediate Jeopardy existed in the facility on 11-11-12 related to the failure of the facility to provide appropriate care and services The findings included: On 12/4/12 at approximately 3:15 PM review of the Five-Day Follow-up related to a Facility Reported Incident received by this office revealed a statement from LPN #2 on 11/13/12. LPN #2 indicated in the statement that s/he was called from her/his assignment on Rogers Unit to Stone Unit on 11/11/12 (actually AM of 11/12/12) by a CNA (Certified Nursing Assistant) who informed her/his there was something wrong with Resident #18. Upon entering the room at 3:00 AM, the resident was found unresponsive. LPN #2 checked the residents's blood sugar and found s/he had a critically low level of 21. The statement further stated that the primary nurse for Stone Unit returned to the floor from outside at 4:05 AM. The LPN's statement indicated that the primary nurse, upon return to the unit, asked LPN #2 why s/he didn't come and get her/him and LPN #2 told her/him there had not been time because the resident was critical. In an interview on 12/5/12 at 7:55 AM, LPN #2 confirmed the accuracy of her/his statement. S/he added that s/he had also been called over to Stone Unit to remove a pressure dressing from a [MEDICAL TREATMENT] site on 11/11/12. LPN #2 also stated that s/he had heard that it had been a problem for the CNAs on Stone to find LPN #1 but had never before been called over to take care of residents. S/he also stated that s/he did not call the on-call nurse as the crisis with Resident #18 had been handled. Further review of the Follow-up Report indicated that Resident #10 voiced a complaint to the facility on [DATE] that he/she did not see the nurse, LPN #1, all night. The facility's report indicated the nurse asked if the resident was ready for his/her medication at 11:10 PM on 11/11/12 but he/she did not receive them until the following morning at approximately 6:15 AM The report further indicated that Resident #10 stated that LPN#1 sent CNA #1 into the room with the medications. S/he had instructed the CNA that the medications she had previously poured were on the top of the medication cart and the CNA should administer those medications to the resident. The facility's investigation indicated that the CNA told Resident #10 that the nurse was not in the building. The facility's report also indicated that Resident #10 stated s/he was crying in pain and that s/he rated his pain as 9. Resident #10 could not be interviewed during the Survey as s/he was transferred to the hospital at 8:00 AM on 12/4/12. Review of CNA #1's facility-obtained statement indicated that LPN#1 was outside most of the night. CNA #1 revealed in his/her statement I had residents yelling for their meds. (medications) .Resident in room (number) was yelling repeatly (sic) yelling I am in pain my body feel like it's cracking in half please can I have my meds (and) tell the nurse to please come and please bring my meds. CNA #1 stated s/he located LPN #1 outside but was told by the LPN that s/he couldn't come in right then. The CNA's statement indicated LPN #1 said s/he already had the medications ready (previously poured) and would the CNA please take them to Resident #10? Per the nurses instructions, the CNA then administered a cup of medications found on top of the medication cart to the resident. CNA #1 also indicated in her/his statement that s/he had called the Nurse from Rogers Unit to assist with an emergency with a resident. During an interview on 12/5/12 at 7:35 AM, CNA #1 confirmed the accuracy of her/his statement and added that LPN #1 did take a lot of cigarette breaks. CNA #1 also stated that when s/he gave Resident #10's medications, there were 3 or 4 pills in the medicine cup and s/he did not know what they were. Additional review of the Reportable file indicated a statement had been obtained from Registered Nurse (RN) #1 who had worked 7:00 PM to 7:00 AM on 11/10/12. RN #1's statement indicated the CNAs on Stone Unit had voiced concerns about finding the nurse on that side. RN #1 indicated that s/he texted the on-call nurse between 2:00 and 3:00 AM about the CNAs concerns and that numerous times throughout the night the CNAs were searching for the nurse. CNA #4 also gave a written statement to the facility that stated s/he had worked on Rogers Unit on 11/10-11/11/12 on the 11:00 PM to 7:00 AM shift. S/he indicated that the Stone Unit CNAs kept coming over on Rogers to get the nurse to come over there because they couldn't find their nurse.' S/he further stated that caused LPN #2 to get behind in (her/his) work. A statement was also obtained by the facility from LPN #5 that indicated s/he worked on the day after the incident. S/he indicated that one one resident stated she (LPN # 1) stayed outside all night long and that LPN #1 wouldn't give me my medicine. S/he further indicated that Resident #10 also informed her that LPN #1 didn't do her job, s/he didn't give me my meds, other residents were banging on walls. Review of the Five Day Follow-up report revealed the facility had camera videos and a time line was developed for LPN #1 from 7:00 PM 11/09/12 through 7:00 AM 11/12/12. The facility provided a copy of the time line with the report. Review of the time line revealed LPN #1 left the building 9 times between 7:00 PM and 7:25 AM on 11/09/12: 8:17 PM, 8:35 PM, 9:31 PM, 9:33 PM, 10:25 PM, 1:15 AM, 2:35 AM, 3:21 AM, and 5:09 AM. In addition, LPN #1 was seen coming back into the building at 4:30 AM but the facility was unable to determine when s/he exited. On 11/10/12, s/he exited the building 12 times that the exit and entrance times could be determined: 7:07 PM, 8:02 PM, 9:10 PM, 10:09 PM, 10:45 PM, 11:03 PM,11:57 PM, 1:21 AM, 2:08 AM, 3:20 AM, 3:55 AM,and 6:49 AM. Additionally, at 4:59 LPN #1 was seen exiting the building. LPN #1 was not seen re-entering the building and was visualized at the dumpster at 6:08 AM and 6:20 AM and re-entered the building at 6:31 AM. On 11/11/12, LPN #1 did not clock in or out per the facility's time line. LPN #1 exited the building at 8:40 PM, 10:19 PM, 11:14 PM, 12:41 PM, 1:28 AM, 1:58 AM, 2:13 AM, 5:41 AM, and 6:20 AM. In addition, LPN #1 was seen on the video entering the building at 6:55 AM but the facility was unable to determine when s/he exited. The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Further review revealed LPN #2 documented administration of [MEDICATION NAME] 1mg (Milligram) at 3:30 AM. LPN #2 continued to check Resident #18's blood sugar per protocol until it was over 106, at 4:05 AM. On 12/5/12 at 1:15 PM review of the Nurse's Notes revealed a note dated 11/12/12 at 3:30 AM that stated Resident unresponsive. Blood Sugar check 21 [MEDICATION NAME] 1 mg (milligram) SQ (subcutaneously) (right) thigh monitor BS (Blood Sugar) (every) 5-15 min(utes) 3:45 26, 3:50 53, 3:55 67, 4 AM 90, 4:05 AM BS 106. (Physician) notified Hold [MEDICATION NAME] 500 mg this AM administer 6 PM [MEDICATION NAME] Make sure resident eat ( documented by LPN #2). The facility admitted Resident #10 to the facility with [DIAGNOSES REDACTED]. Record review on 12/4/12 at 5:43 PM revealed Resident #10 had a BIMS (Brief Interview for Mental Status) of 15, indicating the resident was cognitively intact. The Minimal Data Set (MDS) further indicated Resident #10 required extensive to total assistance with all aspects of Activities of Daily Living except eating. At 10:27 AM on 12/5/12, review of the Resident # 10's Nurse's Notes revealed no documentation by LPN #1 on 11/10/12 through 11/12/12. On 12/5/12 at 11:05 AM, review of the Medication Administration Record [REDACTED]. On the back of the MAR, in the Nurse's Medication Notes, the administration of the [MEDICATION NAME] was documented on 11/11/12 with no time, 11/12 at 1:30 AM and 11/12/12 at 8:30 AM. The resident's statement on 11/13/12 indicated he/she did not receive the medication at 1:30AM but at approximately 6:15 AM, thus potentially indicating the resident received [MEDICATION NAME] at 6:15 AM and again at 8:30 AM. Review of the admission orders [REDACTED]. An Allegation of Compliance (AOC) was submitted by the facility. The AOC was accepted on 12/18/12 and after verification that the plan was implemented, the Immediate Jeopardy was removed and the Scope and Severity of F-309 was lowered to a Scope and Severity of F.",2015-12-01
8768,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,411,C,1,0,Q5B511,"br>On the day of the Extended Survey, based on interviews and review of the facility's files made in reference to the extended survey, the facility failed to have a contract or agreement with a dentist to provide routine and/or emergent dental services to residents. The findings included: On 12/18/12 at approximately 4:45 PM, review of the facility's contracts revealed no contract or other agreement with a dentist to provide dental services to the residents of the facility. During an interview at approximately 5:30 PM on 12/18/12, the Administrator confirmed that the facility had no contract or agreement with a dentist. S/he further stated that residents' families make appointments with personal dentists for services.",2015-12-01
8769,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,490,L,1,0,Q5B511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint and Extended Surveys, based on record review, interviews and review of the facility's files made in reference to a complaint received by this office, the facility failed to effectively utilize resources to ensure that necessary care and services were provided to reduce the residents' risk for harm and that services provided met professional standards. The nurse assigned to Stone Unit left the building multiple times during the 7:00 PM-7:00 AM shift on 11/9/12, 11/10/12 and 11/11/12. On 12-18-12 at 10:35 AM the Administrator was notified that Immediate Jeopardy was Identified at F-490 and that Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 11-11-12 related to the failure of the facility to provide appropriate care and services. The findings included: On 11/13/12 a report was received by this office from the facility alleging neglect by LPN (Licensed Practical Nurse) #1 who had left Stone Unit multiple times during the 7:00 PM to 7:00 AM shift on 11/9 through 11/11/12. Review of the Five Day Follow-up report received by this office on 11/19/12 revealed Resident #18 was found unresponsive by CNA #1 at approximately 3:00 AM on 11/12/12. The CNA called Rogers Unit and requested the LPN #2 come to Stone Unit. Upon arrival to Stone Unit, LPN #2 obtained a blood sugar which was critically low at 21. S/he initiated the facility's protocol for [DIAGNOSES REDACTED] and stayed on Stone Unit from approximately 3:00 AM until LPN #1 returned at 4:05 AM, leaving Rogers Unit unattended during that time. During an interview on 12/5/12 at 7:58 AM, LPN #2 stated s/he did not call the on-call nurse to report that LPN #1 was not on her/his assigned unit from 3:00 AM to 4:04 AM. During an interview on 12/5/12 at 7:35 AM, CNA #1 stated that s/he told LPN #2 that LPN #1 had been outside most of the night. S/he further stated that LPN #2 did not respond. In a facility-obtained statement dated 11/14/12, RN (Registered Nurse) #1 indicated s/he texted the on-call nurse around 2-3 AM about concerns voiced by the CNAs that they were unable to locate their nurse on Stone Unit. S/he further indicated that numerous times throughout the night the CNAs were searching for the nurse. During an interview on 12/5/12 at 10:05 AM, the DON (Director of Nursing) confirmed that s/he was the ADON (Assistant Director of Nursing) during that time and that s/he was on call from 7:00 AM on Saturday 11/10/12 until 7:00 AM on Monday 11/12/12. The DON further confirmed receiving a text message that the CNAs were having trouble finding their nurse on Stone Unit. S/he stated that s/he texted LPN #1 and asked where s/he was. LPN #1 responded via text that s/he was in the bathroom. The DON denied receiving any further communication from the staff at the facility related to LPN #1 not being available. On 12/5/12 at 3:30 PM the Administrator stated that all staff had been instructed in the past to call her/him if they don't get an appropriate response from the on call nurse and had provided the cell phone number for them to contact. S/he further stated that s/he couldn't say if the on call nurse's response was appropriate without further investigation. S/he further stated that the CNA had reported on the morning of 11/12/12 at the end of her shift that there had problems over the week-end. S/he further stated that s/he investigated and found that LPN #1 had signed off all the medications and completed the documentation necessary and had not investigated further. S/he was not aware of any problems until Resident #10 reported that he/she had to wait several hours to get his/her medications and that the nurse was not doing her/his job per his/her facility-obtained statement. In addition, the Administrator stated that s/he had reviewed the camera videos only for the time frame of 11/9/12 through 11/12/12. S/he stated that s/he felt that was enough information to terminate LPN #1 and had not reviewed any other time frames. On 12/18/12 at 11:53 AM, review of employee files of 4 Licensed Practical Nurses (LPN) and all Registered Nurses (RN) revealed the facility failed to ensure that all licensed nurses had renewed their licenses prior to the expiration date. During an interview on 12/18/12 at approximately 5:30 PM, the MDS (Minimal Data Set) Consultant confirmed the LPN and RN renewal verifications were not printed until 6/28/12 and stated that all of the renewals were printed at the same time. In addition, the MDS Consultant provided a copy of an e-mail dated 4/30/12 from Human Resources that indicated that 4 nurses had not renewed their licensed as of 4:08 PM on 4/30/12. The 4 nurses included RN B and two other LPNs who are still employed at the facility but whose employee files were not reviewed. On 12/18/12 at approximately 4:45 PM, review of the facility's contracts revealed no contract or other agreement with a dentist to provide dental services to the residents of the facility. On 12/18/12 at approximately 4:45 PM, review of the facility's contracts also revealed no contract or other agreement with a laboratory to provide laboratory services to the residents of the facility. During an interview at approximately 5:30 PM on 12/18/12, the Administrator confirmed that the facility had no contract or agreement with a laboratory and further confirmed the facility had not contract or other agreement with a dentist. Cross Refer 483.20(k)(3) F-281 Professional Standards related to LPN #1 leaving her/his assigned unit multiple times during her/his shifts for extended periods leaving Stone Unit unattended by a nurse. In addition, when CNA #1 reported to LPN #1 that Resident #10 who was yelling that he/she was in pain, LPN #1 instructed CNA #1 to administer Resident #10's medications, which were in a medicine cup on top of the medication cart while the nurse was out of the building. Cross Refer 483.25 F-309 Quality of Care related to residents being at risk for harm due to the LPN #1 being absent from Stone Unit multiple times during her/his shifts. Resident #18 experienced an episode of [DIAGNOSES REDACTED] with a Finger Stick Blood Sugar of 21 while the LPN #1 was out of the building leaving Stone Unit unattended. The nurse from Rogers Unit responded to the Certified Nursing Assistant's (CNA) request for help, leaving Rogers unit unattended for at least an hour and placing those residents on Rogers Unit at risk while s/he attended to the emergency on Stone Unit. In addition, Resident #10 reported that he/she was in pain and did not receive his/her pain medication for several hours. On 12-18-12 at 10:35 AM the Administrator was notified that Substandard Quality of Care at Immediate Jeopardy was Identified at F-281, F-309, F-490 and F-520. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 11-11-12 related to Resident #11 and Resident #18. Cross Refer 483.55(a) F-411 Dental Services Skilled Nursing Facilities related to the facilities failure to have a contract or agreement with a dentist to provide routine and/or emergent dental services to residents. Cross Refer 483.75(g) F-499 Staff Qualifications related to the facilities failure to ensure that professional staffs' licenses were renewed timely in accordance with state law. Cross Refer 483.75(j)(1)(i) F-503 related to the facility's failure to have a contract with a laboratory to provide services to it's residents. An Allegation of Compliance (AOC) was submitted by the facility. The AOC was accepted on 12/18/12 and after verification that the plan was implemented, the Immediate Jeopardy was removed and the Scope and Severity of F-490 was lowered to a Scope and Severity of F.",2015-12-01
8770,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,499,F,1,0,Q5B511,"br>On the days of the Recertification, Complaint and Extended Surveys, based on interviews and review of the facility's files in reference to the extended survey, the facility failed to ensure that licensed nurses had renewed their licenses prior to the expiration date of the licenses. The findings included: On 12/18/12 at 11:53 AM, employee files of 4 Licensed Practical Nurses (LPN) and all Registered Nurses (RN) were reviewed as part of the extended survey. The findings were as follows: LPN A was hired on 8/23/12 as a Licensed Practical Nurse. Review of the employee file revealed a Certificate from the State Board of Nursing for South Carolina that conveyed the title of Licensed Practical Nurse to the employee dated 8/31/12. Further review revealed a License Verification that stated the LPN's license was issued on 8/15/12 but the facility did not obtain the verification until 11/5/12. RN A was hired on 12/15/09. Review of the employee file revealed the earliest license renewal verification was dated 10/13/11 with an expiration date of 4/30/12. Further review revealed the RN's license renewal verification was not obtained until 5/14/12. RN B was hired on 8/30/11. Review of the employee file revealed the earliest license renewal verification was dated 9/8/12 as a Licensed Practical Nurse with an expiration date of 4/30/12. Further review revealed a Registered Nurse license was issued on 9/13/11 with an expiration date of 4/30/12 that was obtained by the facility on 9/14/12. Continued review revealed the facility did not obtain a license renewal verification until 6/28/12. RN C was hired on 6/29/11. Review of the employee file revealed a license verification was obtained by the facility on 6/15/11 with an expiration date of 4/30/12. Further review revealed the license renewal verification was obtained on 6/28/12. RN D was hired on 12/6/11. Review of the employee file revealed a license verification dated 12/1/11 with an expiration date of 4/30/12. Further review revealed the license renewal verification was obtained by the facility on 6/28/12. During an interview on 12/18/12 at approximately 5:30 PM, the MDS (Minimal Data Set) Consultant confirmed the LPN and RN renewal verifications were not printed until 6/28/12 and stated that all of the renewals were printed at the same time. In addition, the MDS Consultant provided a copy of an e-mail dated 4/30/12 from Human Resources that indicated that 4 nurses had not renewed their licensed as of 4:08 PM on 4/30/12. The 4 nurses included RN B and two other LPNs who were still employed at the facility but whose employee files were not reviewed.",2015-12-01
8771,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,503,C,1,0,Q5B511,"br>On the day of the Extended Survey, based on interviews and review of the facility's files in made in reference to the extended survey, the facility failed to have a contract or agreement with a laboratory that meets the requirements of federal regulations to provide laboratory services to residents. The findings included: On 12/18/12 at approximately 4:45 PM, review of the facility's contracts revealed no contract or other agreement with a laboratory to provide laboratory services to the residents of the facility. During an interview at approximately 5:30 PM on 12/18/12, the Administrator confirmed that the facility had no contract or agreement with a laboratory. S/he stated that /she had been in contact with the laboratory on 12/18/12. S/he stated that the laboratory had informed her/him that there was no contract because the laboratory does not provide phlebotomy services.",2015-12-01
8772,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-12-18,520,L,1,0,Q5B511,"**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 to identify issues with respect to which quality assessment and assurance activities are necessary; and develop and implement an appropriate plan of action to correct identified concerns. On 12-18-12 at 10:35 AM the Administrator was notified that Immediate Jeopardy was Identified at F-520 and that Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 11-11-12. The facility was aware of resident and staff reported concerns but failed to fully explore the full outcome and consequences of the reported behavior. Additionally, the facility failed to develop an action plan to identify and or prevent reoccurrence. The findings included: During an interview on 12/5/12 at approximately 3:30 PM, the Nursing Home Administrator stated that Certified Nursing Assistant #1 (CNA) had reported on the morning of 11/12/12 at the end of her shift that there had problems over the week-end with Licensed Practical Nurse (LPN) #1, assigned to the Stone Unit. The Administrator further stated that s/he investigated and found that LPN #1 had signed off all the medications and completed the documentation necessary and had not investigated further. S/he was not aware of any other problems until Resident #10 reported that he/she had to wait several hours to get his/her medications and that the nurse was not doing her/his job per his/her facility-obtained statement. The Administrator further stated that s/he had reviewed camera videos to verify that LPN #1 had been out of the building as reported only for the time frame of 11/9/12 through 11/12/12. S/he stated that s/he felt that was enough information to terminate LPN #1 and had not reviewed any other time frames. The Administrator also stated that all staff had been instructed in the past to call her/him if they didn't get an appropriate response from the on call nurse and had provided the cell phone number for them to contact. S/he further stated that s/he couldn't say if the on call nurse's response was appropriate without further investigation. The Administrator stated that the concerns reported by the CNA and Resident #10 had not been taken to the Quality Assessment and Assurance committee and that the facility had not implemented a plan of action related to the deficiencies cited at F-281 or F-309. Cross Refer 483.20(k)(3) F-281 Professional Standards related to LPN #1 leaving her/his assigned unit multiple times during her/his shifts for extended periods leaving Stone Unit unattended by a nurse. In addition, when CNA #1 reported to LPN #1 that Resident #10 was yelling that he/she was in pain, LPN #1 instructed CNA #1 to administer Resident #10's medications, which were in a medicine cup on top of the medication cart while the nurse was out of the building. Cross Refer 483.25 F-309 Quality of Care related to residents being at risk for harm due to the LPN #1 being absent from Stone Unit multiple times during her/his shifts. Resident #18 experienced an episode of [DIAGNOSES REDACTED] with a Finger Stick Blood Sugar of 21 while the LPN #1 was out of the building leaving Stone Unit unattended. The nurse from Rogers Unit responded to the Certified Nursing Assistant's (CNA) request for help, leaving Rogers unit unattended for at least an hour and placing those residents on Rogers Unit at risk while s/he attended to the emergency on Stone Unit. In addition, Resident #10 reported that he/she was in pain and did not receive his/her pain medication for several hours. An Allegation of Compliance (AOC) was submitted by the facility. The AOC was accepted on 12/18/12 and after verification that the plan was implemented, the Immediate Jeopardy was removed and the Scope and Severity of F-520 was lowered to a Scope and Severity of F.",2015-12-01
9038,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-05-31,250,E,1,0,2PH311,"**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 that residents received medically-related social services for the mental and psychosocial well-being of residents for 1 of 1 resident reviewed with behavioral symptoms (Resident #1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the initial Resident Assessment Instrument with an assessment reference date of 1/19/12 showed the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15/15. There were no mood indicators or behavioral symptoms noted on this assessment. Shortly after her initial assessment, the resident began displaying behavioral symptoms of calling out or using the call light to summon staff frequently, often for things that she could do for herself. The initial care plan showed a problem of Anxiety as evidenced by frequently yelling out and constantly using call light. Staff were to to give support, allow venting, use a calm and soothing approach, and to give medications if those approaches were unsuccessful. The remaining approaches included monitoring effect of medication, inform social worker, monitor for adverse side effects of medication, ensure resident was safe, and encourage participation in activities. Review of the Social Progress Notes of 1/30/12 revealed that the resident scored a 15 on the mood assessment which indicated severe depression. The resident denied wanting to hurt herself and verbalized wanting to go home. However, this was not possible. Her family could not longer care for her at home. In addition to her psychiatric conditions, the resident had a history of [REDACTED]. The resident reported feeling better on 1/31/12. Social Progress Notes did not mention behavior issues until the note on 4/3/12 stating the resident was constantly ringing her call bell. In conversation with the resident's sister, it was discovered that the resident had been a patient of Berkeley Mental Health in the past. The sister reported that a psychiatrist saw the resident at the prior long term care facility and he did not want the resident's medications changed. However, the physician at this facility had changed the medications and completely took her off one of them. Review of the quarterly Minimum Data Set with an assessment reference date of 4/5/12 showed the resident remained cognitively intact and she now showed mood indicators. The resident was feeling down, having sleep problems, feeling tired, had decreased appetite, felt bad about herself, had difficulty concentrating, was slow in movement, and expressed a feeling that she would be better off dead. Further assessment revealed she had no suicidal ideations and was not a danger to herself. No behavioral symptoms were noted in the assessment. Continued review of the Social Progress Notes revealed the Social Worker contacted the resident's physician and requested a psychiatric consult. He declined to order the consult saying ""Patient has bipolar illness no referral needed."" The Social Progress Notes did not show an attempt to obtain records from the previous psychiatric consult, or records from the mental health agency. There was no attempt to involve the medical director in an effort to assist the resident get mental health assessment and treatment. At a meeting on 4/11/12, the resident's sister said she would call Mental Health. There was no further documentation concerning obtaining mental health assistance for the resident. This information was confirmed by the Social Worker during an interview at 5 PM on 5/31/12. Review of the medical record revealed the resident had frequent episodes of yelling out, demanding immediate attention. She reported events and staff inaccurately to her family. Her care plan was updated on 4/19/12 because of making false statements. The use of two caregivers at a time was instituted. The resident refused to take some of her medications, saying they made her too sleepy, while almost constantly demanding a nebulizer treatment in the absence of any respiratory symptoms. Examples of the resident's behavior in the Nurse's Note included the following: 4/1/12, 7 PM, ""Resident continues to yell out 'nurse, nurse, nurse' when staff answers call bell, resident will ask that her table be pulled closer to bed, as soon as you exit room , call light is on, again, with another request, even thought you ask before you leave the room 'Is there anything else I can do for you!"" 4/12/12, ""Resident has been on call light excessively this 12 (hour) shift. She states she did not sleep well last night. She slept thru (through) breakfast she said. However she demanded a breathing tx and her tray was brought to her and she was awake. Same incident (with) lunch. ..."" 4/19/12, 2 AM, ""... continue (with) demanding behavior. Ring bell for Kleenex to be place in hand off bedside table."" 5/1/12, 3 AM, "" ... stated earlier this shift that she was not voiding, however this nurse witnessed resident in restroom voiding. ..."" 5/2/12, 2:30 PM, ""Res. yelling down hall for water, then light on to pull curtain because air too cool. Then light on to turn off heat. Then light on to get her a tissue."" 5/9/12, 2:30 AM, ""... light on again wanting to go to bathroom. She was on toilet by the time CNA (Certified Nursing Assistant) was able to answer light. She wanted CNA to wipe her derrier (sic). She had walker and was encouraged to walk back to bed. She got to bed and yelled out for someone to put her in the bed. I encouraged her to get back in bed as she was able to get out of bed and walk to bathroom with asst. (assistance) from her walker. She got into bed and put light on to pull her covers on her. Resident encouraged to do these little tasks for herself. She did so. No sooner did I make my way to nurses station than she put light on again. this time she wanted a breathing tx (treatment). I listened (with) stethoscope and lungs clear, no wheezing, no labored breathing, O2 Sats 96%. Res. threatened this nurse stating 'you will give me a breathing tx when I ask for it.' ..."" Review of the medical record did not show any assessment of the resident's behaviors in an attempt to discover any patterns or triggers to the behaviors. Without an assessment, the facility was unable to develop an individualized plan of care to address the resident's issues and assist the resident in managing some of her anxiety.",2015-08-01
9039,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-05-31,279,D,1,0,2PH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review, the facility failed to develop a comprehensive plan of care for 1 of 1 resident reviewed with repeated behaviors of yelling out and constantly using the call light to demand attention (Resident #1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the initial Resident Assessment Instrument with an assessment reference date of 1/19/12 showed the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15/15. There were no mood indicators or behavioral symptoms noted on this assessment. Shortly after her initial assessment, the resident began displaying behavioral symptoms of calling out or using the call light to summon staff frequently, often for things that she could do for herself. Review of the quarterly Minimum Data Set with an assessment reference date of 4/5/12 showed the resident remained cognitively intact and she now showed mood indicators but no behavioral symptoms. The initial care plan, dated 1/20/12, showed a problem of Anxiety as evidenced by frequently yelling out and constantly using call light. Staff were to to give support, allow venting, use a calm and soothing approach, and to give medications if those approaches were unsuccessful. The remaining approaches included monitoring effect of medication, inform social worker, monitor for adverse side effects of medication, ensure resident was safe, and encourage participation in activities. The goal for this problem stated ""This resident will have decreased episodes of yelling out to no more than three episodes per shift."" The care plan was updated on 4/19/12 to show a problem of : ""Resident will at times become accusatory or misinterpret event. When resident does not receive the attention desired her behaviors will intensify or she will become accusatory."" The use of two caregivers at a time was instituted. Other approaches included: inform resident of what is and is not medically needed and why; be calm and supportive when providing care; encourage and empower resident to do things for herself; re-approach as needed; use positive reinforcement when she goes a period of time without seeking unneeded medical attention; keep resident involved in activities of interest so that she is receiving positive attention and is not idle. The facility's goal for this problem was: ""This resident will be informed and accept care when needed. She will have decreased episodes of accusatory behavior by the next review. The update to the care plan did not say how the resident was to be encouraged and empowered, what types of positive reinforcement were to be tried, or how the staff would get the resident involved in activities. Review of the Social Services Admission History and Assessment revealed the resident loved bingo, she was an artist (painting and drawing), she liked making things with her hands, and loved to sew. None of these activities were included in the care plan. Without a baseline of frequency of her behavior, the goal of ""decreasing"" them was not measurable. This problem was updated on 5/1/12 saying ""making false statements toward staff."" A new approach, dated 5/4/12, was added repeating that two caregivers, buddy system, was to be used when providing care. A care plan problem of ""[DIAGNOSES REDACTED]. This problem had the same approaches as the earlier anxiety problem with the addition of ""follow up appointment with psychiatrist as scheduled"" with a handwritten note saying ""ordered"" at the end of the approach. The goal for this problem said: ""Resident will be free of Signs and Symptoms of anxiety by next review."" For a resident with a [DIAGNOSES REDACTED]. In early May, the resident began refusing to take some of her medications, saying they made her too sleepy. Review of the care plan on 5/31/12 failed to show this problem was addressed.",2015-08-01
9040,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-05-31,281,D,1,0,2PH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews, the facility failed to ensure that transcription of physician's orders was accurately completed for 1 of 3 residents reviewed who were admitted or readmitted to the facility (Resident #1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. A Nurse's Note on that day stated the resident's physician was notified and advised the facility to keep the medications the same as on the hospital discharge summary. Review of the hospital discharge summary orders and the facility admission orders [REDACTED]. These discrepancies were as follows: [MEDICATION NAME] XR 200 milligrams (mg.) one tablet twice a day was on the discharge summary but [MEDICATION NAME] 200 mg. three times a day was entered on the admission orders [REDACTED] [MEDICATION NAME] 10 mg. one tablet twice a day was on the discharge summary while [MEDICATION NAME] ([MEDICATION NAME]) 10 mg. three times a day was entered into the admission orders [REDACTED] [MEDICATION NAME] 200 mg. one tablet twice daily was on the discharge summary but [MEDICATION NAME] 200 mg, two tablets twice a day was noted on the admission orders [REDACTED] Insulin [MEDICATION NAME] 58 units subcutaneously three times a day as needed plus SSI (sliding scale insulin) for diabetes was not transcribed to the admission orders [REDACTED] Vitamin D2 capsules daily as directed was not transcribed from the hospital discharge summary to the facility admission orders [REDACTED] [MEDICATION NAME] one capsule inhaled daily was on the facility admission orders [REDACTED].",2015-08-01
9041,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-05-31,309,E,1,0,2PH311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews, the facility failed to ensure residents received appropriate care and services related to medications administered in error caused by an inaccurate transcription of the physician's orders [REDACTED].#1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. A Nurse's Note on that day stated the resident's physician was notified and advised the facility to keep the medications the same as on the hospital discharge summary. Review of the hospital discharge summary orders and the facility admission orders [REDACTED]. These discrepancies were as follows: [MEDICATION NAME] XR 200 milligrams (mg.) one tablet twice a day was on the discharge summary but [MEDICATION NAME] 200 mg. three times a day was entered on the admission orders [REDACTED] [MEDICATION NAME] 10 mg. one tablet twice a day was on the discharge summary while [MEDICATION NAME] ([MEDICATION NAME]) 10 mg. three times a day was entered into the admission orders [REDACTED] [MEDICATION NAME] 200 mg. one tablet twice daily was on the discharge summary but [MEDICATION NAME] 200 mg, two tablets twice a day was noted on the admission orders [REDACTED] Insulin [MEDICATION NAME] 58 units subcutaneously three times a day as needed plus SSI (sliding scale insulin) for diabetes was not transcribed to the admission orders [REDACTED] Vitamin D2 capsules daily as directed was not transcribed from the hospital discharge summary to the facility admission orders [REDACTED] [MEDICATION NAME] one capsule inhaled daily was on the facility admission orders [REDACTED]. Review of the Medication Administration Records for April 27 - 30 and May 2012 revealed the resident was administered: [MEDICATION NAME] three times a day from 4/28/12 to 5/30/12; [MEDICATION NAME] three times a day from 4/28/12 to 5/29/12; [MEDICATION NAME] two tablets twice a day from 4/28/12 to 5/30/12; and [MEDICATION NAME] one capsule inhaled once a day from 4/28/12 to 5/31/12. As a result of the transcription order, the resident received more [MEDICATION NAME], and [MEDICATION NAME] than intended. She also received a daily dose of [MEDICATION NAME] that was not ordered by the physician.",2015-08-01
9042,ST GEORGE HEALTHCARE CENTER,425143,905 DUKE STREET,SAINT GEORGE,SC,29477,2012-05-31,425,E,1,0,2PH311,"**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 facility pharmacy policies, the facility failed to ensure that it had a procedure in place to receive and dispense medications from an alternate pharmacy for 1 of 1 resident whose medications came from the Veterans Administration (VA) pharmacy and not the facility's main pharmacy (#1). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident's sister, informed the facility that she would provide medications from the VA for use at the facility. Resident #1 was hospitalized briefly, from 4/24 - 27/12 for a urinary tract infection. On 4/28/12, the resident's sister filed a grievance with the facility stating she did not think nurses were cutting the Lisinopril 40 milligram (mg.) tablets in half for the 20 mg. dose ordered. She stated that the nurse on duty did not know the resident had medications from the VA in the third drawer of the medication cart, and that she discovered there was no Imdur or Prozac for the resident. The facility's investigation revealed the Lisinopril bottle's seal was intact. The nurse on duty admitted to borrowing the medication from another resident. An interview with the Director of Nurses (DON) at 2 PM on the day of the complaint inspection revealed that she did an inventory of the resident's medications with the sister on the next Monday (4/30/11). The Lisinopril, Prozac, and Imdur were found in the medication cart. The DON stated she did not keep a written inventory of that day's findings. The Administrator, who was present during the interview stated that since the nurses signed the Medication Administration Record [REDACTED]. When the Administrator was asked if she interviewed the nurses about splitting the pills, she stated she had not. The DON said she thought one of the nurses bought a pill splitter. There was no receipt for a pill splitter available to view. A meeting with the resident's sister, facility personnel, and regional Ombudsman was conducted on 5/8/12. A procedure was agreed upon related to the resident's medications: [REDACTED]. If a new medication was ordered, the facility was to call the main pharmacy for a two week supply, allowing the VA to dispense and send the medication to the sister. The DON provided a copy of her Action Plan resulting from the sister's complaint. It was dated for 5/8/12, but when the DON was questioned about when it was written, she said it was formulated on 5/8/12 but written on the day of the complaint inspection (5/31/12). The Action Plan stated that the Lisinopril 40 mg. tablets were removed from the medication cart and replaced with 20 mg. tablets obtained from the main pharmacy. Any medications brought to the facility for the resident should be checked in by the DON or Administrator and checked for accuracy with a signed copy kept by the facility and the resident's sister. All medication containers must be sealed. The resident's sister was listed as the responsible party to address the problem with a target date of 5/9/12. The outcome restated the plan put in place. ""Date & auditor"" showed no name but a date of 5/31/12. The facility was asked to provide their policy and procedure for medications supplied by a pharmacy other than their main pharmacy. A policy titled Medication Brought by Resident was provided for review. The stated Purpose was: ""To ensure that all medications to be administered have been dispensed from a known pharmacy and that the medications in the package are as stated."" The Fundamental Information section said: ""Medication brought by, with, or for the resident from any source other than the pharmacy may not be used."" Medications brought by a resident from home were to be returned or destroyed. This policy did not provide information as to how the medications supplied by an alternate pharmacy were to be ordered or received. There was no provision to show how nursing staff was made aware that a resident used an alternate pharmacy. The facility's policy did not show how the medications would be accounted for related to date received and how many units of each medication was received. There were no instructions for reordering a medication from an alternate pharmacy before it ran out. Policies were in place for drug labeling, change of direction notices, and ordering medications from the main pharmacy. The facility was asked to provide it's policy and procedure for splitting pills. An Alteration of Medication Form was provided. However, it only addressed crushing medications.",2015-08-01
2652,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2020-01-03,550,D,1,0,XVX011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of facility policy, the facility failed to ensure dignity was provided to 1 of 1 resident reviewed for quality of care (Resident #340). The findings included: Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/13/2019, the facility was notified that Resident #340 had arrived to their [MEDICAL TREATMENT] appointment only wearing a shirt and a brief. Record review on 1/2/2020 at 3:57 PM revealed Resident #340 had a Brief Interview of Mental Status (BI[CONDITION]) score of 4, indicating s/he was cognitively impaired. S/he was extensive assistance to total dependence with activities of daily living (ADLs). Review of the medical record shows a Physician order [REDACTED].>During an interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 1:51 PM, s/he stated The night shift washed the resident off and got them situated. When transport picked them up, s/he was in another room and did not get a chance to double back and finish getting them dressed. Transport sometimes comes early, but will ask if the resident is ready prior to taking them. Since the resident is tube-fed, the nurse has to disconnect it prior to them leaving. Since the nurse had to disconnect it prior to them going, it should have been noted that the resident was not properly dressed. When asked by the surveyor if it would have been realized that the resident was not dressed at any other time prior to leaving the facility, the CNA confirmed that it would have been noticeable, although a sheet was in place. The facility was unable to provide a policy related to dignity, but did provide a list of residents' rights. During an interview with the Director of Nursing on [DATE] at 1:30 PM, s/he stated it is the facility's expectation that when residents leave to go to outside appointments that they are properly dressed. Per the facility's policy titled, Self Determination reviewed on [DATE] at 2:15 PM, it states, Basic Rights - Each resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must provide equal access to quality care regardless of diagnosis, severity of condition or payment source.",2020-09-01
2653,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2017-03-30,241,D,0,1,NOJA11,"Based on observation, interview, and record review, the facility failed to ensure three residents at the same dining table were served meals at the same time. Two residents at the table received their meals together while Resident (R) 110 was allowed to sit and watch table mates eat their meal. The facility census at the time of survey was 127. Findings include: Observation of the midday meal on 3/27/17 at 12:10 p.m. revealed three people seated at one table (2 ladies and a gentleman) and 2 residents (male in geriatric chair (aka: geri-chair; a more substantial seating platform than is provided by a conventional wheel chair) and female in high back wheel chair) at a second table; the tables were closest to the 200 hallway. Observation of meal tray delivery showed the male at table one received a tray at 12:10 p.m.; and one female at table 1 received a meal at 12:15 p.m. No tray was provided for the third person (R110) at this time. At 12:19 p.m., the female resident at the table was observed to offer R110 her plate; and at 12:30 p.m., the female at the table was observed to ask Nurse Aide (NA) 40 where R110's plate was; NA40 stated her plate is usually here about this time. In an interview on 3/27/17 at 12:25 p.m. NA22 stated the second tray cart for room trays that comes out at 12:40-12:45 p.m. sometimes has dining room trays on it. In an interview on 3/27/17 at 12:50 p.m. R110 stated she had not and it would probably be cold. The room trays in the second transport cart came to the dining room at 12:50 p.m., and was searched for R110's tray; the two trays for male and female resident were delivered to the table and staff started to assist them eating. The cart was then taken down the 200 hall. NA27 asked the staff delivering room trays to look again for R110's tray - not found, NA27 went to the kitchen. Upon return to the dining room, NA27 stated the kitchen said it was on the cart. NA27 went down to look at the cart again, the tray was not found, and NA27 returned to the kitchen and carried R110's tray to the dining room to R110 at 1:01 p.m. After a few bites, R110 was queried if the food was hot, and responded it's not warm and it's dry. (The meal was green beans, noodles and Swedish Meatballs and observed to not have any type of gravy or sauce on the meat.) A review of R110's plan of care for nutrition revealed R110 was able to eat independently after tray set up. During an interview on 3/28/17 3:35 p.m. the Administrator stated it was a policy that all residents at the table should receive their meals at the same time. A review of the facility provided Nutrition Policies and Procedures, Subject: Meal Delivery revealed . 16. Serve patients/residents seated together their meal at the same time.",2020-09-01
2654,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2017-03-30,258,D,0,1,NOJA11,"Based on observation, interview and review of facility's policy and procedure it was determined the facility failed to ensure comfortable sound levels were maintained for two residents (R172, R179) of 12 sampled residents. Findings include: 1. Interview with Resident #172 on 03/27/17 at 10:50 a.m., revealed the facility is very noisy all through the night until early morning. She further revealed you can hear staff laughing and talking going into and exiting from the hallways and doors slamming all hours of the night. 2. Review of R #179's medical record revealed a Brief Interview for Mental Status (BIMS) assessment score of 10 out of 15 indicating the resident had some difficulty with cognition in new situations only and was reliable for interview. Interview with Resident #179 on 03/29/17 at 6:50 a.m., revealed the slamming door can be heard at night. When asked about noise he replied who hasn't heard the door slam. He further revealed when the door was slammed hard at night it would wake you up. Observation on 3/29/17 at 6:55 a.m., revealed numerous staff going into a door way off the lower end of the 100-hallway located on the Indigo wing of the facility. Audible slamming of the door was heard after each person entered and exited the doorway. Further observation revealed more staff members going into and out of the doorway letting the door slam each time they entered and exited the door. Continued observation revealed the door to the kitchen area that was located adjacent to the resident rooms on the same hallway also slammed when it was closed. Interview with Licensed Practical Nurse (LPN15), on 3/29/17 at 7:10 a.m., revealed the doorway lead to one of the outside entrance to the facility as well as the only time clock in the facility. She further revealed every employee must use the time clock to check in and out of the facility. Interview with Maintenance Director on 3/30/17 at 8:45 a.m., revealed the doors can be adjusted and have been adjusted in the past due to a loud slam when closing. He further revealed he agreed the doors were a little loud when they closed and that the room would be in use throughout the day and night until the last shift clocked out at 11:00 p.m. Interview with Administrator on 3/30/17 at 1:00 p.m., revealed the facility policy included equipment checks throughout the facility and the frequency they were to be checked but the list did not include the doors throughout the facility. The Administrator continued to reveal that items could be added to the list as the need occurred. Review of Facility Policy titled: Maintenance/Housekeeping Policy and Procedure (dated 3/2006), revealed a summary of preventative maintenance equipment and frequency to be checked however there was no mention of door systems on the schedule to be monitored.",2020-09-01
2655,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2017-03-30,279,D,0,1,NOJA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to initiate a care plan for vision when a resident with a significant change was identified based on the quarterly Minimum Data Set. (MDS). This was evident for 1 of 13 Residents (R25) care plans reviewed. Findings include: Review of R25's medical record, indicated per the MDS quarterly dated 11/13/16: Resident Assessment Section B. Hearing/Speech/Vision. Vision: Adequate, Corrective Lenses: Yes. Review of R25's Quarterly MDS dated [DATE]: Resident Assessment Section B. Hearing/Speech/Vision. Vision: Moderately Impaired, Corrective Lenses-No Review of R25's care plans failed to identify a care plan for a change in vision based on the MDS assessment completed on 2/1/17. Interview of the MDS nurse on 3/29/17 at 1:40 p.m. revealed there was no rationale as to why a vision care plan for R25 was not implemented when the MDS triggered a resident change. The Minimum Data Set(MDS) 3.0 is a Federally mandated process for clinical assessment for all resident Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Based on identified health problems, a care plan is initiated.",2020-09-01
2656,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2017-03-30,323,J,0,1,NOJA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During the course of the Recertification, Complaint and Extended Survey, based on observations, interview, and record review, the facility failed to provide interventions to ensure the safety of residents assessed for potential elopement after Resident (R) 138 successfully eloped through a resident room window. This not only had the potential to affect the two residents reviewed for accidents in the course of the survey (R138 and R132) but also the remaining 18 residents that wear a Wanderguard system due to an elopement risk. The facility census at the time of survey was 127. Findings include: 1) A review of R138's Resident Face Sheet (a cover sheet to a multipage document that contains demographic information, preferences, contact information, and limited medical information) revealed a facility admission date of [DATE] with medical [DIAGNOSES REDACTED]. A review of R138's care plan revealed a page with Problem Category: Behavioral Symptoms Resident is at risk for elopement. Problem Start Date: 12/30/2016 Edited: 01/17/2017 The Goal of the page was Resident will wander safely within specified boundaries. Will not have any successful elopements. Created: 01/17/2017 with Approaches (all with a start date of 12/30/2016 and created on 1/17/2017) of: -Approach from the front. Walk in step with resident first before redirecting. -Elopement assessment to be completed quarterly and as needed. -Engage in activities when wandering or elopement attempts occur -Maintain a calm environment and approach to the resident. -Place picture in elopement books. -Remove resident from other resident's rooms and unsafe situations. A review of the Progress Notes in R138's record revealed the following entries: -12/31/2016 11:55AM alert but confused. morning meds tolerated well. res (Resident) likes to roam halls (with and without walker) and visit others. skilled services provided for nursing and rehab. res in therapy gym with therapist. -01/01/2017 12:33AM Res was found in another res's room going through his drawers looking for clothes. 2 person assist to redirect and assist res to his own room. -01/01/2017 5:44AM Res up all night - up and down - taking off clothes and putting back on - check on res - not in room - found in rm (room) 103 - took another res's blanket and was dragging it behind him. Not able to redirect or comprehend instructions such as use of call bell even when demonstrated - cannot return demonstration. -01/01/2017 3:05PM Note(sic): Late entry 1/1/17 2:25 Res wandering constantly down hallway res attempted x 2 to exit doors staff redirected res easily with first attempt from exit doors 2nd attempt to exit door Res stated I'M (sic) getting out of this place and I'm not coming back in this place Md (sic) notified and new order to Move res to Room 322A res continues to stand at indigo (hall name) front door res stated I'm not moving unable to redirect res with redirection methods staff members continues (sic) to monitor resident area clear of objects around resident active rom (range of motion) to extremities res refusing to use walker with ambulation res standing at side of door with back to the door looking into the dayroom at this time 2:30 Res ambulating self in dayroom denies pain or discomfort res cooperative with care refused to ambulate with walker res moved to room 322A res made aware of new order -01/01/2017 6:44PM pt in the unit wandering in the hallway. redirected by staff easily. no aggressiveness noted. confused, reoriented by staff. accompanied by staff to his room. will continue to monitor -01/01/2017 11:02PM Resident alert with confusion. Wandering aimlessly down the halls and in and out of other resident's rooms. Went into room 320 and refused to get out. Going through 320B's belongings and putting on clothes that were not his. Took apart the empty bed and moved the spare dresser into the middle of the floor. Unable to be redirected out of the room even with much coaxing and with one on one. After a couple of hours, resident finally came out of the room. Care provided. Resident now sitting up in chair in dining area. -01/02/2017 6:22AM Resident up most of the night walking in and out of resident's room plundering through their belongings. Slept for half an hour sitting up in the dining area. No combative behavior noted. -01/02/2017 4:20PM Resident visiting with family members. Several attempts to exit seek. Not easily redirected. Took AM medications whole without difficulty. PO (oral) intake good, feeds self with set up from staff. Resident had both left and right hearing aids. Family requested that nurse take hearing aid out each night. N.O. (new order) place to remove hearing aids at bedtime. Extra batteries labeled with residents (sic) room number and placed in med cart. No c/o (complaint of) pain, will continue to monitor. -01/03/2017 4:11PM Resident left unit with therapy at 1300 (1:00PM). Therapy called about 30 minutes later stating that resident was standing at door, attempting to exit seek and would not leave door. This nurse was called to therapy and was unsuccessful in getting resident to leave door. The physician was called and a one time dose of Haldol (an atypical anti-psychotic medication) 5 mg (milligrams) was ordered. Call ALL RP (responsible parties) listed on face sheet and left message for return to call to notify of changes. Awaiting call back. Resident returned back to unit accompanied by Indigo UM (unit manager). Resident currently sitting in dining area eating snacks, will continue to monitor. -01/04/2017 4:15AM Pt (patient) sitting in room quietly. Tried to get ppd (a skin test for [DIAGNOSES REDACTED]) 2x and patient refused. -01/04/2017 12:17PM Rd (resident) in room with visitor. No c/o pain, no s/s (signs/symptoms) of discomfort or distress. Continue 15 minute checks. Wanderguard placed on rd (resident) right ankle. Call bell within reach. -01/04/2017 12:25PM PPD (purified protein derivative a skin test for [DIAGNOSES REDACTED]) given in right forearm. Lot 7 Exp (expiration) 1/9/17. Rd tolerated well. -01/05/2017 3:51AM Rsdt (resident) alert and oriented to self with confusion. Verbal with clear disoriented speech. Able to follow some commands and voice needs to staff. Rsdt took medications whole without difficulty. Ambulates independently. Rsdt roamed hallways and sat on sofa in TV area until assisted to bed at 1am. One attempt to exit side door this shift. Staff redirected without incident. Wander guard in place and functional. No c/o pain or discomfort. No combative behaviors. -01/05/2017 6:35PM Rd in room at present. No c/o pain, no s/s of discomfort or distress. Rd had some confusion earlier in shift. Rd pleasant at this time. Call bell within reach. -01/06/2017 4:27AM Rsdt alert and oriented to self with confusion. Verbal with clear speech. Does not respond appropriately to questions at times. Speech is confused. Rsdt does understand rested in bed until 9pm. Rsdt took medications whole. Up to chair in day room watching TV at this time. PO fluids and snack provided. Tolerated well. Incontinent episodes occurring this shift. Staff assisted with incontinent care dressing and grooming this shift. Two attempts to exit side doors this shift. Staff was able to easily redirected rsdt without incident. Wander guard is in place and functional. No behaviors noted thus far. No c/o pain or discomfort. PPD read this shift. Negative results. -01/06/2017 6:01PM Resident sitting in bedroom eating dinner. No behaviors noted. Resident had periods throughout day where he sat on the floor in front o (sic) the door looking out the window. No attempts to exit seek. Family in to visit with resident. Denies any type of pain, will continue to monitor. -01/07/2017 8:35AM Rsdt rested in bed until 12am. Rsdt initially refused medications while resting in bed stating not right now. Rsdt took medications after rsdt woke up and got out of bed at midnight. Took medications whole. Rsdt then sat in dining room area. Snacks were provided for rsdt. Po fluids encouraged. Rsdt returned to bed at 4am. Rsdt incontinent this shift. Requiring staff assistance with ADLs. No exit seeking noted. No behaviors. No s/sx of pain. Call light in each. -01/09/2017 7:41AM Resident alert, verbally responsive, ambulates, confused, got agaitated (sic)during this shift, redirected, call DON (Director of Nursing) @0530, called MD (physician) @ 545, currently in bed with eyes opened, calm now. MD stated, will call back and take a look @ meds. Will continue to monitor. -01/09/2017 1:20PM Resident verbally and physically abusive with staff. Not easily redirected. Get (sic) irate and agitated when tries to redirect. Several attempts to exit seek from all doors to unit. Resident stood at door for over thirty minutes attempting to exit seek. Dr. (surname) ordered a one time dose of Haldol 5 mg IM (intramuscular). IM given at 1300 and resident presently sitting in dining area. RP/Sister (name) notified and aware of resident behaviors, will continue to monitor. -01/09/2017 4:13PM Resident went out of facility with sister/rp to pay bills. Resident pleasant and cooperative. Wander guard removed until return. -01/09/2017 5:45PM Resident returned back to facility at 1740 (5:40PM) with much resistance. This nurse and CNA (certified nurse aide) assisted resident back into facility. Resident sitting eating dinner at this time. Wander guard applied to left ankle, will continue to monitor. -01/09/2017 11:47PM Resident alert, verbally responsive with confusion, no pain or discomfort noted, no behaviors noted @ (at) this time, currently in bed with eyes closed, call light within reach. -01/10/2017 3:54AM Res was sitting on bed and roommate accused him of stealing something from him and started swinging. Res tried to hold his hands down and then hit roommate in the face. They were separated and are being monitored. Dr. was notified. -01/10/2017 4:25PM Res has been taking his hearing aides apart. Was encouraged to give to staff and res has refused. will continue to encourage. -01/11/2017 2:58PM Res has been calm this shift. Has not been exiting seeking at this time. Res has been in common area watching TV. Will continue to monitor. -01/12/2017 5:34AM Rsdt alert with confusion. Verbal with clear disorganized speech. Ambulates independently. Incontinent of bowel and bladder this shift. Incontinent care provided by staff q 2 hrs and prn. Rsdt took medications whole with thin liquids. Remained in room until 4am. Rsdt sat in dining room eating snack until 5am. Rsdt then returned to bed. No exit seeking or combative behaviors noted this shift. Call light in reach. -01/12/2017 4:53PM Res has been trying to wait by doors this shift to get out. Res gets very confused and has been in and out of other res rooms. Res has gotten agitated but not combative. Will continue to monitor for behaviors. -01/12/2017 11:56PM Resident alert with confusion. Ambulates independently. Exit seeking behavior noted. Able to be redirected away from the door with much coaxing. Took all the evening meds whole with no difficulty or refusal. Wanders around the unit aimlessly. Going in and out of other resident's rooms. Staff have to continuously redirect him out of the rooms. Snacks and one on provided with ineffective results. Resident continues with the behaviors. -01/13/2017 12:36AM Body Audit Note: Resident alert with confusion. Transfers self and ambulates independently. Has exit seeking behaviors. One assist with bathing, dressing, and grooming. Continent of bowel and bladder with incontinent episodes at times. Feeds self with tray set up. Po intake adequate. Takes all meds whole. Scalp free of dandruff. Lesions to face. Oral mucosa moist. Hard of hearing. No redness to chest. Old scars noted on back and left outer arm. All knuckles on both hands calloused. Treatment in place to apply petroleum jelly q shift in place. Toenails thick. Denies pain -01/13/2017 3:34AM Resident found in [RM #] urinating in the trash can. Aide cleaned up the mess and escorted resident out of room with no issues. -01/14/2017 3:50AM Reisdent (sic) restless. Stays up all night. Wanders around the unit aimlessly. Goes in and out of other resident's rooms and rummages through their belongings. Took out his private part and peed on the dining room floor. No exit seeking behavior thus far. -01/14/2017 3:35PM pt alert, plesantly (sic) confused throughout the shift. took meds without issues. easily redirected. no aggressiveness noted. no exit seeking noted. needs attended. safety maintained. will continue to monitor -01/14/2017 10:51PM Resident was sitting up in dining area having confused conversation with self. Yelling and arguing with people who aren't there. Wanders up and down the hallways into other resident's rooms. Resident from 320B was yelling out because resident was in his room refusing to get out. Resident became combative with staff when trying to redirect out of the room. Grabbed the spare bed and began shaking it. After much coaxing, aide was able to get resident out of the room. -01/15/2017 5:29AM Resident had door barricaded with two trashcans and wash basin. Drawers laying on the floor and the closet doors open. Resident was sitting on the bed talking to himself. -01/15/2017 11:33AM pt (patient) confused but pleasant. easily redirected. pt attempted to get out of exit door, alarm goes several times already since this morning. redirected away from exit doors. offered drinks and snacks. encouraged to watch TV and sit down. needs attended. no violent behaviors noted thus far. will continue to monitor -01/15/2017 6:40PM family brought pt one piece of hearing aid also a charger for the hearing aid -01/15/2017 10:05PM Door alarm sounding. Resident made an elopement attempt and succeeded in getting out of the building. Aide ran down the down hall to try and stop him before he could get out but didn't make it in time. Resident made it to the grass in front of the carport when the aide caught him. Resident brought back inside building. Resident talking and arguing with people who are not there. Refusing to sit down. Wandering around the unit cackling out loud. Goes in and out of resident's rooms. Refused evening meds x3 attempts. Kept pushing this nurse's hand away. Refused to have his hearing aid removed. Put his hand over his ear and told this nurse to get the hell away from him. Unable to be redirected. Snacks and one on one ineffective. ADON (Assistant Director of Nursing) notified of incident. On call MD (medical doctor) notified about resident's behaviors and unable to be redirected. Order to give Haldol 2mg IM one time. IM injection given in right deltoid. -01/15/2017 10:54PM RP notified. Refused VS (vital signs). -01/16/2017 12:57PM Haldol 2mg IM somewhat effective. Sitting up in dining area, resident continued to talk to people who were not there. Would nod out for brief periods then wake up and begin having conversations with self. No further exit seeking attempts. -01/16/2017 5:32AM Resident restless. Sits for only brief periods then up wandering around the unit. Goes in and out of other resident's rooms. Urinated on the floor near room 301. With much coaxing, resident came back into dining area and sat down. -01/17/2017 1:52AM At aprox (approximately) 7:00pm, (on the 16th) res noted in another res room with door closed.Staff (sic) unable to maintain access into room.Res (sic) blocking door with res body.Much (sic) emotional support and encouragement provided with effective results.Res (sic) up wandering in and out of other res rooms.Pushes (sic) on exit doors in attempt to exit building.Res (sic)refused all HS (bedtime) meds.Res (sic) running from N/A in dining area at aprox 10:00pm, (on the 16th) feet got tangled within each other and res fell to floor.Res (sic) fall wittnessed.Res (sic) did not hit head.Full ROM.No (sic)visible signs injury noted.Head (sic) to toe asses done.Vitals (sic) taken and within normal limits.Res (sic) assisted into chair in dining room.Res (sic) sat for a few moments,got (sic) back up and proceded (sic) to wander aimlessly.Res (sic) sister,(R/P),notified and aware of res uncooperativeness,unable (sic) to redirect,refusal (sic) of medication,and fall.Will (sic) refer res to P/T to eval (evaluate) and tx (treatment).MD (sic) notified via MD book.Res (sic) resting quietly in bed at this time.No (sic) distress noted. -01/17/2017 5:21AM MD notified, N.O. (new order) to send out to ER for eval (evaluation). -01/17/2017 7:41AM Res arose at aprox (approximately) 5:00am.Res (sic)noted in another res room turning over all W/Cs (sic) (wheelchairs),urinating on floor and breaking blinds on windows.Res (sic) assisted back to res room and into bed.At (sic) aprox 5:10am res in bed resting quietly.At (sic) aprox 5:11am,nurse rechecked res to discover res opened res room window and climbed out window.Nurse (sic) alerted staff.Nurse (sic) exited building out back door by res room.Res (sic) noted running down walkway at back of building.Res (sic) ran off nursing facility property onto street.Nurse (sic) caught res after aproximatly (sic) mile chase.Res (sic) became combative with nurse when nurse attempted to coax res back to building.[NAME] (sic) man walking down street came and assisted nurse to calm res down by telling res we needed to go back to building to smoke D/T (due to) res requesting to smoke.N/A (sic) (nurse aide) pulled up in car,encouraged (sic) res to get in car.Nurse (sic) assisted res into n/a car without incident.Res (sic) assisted back into facility without incident.Unit (sic) manager,ADON,DON,and (sic)administrator notified of elopement.Nurse (sic) instructed to send res to ER for eval and TX.Squad (sic) notified of need for res transport.Sister (sic) notified and aware of elopement.Res (sic) transported to ER per squad at aprox 6:00am Observation of open resident room windows on 3/29/2017 prompted a tour with Maintenance Employee (ME) 14 of the hall where R138 had resided on 1/17/17. The window in the room previously occupied by R138's opened to a screen area of 22 height x 29 width (measuring tape was read by ME14); room 304, which was located at the other end of the hall, opened to a height of 23.5 inches. At 8:40 a.m., ME14 stated the windows on the hall may not all be identical in size like we just saw they opened to different heights, but they are all the same style and they all go up. In an interview on 3/29/17 at 5:15 p.m., the Maintenance Director, after ruling out windows that would egress to a secure area, stated there were 122 windows that would open to an unsafe area. In an interview on 3/29/17 at 1:28 p.m. the Administrator stated R138 was transferred out and not accepted back as the facility could not meet his needs and there were no other residents like that (R138) in the building. R138 was admitted to the hospital with [REDACTED]. The Resident was discharged from the hospital on [DATE] to home with family with a referral to [NAME]town Mental Health and to see his family physician. 2) A review of R132's Resident Face Sheet revealed an admittance date to the facility of 4/28/16 and a re-admittance date of 11/19/16, with medical [DIAGNOSES REDACTED]. A review of R132's care plan revealed a problem of: Category: Behavioral Symptoms Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). Resident often times goes to the unit door, pushes down on the door in hopes it may open. Staff attempts to re-direct her away from the door with food, activities, etc. Problem Start Date: 05/01/2016 Edited: 02/24/2017. The goal of the care plan was Resident will wander safely within specified boundaries. Edited: 01/23/2017. The approach to attain the goal was: Remove resident from other resident's rooms and unsafe conditions. Created 06/28/2016. In an interview on 3/30/17 at 3:20 p.m. the DON stated she felt the above care plan was for exit seeking and that was the only approach for the problem. Another page of R132's care plan listed a problem of: Category: Behavioral Symptoms Resident wanders around unit, at times needs redirection out of other rooms, attempts to void in inappropriate places/trash cans, prefers to sleep on couch in main area at times. Wanderguard in place. Problem Start Date: 05/05/2016 Edited: 03/28/17. The goal of the plan was Resident will wander safely without any negative outcomes from wandering. Approaches, all starting and created on 05/05/16, to attain the goal were: -Approach from the front. Walk in step with resident first before redirecting. -Provide activities based on prior lifestyle/interests: folding towels (specify). -Remove resident from other resident's rooms and unsafe situations. -When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.) A review of R132's Progress Notes revealed the following selected entries: -01/23/2017 2:22PM Resident up and combative with staff. Redirection with snacks and conversation attempted, unsuccessful. IM Ativan given to left deltoid. Resident running up and down halls at this time -01/25/2017 3:40AM Rsdt ambulating independently. Wandering in and out of other rsdt's rooms. Difficult to redirect. Attempting to remove clothing. Exit seeking. At 7:30 rsdt noted running down hallway with pants around anlkles(sic). Rsdt given prn (as needed) Klonopin (a benzodiazepine medication) with effective results. Rsdt resting comfortably in bed at this time. Call light in reach. -01/30/2017 6:30AM Resident took evening meds with much coaxing. Went into other residents rooms. Easily redirected out. Had no combative or exit seeking behaviors. Slept throughout out the night. Denies pain -02/01/2017 4:36PM Rd (resident) in day room at present. No c/o pain, no s/s of discomfort or distress. Rd removed from room 323 when witnessed with pants down over trashcan. Redirected to own bathroom in room. Redirected from several other rooms this shift. No combativeness noted. -02/05/2017 6:41PM pt attempted to exit doors several times today. alarm doors went off, staff was able to reach the exit door before 15s automatic door open. pt (patient) hard to redirect. will continue to monitor -02/07/2017 6:48PM At approximately 1715 (5:15 p.m.), rd observed chasing a staff member out of room 302. Rd was very agitated. As this nurse was approaching rd, the rp (responsible party) for room 304 approached rd to talk to her. Rd grabbed the visitor by the [NAME]et and arm. This nurse approached rd and loosened hands off of visitor. Visitor states she is ok, but her chest and arm are sore and that she is going to have to rub them tonight. No injury observed to visitor. MD and RP notified. Rd is calm at this time -02/08/2017 4:10AM Resident became combative towards the CNA during care. After about 10 minutes, the resident had calm down and allowed the staff to provide care. -02/09/2017 6:17PM Resting in chair. Med pass tolerated. Res. entered hallway with just breif (sic) and shirt. Redireted(sic) easily. Wandering into others rooms.Toilete (sic) and offered snacks with were uneffective (sic) interventions. Attempting to exit through doors x 6 by holdign (sic) until alram (sic)sounds. When redirected from one will briskly walk to other end of corridor to try the other exit. No complaints of pain. No s/s od ditress (sic). Call light in reach. -02/10/2017 Resting in bed and call light in reach. While awake resident was ambulating down the hallways and wandering from room to room. No combativeness or taking off clothes. Cooperative and pleasant with the staff. -02/10/2017 6:39PM At approximately 1800, called to room 300 r/t rd in 300A tried to push this rd out of her room and this rd scratched the back of both hands on the rd. Rd easily redirected to day room. No apparent injury noted. Other rd would try to approach this rd and talk with her demanding to know why she scratched her. MD and RP notified. Will continue to monitor. -02/11/2017 4:29PM Rd is walking aroung (sic) the unit. No c/o pain, no s/s of discomfort or distress. No behaviors or combativeness noted. Rd has had several attempts to exit seek, but is easily redirected. Will continue to monitor. -02/13/2017 3:11PM Res tried taking clothes off x2 today. Res was toileted and quit disrobing. Res can get agitated quickly and is hard to redirect at times. will continue to monitor her behaviors. -02/17/2017 1:18AM Resident alert with confusion noted. Found resident in another resident room, redirected resident to dayroom. Tolerated meds crushed in applesauce without differculty (sic). No behavior issues or combativeness noted. Will continue to monitor. -02/17/2017 11:02PM Resident had exit seeking behaviors. Difficult to redirect. One on one and snack provided ineffective. PRN Klonopin 0.5 mg given at 2003. Had no combative behaviors or refusals of care. Resting quietly in bed at present time. -02/19/2017 6:50PM pt attempted to get out of the door exit today several times. door alarm goes off several times. made sure Wanderguard is on. Pty (sic) redirected away from door exit. easily redirected. no aggressiveness noted. offered fluids and food and encouraged to rest. needs attended. will continue to monitor -02/25/2017 7:41PM Rd was running hall and ran into room 321 and hit head on bathroom door. 1 cm (centimeter) laceration above left eye. Steri strips applied. New order to monitor steri strips for s/s of infection q (every) shift. PT (physical therapy) referral done. Neuro checks started. No other apparent injury noted. MD and RP notified. -02/25/2017 10:25PM Resident running around the unit. Gait unsteady. Attempts to exit seek x3. Going in other resident's rooms and rummaging through their drawers. Difficult to redirect. One on one ineffective. Resident unable to sit still. Prn (as needed) Klonopin 0.5 mg given at 1908 (7:08 p.m.) with positive effects. Resident is resting quietly in bed at present time. -03/03/2017 4:26PM At 1515, rd was running in the day room towards the nurses desk and tripped over the wheel of another rd's wheelchair. Rd did not hit her head. Head to toe assessment and ROM done with no apparent injury. Rd denies pain. Rd refuses to wear safety helmet and is not a good candidate for therapy r/t not able to follow commands. Will encourage rd to rest more. MD and RP notified. -03/04/2017 Resident pushing on the door handle x2. Easily redirected away from the door both times. No combative behaviors. No refusals of care or meds. Resting quietly in bed at present time. -03/06/2017 5:33PM Rd is walking the halls. No c/o pain, no s/s of discomfort or distress. Rd refuses to wear safety helmet. Rd is wearing elbow and knee pads as tolerated. No combativeness noted. Steri strips in place with no s/s of infection noted. Several attempts to exit seek this shift. -03/13/2017 12:08AM Residenr (sic) made several exit seeking attempts. Redirected away from the door each time. Running up and down the hallway. Going in and out of resident's rooms. Was found defecating on the floor in 312. Non-compliant with wearing safety helmet. Prn Klomopin (sic) 0.5 mg given at 1929 for increased anxiety. Positive effects. Resting quietly in bed at present time. -03/16/2017 8:01AM Rsdt is alert and oriented to self with confusion. Verbal with clear disorganized speech. Responds to simple questions. Staff anticipates needs. Ambulates independently. Rsdt roaming unit. Exit seeking. Delusions and increased agitation noted. Reported to this nurse by N/A that rsdt had become combative with care that shift. Prn Fluphenazine 2.5mg given at 8:38pm with little effect. At 9pm this nurse heard yelling in rsdta??s (sic) room. This nurse entered rsdt's room to note roommate sitting on floor yelling. Rsdt standing close by. Rsdta??s (sic) roommate stated I was going to come out of the room and come down to the dining room when she came behind me and pushed me down. This nurse asked rsdt a?? (sic) Did you push her down?a?? (sic) Rsdt began to rummage through roommatea??s (sic) things mumbling a??(sic) church peoplea?? (sic) and a?? (sic) I need to leave.a?? (sic) Rsdt did not respond to question directly. Rsdts were separated. Roommate requested to come into dining area to watch TV. Rsdt remained in room with CN[NAME] Notified DON at 9:16pm. ADON notified at 9:18pm. Called and left VM for MD to return call at 9:20pm. Call to notify RP at 9:21pm. RP did not answer. Left VM to return call ASAP. Awaiting return call at this time. Prn Klonopin 0.5mg given for increased anxiety and combative behaviors. Effective results. 1:1 provided by CNA until rsdt fell asleep and was resting quietly in bed. Roommate returned to room at that time. Will continue to monitor frequently. -03/16/2017 3:45PM 3:15pm Resident refused incontinence care x 2 attempts. Resident becoming agitated (sic) and pacing back and forth in hallway. Rummaging through items. Staff offered fluids. Resident went to sit in dining room chair and sat down, tipping chair over in dining room. Witnessed per nurse. Resident did not hit head. Denies pain. Able to move extremities without difficulty. Staff provided one on one care, PRN Klonipin (sic) given for agitation (sic). Dr (surname) notified via phone of fall and VM left with RP (name). -03/19/2017 7:28PM Resting in chair. Med admin tolerated well. Appetite adequate when fed at 100%. Attempt yo (sic) exit building by pushing on door. Punched CNA in ab (abdomen) when redirected from open exit. No futher (sic) attempts. Wanderguard in place and functional. Safety maintained (sic). -03/20/2017 Resident had two exit seeking attempts. Going to the door and pushing on the handle. Redirected away from the door each time. No combative behaviors noted. Took all evening meds crushed in applesauce with much encouragement. No refusals of care. Asleep at present time. -03/24/2017 11:50PM Resident running around the unit. Going to the doors and pushing on the handle setting off the alarm. Reidrected (sic) away from the door each time. Continued with the behavior. Prn Klonopin 0.5 mg given at 1922 with positive results. Resident took all evening meds crushed with much encouragement. No combative behaviors or refusals of care. Resting quietly in bed at present time. -03/25/2017 4:54PM Rd sitting in day room. No c/o pain, no s/s of discomfort or distress. Rd has attempted to climb on tables several times this shift. Rd easily redirected. No combativeness noted. Rd refuses to wear helmet. -03/26/2017 5:48AM Resident went to the door x1. No combative behaviors. Took all evening meds crushed in applesauce. Slept throughout the night. No s/s of pain -03/28/2017 5:43PM Res ambulating around unit ad lib. Res has been exiting seeking and gets agitated quickly. Res can be redirected although is difficult at times.Res (sic) will not wear knee pads or helmet. On 3/29/17 at 11:18 a.m. the Administrator provided a list of residents that were using Wander guards. R132 was on the list of 19 residents. In an interview on 3/30/17 at 10:05 a.m., Licensed Practical Nurse (LPN)11 stated R132 could ambulate - she's fast/quick - she can run. When asked if LPN11 thought R132 could open a window, LPN11 responded Yeah, I would say she could, but if she hears an alarm she backs off. In a meeting on 3/29/17 at 3:20 p.m. between the Administrator, DON, Clinical Consultant, and Survey Team the facility was notified of (TRUNCATED)",2020-09-01
2657,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2017-03-30,371,F,0,1,NOJA11,"Based on observation, staff interview, and policy review, the facility failed to ensure that resident food was stored in a sanitary manner and was prepared using clean, well maintained equipment and sanitary practices. Failure to do so results in an increased risk of food borne illness for 118 residents receiving food from the kitchen. Findings include: 1. During a tour of the facility kitchen and food storage areas at 8:30 a.m. on 3/27/17, the following was observed: a. A radio was sitting on top of a large mixer, next to a clean 2 compartment sink. b. An uncovered, overflowing trash barrel was positioned right in front of the mixer. c. The mixer was noted to need cleaning. d. Condensation and mold was noted around the edge of the door to the walk-in refrigerator. e. A small freezer in the dish storage room contained two undated boxes of sherbet, there was no thermometer present in the freezer and there was approximately one quarter inch of ice buildup in this freezer. f. A plastic stacking bin filled with plastic cup lids was being stored on top of a rotating toaster, which was operating at the time of the tour. Personal items/pocketbook were noted to be on a shelf under the toaster table. g. A dry storage room, next to the walk-in refrigerator contained mop buckets which were upside down on floor, and there were buckets of chemicals for the dishwasher stored across from the shelves holding dry storage, on the right of the room. h. The kitchen ice machine was open and there was no thermometer noted. i. An additional dry storage room, located off a hallway outside the kitchen contained an open, undated bag of cornmeal and an open undated container of bread crumbs. j. Observations in the walk-in refrigerator included an open, undated package of sliced turkey on the top shelf of a metal rack on the left side of the walk-in refrigerator, an open, undated, five-pound bag of grated cheddar cheese (Casa Solana brand with a best by date of 8/17), which was half empty was also on the top shelf of the metal rack. On the middle shelf of the metal rack was an open, uncovered, undated box of purple grapes. Case of milk cartons were stored on the floor. k. Observations in the walk-in freezer included multiple boxes of potatoes and French fries on the floor and an open, undated box of beef patties on the top shelf of a metal rack on the right side of the freezer. The beef patties were freezer burned. On the top shelf of the metal rack on the left side was an open, undated box of freezer burned chicken pot pies. Other miscellaneous boxes were haphazardly stacked on the floor in the freezer and the floor underneath the metal racks was noted to be dirty. During an interview with the Dietary Supervisor during this observation tour on 3/27/17 at 8:30 a.m., the Dietary Supervisor said this happened over the weekend, and when asked what happened over the weekend she said you don't want to know. During an interview with the Dietary Manager at 8:40 a.m. on 3/27/17, he said that the freezers should not be arranged like that and that food should be labeled, sealed, dated, and off the floor. he Dietary Manager said there should be a thermometer in the small freezer and nothing should be stored on top of the rotating toaster. He said that the ice machine required a thermometer. 2. During a tour of the Facility kitchen area at 3:15 p.m. on 3/28/17, the following observations were made: a. An uncovered, full trash barrel was in front of the mixer and the clean 2 compartment sink. b. The rotating toaster was not operating, however there was an open loose leaf notebook on top of it. c. The small freezer in the dish storage room still had a buildup of frost, and there was slight condensation noted around the top edge of the walk- in refrigerator door. During an interview with the Dietary Manager at 3:15 p.m. on 3/28/17, during the tour, the Dietary Manager said the notebook should not be on top of the toaster, the trash barrel should be covered and not overflowing, and the freezer needed defrosting. 3. During a tour of the Facility kitchen area at 4:30 p.m. on 3/29/17 the following was observed: a. The fryer was noted to contain dark, rancid smelling oil and the outside surrounding surfaces of the fryer was covered with splashes of oil. During an interview with the Dietary Manager at the time of the tour he said the fryer was cleaned on Monday (3/27/17), and a log book indicated it was documented as having been cleaned, however a rancid odor was noted. b. The cutting blade on the large can opener attached to the counter chipped. This was confirmed by the Dietary Manager who was present during the tour at 4:30 p.m. on 3/29/17. 4. During a tour of the Facility kitchen area at 11:15 a.m. on 3/30/17, a sheet of wax paper was noted on top of the griddle (part of the stove and oven which was being used). On top of the wax paper was a saucepan, tongs and a Styrofoam cup. The items were removed by the Dietary Manager who said that wax paper should not be used to line the top of the griddle. The far-left knob to turn the griddle on was missing. 5. During the tour of the Facility kitchen area at 11:15 a.m. on 3/30/17, the Cook was observed checking the temperature of foods in the steam table while preparing for the lunch meal. The Cook was observed wiping the probe of the thermometer with a paper towel between testing the pureed meat and the pureed carrots, at which time the Dietary Manager handed her several individually wrapped alcohol wipes to use to clean the thermometer probe between foods. During an interview with the Cook at the time of the observation, she said she should have been using the alcohol wipes for the entire process instead of the paper towel. The Dietary Manager, who was present confirmed that the Cook should not use paper towel to clean the thermometer probe between foods. Review of the Facility policy Food Safety in Receiving and Storage, dated 5/1/15, indicated chemicals should be stored in an area separate from food. Review of the Facility policy Safe Food Temperatures, dated 5/1/15, indicated the thermometer must be cleaned and sanitized and the use of foil wrapped alcohol pads is acceptable for sanitizing thermometer probes. Review of the Facility policy Cleaning the Can Opener (Bench type), dated 5/1/15, indicated the blade should be checked for sharpness and cleaned with a small wire brush. The policy indicated that metal shavings and shredding can result from a dull cutting blade or worn out cogwheel. Review of the Facility policy Fire Prevention and Control, dated 5/1/15 indicated that garbage and trash areas should be kept clean and sanitary with all waste containers covered and trash no allowed to accumulate.",2020-09-01
2658,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2017-03-30,490,J,0,1,NOJA11,"During the Recertification, Complaint and Extended Survey, based on observation, record reviews, and interviews, the facility Administration failed to effectively protect residents in the facility against the possibility of elopement through windows that opened after an incident of elopement using a window as an egress point. The windows in the facility were identified as 122 in number that remain with open access for residents to unsafe areas. This not only had the potential to affect the two residents reviewed for accidents during the survey (R138 and R132) but also the remaining 18 residents that wear a Wanderguard system due to an elopement risk. Cross reference to F323 Accidents, Hazards/Supervision Cross reference F520 Quality Assurance Findings include: During the survey, Resident (R)138 was triggered for a review under the category of accidents. Progress Notes were reviewed in R138's record regarding subjects including: -wandering to other resident's rooms -verbal altercations with staff and other residents -physical altercations with staff and other residents -relieving himself in other resident rooms -exit seeking behaviors R138 eloped from the facility via his room window on 1/17/17 and was chased a mile down the road prior to staff reaching him. Observations and interview with a Maintenance Employee (ME) on 3/29/17 at 8:40 a.m. revealed windows still fully open. Interview of ME14 on 3/29/17 at 5:15 p.m. identified 122 windows that would open to an unsafe area. In an interview on 3/29/17 at 3:20 p.m. the Administrator stated after the incident, the Maintenance Director contacted the local Fire Marshall and was told they could not keep the windows from opening and as R138 was no longer there and no other resident's like R138, the issue was dropped. No action was taken. In an interview on 3/29/17 at 3:45 p.m., a Captain from the [NAME]town Fire Department and the local Fire Marshall, stated he was the authority having jurisdiction - AHJ and stated that all original design features of windows must be maintained. He stated he was not in this position in (MONTH) and had not spoken to a facility representative. At 3:50 p.m. the Captain stated he would recommend the facility use alarms but is unaware if that was suggested by his predecessor. A review of R132's record, that also triggered for accident review, revealed Progress Notes after 1/17/17 regarding subjects including: -wandering to other resident's rooms -physical altercations with staff and other residents -relieving herself in other resident rooms -exit seeking behaviors R132 does wear a Wander Guard alarm bracelet due to her elopement risk; and the opinion of a nursing staff member that R132 would be able to physically open a window. Administration did not identify the similarities between the two residents and, therefore, the potential of elopement via an open window continued. In a meeting on 3/29/17 at 3:20 p.m. between the Administrator, DON, Clinical Consultant, and Survey Team the facility was notified of the Immediate Jeopardy existing related to F490 Effective Administration/resident Well-Being as of (MONTH) 17, (YEAR). Resident 132 was demonstrating many of the same types of behaviors exhibiting by Resident 138 prior to his elopement and the facility Administration failed to ensure an intervention for the potential of the use of a window as a point of egress for other residents was identified. On 3/30/17 at 1:30 p.m. the facility provided a written plan of action to remove the immediacy of the jeopardy. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur were put in place by the facility as follows: Previously identified resident that exited facility through resident room window on 1/17/17 was immediately discharged to [NAME]town Memorial Hospital at time of incident. No other facility residents had previously exited through a resident room window prior to 1/17/17. There have been no other elopements from the facility since 1/17/17. All facility residents have been validated to be present in the facility on 3/29/17 at 4:05 p.m. by the facility Assistant Director of Nursing, with 4 residents being out of the facility for appropriate reasons known to staff. Residents in the facility identified as elopement risk are being monitored by facility nursing staff every 15 minutes to validate they are not exhibiting exiting seeking via facility windows. This monitoring was initiated on 3/29/17 at 3:45 p.m. and will continue until an appropriate intervention is implemented to prevent future exit attempts via facility windows. The facility Staff Development Coordinator has re-educated all facility staff on reporting observation of exit seeking behavior via facility window to nursing leadership or facility administration. This re-education was completed on 3/29/17. Any facility staff member not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. All newly admitted residents will be evaluated for risk of elopement with interventions to be implemented as appropriate. The facility management is actively pursuing an appropriate intervention for facility windows to prevent future exit attempts. The facility Administrator will review all related information for concerns on an ongoing basis. The Director of Nursing will report all findings from audits and monitoring to the Quality Assurance Improvement committee monthly. Any areas of concern will be addressed at the time of discovery for further intervention. Observations, record reviews, and interviews revealed the plan submitted by the facility on 3/30/17 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. On 3/30/17 at 3:01 p.m. the State Agency accepted the facility written plan of action presented on 3/30/17 at 1:30 p.m. that removed the Immediate Jeopardy. The citation F490 will continue at a lower scope and severity level of D.",2020-09-01
2659,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2017-03-30,520,J,0,1,NOJA11,"During the Recertification, Complaint and Extended Survey, based on observations, interview, and record review, the facility failed to ensure the Quality Assurance (QA) Committee identified a potential elopement egress point and interventions to ensure the safety of residents assessed for potential elopement after Resident (R) 138 successfully eloped through a resident room window. This not only had the potential to affect the two residents reviewed for accidents during the survey (R138 and R132) but also the remaining 18 residents that wear a Wanderguard system due to an elopement risk. The facility census at the time of survey was 127. Cross Reference F323 Accidents Hazards and Supervision Cross Reference F490 Effective Administration/resident Well-Being Findings include: During the course of the survey, Resident (R)138 was reviewed for accidents. Progress Notes were reviewed in R138's record and included notes regarding subjects including: -wandering to other resident's rooms -verbal altercations with staff and other residents -physical altercations with staff and other residents -relieving himself in other resident rooms -exit seeking behaviors R138 eloped from the facility via his room window on 1/17/17 and was chased a mile down the road prior to staff reaching him. Reference findings under F323. Observations and interview with a Maintenance Employee on 3/29/17 5:15 p.m. revealed 122 windows leading to unsafe areas could be fully opened. A review of the facility provided Leadership Policies and Procedures Subject: Elopement, showing a Complete Revision: 5/11/2013 revealed . 11. Facilities Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences. In an interview on 3/29/17 at 11:58 a.m., the Administrator showed documentation that the incident had been taken to the QA committee at the next meeting on 2/10/17. A review of the QA documentation the Administrator presented for the 2/10/17 meeting revealed a sign in sheet of at least 17 attendees. On the last page, in a section titled Safety (identified trends brought to QAPI (Quality Assurance Performance Improvement) from Safety Meeting in the row titled Elopement Drills was a handwritten note that stated *Resident went out window* and a handwritten note at the bottom of the page stated *Resident windows cannot be screwed shut due to fire regs (regulations). Responding to the query regarding number 11 on the Elopement policy, the Administrator stated Not very complete (referencing the handwritten items) and stated R138 was transferred out and not allowed to return was the intervention to prevent reoccurrences. In an interview on 3/29/17 at 3:20 p.m. the Administrator stated after the incident, the Maintenance Director contacted the local Fire Marshall and was told they could not keep the windows from opening and as R138 had been transferred out of the facility, the issue was dropped. In an interview on 3/29/17 at 3:45 p.m., a Captain from the [NAME]town Fire Department and the local Fire Marshall, stated he was the authority having jurisdiction - AHJ and stated that all original design features of windows must be maintained. He stated he was not in this position in (MONTH) and had not spoken to a facility representative. At 3:50 p.m. the Captain stated he would recommend the facility use alarms but is unaware if that was suggested by his predecessor. A review of R132's record, that also triggered for accident review, revealed Progress Notes after 1/17/17 regarding the majority of the same items listed above for R138 (also see F323 and/or synopsis in F490) and R132 had been previously been identified as an elopement risk; who nursing staff felt would be able to open a window. The QA Committee failed to identify another resident that was in house and showing many of the same behaviors as R138; or review the other 18 residents identified as elopement risks and wearing Wander Guard alarm bands to ensure none had behaviors or capabilities that presented risk. The QA Committee failed to search for options to modify the windows while still maintaining the original functionality to prevent reoccurrences. In a meeting on 3/29/17 at 3:20 p.m. between the Administrator, DON, Clinical Consultant, and Survey Team the facility was notified of the Immediate Jeopardy at F520 Quality Assurance existing in the facility as of (MONTH) 17, (YEAR). Resident 132 was demonstrating many of the same types of behaviors exhibiting by Resident 138 prior to his elopement and the facility failed to ensure an intervention for the potential of the use of a window as a point of egress for other residents was identified. On 3/30/17 at 1:30 p.m. the facility provided a written plan of action to remove the immediacy of the jeopardy. Measures put into place or system changes made to ensure that the immediate jeopardy will not recur were put in place by the facility as follows: Previously identified resident that exited facility through resident room window on 1/17/17 was immediately discharged to [NAME]town Memorial Hospital at time of incident. No other facility residents had previously exited through a resident room window prior to 1/17/17. There have been no other elopements from the facility since 1/17/17. All facility residents have been validated to be present in the facility on 3/29/17 at 4:05 p.m. by the facility Assistant Director of Nursing, with 4 residents being out of the facility for appropriate reasons known to staff. Residents in the facility identified as elopement risk are being monitored by facility nursing staff every 15 minutes to validate they are not exhibiting exiting seeking via facility windows. This monitoring was initiated on 3/29/17 at 3:45 p.m. and will continue until an appropriate intervention is implemented to prevent future exit attempts via facility windows. The facility Staff Development Coordinator has re-educated all facility staff on reporting observation of exit seeking behavior via facility window to nursing leadership or facility administration. This re-education was completed on 3/29/17. Any facility staff member not receiving this re-education by this date will receive prior to next scheduled shift. This information will be presented in new hire orientation. All newly admitted residents will be evaluated for risk of elopement with interventions to be implemented as appropriate. The facility management is actively pursuing an appropriate intervention for facility windows to prevent future exit attempts. The facility Administrator will review all related information for concerns on an ongoing basis. The Director of Nursing will report all findings from audits and monitoring to the Quality Assurance Improvement committee monthly. Any areas of concern will be addressed at the time of discovery for further intervention. Observations, record reviews, and interviews revealed the plan submitted by the facility on 3/30/17 had been implemented by the facility and was in practice, removing the immediacy of the deficient practice. On 3/30/17 at 3:01 p.m. the State Agency accepted the facility written plan of action presented on 3/30/17 at 1:30 p.m. that removed the Immediate Jeopardy. The citation F520 will continue at a lower scope and severity level of D.",2020-09-01
2660,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-05-23,609,D,1,0,VF0911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews, and review of the facility's policy entitled Leadership Policies and Procedures: Section III: Organizational Ethics: Abuse, Neglect, Exploitation, or Mistreatment, the facility failed to report allegations of abuse within the required 2 hour period for 2 of 3 incidents reviewed involving 3 residents (Residents #2, #3, and #4). The findings included: The facility admitted Resident #2 on 3/29/16 with [DIAGNOSES REDACTED]. Review of 4/19/19 7:31 PM Progress Note and Patient/Resident Incident/Accident Investigation Worksheets on 5/22/19 revealed that on 4/19/19 at 5:15 PM, Licensed Practical Nurse (LPN) #1 noted: Informed per staff that resident (Resident #2) and another resident (Resident #3) had an incident and that (Resident #3) shook his (her) walker at this resident and splashed water on him (her) and then the two of them was (sic.)and then the two of them was (sic.) hitting at each other but neither made contact. This resident has a dark bruise to left leg that is non-tender nor painful to touch. This resident states that other resident hit him (her) with the walker. Review of the facility's reportable/investigation file on 5/22/19 revealed that the Initial 2/24-Hour Report was not sent to the State Agency until 4/22/19 and staff interviews were not initiated until 4/23-25/19. During an interview at 7 AM on 5/22/19, Certified Nursing Assistant (CNA) #1 verified his/her 4/24/19 statement which noted: (Resident #3) was shaking his (her) walker at (Resident #2) and while doing so, the walker made contact with (Resident #2's) shin. There was a cup of water attached to the walker and the water spilled when he (she) was shaking walker. CNA #1 stated s/he does not feel (Resident #3) intentionally meant to hit (Resident #2) with his (her) walker, nor to cause him (her) harm. During an interview at 9:33 AM on 5/23/19, LPN #1 stated s/he was in a room with another resident when LPN #2 came & told me I think we have a resident to resident issue. (Resident #2) said '(Resident #3) hit me' but the CNAs said (Resident #2) shook the walker but they did not see the one resident hit the other. S/he stated CNA #1 was with other residents in the area. The nurse noted that Resident #3 had a reacher tied on the walker that could have hit Resident #2. S/he stated, (Resident #2) had a dark bruised area on his (her) leg. The resident said Resident #3 caused the bruise and that s/he just did it. LPN #1 stated s/he filled out an incident report, called LPN #3, the Unit Manager and told her/him everything. The LPN also stated s/he reported the incident to the Assistant Director of Nurses and the night shift supervisor. During an interview at 10:15 AM on 5/23/19, the Director of Nurses (DON) reviewed the investigation file and confirmed that the Initial 2/24-Hour Report regarding the 4/19/19 resident-to-resident abuse allegation was faxed on 4/22/19 at 11:15 AM. The DON stated, On 4/22/19, (Resident #2) told the nurse (? LPN #1) he (she) had a bruise on his (her) leg from (Resident #3) hitting him (her) with his (her) walker. (LPN #2) noted a bruise at that time but there were no witnesses of any contact. They didn't find anyone who said they witnessed the incident. When asked about CNA #1's statement, the DON admitted they did get a statement from CNA #1 who saw the incident and that the walker did hit the resident. The DON stated s/he had been notified of the incident on 4/19/19 by LPN #2 who stated there had been no contact between the residents, then got to Mondays morning meeting and found out there was. The DON stated the 2 hour report had been done after s/he had been made aware. The facility admitted Resident #4 on 1/29/16 with [DIAGNOSES REDACTED]. Review of the facility's reportable/investigation file on 5/22/19 revealed that the Initial 2/24-Hour Report of an allegation of physical abuse was faxed to the State Agency on 4/22/19 at 1:24 PM. Further review revealed that on 4/21/19, LPN #5 reported 2 separate encounters with Resident #4 on 4/21/19. At an undefined time, Resident #4 became agitated, yelling and screaming out when s/he observed CNA #2 and Resident #3 talking in the hallway. Later, the resident was yelling, spitting, and screaming, then started hitting him/herself in the face over his/her right eye after LPN #4 had administered medication and exited the room. The LPN asked if someone had hit him/her. The resident kept pointing to the door that LPN #4 had just exited. Both nurses had provided care using the buddy system due to the resident's unsubstantiated allegations in the past and LPN #5 observed no abuse. Following a thorough investigation, the allegation was unable to be substantiated. During an interview at 10:44 AM on 5/23/19, the DON reviewed the investigation file and verified that the allegation of abuse was made on 4/21/19. When reviewing the State Agency reports, the DON verified that the physician was notified on 4/22/19 at 8:15 AM though the time of the incident was recorded as 12:45 PM. S/he stated s/he had completed the Date/Time of Reportable Incident section with the date/time s/he had been notified of the incident (4/22/19 at 12:45 PM). The DON confirmed that the allegation had not been reported within the required 2 hours. S/he said, If I reported it on Monday (4/22/19), I didn't know about it until Monday. The person that trained me said to put the time I was notifed. It (the allegation) had to have occurred after the last med pass time for 4/21/19 on the 3-11 shift.",2020-09-01
2661,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,550,D,0,1,KY5E11,"Based on observations and interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality during meal service on the Magnolia Hall. Staff were observed entering resident rooms with meal trays without first knocking and waiting for residents to give permission to enter. Staff were also observed yelling, Knock, Knock, and entering rooms without waiting for permission to enter the room during 2 of 2 lunch meal observations. The findings included: An observation on 7/23/2018 at approximately 1:20 PM of the lunch meal service on the Magnolia Hall revealed staff entering resident rooms with lunch trays without knocking and waiting for residents to give permission to enter. An additional observation on 7/23/2018 at approximately 1:25 PM of the lunch meal service on the Magnolia Hall revealed staff yelling, Knock, Knock, and entering rooms without waiting for permission from residents to enter. An observation on 7/27/2018 at approximately 1:15 PM of the lunch meal service on the Magnolia Hall revealed staff entering resident rooms with lunch trays without first knocking and waiting for residents to give permission to enter. An additional observation on 7/27/2018 at approximately 1: 20 PM of the same lunch meal service on the Magnolia Hall revealed staff yelling, knock, knock, and entering residents rooms without waiting for permission from residents to enter. An interview on 7/27/2018 at approximately 1:25 PM with CNA (Certified Nursing Assistant) #1 and CNA #2 confirmed the observations. CNA #1 stated, We usually knock, we don't usually just walk in the rooms. CNA #2 stated, My hands were full, I was carrying the tray. I guess I should have held the tray with one hand and knocked with the other.",2020-09-01
2662,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,580,E,1,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility policy titled, Physician and Other Communication/Change in Condition, the facility failed to notify the physician of a change in condition related to behaviors for Resident #134 for 1 of 1 resident reviewed for Discharge and failed to immediately inform the resident/resident representative when there was a significant change in the resident's physical status. Resident #2 and Resident #4's responsible party was not notified when the resident was noted to have a change in skin condition. Resident #3's responsible party was not notified when the resident went out to the emergency department. Three of 4 residents reviewed for notification The findings included: The facility admitted Resident #134 with [DIAGNOSES REDACTED]. Review on 7/27/2018 at approximately 8:25 PM of the medical record for Resident #134 revealed an admission date of [DATE] and a Nurse's Note dated 7/10/2018 at 7:55 AM that states, At 7:15 AM a staff member was coming in the main entrance to unit and this resident slammed door open and started swinging and punching at staff. Resident headed towards the woods and a male Certified Nursing Assistant kept him/her in sight. The DON (Director of Nursing), the ADON (Assistant Director of Nursing) and the Administrator is aware. Sister was called and notified. Was encouraged to pick brother up. Resident came back in the building but stated, I am not staying here, I will stay in jail or a shelter. I can take care of myself, I am not staying in no nursing home. I have my right mind and I am leaving. Currently sitting in dayroom with male CNA talking more calm. Awaiting sisters arrival. Further review on 7/27/2018 at approximately 8:37 PM of the medical record for Resident #134 revealed Nurse's Notes that contained documentation that Resident #134 refused care and medications. A Nurse's note dated 7/10/2018 at 2:55 PM states, Resident's sister has been called several times on this matter and is aware of the situation. A second Nurse's Note dated 7/10/2018 at 2:55 PM states, Around 2:15 PM resident came to the desk for about the 5th time asking why he/she was here, saying that he/she wasn't staying here and this was going to be a short trip. Resident then began walking from door to door attempting to open them and then getting upset and throwing his/her body into the door. Resident continued this behavior, and appeared to be escalating until E[CONDITION] (Emergency Medical Service) called to escort resident to the ER (emergency room ). No documentation could be found to ensure the Physician was called for elopement, aggressive behavior towards staff. The Physician was not notified of sending Resident #134 to the ER. No physician orders were obtained to send Resident #134 to the ER. During an interview on 7/27/2018 at approximately 8:37 PM the DON could not document where the physician was notified of a change in condition, (ie. aggressive behavior, refusing medications and care and transporting to the ER). Review on 7/27/2017 at approximately 8:45 PM of the facility policy titled, Physician and Other Communication/Change in Condition. states under Policy: To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in patient's/resident's condition, and provide guidance for the notification of patient's/residents and their responsible party regarding changes in condition. Under Procedures: 1. states, Complete assessment of the patient/resident which may include but is not limited to: B. Current physical condition. D. Previous and current mental status. 3. Notify the physician of the change in medical condition. The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. 7. All attempts to notify physician's and family members/legal representatives will be thoroughly documented in the patient's/resident's medical record. These guidelines are not intended to substitute for good nursing judgement. If the nurse feels uncomfortable with a situation he/she should not delay contacting the physician or call 911 if it appears to be a life threatening event. Review of Resident #2's medical record revealed a Nursing Note dated 5/1/17 that indicated per responsible party request skin prep applied to calloused areas on toes of right foot. Review of the resident's Physician Orders beginning 4/1/17 revealed the first order noted for treatment of [REDACTED]. New orders for treatment were started on 6/5/17. Review of the Nursing Progress Note dated 5/15/17 revealed the resident returned from wound center appointment. There was a new order for treatment to the right second toe measuring 0.4 x 0.4 x 0.1. There was no documentation that the resident's responsible party was notified of the orders. Review of facility Weekly Wound Documentation revealed the first documentation of observation of the right 2nd toe area was on 5/16/17. The area was noted to be 0.4 x 0.4 x 0.1. The documentation indicated the resident's family was not notified of changes. Review of the Wound Center physician progress notes [REDACTED]. 2nd toe ulceration on right foot. Patient is still not eating much, states s/he does not have much of an appetite. Think need to have a long discussion with family and the patient most likely needs a feeding tube and try to increase nutritional base or perhaps hospice. Doubt that these wounds will heal and patient most likely needs toe amputation/AKA. Review of the Wound Center physician progress notes [REDACTED]. Had a long discussion with patient's spouse and daughters. Discussed feeding tube and amputation versus. hospice and they will think about options. In an interview with the surveyor on 7/19/18 at approximately 3:00 PM, the DON (Director of Nursing) confirmed the first documentation in the electronic medical record related to the area on Resident #2's toes was on 5/15/17. The DON confirmed there was no documentation that the resident's responsible party was notified related to the area. Resident #3 was admitted to the facility on [DATE] and sent out to the hospital on [DATE]. Review of the resident's Progress Notes revealed an entry dated 7/2/18 at 4:59 AM. The nurse documented that at 7:35 PM Resident #3 complained of chest pain. The nurse documented there were no signs/symptoms of distress noted. Resident voiced to the nurse that s/he wished to be sent to the emergency department to be evaluated. The nurse assured the resident that E[CONDITION] would be called. The nurse contacted the Director of Nursing and the physician per facility protocol. Resident left the facility at 8:40 PM. There was no documentation that the nurse contacted Resident #3's responsible party to notify them the resident had been sent to the hospital. At 1:40 AM the hospital called the facility to notify them the resident was admitted with [DIAGNOSES REDACTED]. Diff. Review of Resident #3's Face Sheet revealed the resident's spouse was listed as the resident's emergency contact and responsible party. On 7/18/18 at approximately 2:22 PM the surveyor called the LPN on duty when the resident was sent out to the hospital and left a message asking to return call. The surveyor also provided contact information to the administrator and DON and asked that the LPN call the surveyor. The surveyor never received a call from the LPN. The facility admitted resident #4 on 11/27/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Care Plan dated 12/15/17: Resident has odor and drainage from wound related wound infection. Administer antibiotics, encourage fluids, provide adequate rest periods infection control, universal/standard precautions. Review of the Interdisciplinary Progress Notes from 11/27 through 12/25/17 (All disciplines) revealed: admitted [DATE] Alert and verbal. Healed area to sacrum. Bilateral heels boggy. Incontinent of bowel and bladder. Resident alert and verbally responsive. Resident with Left sided weakness related to stroke. Seen by physician on 11/28/17. 12/5/17: Obtained two skin tears to left buttocks. Area cleaned, pat dry, skin prep to surrounding skin and followed with a dressing. 12/8/17: Wounds have red granulation with scant serosanguineous drainage with no odor. Resident up in wheel chair. Turned and positioned side to side q 2 hours. 12/9/17: Noted area increased in size. 12/11/17 Treatment to buttocks with yellow slough within red wound bed, no drainage or foul smell. Positioned off buttocks (side to side). Dr. notified of change in wound. New orders for Vitamin C. Family visited. 12/14/17 Updated Medical Doctor (MD) regarding changes in wound, large area of yellow/tan slough with slight foul odor. New orders for [MED] DS, new wound treatment ordered. Family updated. 12/21/17: Open area to sacrum, treatment in place. 12/23/17 Leave of absence (LOA) with family, returned at 11:00 PM. Change in wound. MD notified, orders for wound consult. Unable to reach Responsible Party, unable to leave message. 12/24/17: Out with family. 12/25/17- 2:35 PM: Out with family for Christmas. 11:10 PM Spoke with hospital. Unable to give facility admitting diagnoses. On 12/5/17 the resident was identified to have 2 skin tears on left buttocks. The area was cleaned, patted dry, skin prep to surrounding skin followed by dressing. 12/9/2017 Noted area to have increased in size. Resident turned and repositioned side to side every 2 hours. 12/11/2017 Treatment to buttocks continues with yellow slough tissues noted within red wound bed, no drainage or foul smell. New orders for Vitamin C. 12/14/17 Wound continued to deteriorate. Updated physician to change in sacral wound. New orders for [MED] DS times 10 days and new wound treatment ordered. Family updated on all new orders. There was no documentation the resident's family was notified of skin tears, open wound or treatments until 12/14/17. On 7/19/18 at 11:45 AM the surveyor interviewed the Unit Manager regarding the changes in the resident's skin. I don't know how s/he got the skin tears. I don't know if I would have called it a skin tear. It looked like moisture associated skin, excoriation. Agreed no evidence of documentation of skin tears to MD or family. Reviewed Physician's notes. Physician order of 12/5 for treatment to left buttock wounds.",2020-09-01
2663,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,600,D,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to identify abuse for Res #48, for 1 of 1 reviewed for Abuse. The findings included: The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Observation on 07/25/18 at approximately 9:04 AM revealed Resident #48 with purplish/blue bruising on bilateral upper arms, nurse stated to this surveyor that Resident #48 and another resident had been in an altercation and they grabbed each other's upper arms. Record review on 07/26/18 at approximately 9:04 AM revealed an incident report dated 07/23/18 stating Resident #48 was walking in the hallway with another resident when the other resident became agitated and resisted walking. The two residents started arguing and grabbed each other's upper arms. The report stated follow up steps taken to prevent reoccurrence and person(s) responsible: Resident's separated and redirected by staff until time for bed. In an interview on 07/26/18 10:14 AM the Administrator, who is the Abuse Coordinator, stated when notified of the incident, it was discussed and concluded that it was not reportable as abuse because there was no intent.",2020-09-01
2664,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,607,D,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to identify abuse for Res #48, for 1 of 1 reviewed for Abuse. The findings included: The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Observation on 07/25/18 at approximately 9:04 AM revealed Resident #48 with purplish/blue bruising on bilateral upper arms, nurse stated to this surveyor that Resident #48 and another resident had been in an altercation and they grabbed each other's upper arms. Record review on 07/26/18 at approximately 9:04 AM revealed an incident report dated 07/23/18 stating Resident #48 was walking in the hallway with another resident when the other resident became agitated and resisted walking. The two residents started arguing and grabbed each other's upper arms. The report stated follow up steps taken to prevent reoccurrence and person(s) responsible: Resident's separated and redirected by staff until time for bed. In an interview on 07/26/18 10:14 AM the Administrator, who is the Abuse Coordinator, stated when notified of the incident, it was discussed and concluded that it was not reportable as abuse because there was no intent.",2020-09-01
2665,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,609,D,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to identify and report to the State Agency abuse for Res #48, for 1 of 1 reviewed for Abuse. The findings included: The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Observation on 07/25/18 at approximately 9:04 AM revealed Resident #48 with purplish/blue bruising on bilateral upper arms, nurse stated to this surveyor that Resident #48 and another resident had been in an altercation and they grabbed each other's upper arms. Record review on 07/26/18 at approximately 9:04 AM revealed an incident report dated 07/23/18 stating Resident #48 was walking in the hallway with another resident when the other resident became agitated and resisted walking. The two residents started arguing and grabbed each other's upper arms. The report stated follow up steps taken to prevent reoccurrence and person(s) responsible: Resident's separated and redirected by staff until time for bed. In an interview on 07/26/18 10:14 AM the Administrator, who is the Abuse Coordinator, stated when notified of the incident, it was discussed and concluded that it was not reportable as abuse because there was no intent.",2020-09-01
2666,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,610,D,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to identify and investigate abuse for Res #48, for 1 of 1 reviewed for Abuse. The findings included: The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Observation on 07/25/18 at approximately 9:04 AM revealed Resident #48 with purplish/blue bruising on bilateral upper arms, nurse stated to this surveyor that Resident #48 and another resident had been in an altercation and they grabbed each other's upper arms. Record review on 07/26/18 at approximately 9:04 AM revealed an incident report dated 07/23/18 stating Resident #48 was walking in the hallway with another resident when the other resident became agitated and resisted walking. The two residents started arguing and grabbed each other's upper arms. The report stated follow up steps taken to prevent reoccurrence and person(s) responsible: Resident's separated and redirected by staff until time for bed. In an interview on 07/26/18 10:14 AM the Administrator, who is the Abuse Coordinator, stated when notified of the incident, it was discussed and concluded that it was not reportable as abuse because there was no intent.",2020-09-01
2667,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,623,D,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure Resident #132, #23, #35 and Resident #61 and his/her responsible party received in writing and in a language they could understand the reason for the transfer or discharge to the hospital for 4 of 5 residents reviewed for hospitalization . The findings included: The facility admitted Resident #61 with [DIAGNOSES REDACTED]. Review on 7/27/2018 at approximately 1:58 PM of the medical record for Resident #61 revealed a hospitalization on [DATE] and returned to the facility on [DATE]. No documentation could be found in the medical record for Resident #61 to ensure he/she and the responsible party received in writing and in a language they could understand the reason of the transfer to the hospital . During an interview on 7/27/2018 at approximately 6:00 PM with the DON (Director of Nursing) he/she confirmed that the resident and the responsible party did not receive in writing and in a language they could understand the reason for the transfer or discharge to the hospital. The facility admitted Resident #132 with [DIAGNOSES REDACTED]. Record review on 07/25/18 at approximately 1:38 PM revealed Resident #132 was admitted to the hospital on [DATE] and 04/18/18. No Notice of Transfer or documentation that a notice was provided was in the record. Resident # 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record reviewed on 7/27/18 at 4:48 PM revealed that the facility sent Resident #35 to the hospital emergency room (ER) on 4/27/17, 5/2/18 and 5/7/17 related to of Dissection of aorta, acute [MEDICAL CONDITION], and [MEDICAL CONDITION] activity, among others health issues. The resident returned to the facility from his/her last hospital stay on 5/8/18. However, the resident's medical record revealed no evidence to indicate that the facility notified the resident and the resident's representative, in writing, the reasons why the facility sent the resident to the hospital ER. During an interview with the director of nursing (DON) on 7/27/18 at 5:34 PM s/he confirmed that the facility did not notify the resident and the resident's representative of the transfer. Resident # 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., and Muscle spasm. Record reviewed on 7/27/18 at 7:00 PM revealed that the facility transferred Resident # 23 to hospital emergency room (ER) on 1/10/18 with symptoms of confusion. The resident was admitted into the hospital, treated for [REDACTED]. However, the resident's medical record revealed no evidence to indicate that the facility notified the resident and the resident's representative, in writing, the reasons why the facility sent the resident to the hospital ER. During an interview with the director of nursing (DON) on 7/27/18 at 7:34 PM s/he confirmed that the facility did not notify the resident and the resident's representative of transfer.",2020-09-01
2668,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,625,D,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility titled, Bed Hold Policy, the facility failed to ensure Resident #132, #23, #35 and Resident #61 or their personal representative received the bed hold policy with the bed payment prior to transfer/discharge to the hospital for 4 of 5 residents reviewed for hospitalization . The findings included: The facility admitted Resident #61 with [DIAGNOSES REDACTED]. Review on 7/27/2018 at approximately 1:58 PM of the medical record for Resident #61 revealed a hospitalization on [DATE] and returned to the facility on [DATE]. No documentation could be found in the medical record for Resident #61 to ensure he/she and or the responsible party received notification of the Bed Hold Policy with the bed payment prior to transfer/discharge to the hospital. During an interview on 7/27/2018 at approximately 6:00 PM with the DON (Director of Nursing) he/she confirmed that Resident #61 and or the responsible party had received, prior to a transfer/discharge to the hospital, the Bed Hold Policy with bed payment. Review on 7/27/2018 at approximately 6:15 PM of the facility policy titled, Bed Hold Policy, states. hospitalization , When a resident is admitted to the hospital, a bed may be reserved if a resident wishes. Semi private room rates are $210.00 per day and private room rates are $235.00 per day. Resident # 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record reviewed on 7/27/18 at 4:48 PM revealed that the facility sent Resident #35 to the hospital emergency room (ER) on 4/27/17, 5/2/18 and 5/7/17 related to of Dissection of aorta, acute [MEDICAL CONDITION], and [MEDICAL CONDITION] activity, among others health issues. The resident returned to the facility from his/her last hospital stay on 7/27/18. However, the resident's medical record reviewed on the same day from approximately 5:48 PM showed no proof that the facility provided written information or that the facility discussed/explained with/to the resident or resident representative the facility's bed-hold policy. During an interview with the Director of Nursing (DON) on 7/27/18 at 5:34 PM s/he stated that the facility does send the bed-hold policy with the resident upon hospital transfer (hospital transfer package). However, the DON could not testify that the facility provides and explains, to the resident and resident representative, the facility's bed-hold policy prior discharge/hospital transfer. R#23 Resident # 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., and Muscle spasm. Record reviewed on 7/27/18 at 7:00 PM revealed that the facility transferred Resident # 23 to hospital emergency room (ER) on 1/10/18 with symptoms of confusion. The resident was admitted into the hospital, treated for [REDACTED]. However, the resident's medical record reviewed on the same from approximately 5:48 PM showed no proof that the facility provided written information or that the facility discussed/explained with/to the resident or resident representative the facility's bed-hold policy. During an interview with the Director of Nursing (DON) on 7/27/18 at 7:34 PM s/he stated that the facility does send the bed-hold policy with the resident upon hospital transfer (hospital transfer package). However, the DON could not testify that the facility provides and explains, to the resident and resident representative, the facility's bed-hold policy prior discharge/hospital transfer.",2020-09-01
2669,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,656,D,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to develop a resident-centered care plan to include the resident's preference related to activities of daily living (ADL) for one of two residents sampled reviewed for ADL. The findings included: Resident # 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial survey tour on 7/23/18 at approximately 1:00 PM Resident # 27 was observed in his/her bed ungroomed. The resident did not have clothes on from the waist up, his/her hair appeared unkempt and long and s/he has long facial hair. The resident remained in the same conditions on 24th, 25th, and 26th and that the resident prefers to stay in bed. But, the care plan does not address the resident's preference for not wearing clothes while in bed and for keeping hair and facial hair long. During an interview the unit manager, Licensed Practical Nurse (LPN) on 7/27/18 at 10:38 AM s/he stated that Resident #27 does not like to wear clothes while in bed and prefers to wear his/her hair long and loose and keep his/her facial hair. The LPN confirmed that a plan of care had not been developed to include these preferences.",2020-09-01
2670,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,657,E,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to insure participation by all required disciplines in the Care Plan Conferences for Residents #184, 27, 85, 387, 62, 23, 35, 111, 8, 103, 122, 81, 97, and 49. One or more disciplines were not represented for 16 of 30 Care Plans reviewed. The findings included: The facility admitted Resident #49 with diagnoses, including but not limited to, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], Acute Kidney Failure, Diarrhea, Constipation, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] Fibrillation, Dementia, Pain, Depressive Episodes and Mood disorder. Record review on 07/27/18 at approximately 6:43 AM revealed the sign in sheet for the Care Plan Conference held on 06/05/18 did not include a representative from the Dietary department. The facility admitted Resident #97 with diagnoses, including but not limited to, Dementia, Acute Pain due to Trauma, Laceration, Chronic Pain, Seborrhea Capitis, [MEDICAL CONDITION] Dysphagia, Retention of Urine, Depression, Benign Prostate, [MEDICAL CONDITION], Delusional Disorders, Long term use of Aspirin and Vitamin Deficiency. Record review 07/27/18 at approximately 7:38 PM revealed the sign in sheet for the Care Plan Conference held on 07/03/18 did not include a representative from the Dietary department. In an interview on 07/27/18 the Dietary Manager confirmed that there was no signature from Dietary on the sheet as s/he is sometimes does not attend but will review and sign at a later date when possible. The facility admitted Resident #81 with [DIAGNOSES REDACTED]. Review on 7/25/2018 at approximately 12:57 PM of the Care Plan Conference Summary for Resident #81, dated 6/26/2018, revealed no documentation to ensure Dietary had input into the care planning process. The facility admitted Resident #184 with [DIAGNOSES REDACTED]. Review on 7/26/2018 at approximately 10:38 AM of the Care Plan Conference Summary sheet, dated 7/24/2018, revealed no documentation to ensure Dietary nor the CNA (Certified Nursing Assistant) closely involved with the care for Resident #184 had input into the care planning process. The facility admitted Resident #61 with [DIAGNOSES REDACTED]. Review on 7/26/2018 at approximately 11:30 AM of the Care Plan Conference Summary for Resident #61, dated 5/8/2018, revealed no documentation that Dietary had input into the care planning process. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review on 7/26/2018 at approximately 8:53 PM of the Care Plan Conference Summary dated 7/24/2018, revealed no documentation that Dietary had input into the care planning process for Resident #8. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. Review on 7/26/2018 at approximately 10:05 PM of the Care Planning Conference Summary dated 6/12/2018 for Resident #62 revealed no documentation to ensure Dietary had input into the care planning process. The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Review on 7/26/2018 at approximately 11:19 PM of the Care Plan Conference Summary dated 5/22/2018 for Resident #33 revealed no documentation to ensure Dietary had input into the care planning process. The facility admitted Resident #86 with [DIAGNOSES REDACTED]. Review on 7/27/2018 at approximately 11:19 PM of the Care Plan Conference Summary sheet, dated 6/19/2018 revealed no documentation to ensure dietary had input into the care planning process for Resident #8. The facility admitted Resident #85 with [DIAGNOSES REDACTED]. Review on 7/27/2018 at 12:22 AM of the Care Plan Conference Summary for Resident #85, dated 6/26/2018, revealed no documentation to ensure Dietary had input into the care planning process. Resident # 23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., and Muscle spasm. Record reviewed on 7/27/18 at approximately 6:25 PM revealed that Resident #23's comprehensive care plan has not been reviewed and revised by the certified dietary manager or dietitian. During an interview with the dietary manager on 7/27/18 at approximately 6:40 PM s/he confirmed the above findings. Resident # 27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record reviewed on 7/27/18 at approximately 10:57 AM revealed that Resident #27's comprehensive care plan has not been reviewed and revised by the certified dietary manager or dietitian. During an interview with the dietary manager on 7/27/18 at 11:20 AM s/he confirmed the above findings. Resident # 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record reviewed on 7/27/18 at approximately 4:15 PM revealed that Resident #35's comprehensive care plan has not been reviewed and revised by the certified dietary manager or dietitian. During an interview with the dietary manager on 7/27/18 at 4:30 PM s/he confirmed the above findings. Resident # 103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record reviewed on 7/27/18 at 1:35 AM revealed that Resident #103's comprehensive care plan has not been reviewed and revised by the certified dietary manager or dietitian. During an interview with the dietary manager on 7/27/18 at 1:45 AM s/he confirmed the above findings. Resident # 111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record reviewed on 7/27/18 at 9:43 AM revealed that Resident #111's comprehensive care plan has not been reviewed and revised by the certified dietary manager or dietitian. During an interview with the dietary manager on 7/27/18 at 10:00 AM s/he confirmed the above findings. Resident # 117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record reviewed on 7/26/18 at 5:05 PM revealed that Resident #117's comprehensive care plan has not been reviewed and revised by the certified dietary manager or dietitian. During an interview with the dietary manager on 7/26/18 at 5:20 PM s/he confirmed the above findings. Resident # 122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record reviewed on 7/27/18 at 11:37 AM revealed that Resident #122's comprehensive care plan has not been reviewed and revised by the certified dietary manager or dietitian. During an interview with the dietary manager on 7/27/18 at approximately 11:55 AM s/he confirmed the above findings. Resident # 387 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record reviewed on 7/26/18 at 12:01 PM revealed that Resident #103's comprehensive care plan has not been reviewed and revised by the certified dietary manager or dietitian. During an interview with the dietary manager on 7/27/18 at approximately12:15 AM s/he confirmed the above findings.",2020-09-01
2671,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,677,D,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to insure that Activities of Daily Living (ADL) choices were honored for 1 of 2 reviewed for ADLs. Resident #68's preference for grooming was not carried out. The findings included: The facility admitted Resident # 68 with diagnoses, including but not limited to, [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], Abnormal Posture, Complete traumatic amputation of 2 or more right lesser toes, [MEDICAL CONDITION], Diabetes, Difficulty in walking, Unsteadiness on Feet, Muscle Weakness, Lack of Coordination, Vita deficiency, Urinary Tract Infection, Chronic Pain, [MEDICAL CONDITION], Heart Failure, [MEDICAL CONDITIONS], Shortness of Breath, Hiccup, Bacterial Infection, Gastro-[MEDICAL CONDITION] Reflux Disease, Ischemic [DIAGNOSES REDACTED], Lack of Coordination, [MEDICAL CONDITIONS] of Native Coronary Artery, Presence of Coronary Angioplasty Implant and Graft and Hypertension. Observation and interview on 07/25/18 at approximately 9:38 AM revealed Resident #68 to have several days beard growth. The Resident stated s/he would prefer to have a clean face but is not allowed to shave and only gets shaved every 4-5 days. Resident #68 was observed unshaven on 07/26/18 at approximately 3:12 PM. Record review on 07/26/18 revealed no documentation of when Resident #68 preferred to be shaved. In an interview on 07/26/18 04:51 PM the Assistant Director of Nursing (ADON) stated the resident's preference for shaving should be on the care plan but upon review could not find this in the care plan. The ADON stated Resident #68 can be shaved every day if that is their choice.",2020-09-01
2672,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,684,D,1,0,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Resident #3 was admitted with a Foley catheter and there were no orders for catheter care upon admission. The findings included: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] at 4:50 PM. The resident was noted upon admission to have a Foley catheter in place. Review of the Physician order [REDACTED]. an order for [REDACTED]. In an interview with the surveyor on 7/18/18 at approximately 2:30 PM, the DON (Director of Nursing) stated they contacted the previous facility about when the resident's catheter needed to be changed. The DON reviewed Resident #3's Physician orders [REDACTED].",2020-09-01
2673,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,690,D,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy titled, Catheter-Urinary Catheter Cleaning and Maintenance, the facility failed to ensure proper catheter care for Resident #61 for 1 of 1 resident reviewed for Catheter Care. The findings included: The facility admitted Resident #61 with [DIAGNOSES REDACTED]. An observation on 7/25/2018 at approximately 4:30 PM of foley catheter care revealed the following: LPN (Licensed Practical Nurse) #3 knocked on the door and Resident #61 yelled, come in. LPN #3 explained the procedure to Resident #61, and this surveyor asked permission to observe the LPN during the procedure. Resident #61 stated it was ok for this surveyor to observe. LPN #3 washed his/her hands and applied gloves and went to the bedside table and pulled a chucks from the drawer and applied it to the top of the over bed table. The over bed table was not observed as being cleaned prior to the application of the chucks pad. LPN #3 them provided privacy and removed the gloves and washed his/her hands and then applied clean gloves. He/she then proceeded to pull back the covers and removed the brief, using the same gloved hands opened the wipes and took 1 wipe out and clean around the catheter insertion site 3 times using a clean wipe each time. The LPN then, using the same gloved hands wiped down the tubing 3 times using a clean wipe each time. LPN #3 pulled up the covers using the same gloved hands and put the package of wipes in the bedside drawer and put the chucks in the trash and tied up the trash. After he/she tied up the trash and then put a clean trash bag in the trash can and them removed his/her gloves and placed them in the trash can. LPN #3 then carried the trash to the soiled utility room and washed his/her hands and then charted the treatment as complete. During an interview on 7/27/2018 at approximately 4:50 PM LPN #3 confirmed that he/she did not removed his/her gloves and wash his/her hands after touching multiple items in Resident #61's room before continuing with the catheter care. Review on 7/27/2018 at approximately 5:15 PM of the facility policy titled, Catheter-Urinary Catheter, Cleaning and Maintenance. states under Policy: Indwelling urinary catheters will be cleaned and maintained to reduce the risk of urinary tract infections or other urinary complications.",2020-09-01
2674,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,755,E,1,0,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide pharmaceutical services to meet the needs of each resident. Resident #3 was noted to have orders that were not administered because medications were not available. The findings included: Resident #3 was admitted to the facility on [DATE] from another facility. Review of the other facility's Discharge Summary Report dated 6/26/18 revealed discharge medications included [MEDICATION NAME] 5% patch, 1 topical daily, apply above sacral wound. There was a handwritten note on the Discharge Summary Report that indicated topical cream 4%. Review of the Physician order [REDACTED]. Special instructions indicated to apply small amount above sacral wound for [DIAGNOSES REDACTED]. Review of the [MEDICATION NAME] order revealed it was ordered 6/28/18 at 4:33 PM. Review of Resident #3's Treatment Administration Record revealed the [MEDICATION NAME] [MED] 4% cream was signed as administered 6/28/18 on the 7:00 AM-7:00 PM shift. On 6/28/18 the treatment was not signed as administered on the 7:00 PM-7:00 AM shift and indicated awaiting pharmacy delivery. The treatment was not signed as administered on either shift on 6/29/18 or 6/30/18 and documentation indicated the reason was waiting on pharmacy delivery. Review of the Physician order [REDACTED]. Review of Resident #3's Medication Administration Record [REDACTED]. On 6/27/28 the 4:00 PM scheduled dose was not administered and the pharmacy was called to STAT the medication. On 6/27/18 the 8:00 PM scheduled dose was not administered and documentation indicated waiting on pharmacy. Review of the facility's E-Kit for new orders only revealed the facility had [MEDICATION NAME] 5 milligrams, #3, in their supply kit. In an interview with the surveyor on 7/18/18 at approximately 3:45 PM, the DON (Director of Nursing) stated they also have an e-kit for STAT orders for narcotics. If they come in after 4:00 PM, then they call back up pharmacy and they deliver within 4 hours of when they call. The nurse should document what they do if a medication is not available. The nurse should document if they are waiting on a hard script. The DON confirmed there was no documentation related to the medication not being available and what was done. In an interview with the surveyor on 7/19/18 at approximately 11:00 AM, the DON stated s/he is not sure why the [MEDICATION NAME] was not delivered and administered as ordered. The DON stated s/he does not believe the [MEDICATION NAME] was administered as signed for on 6/28/18 because they did not have it in the facility. The resident's order was for 4% and they have 1% in the facility. If an order is STAT then they will take it out of the e-kit or call back up pharmacy, which has a 4 hour turnaround time. For regular orders written during the day, the pharmacy delivers the medications around 9:00 PM.",2020-09-01
2675,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,761,E,0,1,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to assure the correct storage of medications according to manufacturer package inserts and labels and that expired medication were removed from active storage in 2 of 3 medication rooms and 3 of 6 medication carts. The findings included: On 07/23/18 at approximately 11:05 AM inspection of the Hall 300 Medication Room revealed the following: -One bottle of [MEDICATION NAME] Acetate Nasal Spray 10 mcg (micrograms)/0.1 ml (milliliter) /spray), 5 ml bottle belonging to Resident # 10 was stored inside the refrigerator whose thermometer read 38 degrees F (Fahrenheit). The manufacturer label stated : Store upright at 68-77 degrees F and the Pharmacy applied label stated: Store at room temperature. -one tube of [MEDICATION NAME] Gel Lot 901 with an expiration date of 4/2018 was found on the second shelf of the storage rack to right of sink. These findings were verified by LPN (Licensed Practical Nurse) # 1 on 7/23/18 at approximately 11:25 AM On 07/23/18 at approximately 12:20 PM inspection of the Hall 100 Front Medication Cart revealed the following: -One opened bottle of Acidophilus Lactobacilli by Optimum which had been dated by the facility as opened 3-24-18. The manufacturer label states Refrigerate after opening to help maximize potency. -One opened bottle of Firnanq [MEDICATION NAME] 50 mg (milligram)/ml by CutisPharma (Lot , expiration 11/19) was stored, unrefrigerated in the medication cart. The manufacturer label reads Must be Refrigerated: and the pharmacy applied label stated Refrigerate. These findings were verified by RN (Registered Nurse) #1 07/23/18 at approximately 12:33 PM. On 07/23/18 at approximately 12:41 PM inspection of Hall 100 Back Medication Cart revealed the following: -One opened bottle of Acidophilus Lactobaccili by Optimim in top right drawer. The manufacturer label states Refrigerate after opening to help maximize potency. -Three syringes of [MEDICATION NAME] Lock Flush Solution, USP (United States Pharmacopoeia) 50 USP U (units)/5 ml, 10 USP units/ml, with an expiration date of 3/31/18 was found in the right bottom drawer, On 7/23/18 at approximately 12:53 PM RN # 1 verified these findings and stated that the [MEDICATION NAME] Lock Flush Solution should not be stored there. On 07/23/18 at approximately 1:05 PM inspection of the Hall 200 Medication Cart room revealed the following: -One [MEDICATION NAME] labeled as taken from the Emergency Box and dated as opened 7/20/18 was found in the refrigerator. Novo [MEDICATION NAME], the manufacturer, states do not store in the refrigerator once opened. This finding was verified by LPN # 2 on 7/23/18 at approximately 1:10 PM On 7/23/18 at approximately 1:15 PM in inspection of the Hall 200 Front Medication Cart revealed the following: -One unopened [MEDICATION NAME] 100 U/ml labeled not used as of 6/10/18. The manufacturer states that unopened [MEDICATION NAME] must be refrigerated. This finding was verified by LPN # 2 on 07/23/18 at approximately 1:19 PM. On 7/25/18 at approximately 10:08 AM the Director of Nursing stated that it is the responsibility of the night nurse to check for expired medications as well as proper storage of medications. On 07/25/18 at approximately 10:30 AM the Administrator provided a copy of the Pharmacy Services Policies and Procedures which states under Section 8 - Medication Storage Policy 1.Medications and biologicals are stored safely, securely and properly following manufacturers recommendations or those of the supplier in accordance with State and federal laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity.",2020-09-01
2676,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,812,E,0,1,KY5E11,"Based on observation and interview and facility policy, staff failed to use proper hand washing during 1 of 1 Food Temperature Taking. The findings included: During an observation on 07/26/18 the Dietary Manager (DM) entered the Kitchen from out in the facility after being located by staff. The DM went into his/her office to put on a chef's coat then came to the steam table, removed a thermometer from his/her pocket and placed into a pan of rice after cleaning with an alcohol pad. When this surveyor asked about calibration of the thermometer the DM, proceeded to the sink to wash his/her hands. In an interview on 07/26/18 at approximately 12:05 PM the DM confirmed not washing his/her hands upon entering the facility kitchen. Review of the facility policy entitled Hand Washing revealed hands should be washed .5 After returning to the kitchen area from any other area.",2020-09-01
2677,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,842,E,1,0,KY5E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to accurately document resident's skin condition for 2 of 4 residents reviewed for pressure ulcer. Resident #3 and #4 developed wounds/changes in skin condition. The findings included: The facility admitted resident #4 on 11/27/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Care Plan dated 12/15/17: Resident has odor and drainage from wound related wound infection. Administer antibiotics, encourage fluids, provide adequate rest periods infection control, universal/standard precautions. Review of the Interdisciplinary Progress Notes from 11/27 through 12/25/17 (All disciplines) revealed: admitted [DATE] Alert and verbal. Healed area to sacrum. Bilateral heels boggy. 12/5/17: Obtained two skin tears to left buttocks. Area cleaned, pat dry, skin prep to surrounding skin and followed with a dressing. 12/8/17: Wounds have red granulation with scant serosanguineous drainage with no odor. 12/9/17: Noted area increased in size. 12/11/17 Treatment to buttocks with yellow slough within red wound bed, no drainage or foul smell. Positioned off buttocks (side to side). Dr. notified of change in wound. New orders for Vitamin C. Son visited. 12/14/17 Updated MD regarding changes in wound, large area of yellow/tan slough with slight foul odor. New orders for [MED] DS, new wound treatment ordered. Son updated. 12/21/17: Open area to sacrum, treatment in place. 12/23/17 LOA with family, returned at 11:00 PM. Change in wound. MD notified, orders for wound consult. Unable to reach responsible party (RP) or family, unable to leave message. 12/24/17: Out with family. On 12/5/17 the resident was identified to have 2 skin tears on left buttocks. The area was cleaned, patted dry, skin prep to surrounding skin followed by dressing. 12/9/2017 Noted area to have increased in size. Resident turned and repositioned side to side every 2 hours. 12/11/2017 Treatment to buttocks continues with yellow slough tissues noted within red wound bed, no drainage or foul smell. New orders for Vitamin C. 12/14/17 Wound continued to deteriorate. Updated physician to change in sacral wound. New orders for [MED] DS times 10 days and new wound treatment ordered. Family member updated on all new orders. The medical record initially documented the resident to have two skin tears to left buttocks. 12/14 documentation of sacral wound with no documentation of the two skin tears. The wound was not identified to be a pressure sore. On 7/19/18 at 11:45 AM the surveyor interviewed the Unit Manager regarding the changes in the resident's skin. I don't know how s/he got the skin tears. I don't know if I would have called it a skin tear. It looked like moisture associated skin, excoriation. Resident #3 was admitted to the facility on [DATE] from another facility. Review of documentation from the previous facility dated 6/19/18 revealed Resident #3 had a Stage 3 pressure ulcer to the sacrum. Wound measurements were 1 x 0.4 x 0.5. Dressing was documented as moist wound healing, protective barrier. Wound care orders for the sacrum from the previous facility from 6/19/18 were faxed to the facility. Treatment indicated to cleanse the area with normal saline and apply border. Review of Resident #3's Admission Body Observation dated 6/26/18 revealed the resident was noted with a pressure sore to the sacrum. Review of the Weekly Wound Tracking Worksheet dated 6/26/18 revealed the wound nurse documented Resident #3's area to the sacrum as wound type other, not pressure ulcer. The area was documented as 1.4 x 0.5 x 0.2 with blanchable pink/red around area. Review of Resident #3's Progress Notes revealed an admission nursing note on 6/26/18 at 6:26 PM that indicated the resident had a sacral wound 1.4 x 0.5 x. 0.2. The resident resided at the facility from 6/26/18-7/1/18. There was no Progress Note related to the resident's pressure ulcer by the facility wound nurse. Review of Resident #3's care plan revealed resident was admitted with a Stage 3 pressure ulcer to his sacrum was identified as a problem area. Approaches were listed on the care plan and included assess the pressure ulcer for location, stage, size, presence/absence of granulation tissue and epithelization weekly and as needed. In an interview with surveyor on 7/18/18 at 3:35 PM, RN (Registered Nurse) #1, the facility wound nurse, stated Resident #3's area was a healed Stage 3 area on the sacrum. On admission, it was raw and excoriated over the scarred area. There was no drainage, some blanchable redness around the edges. They put in the order for zinc and foam on the sacrum. The order was put in per the resident's request because s/he wanted something covering the area. Review of the Nursing Report Sheet dated 6/27/18 revealed the resident's spouse had stated they used a dry dressing at home. The Nursing Report Sheet dated 6/28/18 indicated Resident #3's spouse requested dressing and zinc to the area to the sacrum because it worked before at home. Review of Resident #3's Physician order [REDACTED]. There was no previous treatment order for the area to the sacrum.",2020-09-01
2678,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-07-27,880,D,0,1,KY5E11,"Based on observation and interview the facility failed to make sure that staff follows hand hygiene practices consistent with accepted standards of practice during meal distribution. The findings included: On 7/27/18 at 8:49 AM Certified Nursing Assistant (CNA) # 3 entered Resident # 117's room with a breakfast tray on hands. The C.N.A set the breakfast on the overbed table and went out of the resident's room. C.N.A # 3 returned to the room accompanied by another staff. The two of them assisted the resident sit-up in the bed by grabbing and pulling on the bed pad so the resident would sit up to eat in bed. C.N.A # 3 took the lip off the drinks, unwrapped the utensils and applied condiments to the resident's meal without sanitizing or washing his/her hands. Then s/he went out of the room to the tray cart and grabbed another resident's breakfast tray and went into the resident's room. At no point, the C.N.A washed or sanitized his/her hands. On 7/27/18 at 8:57 AM the surveyor confronted the C.N.A with the observation. S/he knotted his/her head in agreement but did not say anything. At 9:05 AM the surveyor, informed the unit manager of the C.N.A's lack of hand hygiene during meal service.",2020-09-01
2679,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-09-07,600,K,1,0,4EIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident remained free from abuse. Resident #5 and Resident #6 were noted to have two altercations that involved physical abuse. The facility failed to implement interventions to prevent the abuse. 2 of 4 residents reviewed for resident to resident abuse. The findings included: Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. The resident was observed on initial tour of the facility on 9/4/18 at approximately 12:02 AM, Resident #5 was in his/her room in bed, with lights and radio on. The surveyor observed that Resident #5 and Resident #6 resided in rooms that were next to each other. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. The Discharge Summary for Resident #5's hospital visit on [DATE] indicated the physician talked with the resident's son. Resident's son stated he had spoken to the nursing staff at the facility before, he thinks there may be one person, either staff member or even another resident that just seems to set the patient off as soon as s/he sees them. The son is going to speak with staff to determine if there is any better way to keep the patient's behaviors and dementia under control, specifically separating him/her from whichever person seems to agitate him/her. The Initial ER report indicated that according to nursing report who received telephone report from the nursing home, the resident's behavior has been going downhill for about 3 months. Friday afternoon the patient apparently attempted to hit a nurse and was sent to the emergency department for evaluation. Resident #5's Progress Notes were reviewed and the following noted: 5/22/18 at 4:24 AM - Resident tried to remove the television from off the wall once, the nurse turned it off so the resident could go to sleep. 6/5/18 at 6:29 AM - Resident had 2 BMs on the floor, both times he had it in his hands sitting on the tables in his room and squishing it between his fingers. Resident also tore bulletin board off wall and threw it across the room. No notification of MD or RP noted. 6/10/18 - MD Progress Note with no documentation related to resident's behaviors. 6/13/18 at 12:52 AM - Resident up in room smearing feces on floor and wall and in hands. Taken into bathroom and showered resident saying give me a hammer and I'll kill myself and if I could find a knife I'd cut myself. Resident having loose stools while given a shower. Another resident got up and started to enter his room and he started cussing and in a fighting stance going to hit the other resident, very aggressive behavior. No documentation of RP or MD notification. No MD note related to incident. 7/8/18 at 4:23 AM - resident becoming increased aggressive, was hitting bed with his/her belt cursing. Difficult to redirect in the beginning then s/he calmed down. Resident #5 also went into another resident's room and was going to hit him/her with a remote control. Staff stopped the resident in time and s/he was very quick to leave and go next door. 7/8/18 at 8:16 PM - MD note with no mention of behaviors. 7/10/18 at 4:31 PM - resident standing in his/her room with the bathroom door open and s/he is hitting the door. The nurse went to the door to talk to the resident and resident stated You better move, I'm going to kill. Resident continued to hit the bathroom door and the door is broken and will not close and the tissue roll is broken. Then the resident began slamming the closet door and continued to have increased behavior. 7/19/18 at 8:18 AM - resident having increased agitation. Resident saw another resident walking in hallway and got up from his/her chair. Resident #5 then began to attempt to raise his/her fist at other resident and stated I'm going to kill you! No contact made with other resident, staff able to redirect. Unit manager and DON made aware of increased agitation. MD notified of resident increased agitation and aggressive behavior. New order received for [MEDICATION NAME] 0.25 mg BID. 7/19/18 at 5:05 PM - resident sitting in hallway chair when s/he saw another resident and stood up and raised closed fist at other resident, stating get away from me! I'll hit you. 7/21/18 at 10:49 PM - resident noted to raise hand to hit female resident x 2 so far this shift. No contact was made, staff intervened. MD made aware with new order to d/c [MEDICATION NAME], increase [MEDICATION NAME] to TID. 7/26/18 at 11:29 PM - resident went into another resident's room and took his/her TV remote control. Then went into another resident's room and threw the remote at another resident but did not hit the resident. 8/9/18 at 6:06 PM - MD note that indicated stable clinically, continue medications. 8/10/18 at 1:53 AM - resident in chair beside nurses' station. Resident will become agitated when a certain resident comes near him/her and s/he starts cussing and say s/he will hit the resident. 8/12/18 at 2:44 PM - resident continues to try to hit resident #6. 8/13/18 at 10:26 PM - Resident #6 was in view of Resident #5, Resident #5 states I'm going to kill her. 8/14/18 at 6:31 AM - resident noted to enter a female resident's room and knock her pencils over on her while she was in bed. Resident #5 was standing over female resident cursing when the nurse entered the room. MD called and made aware, no changes at this time. There was no physician note that referenced the incident. 8/15/18 at 12:45 AM - resident gets agitated when s/he sees resident #6. Resident #5 tries to hit this resident but staff intervenes. 8/15/18 at 5:52 AM - resident #6 up walking in hallway and passing by resident #5. Resident #5 tried to hit resident #6 requiring staff to hold him/her while resident #6 passes by. 8/16/18 at 1:40 AM - resident noted cussing at resident #6 as s/he was walking up hallway. Resident also noted to pull back his/her arm as to try and hit Resident #6 but staff intervened and stopped attempt. 8/16/18 at 5:52 PM - resident continue to wander in and out of other resident's room and to other unit. Resident #5 continue to want to fight resident in room next door, s/he make statement that s/he is going to slap him/her. 8/17/18 at 6:00 AM - resident became upset when s/he saw the resident from the room next door in the hallway and staff head to intervene when resident #5 acted like s/he was going to hit the resident by drawing his/her arm back. 8/21/18 at 11:44 AM - resident ripped paper towel dispenser off wall in bathroom. Maintenance notified. Resident had bowel movement in corner of closet and also threw feces on air-conditioning. 8/24/18 at 1:15 PM - Called to another resident's room, resident #5 in room plundering through drawers, urinated in floor and doorway. 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. 8/25/18 at 8:23 AM - Physician notified of resident's behavior. Grabbing and pinching female resident (#6). New order noted to increase [MEDICATION NAME] to 1.5 mg TID due to residents aggressiveness. 8/25/18 at 11:25 AM - DON notified of incident this morning concerning resident. Informed resident placed on 15 minute checks. DON stated Place him on 1:1 supervision along with the 15 minute checks. 8/26/18 at 6:11 PM - resident 1:1 due to his/her increased behavior. Resident has become very aggressive with staff and cussing at staff. S/he is very hard to redirect. S/he continues to go in and out of other resident room. 8/27/18 at 1:24 PM - Resident has been 1:1 since Saturday 8/25/18. Per staff nurse today, staffing coordinator called and stated 1:1 to be stopped if not further incidence. 8/30/18 at 7:54 AM - report from CNA (Certified Nursing Aide) stating that yesterday afternoon, resident went into a resident's room on . unit and defecated in the floor. Resident # 5 noted to reside on another unit. [DATE] at 5:36 PM - resident was sitting in a chair in the hall and resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON, MD and RP notified and resident sent out to ER. [DATE] at 8:24 PM - resident back in facility from hospital, reported to another nurse by resident's son that as resident was entering the facility, another resident approached the resident asking why s/he doesn't like him/her. 9/1/18 at 2:07 AM - resident noted to be checked on every 15 minutes for safety. 9/2/18 at 5:36 AM - Resident up wandering earlier and went into another resident's room 9/2/18 at 5:56 PM - Resident walked down to dining room and grabbed a walker, s/he began to throw it. Staff had to redirect him/her back to his/her room. S/he then went back to his/her room and began to shake bathroom door. 9/4/18 at 7:14 PM- Resident continues to wander in and out of other residents room 9/6/18 at 10:56 AM indicated 8/26/18 resident went into another resident room and stated get out of my dam bed. Resident was redirected by staff and continues to cuss at the other resident while leaving the room. 9/6/18 at 6:14 PM - wandering around unit and to (another) unit as usual this shift. To dining room at times. Attempted to go into other rooms off/on. Urinated in floor in own room. 1:1 initiated. 9/6/18 at 6:36 PM - phone call to MD to increase [MEDICATION NAME] back to 1.5 mg. Called resident contact and discussed medication change with him/her. Stated to the nurse that his/her brother is having an issue with another resident and s/he stated that this resident looks identical to a woman that s/he has had a lot of problems with in years past. S/he states that this other woman has been to this facility with a family member to visit other residents and has attempted to speak to her/him. S/he states that s/he gets very upset when s/he sees him/her and that this other resident must remind her/him of that other woman. 9/6/18 at 6:40 PM - physician note that indicated MD addendum - resident has been seen and discussed with staff several times. Already on therapeutic approach with medications for her/his unpredictable combativeness/behavior issue mainly due to dementia related. 9/6/18 at 8:25 PM - note by the DON indicates this nurse spoke to the medical director regarding recently identified behavioral issues. Medical Director gave order to discontinue [MEDICATION NAME]. New order received to send to MUSC for psychiatric evaluation. Medical Director to be contacted upon resident return and recommendations reviewed. MDS: Quarterly 8/17/18 - ST and LT memory problem with severely impaired cognitive skills for daily decision making Care Plan: Review of the resident's care plan revealed resident at risk for adverse consequences related to receiving antipsychotic medication with a problem start date of 7/19/18. Review of resident's care plan revealed behavioral symptoms, resident was observed wandering into other resident's room(s). The wandering is related to a dementia [DIAGNOSES REDACTED]. The evaluation note on 8/18/18 indicated the resident has begun to wander more frequently lately. Review of resident's care plan revealed behavioral symptoms, resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) with a problem start date of 4/23/18. The evaluation note on 8/18/18 indicated the resident curses and strikes out at staff and others at times. On [MEDICATION NAME] for restlessness and agitation. Social services and psych referrals as needed. Review of the resident's care plan revealed psychosocial well-being, resident expresses sadness as evident by the following statement I don't want to live anymore with a problem start dated of 2/20/18. Approaches included staff will make referral psychiatric nurse practitioner. Evaluation notes on 5/18/18 indicated resident is very confused and gets agitated at the TV, furniture, etc., and history of roommate issues. Social services and psych referrals as needed. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., excessive and/or continually urinating and/or defecating in her/his room trashcan and/or in the A/C unit in her/his room, smearing bodily wastes on the wall(s), etc.) S/He fusses at the TV and becomes agitated and aggressive at times with a problem start dated of 12/1/17. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., throwing or smearing food or bodily wastes on walls/floor, etc.) with a problem start date of 2/6/17. The evaluation note on 5/18/18 indicated resident defecates and urinates in inappropriate places at times, pulls drawers out of furniture and curses at TV. Psych and social services referrals as needed. Issue with roommates and was moved to private room. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 12:15 PM, CNA #1 stated s/he has been at the facility 6 years. CNA #1 stated Resident #5 has been at the facility 2 years. CNA #1 has been working with the resident since s/he was admitted . CNA #1 stated Resident #5 is losing his/her focus and vision. CNA #1 stated the resident is going down fast. When the resident came in, s/he was alert and would hold conversation. Now the resident is not alert and can't have conversation. Resident #5 did not have behaviors when they were admitted to the facility. CNA #1 stated they have 6 sections and they rotate resident assignments every day. CNA #1 stated they have been rotating assignments for about a month. CNA #1 stated before Resident #5 would have little behaviors, the resident would relax if approached her/him calmly. Resident #5 would have tantrums, knock stuff off the table. Resident #5 would get in a rage, you would have to wait for him/her to calm down. Resident #5 has had a big change in the last 6 months and his/her behaviors have really increased. Resident #5 has knocked a paper towel dispenser off the wall, and the television. CNA #1 stated s/he just learned the resident is going in other resident rooms. Resident #5 is touching things and s/he has used the bathroom in another resident's room floor. Resident #5 hits at the mirror on the wall, they took the mirror off the wall. Resident #5's outburst will come out of nowhere and have been getting worse over the last 6 months. They put up the gadget board a few weeks ago but the resident doesn't do anything with hit. CNA #1 stated Resident #6 reminds Resident #5 of someone s/he knew when s/he was younger. Resident #5's sister told CNA #1 that. Resident #6 will come stand in between people when they are trying to talk and start talking. Resident #5 gets agitated because Resident #6 is repetitive, s/he will keep asking how you are doing. The facility does behavior training on the computer yearly. CNA #1 stated they complete training on the computer, and no one talks to them about the dealing with resident behaviors/dementia. In an interview with the surveyor on 9/6/18 at approximately 12:45 PM, Unit Manager LPN (Licensed Practical Nurse) #1 stated Resident #5 liked to piddle, take things apart. They could not keep an alarm on him/her because s/he would take it apart. LPN stated s/he has seen Resident #5 decline, s/he has early onset [MEDICAL CONDITION] with behaviors, history of alcohol and drugs. The decline has been gradual over the past year. It was a year ago when LPN #1 started trying to get Resident #5 on the . unit (a separate building). The . unit has more residents with Alzheimer's and behaviors, but the resident has not gone back there. It has been knocked down every time s/he brings it up. One reason was because s/he was defecating on the floors, ac units, urinating in other residents' rooms. That behavior started a year ago. It was bothering other residents on . (unit) that the resident was doing that in their rooms. LPN #1 brought it up to the DON in clinical morning meeting. The response was they were not going to transfer him/her back there because the residents back there might play in his/her feces. LPN #1 stated s/he brings up moving the resident almost monthly, if not more. As Resident #5 has gotten worse, s/he has tried to push it. One response has been that it would be too much stimulation. LPN #1 stated it is always one of those 2 responses when s/he brings up moving the resident to the . unit. The . unit is a locked unit with the day room in front of the nurses' stations. LPN #1 feels Resident #5 could benefit from that environment. Right now s/he just sits beside their nurses' station most of the day and does not get that stimulation. LPN #1 stated . (unit) is considered an Alzheimer's unit. The DON usually decides who to send to the . unit. Since June, Resident #5's behaviors have increased. The resident no longer has a TV in his/her room because s/he ripped it off the wall. S/he ripped the paper towel holder off the wall in his/her bathroom, they had to take the mirror out the bathroom because s/he was going to punch it. Resident #5 tried to take the bathroom door down and broke the metal door frame. Resident #5's vision has gotten worse, s/he thought someone else was there and was going to punch them and that is why they took the mirror down. Resident #5 will go to other residents' rooms on both . (unit) and . (another) unit. Resident #5 will defecate on the floor, go through their things, and rummage through their room. The resident has thrown a box of colored pencils on a resident lying in bed. They put a stop sign on the door to one room for him/her to not enter, that did not deter the resident for long. Resident #5 just took it down and went in. LPN #1 stated s/he does not understand why Resident #5 goes after Resident #6 aggressively, that is the only resident s/he is aggressive with. Resident #5 will cuss at him/her when s/he is walking down the hall, says s/he is going to kill him/her, calls him/her names. When Resident #5 struck Resident #6 on Friday ([DATE]), the resident told Resident #6 s/he was going to kill him/her. Resident #5 will try to get to Resident #6, s/he will get up and chase the resident down the hall. Staff will intervene, they are almost always there and are [MEDICAL CONDITION]. All the staff on the unit are aware of the behavior. Resident #5 is on 15 minute checks since the incident on Friday [DATE]. The weekend before when s/he grabbed Resident #6's arm and left a bruise s/he was put on 1:1 until Monday morning. The incident occurred on 8/25/18, Saturday. Resident #5 came off 1:1 because the DON discontinued it because there were no further behaviors. LPN #1 stated the problem with Resident #6 exacerbated the first part of August, and that is when the documented aggression started toward him/her. Resident #5's sister told one of the nurses' that s/he and Resident #6 knew each other in the community. Resident #5 was sent out to the hospital on [DATE] after striking Resident #6. The DON said s/he wanted the resident sent out and LPN #1 got the order from the physician. The ER physician summary indicated that the facility had sent 2 residents around the same time, they did not have any findings. LPN #1 reported to the hospital s/he had been aggressive with another resident. LPN #1 stated the resident is not seen by psych. They have a psych NP (Nurse Practitioner) that comes once a month, or once every other month. The resident has a busy board in his/her room, installed in July. They wanted to try to give him/her more activities to do, s/he does not use the board. The administrator and DON made the decision to put the board in place. Other than removing things from the resident's room, there have not been any interventions put in place. The sister told the facility about the resident's previously knowing each other this past Saturday, 9/1/18. LPN #1 talked with the Resident #5's sister and son (RP) about transferring the resident to . unit a year ago and they were okay. Resident #6's family comes in a lot and knows Resident #5 is the aggressor. LPN #1 stated s/he has fought moving Resident #6 because s/he feels it will be detrimental to the resident. Resident #6 is confused, but knows where his/her room is. LPN #1 stated Resident #5 has been in a private room for several months. When s/he had roommates before, s/he would be staring over them at 3 in the morning, stand and cuss at them. They would feel threatened and so the resident was put in a private room. LPN #1 stated s/he thinks they went through 3 residents before they put Resident #5 in a private room. LPN #1 stated s/he feels since . (unit) is an Alzheimer's unit, they would be able to work with Resident #5 better. They have activities in the open dayroom where s/he could participate. In an interview with the surveyor on 9/6/18 at approximately 3:15 PM, LPN #2, . Unit Manager, stated s/he has been at the facility since 2009 and . Unit Manager for 2 years. They have mostly wanderers and exit seekers on the unit, they can see all the doors with the layout of the unit. They have more resident's on their unit that have [MEDICAL CONDITION]. LPN #2 stated there are 6 empty beds on the . unit. They have one private room that is occupied. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August. They are trying to keep the residents away from each other. They spoke today and last week about room changes. The DON talked with Resident #6's family about a room change and they were worried about the resident falling. They have looked into changing Resident #5's. The resident will get set off if there is a loud noise. Family is very adamant they don't want Resident #6 moved. The DON stated they don't have another room they can put Resident #5 in. The DON stated the problem with roommates is the noise and roommates don't like being in the bathroom with a resident who makes a mess. He has been on every 15 minute checks since s/he came back from theER on Friday. Resident #5 was on 1:1 with the prior incident on 8/25/18 until the following Monday, there was no further incident. He was on 1:1 form 8/25/18-8/27/18. 1:1 is a nursing intervention and does not require a physician order. There is no documentation in the chart about assessing for 1:1. The ADON and unit manager decided to do the 15 minute checks when he came back from the hospital on [DATE]. Reviewed documentation from hospital to see if any psych done and confirmed there was none. The DON called the facility on Saturday and talked with the nurse to see if there was any further agitation. The DON had not been made aware of any increase in behaviors until the first part of August. The DON stated most of the behavior discussion they have had about Resident #5 have been about his/her toileting. The DON stated the Psych NP usually comes once a month and anyone who has had an incident will be on the list for the NP to see. The DON stated they assumed the reason Resident #5 was hitting things is because of noises. The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. The DON stated that someone at the meeting with Resident #6's family and the ombudsman today said they knew each other out in the community. The DON stated that today is the first s/he heard of them knowing each other before the facility. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0[AGE]0 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.",2020-09-01
2680,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-09-07,607,K,1,0,4EIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #5 and Resident #6 were noted to have 2 altercations that involved allegations of physical abuse. The facility did not have interventions in place to protect Resident #6 from harm from Resident #5. 2 of 4 residents reviewed for resident to resident abuse. The findings included: Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. The resident was observed on initial tour of the facility on 9/4/18 at approximately 12:02 AM, Resident #5 was in his/her room in bed, with lights and radio on. The surveyor observed that Resident #5 and Resident #6 resided in rooms that were next to each other. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. The Discharge Summary for Resident #5's hospital visit on [DATE] indicated the physician talked with the resident's son. Resident's son stated he had spoken to the nursing staff at the facility before, he thinks there may be one person, either staff member or even another resident that just seems to set the patient off as soon as s/he sees them. The son is going to speak with staff to determine if there is any better way to keep the patient's behaviors and dementia under control, specifically separating him/her from whichever person seems to agitate him/her. The Initial ER report indicated that according to nursing report who received telephone report from the nursing home, the resident's behavior has been going downhill for about 3 months. Friday afternoon the patient apparently attempted to hit a nurse and was sent to the emergency department for evaluation. Resident #5's Progress Notes were reviewed and the following noted: 5/22/18 at 4:24 AM - Resident tried to remove the television from off the wall once, the nurse turned it off so the resident could go to sleep. 6/5/18 at 6:29 AM - Resident had 2 BMs on the floor, both times he had it in his hands sitting on the tables in his room and squishing it between his fingers. Resident also tore bulletin board off wall and threw it across the room. No notification of MD or RP noted. 6/10/18 - MD Progress Note with no documentation related to resident's behaviors. 6/13/18 at 12:52 AM - Resident up in room smearing feces on floor and wall and in hands. Taken into bathroom and showered resident saying give me a hammer and I'll kill myself and if I could find a knife I'd cut myself. Resident having loose stools while given a shower. Another resident got up and started to enter his room and he started cussing and in a fighting stance going to hit the other resident, very aggressive behavior. No documentation of RP or MD notification. No MD note related to incident. 7/8/18 at 4:23 AM - resident becoming increased aggressive, was hitting bed with his/her belt cursing. Difficult to redirect in the beginning then s/he calmed down. Resident #5 also went into another resident's room and was going to hit him/her with a remote control. Staff stopped the resident in time and s/he was very quick to leave and go next door. 7/8/18 at 8:16 PM - MD note with no mention of behaviors. 7/10/18 at 4:31 PM - resident standing in his/her room with the bathroom door open and s/he is hitting the door. The nurse went to the door to talk to the resident and resident stated You better move, I'm going to kill. Resident continued to hit the bathroom door and the door is broken and will not close and the tissue roll is broken. Then the resident began slamming the closet door and continued to have increased behavior. 7/19/18 at 8:18 AM - resident having increased agitation. Resident saw another resident walking in hallway and got up from his/her chair. Resident #5 then began to attempt to raise his/her fist at other resident and stated I'm going to kill you! No contact made with other resident, staff able to redirect. Unit manager and DON made aware of increased agitation. MD notified of resident increased agitation and aggressive behavior. New order received for [MEDICATION NAME] 0.25 mg BID. 7/19/18 at 5:05 PM - resident sitting in hallway chair when s/he saw another resident and stood up and raised closed fist at other resident, stating get away from me! I'll hit you. 7/21/18 at 10:49 PM - resident noted to raise hand to hit female resident x 2 so far this shift. No contact was made, staff intervened. MD made aware with new order to d/c [MEDICATION NAME], increase [MEDICATION NAME] to TID. 7/26/18 at 11:29 PM - resident went into another resident's room and took his/her TV remote control. Then went into another resident's room and threw the remote at another resident but did not hit the resident. 8/9/18 at 6:06 PM - MD note that indicated stable clinically, continue medications. 8/10/18 at 1:53 AM - resident in chair beside nurses' station. Resident will become agitated when a certain resident comes near him/her and s/he starts cussing and say s/he will hit the resident. 8/12/18 at 2:44 PM - resident continues to try to hit resident #6. 8/13/18 at 10:26 PM - Resident #6 was in view of Resident #5, Resident #5 states I'm going to kill her. 8/14/18 at 6:31 AM - resident noted to enter a female resident's room and knock her pencils over on her while she was in bed. Resident #5 was standing over female resident cursing when the nurse entered the room. MD called and made aware, no changes at this time. There was no physician note that referenced the incident. 8/15/18 at 12:45 AM - resident gets agitated when s/he sees resident #6. Resident #5 tries to hit this resident but staff intervenes. 8/15/18 at 5:52 AM - resident #6 up walking in hallway and passing by resident #5. Resident #5 tried to hit resident #6 requiring staff to hold him/her while resident #6 passes by. 8/16/18 at 1:40 AM - resident noted cussing at resident #6 as s/he was walking up hallway. Resident also noted to pull back his/her arm as to try and hit Resident #6 but staff intervened and stopped attempt. 8/16/18 at 5:52 PM - resident continue to wander in and out of other resident's room and to other unit. Resident #5 continue to want to fight resident in room next door, s/he make statement that s/he is going to slap him/her. 8/17/18 at 6:00 AM - resident became upset when s/he saw the resident from the room next door in the hallway and staff head to intervene when resident #5 acted like s/he was going to hit the resident by drawing his/her arm back. 8/21/18 at 11:44 AM - resident ripped paper towel dispenser off wall in bathroom. Maintenance notified. Resident had bowel movement in corner of closet and also threw feces on air-conditioning. 8/24/18 at 1:15 PM - Called to another resident's room, resident #5 in room plundering through drawers, urinated in floor and doorway. 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. 8/25/18 at 8:23 AM - Physician notified of resident's behavior. Grabbing and pinching female resident (#6). New order noted to increase [MEDICATION NAME] to 1.5 mg TID due to residents aggressiveness. 8/25/18 at 11:25 AM - DON notified of incident this morning concerning resident. Informed resident placed on 15 minute checks. DON stated Place him on 1:1 supervision along with the 15 minute checks. 8/26/18 at 6:11 PM - resident 1:1 due to his/her increased behavior. Resident has become very aggressive with staff and cussing at staff. S/he is very hard to redirect. S/he continues to go in and out of other resident room. 8/27/18 at 1:24 PM - Resident has been 1:1 since Saturday 8/25/18. Per staff nurse today, staffing coordinator called and stated 1:1 to be stopped if not further incidence. 8/30/18 at 7:54 AM - report from CNA (Certified Nursing Aide) stating that yesterday afternoon, resident went into a resident's room on . unit and defecated in the floor. Resident # 5 noted to reside on another unit. [DATE] at 5:36 PM - resident was sitting in a chair in the hall and resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON, MD and RP notified and resident sent out to ER. [DATE] at 8:24 PM - resident back in facility from hospital, reported to another nurse by resident's son that as resident was entering the facility, another resident approached the resident asking why s/he doesn't like him/her. 9/1/18 at 2:07 AM - resident noted to be checked on every 15 minutes for safety. 9/2/18 at 5:36 AM - Resident up wandering earlier and went into another resident's room 9/2/18 at 5:56 PM - Resident walked down to dining room and grabbed a walker, s/he began to throw it. Staff had to redirect him/her back to his/her room. S/he then went back to his/her room and began to shake bathroom door. 9/4/18 at 7:14 PM- Resident continues to wander in and out of other residents room 9/6/18 at 10:56 AM indicated 8/26/18 resident went into another resident room and stated get out of my dam bed. Resident was redirected by staff and continues to cuss at the other resident while leaving the room. 9/6/18 at 6:14 PM - wandering around unit and to (another) unit as usual this shift. To dining room at times. Attempted to go into other rooms off/on. Urinated in floor in own room. 1:1 initiated. 9/6/18 at 6:36 PM - phone call to MD to increase [MEDICATION NAME] back to 1.5 mg. Called resident contact and discussed medication change with him/her. Stated to the nurse that his/her brother is having an issue with another resident and s/he stated that this resident looks identical to a woman that s/he has had a lot of problems with in years past. S/he states that this other woman has been to this facility with a family member to visit other residents and has attempted to speak to her/him. S/he states that s/he gets very upset when s/he sees him/her and that this other resident must remind her/him of that other woman. 9/6/18 at 6:40 PM - physician note that indicated MD addendum - resident has been seen and discussed with staff several times. Already on therapeutic approach with medications for her/his unpredictable combativeness/behavior issue mainly due to dementia related. 9/6/18 at 8:25 PM - note by the DON indicates this nurse spoke to the medical director regarding recently identified behavioral issues. Medical Director gave order to discontinue [MEDICATION NAME]. New order received to send to MUSC for psychiatric evaluation. Medical Director to be contacted upon resident return and recommendations reviewed. MDS: Quarterly 8/17/18 - ST and LT memory problem with severely impaired cognitive skills for daily decision making. Care Plan: Review of the resident's care plan revealed resident at risk for adverse consequences related to receiving antipsychotic medication with a problem start date of 7/19/18. Review of resident's care plan revealed behavioral symptoms, resident was observed wandering into other resident's room(s). The wandering is related to a dementia [DIAGNOSES REDACTED]. The evaluation note on 8/18/18 indicated the resident has begun to wander more frequently lately. Review of resident's care plan revealed behavioral symptoms, resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) with a problem start date of 4/23/18. The evaluation note on 8/18/18 indicated the resident curses and strikes out at staff and others at times. On [MEDICATION NAME] for restlessness and agitation. Social services and psych referrals as needed. Review of the resident's care plan revealed psychosocial well-being, resident expresses sadness as evident by the following statement I don't want to live anymore with a problem start dated of 2/20/18. Approaches included staff will make referral psychiatric nurse practitioner. Evaluation notes on 5/18/18 indicated resident is very confused and gets agitated at the TV, furniture, etc., and history of roommate issues. Social services and psych referrals as needed. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., excessive and/or continually urinating and/or defecating in his room trashcan and/or in the A/C unit in his room, smearing bodily wastes on the wall(s), etc.) He fusses at the TV and becomes agitated and aggressive at times with a problem start dated of 12/1/17. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., throwing or smearing food or bodily wastes on walls/floor, etc.) with a problem start date of 2/6/17. The evaluation note on 5/18/18 indicated resident defecates and urinates in inappropriate places at times, pulls drawers out of furniture and curses at TV. Psych and social services referrals as needed. Issue with roommates and was moved to private room. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 12:15 PM, CNA #1 stated s/he has been at the facility 6 years. CNA #1 stated Resident #5 has been at the facility 2 years. CNA #1 has been working with the resident since s/he was admitted . CNA #1 stated Resident #5 is losing his/her focus and vision. CNA #1 stated the resident is going down fast. When the resident came in, s/he was alert and would hold conversation. Now the resident is not alert and can't have conversation. Resident #5 did not have behaviors when they were admitted to the facility. CNA #1 stated they have 6 sections and they rotate resident assignments every day. CNA #1 stated they have been rotating assignments for about a month. CNA #1 stated before Resident #5 would have little behaviors, the resident would relax if approached her/him calmly. Resident #5 would have tantrums, knock stuff off the table. Resident #5 would get in a rage, you would have to wait for him/her to calm down. Resident #5 has had a big change in the last 6 months and his/her behaviors have really increased. Resident #5 has knocked a paper towel dispenser off the wall, and the television. CNA #1 stated s/he just learned the resident is going in other resident rooms. Resident #5 is touching things and s/he has used the bathroom in another resident's room floor. Resident #5 hits at the mirror on the wall, they took the mirror off the wall. Resident #5's outburst will come out of nowhere and have been getting worse over the last 6 months. They put up the gadget board a few weeks ago but the resident doesn't do anything with hit. CNA #1 stated Resident #6 reminds Resident #5 of someone s/he knew when s/he was younger. Resident #5's sister told CNA #1 that. Resident #6 will come stand in between people when they are trying to talk and start talking. Resident #5 gets agitated because Resident #6 is repetitive, s/he will keep asking how you are doing. The facility does behavior training on the computer yearly. CNA #1 stated they complete training on the computer, and no one talks to them about the dealing with resident behaviors/dementia. In an interview with the surveyor on 9/6/18 at approximately 12:45 PM, Unit Manager LPN (Licensed Practical Nurse) #1 stated Resident #5 liked to piddle, take things apart. They could not keep an alarm on him/her because s/he would take it apart. LPN stated s/he has seen Resident #5 decline, s/he has early onset [MEDICAL CONDITION] with behaviors, history of alcohol and drugs. The decline has been gradual over the past year. It was a year ago when LPN #1 started trying to get Resident #5 on the . unit (a separate building). The . unit has more residents with Alzheimer's and behaviors, but the resident has not gone back there. It has been knocked down every time s/he brings it up. One reason was because s/he was defecating on the floors, ac units, urinating in other residents' rooms. That behavior started a year ago. It was bothering other residents on . (unit) that the resident was doing that in their rooms. LPN #1 brought it up to the DON in clinical morning meeting. The response was they were not going to transfer him/her back there because the residents back there might play in his/her feces. LPN #1 stated s/he brings up moving the resident almost monthly, if not more. As Resident #5 has gotten worse, s/he has tried to push it. One response has been that it would be too much stimulation. LPN #1 stated it is always one of those 2 responses when s/he brings up moving the resident to the . unit. The . unit is a locked unit with the day room in front of the nurses' stations. LPN #1 feels Resident #5 could benefit from that environment. Right now s/he just sits beside their nurses' station most of the day and does not get that stimulation. LPN #1 stated . (unit) is considered an Alzheimer's unit. The DON usually decides who to send to the . unit. Since June, Resident #5's behaviors have increased. The resident no longer has a TV in his/her room because s/he ripped it off the wall. S/he ripped the paper towel holder off the wall in his/her bathroom, they had to take the mirror out the bathroom because s/he was going to punch it. Resident #5 tried to take the bathroom door down and broke the metal door frame. Resident #5's vision has gotten worse, s/he thought someone else was there and was going to punch them and that is why they took the mirror down. Resident #5 will go to other residents' rooms on both . (unit) and . (another) unit. Resident #5 will defecate on the floor, go through their things, and rummage through their room. The resident has thrown a box of colored pencils on a resident lying in bed. They put a stop sign on the door to one room for him/her to not enter, that did not deter the resident for long. Resident #5 just took it down and went in. LPN #1 stated s/he does not understand why Resident #5 goes after Resident #6 aggressively, that is the only resident s/he is aggressive with. Resident #5 will cuss at him/her when s/he is walking down the hall, says s/he is going to kill him/her, calls him/her names. When Resident #5 struck Resident #6 on Friday ([DATE]), the resident told Resident #6 s/he was going to kill him/her. Resident #5 will try to get to Resident #6, s/he will get up and chase the resident down the hall. Staff will intervene, they are almost always there and are [MEDICAL CONDITION]. All the staff on the unit are aware of the behavior. Resident #5 is on 15 minute checks since the incident on Friday [DATE]. The weekend before when s/he grabbed Resident #6's arm and left a bruise s/he was put on 1:1 until Monday morning. The incident occurred on 8/25/18, Saturday. Resident #5 came off 1:1 because the DON discontinued it because there were no further behaviors. LPN #1 stated the problem with Resident #6 exacerbated the first part of August, and that is when the documented aggression started toward him/her. Resident #5's sister told one of the nurses' that s/he and Resident #6 knew each other in the community. Resident #5 was sent out to the hospital on [DATE] after striking Resident #6. The DON said s/he wanted the resident sent out and LPN #1 got the order from the physician. The ER physician summary indicated that the facility had sent 2 residents around the same time, they did not have any findings. LPN #1 reported to the hospital s/he had been aggressive with another resident. LPN #1 stated the resident is not seen by psych. They have a psych NP (Nurse Practitioner) that comes once a month, or once every other month. The resident has a busy board in his/her room, installed in July. They wanted to try to give him/her more activities to do, s/he does not use the board. The administrator and DON made the decision to put the board in place. Other than removing things from the resident's room, there have not been any interventions put in place. The sister told the facility about the resident's previously knowing each other this past Saturday, 9/1/18. LPN #1 talked with the Resident #5's sister and son (RP) about transferring the resident to . unit a year ago and they were okay. Resident #6's family comes in a lot and knows Resident #5 is the aggressor. LPN #1 stated s/he has fought moving Resident #6 because s/he feels it will be detrimental to the resident. Resident #6 is confused, but knows where his/her room is. LPN #1 stated Resident #5 has been in a private room for several months. When s/he had roommates before, s/he would be staring over them at 3 in the morning, stand and cuss at them. They would feel threatened and so the resident was put in a private room. LPN #1 stated s/he thinks they went through 3 residents before they put Resident #5 in a private room. LPN #1 stated s/he feels since . (unit) is an Alzheimer's unit, they would be able to work with Resident #5 better. They have activities in the open dayroom where s/he could participate. In an interview with the surveyor on 9/6/18 at approximately 3:15 PM, LPN #2, . Unit Manager, stated s/he has been at the facility since 2009 and . Unit Manager for 2 years. They have mostly wanderers and exit seekers on the unit, they can see all the doors with the layout of the unit. They have more resident's on their unit that have [MEDICAL CONDITION]. LPN #2 stated there are 6 empty beds on the . unit. They have one private room that is occupied. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August. They are trying to keep the residents away from each other. They spoke today and last week about room changes. The DON talked with Resident #6's family about a room change and they were worried about the resident falling. They have looked into changing Resident #5's. The resident will get set off if there is a loud noise. Family is very adamant they don't want Resident #6 moved. The DON stated they don't have another room they can put Resident #5 in. The DON stated the problem with roommates is the noise and roommates don't like being in the bathroom with a resident who makes a mess. He has been on every 15 minute checks since s/he came back from theER on Friday. Resident #5 was on 1:1 with the prior incident on 8/25/18 until the following Monday, there was no further incident. He was on 1:1 form 8/25/18-8/27/18. 1:1 is a nursing intervention and does not require a physician order. There is no documentation in the chart about assessing for 1:1. The ADON and unit manager decided to do the 15 minute checks when he came back from the hospital on [DATE]. Reviewed documentation from hospital to see if any psych done and confirmed there was none. The DON called the facility on Saturday and talked with the nurse to see if there was any further agitation. The DON had not been made aware of any increase in behaviors until the first part of August. The DON stated most of the behavior discussion they have had about Resident #5 have been about his/her toileting. The DON stated the Psych NP usually comes once a month and anyone who has had an incident will be on the list for the NP to see. The DON stated they assumed the reason Resident #5 was hitting things is because of noises. The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. The DON stated that someone at the meeting with Resident #6's family and the ombudsman today said they knew each other out in the community. The DON stated that today is the first s/he heard of them knowing each other before the facility. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. Review of the facility's policy on Abuse, Neglect, Exploitation, or Mistreatment indicated the facility's leadership will conduct a prompt investigation of any allegation received of suspected abuse and will implement immediate action to safeguard resident. Prevention included ongoing assessment, care planning, and monitoring of those residents with special needs that may lead to neglect to include those with history of resident to resident altercations. Physical abuse was noted to include hitting, slapping, pinching, and kicking. In the event another resident is accused of abuse/neglect against a resident, the facility will intervene and take appropriate steps to safeguard the resident during and after the investigation. On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0[AGE]7 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.",2020-09-01
2681,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-09-07,657,J,1,0,4EIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to review and revise care plans. Resident #5 had two incidents of physical behavior toward Resident #6. The resident's care plan was not updated to reflect the incidents. 1 of 7 residents reviewed for care plans. The findings included: Cross refer to F0[AGE]0. Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. The resident was observed on initial tour of the facility on 9/4/18 at approximately 12:02 AM, Resident #5 was in his/her room in bed, with lights and radio on. The surveyor observed that Resident #5 and Resident #6 resided in rooms that were next to each other. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. The Discharge Summary for Resident #5's hospital visit on [DATE] indicated the physician talked with the resident's son. Resident's son stated he had spoken to the nursing staff at the facility before, he thinks there may be one person, either staff member or even another resident, that just seems to set the patient off as soon as s/he sees them. The son is going to speak with staff to determine if there is any better way to keep the patient's behaviors and dementia under control, specifically separating him/her from whichever person seems to agitate him/her. The Initial ER report indicated that according to nursing report who received telephone report from the nursing home, the resident's behavior has been going downhill for about 3 months. Friday afternoon the patient apparently attempted to hit a nurse and was sent to the emergency department for evaluation. Resident #5's Progress Notes were reviewed and the following noted: 5/22/18 at 4:24 AM - Resident tried to remove the television from off the wall once, the nurse turned it off so the resident could go to sleep. 6/5/18 at 6:29 AM - Resident had 2 BMs on the floor, both times he had it in his hands sitting on the tables in his room and squishing it between his fingers. Resident also tore bulletin board off wall and threw it across the room. No notification of MD or RP noted. 6/10/18 - MD Progress Note with no documentation related to resident's behaviors. 6/13/18 at 12:52 AM - Resident up in room smearing feces on floor and wall and in hands. Taken into bathroom and showered resident saying give me a hammer and I'll kill myself and if I could find a knife I'd cut myself. Resident having loose stools while given a shower. Another resident got up and started to enter his room and he started cussing and in a fighting stance going to hit the other resident, very aggressive behavior. No documentation of RP or MD notification. No MD note related to incident. 7/8/18 at 4:23 AM - resident becoming increased aggressive, was hitting bed with his/her belt cursing. Difficult to redirect in the beginning then s/he calmed down. Resident #5 also went into another resident's room and was going to hit him/her with a remote control. Staff stopped the resident in time and s/he was very quick to leave and go next door. 7/8/18 at 8:16 PM - MD note with no mention of behaviors. 7/10/18 at 4:31 PM - resident standing in his/her room with the bathroom door open and s/he is hitting the door. The nurse went to the door to talk to the resident and resident stated You better move, I'm going to kill. Resident continued to hit the bathroom door and the door is broken and will not close and the tissue roll is broken. Then the resident began slamming the closet door and continued to have increased behavior. 7/19/18 at 8:18 AM - resident having increased agitation. Resident saw another resident walking in hallway and got up from his/her chair. Resident #5 then began to attempt to raise his/her fist at other resident and stated I'm going to kill you! No contact made with other resident, staff able to redirect. Unit manager and DON made aware of increased agitation. MD notified of resident increased agitation and aggressive behavior. New order received for [MEDICATION NAME] 0.25 mg BID. 7/19/18 at 5:05 PM - resident sitting in hallway chair when s/he saw another resident and stood up and raised closed fist at other resident, stating get away from me! I'll hit you. 7/21/18 at 10:49 PM - resident noted to raise hand to hit female resident x 2 so far this shift. No contact was made, staff intervened. MD made aware with new order to d/c [MEDICATION NAME], increase [MEDICATION NAME] to TID. 7/26/18 at 11:29 PM - resident went into another resident's room and took his/her TV remote control. Then went into another resident's room and threw the remote at another resident but did not hit the resident. 8/9/18 at 6:06 PM - MD note that indicated stable clinically, continue medications. 8/10/18 at 1:53 AM - resident in chair beside nurses' station. Resident will become agitated when a certain resident comes near him/her and s/he starts cussing and say s/he will hit the resident. 8/12/18 at 2:44 PM - resident continues to try to hit resident #6. 8/13/18 at 10:26 PM - Resident #6 was in view of Resident #5, Resident #5 states I'm going to kill her. 8/14/18 at 6:31 AM - resident noted to enter a female resident's room and knock her pencils over on her while she was in bed. Resident #5 was standing over female resident cursing when the nurse entered the room. MD called and made aware, no changes at this time. There was no physician note that referenced the incident. 8/15/18 at 12:45 AM - resident gets agitated when s/he sees resident #6. Resident #5 tries to hit this resident but staff intervenes. 8/15/18 at 5:52 AM - resident #6 up walking in hallway and passing by resident #5. Resident #5 tried to hit resident #6 requiring staff to hold him/her while resident #6 passes by. 8/16/18 at 1:40 AM - resident noted cussing at resident #6 as s/he was walking up hallway. Resident also noted to pull back his/her arm as to try and hit Resident #6 but staff intervened and stopped attempt. 8/16/18 at 5:52 PM - resident continue to wander in and out of other resident's room and to other unit. Resident #5 continue to want to fight resident in room next door, s/he make statement that s/he is going to slap him/her. 8/17/18 at 6:00 AM - resident became upset when s/he saw the resident from the room next door in the hallway and staff head to intervene when resident #5 acted like s/he was going to hit the resident by drawing his/her arm back. 8/21/18 at 11:44 AM - resident ripped paper towel dispenser off wall in bathroom. Maintenance notified. Resident had bowel movement in corner of closet and also threw feces on air-conditioning. 8/24/18 at 1:15 PM - Called to another resident's room, resident #5 in room plundering through drawers, urinated in floor and doorway. 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. 8/25/18 at 8:23 AM - Physician notified of resident's behavior. Grabbing and pinching female resident (#6). New order noted to increase [MEDICATION NAME] to 1.5 mg TID due to residents aggressiveness. 8/25/18 at 11:25 AM - DON notified of incident this morning concerning resident. Informed resident placed on 15 minute checks. DON stated Place him on 1:1 supervision along with the 15 minute checks. 8/26/18 at 6:11 PM - resident 1:1 due to his/her increased behavior. Resident has become very aggressive with staff and cussing at staff. S/he is very hard to redirect. S/he continues to go in and out of other resident room. 8/27/18 at 1:24 PM - Resident has been 1:1 since Saturday 8/25/18. Per staff nurse today, staffing coordinator called and stated 1:1 to be stopped if not further incidence. 8/30/18 at 7:54 AM - report from CNA (Certified Nursing Aide) stating that yesterday afternoon, resident went into a resident's room on . unit and defecated in the floor. Resident # 5 noted to reside on another unit. [DATE] at 5:36 PM - resident was sitting in a chair in the hall and resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON, MD and RP notified and resident sent out to ER. [DATE] at 8:24 PM - resident back in facility from hospital, reported to another nurse by resident's son that as resident was entering the facility, another resident approached the resident asking why s/he doesn't like him/her. 9/1/18 at 2:07 AM - resident noted to be checked on every 15 minutes for safety. 9/2/18 at 5:36 AM - Resident up wandering earlier and went into another resident's room 9/2/18 at 5:56 PM - Resident walked down to dining room and grabbed a walker, s/he began to throw it. Staff had to redirect him/her back to his/her room. S/he then went back to his/her room and began to shake bathroom door. 9/4/18 at 7:14 PM- Resident continues to wander in and out of other residents room 9/6/18 at 10:56 AM indicated 8/26/18 resident went into another resident room and stated get out of my dam bed. Resident was redirected by staff and continues to cuss at the other resident while leaving the room. 9/6/18 at 6:14 PM - wandering around unit and to (another) unit as usual this shift. To dining room at times. Attempted to go into other rooms off/on. Urinated in floor in own room. 1:1 initiated. 9/6/18 at 6:36 PM - phone call to MD to increase [MEDICATION NAME] back to 1.5 mg. Called resident contact and discussed medication change with him/her. Stated to the nurse that his/her brother is having an issue with another resident and s/he stated that this resident looks identical to a woman that s/he has had a lot of problems with in years past. S/he states that this other woman has been to this facility with a family member to visit other residents and has attempted to speak to her/him. S/he states that s/he gets very upset when s/he sees him/her and that this other resident must remind her/him of that other woman. 9/6/18 at 6:40 PM - physician note that indicated MD addendum - resident has been seen and discussed with staff several times. Already on therapeutic approach with medications for her/his unpredictable combativeness/behavior issue mainly due to dementia related. 9/6/18 at 8:25 PM - note by the DON indicates this nurse spoke to the medical director regarding recently identified behavioral issues. Medical Director gave order to discontinue [MEDICATION NAME]. New order received to send to MUSC for psychiatric evaluation. Medical Director to be contacted upon resident return and recommendations reviewed. MDS: Quarterly 8/17/18 - ST and LT memory problem with severely impaired cognitive skills for daily decision making Care Plan: Review of the resident's care plan revealed resident at risk for adverse consequences related to receiving antipsychotic medication with a problem start date of 7/19/18. Review of resident's care plan revealed behavioral symptoms, resident was observed wandering into other resident's room(s). The wandering is related to a dementia [DIAGNOSES REDACTED]. The evaluation note on 8/18/18 indicated the resident has begun to wander more frequently lately. Review of resident's care plan revealed behavioral symptoms, resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) with a problem start date of 4/23/18. The evaluation note on 8/18/18 indicated the resident curses and strikes out at staff and others at times. On [MEDICATION NAME] for restlessness and agitation. Social services and psych referrals as needed. Review of the resident's care plan revealed psychosocial well-being, resident expresses sadness as evident by the following statement I don't want to live anymore with a problem start dated of 2/20/18. Approaches included staff will make referral psychiatric nurse practitioner. Evaluation notes on 5/18/18 indicated resident is very confused and gets agitated at the TV, furniture, etc., and history of roommate issues. Social services and psych referrals as needed. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., excessive and/or continually urinating and/or defecating in his room trashcan and/or in the A/C unit in his room, smearing bodily wastes on the wall(s), etc.) He fusses at the TV and becomes agitated and aggressive at times with a problem start dated of 12/1/17. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., throwing or smearing food or bodily wastes on walls/floor, etc.) with a problem start date of 2/6/17. The evaluation note on 5/18/18 indicated resident defecates and urinates in inappropriate places at times, pulls drawers out of furniture and curses at TV. Psych and social services referrals as needed. Issue with roommates and was moved to private room. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 12:15 PM, CNA #1 stated s/he has been at the facility 6 years. CNA #1 stated Resident #5 has been at the facility 2 years. CNA #1 has been working with the resident since s/he was admitted . CNA #1 stated Resident #5 is losing his/her focus and vision. CNA #1 stated the resident is going down fast. When the resident came in, s/he was alert and would hold conversation. Now the resident is not alert and can't have conversation. Resident #5 did not have behaviors when they were admitted to the facility. CNA #1 stated they have 6 sections and they rotate resident assignments every day. CNA #1 stated they have been rotating assignments for about a month. CNA #1 stated before Resident #5 would have little behaviors, the resident would relax if approached her/him calmly. Resident #5 would have tantrums, knock stuff off the table. Resident #5 would get in a rage, you would have to wait for him/her to calm down. Resident #5 has had a big change in the last 6 months and his/her behaviors have really increased. Resident #5 has knocked a paper towel dispenser off the wall, and the television. CNA #1 stated s/he just learned the resident is going in other resident rooms. Resident #5 is touching things and s/he has used the bathroom in another resident's room floor. Resident #5 hits at the mirror on the wall, they took the mirror off the wall. Resident #5's outburst will come out of nowhere and have been getting worse over the last 6 months. They put up the gadget board a few weeks ago but the resident doesn't do anything with hit. CNA #1 stated Resident #6 reminds Resident #5 of someone s/he knew when s/he was younger. Resident #5's sister told CNA #1 that. Resident #6 will come stand in between people when they are trying to talk and start talking. Resident #5 gets agitated because Resident #6 is repetitive, s/he will keep asking how you are doing. The facility does behavior training on the computer yearly. CNA #1 stated they complete training on the computer, and no one talks to them about the dealing with resident behaviors/dementia. In an interview with the surveyor on 9/6/18 at approximately 12:45 PM, Unit Manager LPN (Licensed Practical Nurse) #1 stated Resident #5 liked to piddle, take things apart. They could not keep an alarm on him/her because s/he would take it apart. LPN stated s/he has seen Resident #5 decline, s/he has early onset [MEDICAL CONDITION] with behaviors, history of alcohol and drugs. The decline has been gradual over the past year. It was a year ago when LPN #1 started trying to get Resident #5 on the . unit (a separate building). The . unit has more residents with Alzheimer's and behaviors, but the resident has not gone back there. It has been knocked down every time s/he brings it up. One reason was because s/he was defecating on the floors, ac units, urinating in other residents' rooms. That behavior started a year ago. It was bothering other residents on . (unit) that the resident was doing that in their rooms. LPN #1 brought it up to the DON in clinical morning meeting. The response was they were not going to transfer him/her back there because the residents back there might play in his/her feces. LPN #1 stated s/he brings up moving the resident almost monthly, if not more. As Resident #5 has gotten worse, s/he has tried to push it. One response has been that it would be too much stimulation. LPN #1 stated it is always one of those 2 responses when s/he brings up moving the resident to the . unit. The . unit is a locked unit with the day room in front of the nurses' stations. LPN #1 feels Resident #5 could benefit from that environment. Right now s/he just sits beside their nurses' station most of the day and does not get that stimulation. LPN #1 stated . (unit) is considered an Alzheimer's unit. The DON usually decides who to send to the . unit. Since June, Resident #5's behaviors have increased. The resident no longer has a TV in his/her room because s/he ripped it off the wall. S/he ripped the paper towel holder off the wall in his/her bathroom, they had to take the mirror out the bathroom because s/he was going to punch it. Resident #5 tried to take the bathroom door down and broke the metal door frame. Resident #5's vision has gotten worse, s/he thought someone else was there and was going to punch them and that is why they took the mirror down. Resident #5 will go to other residents' rooms on both . (unit) and . (another) unit. Resident #5 will defecate on the floor, go through their things, and rummage through their room. The resident has thrown a box of colored pencils on a resident lying in bed. They put a stop sign on the door to one room for him/her to not enter, that did not deter the resident for long. Resident #5 just took it down and went in. LPN #1 stated s/he does not understand why Resident #5 goes after Resident #6 aggressively, that is the only resident s/he is aggressive with. Resident #5 will cuss at him/her when s/he is walking down the hall, says s/he is going to kill him/her, calls him/her names. When Resident #5 struck Resident #6 on Friday ([DATE]), the resident told Resident #6 s/he was going to kill him/her. Resident #5 will try to get to Resident #6, s/he will get up and chase the resident down the hall. Staff will intervene, they are almost always there and are [MEDICAL CONDITION]. All the staff on the unit are aware of the behavior. Resident #5 is on 15 minute checks since the incident on Friday [DATE]. The weekend before when s/he grabbed Resident #6's arm and left a bruise s/he was put on 1:1 until Monday morning. The incident occurred on 8/25/18, Saturday. Resident #5 came off 1:1 because the DON discontinued it because there were no further behaviors. LPN #1 stated the problem with Resident #6 exacerbated the first part of August, and that is when the documented aggression started toward him/her. Resident #5's sister told one of the nurses' that s/he and Resident #6 knew each other in the community. Resident #5 was sent out to the hospital on [DATE] after striking Resident #6. The DON said s/he wanted the resident sent out and LPN #1 got the order from the physician. The ER physician summary indicated that the facility had sent 2 residents around the same time, they did not have any findings. LPN #1 reported to the hospital s/he had been aggressive with another resident. LPN #1 stated the resident is not seen by psych. They have a psych NP (Nurse Practitioner) that comes once a month, or once every other month. The resident has a busy board in his/her room, installed in July. They wanted to try to give him/her more activities to do, s/he does not use the board. The administrator and DON made the decision to put the board in place. Other than removing things from the resident's room, there have not been any interventions put in place. The sister told the facility about the resident's previously knowing each other this past Saturday, 9/1/18. LPN #1 talked with the Resident #5's sister and son (RP) about transferring the resident to . unit a year ago and they were okay. Resident #6's family comes in a lot and knows Resident #5 is the aggressor. LPN #1 stated s/he has fought moving Resident #6 because s/he feels it will be detrimental to the resident. Resident #6 is confused, but knows where his/her room is. LPN #1 stated Resident #5 has been in a private room for several months. When s/he had roommates before, s/he would be staring over them at 3 in the morning, stand and cuss at them. They would feel threatened and so the resident was put in a private room. LPN #1 stated s/he thinks they went through 3 residents before they put Resident #5 in a private room. LPN #1 stated s/he feels since . (unit) is an Alzheimer's unit, they would be able to work with Resident #5 better. They have activities in the open dayroom where s/he could participate. In an interview with the surveyor on 9/6/18 at approximately 3:15 PM, LPN #2, . Unit Manager, stated s/he has been at the facility since 2009 and . Unit Manager for 2 years. They have mostly wanderers and exit seekers on the unit, they can see all the doors with the layout of the unit. They have more resident's on their unit that have [MEDICAL CONDITION]. LPN #2 stated there are 6 empty beds on the . unit. They have one private room that is occupied. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August. They are trying to keep the residents away from each other. They spoke today and last week about room changes. The DON talked with Resident #6's family about a room change and they were worried about the resident falling. They have looked into changing Resident #5's. The resident will get set off if there is a loud noise. Family is very adamant they don't want Resident #6 moved. The DON stated they don't have another room they can put Resident #5 in. The DON stated the problem with roommates is the noise and roommates don't like being in the bathroom with a resident who makes a mess. He has been on every 15 minute checks since s/he came back from theER on Friday. Resident #5 was on 1:1 with the prior incident on 8/25/18 until the following Monday, there was no further incident. He was on 1:1 form 8/25/18-8/27/18. 1:1 is a nursing intervention and does not require a physician order. There is no documentation in the chart about assessing for 1:1. The ADON and unit manager decided to do the 15 minute checks when he came back from the hospital on [DATE]. Reviewed documentation from hospital to see if any psych done and confirmed there was none. The DON called the facility on Saturday and talked with the nurse to see if there was any further agitation. The DON had not been made aware of any increase in behaviors until the first part of August. The DON stated most of the behavior discussion they have had about Resident #5 have been about his/her toileting. The DON stated the Psych NP usually comes once a month and anyone who has had an incident will be on the list for the NP to see. The DON stated they assumed the reason Resident #5 was hitting things is because of noises. The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. The DON stated that someone at the meeting with Resident #6's family and the ombudsman today said they knew each other out in the community. The DON stated that today is the first s/he heard of them knowing each other before the facility. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0657 at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.",2020-09-01
2682,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-09-07,732,C,1,0,4EIF11,"> Based on review of 18 months of Daily Nursing Staff Postings and interview, the facility failed to completed the posting with census changes on each shift. 18 months of 18 months reviewed for Daily Nursing Staff Postings. The findings included: 18 months of 18 months of Daily Postings had the census recorded only at the beginning of the day. The facility had nursing staffing shifts of 7AM to 7PM, 7PM to 7AM, 3PM to 11PM and 11PM to 7AM shifts. During review with the Director of Nursing on 9/7/18, s/he confirmed census was not included after the morning shift.",2020-09-01
2683,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-09-07,742,J,1,0,4EIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that a resident who displays or is diagnosed with [REDACTED]. Resident #5 was noted to have increased behaviors and the facility failed to ensure the resident received appropriate treatment and services. 1 of 4 residents reviewed for resident to resident abuse. The findings included: Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. The resident was observed on initial tour of the facility on 9/4/18 at approximately 12:02 AM, Resident #5 was in his/her room in bed, with lights and radio on. The surveyor observed that Resident #5 and Resident #6 resided in rooms that were next to each other. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. The Discharge Summary for Resident #5's hospital visit on [DATE] indicated the physician talked with the resident's son. Resident's son stated he had spoken to the nursing staff at the facility before, he thinks there may be one person, either staff member or even another resident, that just seems to set the patient off as soon as s/he sees them. The son is going to speak with staff to determine if there is any better way to keep the patient's behaviors and dementia under control, specifically separating him/her from whichever person seems to agitate him/her. The Initial ER report indicated that according to nursing report who received telephone report from the nursing home, the resident's behavior has been going downhill for about 3 months. Friday afternoon the patient apparently attempted to hit a nurse and was sent to the emergency department for evaluation. Resident #5's Progress Notes were reviewed and the following noted: 5/22/18 at 4:24 AM - Resident tried to remove the television from off the wall once, the nurse turned it off so the resident could go to sleep. 6/5/18 at 6:29 AM - Resident had 2 BMs on the floor, both times he had it in his hands sitting on the tables in his room and squishing it between his fingers. Resident also tore bulletin board off wall and threw it across the room. No notification of MD or RP noted. 6/10/18 - MD Progress Note with no documentation related to resident's behaviors. 6/13/18 at 12:52 AM - Resident up in room smearing feces on floor and wall and in hands. Taken into bathroom and showered resident saying give me a hammer and I'll kill myself and if I could find a knife I'd cut myself. Resident having loose stools while given a shower. Another resident got up and started to enter his room and he started cussing and in a fighting stance going to hit the other resident, very aggressive behavior. No documentation of RP or MD notification. No MD note related to incident. 7/8/18 at 4:23 AM - resident becoming increased aggressive, was hitting bed with his/her belt cursing. Difficult to redirect in the beginning then s/he calmed down. Resident #5 also went into another resident's room and was going to hit him/her with a remote control. Staff stopped the resident in time and s/he was very quick to leave and go next door. 7/8/18 at 8:16 PM - MD note with no mention of behaviors. 7/10/18 at 4:31 PM - resident standing in his/her room with the bathroom door open and s/he is hitting the door. The nurse went to the door to talk to the resident and resident stated You better move, I'm going to kill. Resident continued to hit the bathroom door and the door is broken and will not close and the tissue roll is broken. Then the resident began slamming the closet door and continued to have increased behavior. 7/19/18 at 8:18 AM - resident having increased agitation. Resident saw another resident walking in hallway and got up from his/her chair. Resident #5 then began to attempt to raise his/her fist at other resident and stated I'm going to kill you! No contact made with other resident, staff able to redirect. Unit manager and DON made aware of increased agitation. MD notified of resident increased agitation and aggressive behavior. New order received for [MEDICATION NAME] 0.25 mg BID. 7/19/18 at 5:05 PM - resident sitting in hallway chair when s/he saw another resident and stood up and raised closed fist at other resident, stating get away from me! I'll hit you. 7/21/18 at 10:49 PM - resident noted to raise hand to hit female resident x 2 so far this shift. No contact was made, staff intervened. MD made aware with new order to d/c [MEDICATION NAME], increase [MEDICATION NAME] to TID. 7/26/18 at 11:29 PM - resident went into another resident's room and took his/her TV remote control. Then went into another resident's room and threw the remote at another resident but did not hit the resident. 8/9/18 at 6:06 PM - MD note that indicated stable clinically, continue medications. 8/10/18 at 1:53 AM - resident in chair beside nurses' station. Resident will become agitated when a certain resident comes near him/her and s/he starts cussing and say s/he will hit the resident. 8/12/18 at 2:44 PM - resident continues to try to hit resident #6. 8/13/18 at 10:26 PM - Resident #6 was in view of Resident #5, Resident #5 states I'm going to kill her. 8/14/18 at 6:31 AM - resident noted to enter a female resident's room and knock her pencils over on her while she was in bed. Resident #5 was standing over female resident cursing when the nurse entered the room. MD called and made aware, no changes at this time. There was no physician note that referenced the incident. 8/15/18 at 12:45 AM - resident gets agitated when s/he sees resident #6. Resident #5 tries to hit this resident but staff intervenes. 8/15/18 at 5:52 AM - resident #6 up walking in hallway and passing by resident #5. Resident #5 tried to hit resident #6 requiring staff to hold him/her while resident #6 passes by. 8/16/18 at 1:40 AM - resident noted cussing at resident #6 as s/he was walking up hallway. Resident also noted to pull back his/her arm as to try and hit Resident #6 but staff intervened and stopped attempt. 8/16/18 at 5:52 PM - resident continue to wander in and out of other resident's room and to other unit. Resident #5 continue to want to fight resident in room next door, s/he make statement that s/he is going to slap him/her. 8/17/18 at 6:00 AM - resident became upset when s/he saw the resident from the room next door in the hallway and staff head to intervene when resident #5 acted like s/he was going to hit the resident by drawing his/her arm back. 8/21/18 at 11:44 AM - resident ripped paper towel dispenser off wall in bathroom. Maintenance notified. Resident had bowel movement in corner of closet and also threw feces on air-conditioning. 8/24/18 at 1:15 PM - Called to another resident's room, resident #5 in room plundering through drawers, urinated in floor and doorway. 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. 8/25/18 at 8:23 AM - Physician notified of resident's behavior. Grabbing and pinching female resident (#6). New order noted to increase [MEDICATION NAME] to 1.5 mg TID due to residents aggressiveness. 8/25/18 at 11:25 AM - DON notified of incident this morning concerning resident. Informed resident placed on 15 minute checks. DON stated Place him on 1:1 supervision along with the 15 minute checks. 8/26/18 at 6:11 PM - resident 1:1 due to his/her increased behavior. Resident has become very aggressive with staff and cussing at staff. S/he is very hard to redirect. S/he continues to go in and out of other resident room. 8/27/18 at 1:24 PM - Resident has been 1:1 since Saturday 8/25/18. Per staff nurse today, staffing coordinator called and stated 1:1 to be stopped if not further incidence. 8/30/18 at 7:54 AM - report from CNA (Certified Nursing Aide) stating that yesterday afternoon, resident went into a resident's room on . unit and defecated in the floor. Resident # 5 noted to reside on another unit. [DATE] at 5:36 PM - resident was sitting in a chair in the hall and resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON, MD and RP notified and resident sent out to ER. [DATE] at 8:24 PM - resident back in facility from hospital, reported to another nurse by resident's son that as resident was entering the facility, another resident approached the resident asking why s/he doesn't like him/her. 9/1/18 at 2:07 AM - resident noted to be checked on every 15 minutes for safety. 9/2/18 at 5:36 AM - Resident up wandering earlier and went into another resident's room 9/2/18 at 5:56 PM - Resident walked down to dining room and grabbed a walker, s/he began to throw it. Staff had to redirect him/her back to his/her room. S/he then went back to his/her room and began to shake bathroom door. 9/4/18 at 7:14 PM- Resident continues to wander in and out of other residents room 9/6/18 at 10:56 AM indicated 8/26/18 resident went into another resident room and stated get out of my dam bed. Resident was redirected by staff and continues to cuss at the other resident while leaving the room. 9/6/18 at 6:14 PM - wandering around unit and to (another) unit as usual this shift. To dining room at times. Attempted to go into other rooms off/on. Urinated in floor in own room. 1:1 initiated. 9/6/18 at 6:36 PM - phone call to MD to increase [MEDICATION NAME] back to 1.5 mg. Called resident contact and discussed medication change with him/her. Stated to the nurse that his/her brother is having an issue with another resident and s/he stated that this resident looks identical to a woman that s/he has had a lot of problems with in years past. S/he states that this other woman has been to this facility with a family member to visit other residents and has attempted to speak to her/him. S/he states that s/he gets very upset when s/he sees him/her and that this other resident must remind her/him of that other woman. 9/6/18 at 6:40 PM - physician note that indicated MD addendum - resident has been seen and discussed with staff several times. Already on therapeutic approach with medications for her/his unpredictable combativeness/behavior issue mainly due to dementia related. 9/6/18 at 8:25 PM - note by the DON indicates this nurse spoke to the medical director regarding recently identified behavioral issues. Medical Director gave order to discontinue [MEDICATION NAME]. New order received to send to MUSC for psychiatric evaluation. Medical Director to be contacted upon resident return and recommendations reviewed. MDS: Quarterly 8/17/18 - ST and LT memory problem with severely impaired cognitive skills for daily decision making Care Plan: Review of the resident's care plan revealed resident at risk for adverse consequences related to receiving antipsychotic medication with a problem start date of 7/19/18. Review of resident's care plan revealed behavioral symptoms, resident was observed wandering into other resident's room(s). The wandering is related to a dementia [DIAGNOSES REDACTED]. The evaluation note on 8/18/18 indicated the resident has begun to wander more frequently lately. Review of resident's care plan revealed behavioral symptoms, resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) with a problem start date of 4/23/18. The evaluation note on 8/18/18 indicated the resident curses and strikes out at staff and others at times. On [MEDICATION NAME] for restlessness and agitation. Social services and psych referrals as needed. Review of the resident's care plan revealed psychosocial well-being, resident expresses sadness as evident by the following statement I don't want to live anymore with a problem start dated of 2/20/18. Approaches included staff will make referral psychiatric nurse practitioner. Evaluation notes on 5/18/18 indicated resident is very confused and gets agitated at the TV, furniture, etc., and history of roommate issues. Social services and psych referrals as needed. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., excessive and/or continually urinating and/or defecating in his room trashcan and/or in the A/C unit in his room, smearing bodily wastes on the wall(s), etc.) He fusses at the TV and becomes agitated and aggressive at times with a problem start dated of 12/1/17. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., throwing or smearing food or bodily wastes on walls/floor, etc.) with a problem start date of 2/6/17. The evaluation note on 5/18/18 indicated resident defecates and urinates in inappropriate places at times, pulls drawers out of furniture and curses at TV. Psych and social services referrals as needed. Issue with roommates and was moved to private room. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 12:15 PM, CNA #1 stated s/he has been at the facility 6 years. CNA #1 stated Resident #5 has been at the facility 2 years. CNA #1 has been working with the resident since s/he was admitted . CNA #1 stated Resident #5 is losing his/her focus and vision. CNA #1 stated the resident is going down fast. When the resident came in, s/he was alert and would hold conversation. Now the resident is not alert and can't have conversation. Resident #5 did not have behaviors when they were admitted to the facility. CNA #1 stated they have 6 sections and they rotate resident assignments every day. CNA #1 stated they have been rotating assignments for about a month. CNA #1 stated before Resident #5 would have little behaviors, the resident would relax if approached her/him calmly. Resident #5 would have tantrums, knock stuff off the table. Resident #5 would get in a rage, you would have to wait for him/her to calm down. Resident #5 has had a big change in the last 6 months and his/her behaviors have really increased. Resident #5 has knocked a paper towel dispenser off the wall, and the television. CNA #1 stated s/he just learned the resident is going in other resident rooms. Resident #5 is touching things and s/he has used the bathroom in another resident's room floor. Resident #5 hits at the mirror on the wall, they took the mirror off the wall. Resident #5's outburst will come out of nowhere and have been getting worse over the last 6 months. They put up the gadget board a few weeks ago but the resident doesn't do anything with hit. CNA #1 stated Resident #6 reminds Resident #5 of someone s/he knew when s/he was younger. Resident #5's sister told CNA #1 that. Resident #6 will come stand in between people when they are trying to talk and start talking. Resident #5 gets agitated because Resident #6 is repetitive, s/he will keep asking how you are doing. The facility does behavior training on the computer yearly. CNA #1 stated they complete training on the computer, and no one talks to them about the dealing with resident behaviors/dementia. In an interview with the surveyor on 9/6/18 at approximately 12:45 PM, Unit Manager LPN (Licensed Practical Nurse) #1 stated Resident #5 liked to piddle, take things apart. They could not keep an alarm on him/her because s/he would take it apart. LPN stated s/he has seen Resident #5 decline, s/he has early onset [MEDICAL CONDITION] with behaviors, history of alcohol and drugs. The decline has been gradual over the past year. It was a year ago when LPN #1 started trying to get Resident #5 on the . unit (a separate building). The . unit has more residents with Alzheimer's and behaviors, but the resident has not gone back there. It has been knocked down every time s/he brings it up. One reason was because s/he was defecating on the floors, ac units, urinating in other residents' rooms. That behavior started a year ago. It was bothering other residents on . (unit) that the resident was doing that in their rooms. LPN #1 brought it up to the DON in clinical morning meeting. The response was they were not going to transfer him/her back there because the residents back there might play in his/her feces. LPN #1 stated s/he brings up moving the resident almost monthly, if not more. As Resident #5 has gotten worse, s/he has tried to push it. One response has been that it would be too much stimulation. LPN #1 stated it is always one of those 2 responses when s/he brings up moving the resident to the . unit. The . unit is a locked unit with the day room in front of the nurses' stations. LPN #1 feels Resident #5 could benefit from that environment. Right now s/he just sits beside their nurses' station most of the day and does not get that stimulation. LPN #1 stated . (unit) is considered an Alzheimer's unit. The DON usually decides who to send to the . unit. Since June, Resident #5's behaviors have increased. The resident no longer has a TV in his/her room because s/he ripped it off the wall. S/he ripped the paper towel holder off the wall in his/her bathroom, they had to take the mirror out the bathroom because s/he was going to punch it. Resident #5 tried to take the bathroom door down and broke the metal door frame. Resident #5's vision has gotten worse, s/he thought someone else was there and was going to punch them and that is why they took the mirror down. Resident #5 will go to other residents' rooms on both . (unit) and . (another) unit. Resident #5 will defecate on the floor, go through their things, and rummage through their room. The resident has thrown a box of colored pencils on a resident lying in bed. They put a stop sign on the door to one room for him/her to not enter, that did not deter the resident for long. Resident #5 just took it down and went in. LPN #1 stated s/he does not understand why Resident #5 goes after Resident #6 aggressively, that is the only resident s/he is aggressive with. Resident #5 will cuss at him/her when s/he is walking down the hall, says s/he is going to kill him/her, calls him/her names. When Resident #5 struck Resident #6 on Friday ([DATE]), the resident told Resident #6 s/he was going to kill him/her. Resident #5 will try to get to Resident #6, s/he will get up and chase the resident down the hall. Staff will intervene, they are almost always there and are [MEDICAL CONDITION]. All the staff on the unit are aware of the behavior. Resident #5 is on 15 minute checks since the incident on Friday [DATE]. The weekend before when s/he grabbed Resident #6's arm and left a bruise s/he was put on 1:1 until Monday morning. The incident occurred on 8/25/18, Saturday. Resident #5 came off 1:1 because the DON discontinued it because there were no further behaviors. LPN #1 stated the problem with Resident #6 exacerbated the first part of August, and that is when the documented aggression started toward him/her. Resident #5's sister told one of the nurses' that s/he and Resident #6 knew each other in the community. Resident #5 was sent out to the hospital on [DATE] after striking Resident #6. The DON said s/he wanted the resident sent out and LPN #1 got the order from the physician. The ER physician summary indicated that the facility had sent 2 residents around the same time, they did not have any findings. LPN #1 reported to the hospital s/he had been aggressive with another resident. LPN #1 stated the resident is not seen by psych. They have a psych NP (Nurse Practitioner) that comes once a month, or once every other month. The resident has a busy board in his/her room, installed in July. They wanted to try to give him/her more activities to do, s/he does not use the board. The administrator and DON made the decision to put the board in place. Other than removing things from the resident's room, there have not been any interventions put in place. The sister told the facility about the resident's previously knowing each other this past Saturday, 9/1/18. LPN #1 talked with the Resident #5's sister and son (RP) about transferring the resident to . unit a year ago and they were okay. Resident #6's family comes in a lot and knows Resident #5 is the aggressor. LPN #1 stated s/he has fought moving Resident #6 because s/he feels it will be detrimental to the resident. Resident #6 is confused, but knows where his/her room is. LPN #1 stated Resident #5 has been in a private room for several months. When s/he had roommates before, s/he would be staring over them at 3 in the morning, stand and cuss at them. They would feel threatened and so the resident was put in a private room. LPN #1 stated s/he thinks they went through 3 residents before they put Resident #5 in a private room. LPN #1 stated s/he feels since . (unit) is an Alzheimer's unit, they would be able to work with Resident #5 better. They have activities in the open dayroom where s/he could participate. In an interview with the surveyor on 9/6/18 at approximately 3:15 PM, LPN #2, . Unit Manager, stated s/he has been at the facility since 2009 and . Unit Manager for 2 years. They have mostly wanderers and exit seekers on the unit, they can see all the doors with the layout of the unit. They have more resident's on their unit that have [MEDICAL CONDITION]. LPN #2 stated there are 6 empty beds on the . unit. They have one private room that is occupied. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August. They are trying to keep the residents away from each other. They spoke today and last week about room changes. The DON talked with Resident #6's family about a room change and they were worried about the resident falling. They have looked into changing Resident #5's. The resident will get set off if there is a loud noise. Family is very adamant they don't want Resident #6 moved. The DON stated they don't have another room they can put Resident #5 in. The DON stated the problem with roommates is the noise and roommates don't like being in the bathroom with a resident who makes a mess. He has been on every 15 minute checks since s/he came back from theER on Friday. Resident #5 was on 1:1 with the prior incident on 8/25/18 until the following Monday, there was no further incident. He was on 1:1 form 8/25/18-8/27/18. 1:1 is a nursing intervention and does not require a physician order. There is no documentation in the chart about assessing for 1:1. The ADON and unit manager decided to do the 15 minute checks when he came back from the hospital on [DATE]. Reviewed documentation from hospital to see if any psych done and confirmed there was none. The DON called the facility on Saturday and talked with the nurse to see if there was any further agitation. The DON had not been made aware of any increase in behaviors until the first part of August. The DON stated most of the behavior discussion they have had about Resident #5 have been about his/her toileting. The DON stated the Psych NP usually comes once a month and anyone who has had an incident will be on the list for the NP to see. The DON stated they assumed the reason Resident #5 was hitting things is because of noises. The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. The DON stated that someone at the meeting with Resident #6's family and the ombudsman today said they knew each other out in the community. The DON stated that today is the first s/he heard of them knowing each other before the facility. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. The facility provided a list of residents seen by the Geriatric psychiatry Nurse Practitioner in July and August 2018 to the surveyor on 9/7/18. Resident #5 was not on the list as being seen by the nurse practitioner. The list also contained the names of residents who were to be seen by the Geriatric psychiatry nurse practitioner the following week. The list was reviewed and the surveyor noted Resident #5's name was not on the list. Review of the facility's Documentation of Mood and Behavior Needs policy revealed nursing staff will document in accordance with facility guidelines. Suggested documentation guidelines included behaviors: describe behavior, when do they occur, what task was being attempted, who was around or involved. What happened immediately before the behavior, what happened after the behaviors? What are they? When do they occur? Was there an injury? Get a description of how injury occurs. What occurred? Where was the patient/resident? How are they addressed? How long do they last? Is a behavior-tracking tool utilized on the resident? What interventions are utilized? How long do the interventions last? On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0742 at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.",2020-09-01
2684,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-09-07,745,K,1,0,4EIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files 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 each resident. Resident #5 and Resident #6 were noted to have two physical altercations on separate occasions. There was no documentation in the resident's medical records related to the incidents by social services. 2 of 4 residents reviewed for resident to resident abuse. The findings included: Cross refer to F0[AGE]0 Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. Resident #5's Progress Notes were reviewed from 5/22/18 - 9/6/18 and revealed multiple incidents of behaviors. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week.Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August.The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. Resident #6 ' s [DIAGNOSES REDACTED]. Review of Resident #6's medical record revealed a Progress Note on 8/25/18 at 7:27 AM that indicated the resident's responsible party wanted to speak with Social Services on Monday. The responsible party was called to notify them about the incident on 8/25/18 with Resident #5. There was no documentation in the resident's medical record by Social Services on 8/25/18 or after. Resident #6's Progress Notes were reviewed 7/2/18-9/4/18. There were 2 notes documented by Social Services in July related to the resident's level of care. There were no other notes from Social Services. It was revealed during an interview with the surveyor on 9/6/18 at approximately 4:35 PM with the DON (Director of Nursing) that after Resident #5 started with behaviors towards Resident #6, Resident #6 started having behaviors. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Review of the facility's Abuse, Neglect, and Misappropriation of Property revealed the guidelines for investigation included Social Service will provide support services to the resident and implement an interdisciplinary care plan. Review of the facility's Dementia policy revealed staff will be adequately trained to provide necessary care and services that is person centered. Social services assess and identify resident specific needs and approaches during the initial assessment period and ongoing and needs are evident. On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0745 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.",2020-09-01
2685,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-09-07,835,K,1,0,4EIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files 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. Resident #5 and Resident #5 were noted to have 2 incidents of physical altercation. The facility failed to respond to those incidents to protect the residents from further incidents. The findings included: Resident #5 was reviewed for resident to resident abuse allegations. Resident #5's [DIAGNOSES REDACTED]. The resident was observed on initial tour of the facility on 9/4/18 at approximately 12:02 AM, Resident #5 was in his/her room in bed, with lights and radio on. The surveyor observed that Resident #5 and Resident #6 resided in rooms that were next to each other. Review of Resident #5's Progress Notes revealed on 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. Review of Resident #6's medical record revealed on 8/25/18 at 10:23 PM the Progress Note indicated there was a bruise to the resident's right upper arm purple in color. Resident voices no complaints when moving that extremity. Further review of Resident #5's Progress Notes revealed on [DATE] at 5:36 PM - resident was sitting in a chair in the hall and Resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON (Director of Nursing), physician, and RP (responsible party) notified and resident sent out to ER. Review of Resident #6's medical record revealed there was no documentation of the incident in the resident's Progress Notes. Review of Resident #5's SBAR Communication Form dated [DATE] revealed the change in condition was noted as physical aggression toward another resident. This started on 8/1/18 and had gotten worse. The resident struck another resident. Review of Resident #5's Nursing Home to Hospital Transfer Form dated [DATE] revealed the reason for transfer was noted as physical aggression. The Discharge Summary for Resident #5's hospital visit on [DATE] indicated the physician talked with the resident's son. Resident's son stated he had spoken to the nursing staff at the facility before, he thinks there may be one person, either staff member or even another resident that just seems to set the patient off as soon as s/he sees them. The son is going to speak with staff to determine if there is any better way to keep the patient's behaviors and dementia under control, specifically separating him/her from whichever person seems to agitate him/her. The Initial ER report indicated that according to nursing report who received telephone report from the nursing home, the resident's behavior has been going downhill for about 3 months. Friday afternoon the patient apparently attempted to hit a nurse and was sent to the emergency department for evaluation. Resident #5's Progress Notes were reviewed and the following noted: 5/22/18 at 4:24 AM - Resident tried to remove the television from off the wall once, the nurse turned it off so the resident could go to sleep. 6/5/18 at 6:29 AM - Resident had 2 BMs on the floor, both times he had it in his hands sitting on the tables in his room and squishing it between his fingers. Resident also tore bulletin board off wall and threw it across the room. No notification of MD or RP noted. 6/10/18 - MD Progress Note with no documentation related to resident's behaviors. 6/13/18 at 12:52 AM - Resident up in room smearing feces on floor and wall and in hands. Taken into bathroom and showered resident saying give me a hammer and I'll kill myself and if I could find a knife I'd cut myself. Resident having loose stools while given a shower. Another resident got up and started to enter his room and he started cussing and in a fighting stance going to hit the other resident, very aggressive behavior. No documentation of RP or MD notification. No MD note related to incident. 7/8/18 at 4:23 AM - resident becoming increased aggressive, was hitting bed with his/her belt cursing. Difficult to redirect in the beginning then s/he calmed down. Resident #5 also went into another resident's room and was going to hit him/her with a remote control. Staff stopped the resident in time and s/he was very quick to leave and go next door. 7/8/18 at 8:16 PM - MD note with no mention of behaviors. 7/10/18 at 4:31 PM - resident standing in his/her room with the bathroom door open and s/he is hitting the door. The nurse went to the door to talk to the resident and resident stated You better move, I'm going to kill. Resident continued to hit the bathroom door and the door is broken and will not close and the tissue roll is broken. Then the resident began slamming the closet door and continued to have increased behavior. 7/19/18 at 8:18 AM - resident having increased agitation. Resident saw another resident walking in hallway and got up from his/her chair. Resident #5 then began to attempt to raise his/her fist at other resident and stated I'm going to kill you! No contact made with other resident, staff able to redirect. Unit manager and DON made aware of increased agitation. MD notified of resident increased agitation and aggressive behavior. New order received for [MEDICATION NAME] 0.25 mg BID. 7/19/18 at 5:05 PM - resident sitting in hallway chair when s/he saw another resident and stood up and raised closed fist at other resident, stating get away from me! I'll hit you. 7/21/18 at 10:49 PM - resident noted to raise hand to hit female resident x 2 so far this shift. No contact was made, staff intervened. MD made aware with new order to d/c [MEDICATION NAME], increase [MEDICATION NAME] to TID. 7/26/18 at 11:29 PM - resident went into another resident's room and took his/her TV remote control. Then went into another resident's room and threw the remote at another resident but did not hit the resident. 8/9/18 at 6:06 PM - MD note that indicated stable clinically, continue medications. 8/10/18 at 1:53 AM - resident in chair beside nurses' station. Resident will become agitated when a certain resident comes near him/her and s/he starts cussing and say s/he will hit the resident. 8/12/18 at 2:44 PM - resident continues to try to hit resident #6. 8/13/18 at 10:26 PM - Resident #6 was in view of Resident #5, Resident #5 states I'm going to kill her. 8/14/18 at 6:31 AM - resident noted to enter a female resident's room and knock her pencils over on her while she was in bed. Resident #5 was standing over female resident cursing when the nurse entered the room. MD called and made aware, no changes at this time. There was no physician note that referenced the incident. 8/15/18 at 12:45 AM - resident gets agitated when s/he sees resident #6. Resident #5 tries to hit this resident but staff intervenes. 8/15/18 at 5:52 AM - resident #6 up walking in hallway and passing by resident #5. Resident #5 tried to hit resident #6 requiring staff to hold him/her while resident #6 passes by. 8/16/18 at 1:40 AM - resident noted cussing at resident #6 as s/he was walking up hallway. Resident also noted to pull back his/her arm as to try and hit Resident #6 but staff intervened and stopped attempt. 8/16/18 at 5:52 PM - resident continue to wander in and out of other resident's room and to other unit. Resident #5 continue to want to fight resident in room next door, s/he make statement that s/he is going to slap him/her. 8/17/18 at 6:00 AM - resident became upset when s/he saw the resident from the room next door in the hallway and staff head to intervene when resident #5 acted like s/he was going to hit the resident by drawing his/her arm back. 8/21/18 at 11:44 AM - resident ripped paper towel dispenser off wall in bathroom. Maintenance notified. Resident had bowel movement in corner of closet and also threw feces on air-conditioning. 8/24/18 at 1:15 PM - Called to another resident's room, resident #5 in room plundering through drawers, urinated in floor and doorway. 8/25/18 at 7:01 AM - At 5:30 AM this morning, resident walked out of his/her room, saw a female resident (#6) standing down the hall with his/her walker. Resident #5 walked towards him/her, grabbed his/her right upper arm and pinched him/her. There were no words spoken between the two residents to provoke Resident #5 to want to harm him/her. Called and spoke with facility Social Services Director. Incident was reported to him/her. 8/25/18 at 8:23 AM - Physician notified of resident's behavior. Grabbing and pinching female resident (#6). New order noted to increase [MEDICATION NAME] to 1.5 mg TID due to residents aggressiveness. 8/25/18 at 11:25 AM - DON notified of incident this morning concerning resident. Informed resident placed on 15 minute checks. DON stated Place him on 1:1 supervision along with the 15 minute checks. 8/26/18 at 6:11 PM - resident 1:1 due to his/her increased behavior. Resident has become very aggressive with staff and cussing at staff. S/he is very hard to redirect. S/he continues to go in and out of other resident room. 8/27/18 at 1:24 PM - Resident has been 1:1 since Saturday 8/25/18. Per staff nurse today, staffing coordinator called and stated 1:1 to be stopped if not further incidence. 8/30/18 at 7:54 AM - report from CNA (Certified Nursing Aide) stating that yesterday afternoon, resident went into a resident's room on . unit and defecated in the floor. Resident # 5 noted to reside on another unit. [DATE] at 5:36 PM - resident was sitting in a chair in the hall and resident #6 was passing by him/her. Resident #5 hit Resident #6 on his/her left lower arm and stated I'll kill you. DON, MD and RP notified and resident sent out to ER. [DATE] at 8:24 PM - resident back in facility from hospital, reported to another nurse by resident's son that as resident was entering the facility, another resident approached the resident asking why s/he doesn't like him/her. 9/1/18 at 2:07 AM - resident noted to be checked on every 15 minutes for safety. 9/2/18 at 5:36 AM - Resident up wandering earlier and went into another resident's room 9/2/18 at 5:56 PM - Resident walked down to dining room and grabbed a walker, s/he began to throw it. Staff had to redirect him/her back to his/her room. S/he then went back to his/her room and began to shake bathroom door. 9/4/18 at 7:14 PM- Resident continues to wander in and out of other residents room 9/6/18 at 10:56 AM indicated 8/26/18 resident went into another resident room and stated get out of my dam bed. Resident was redirected by staff and continues to cuss at the other resident while leaving the room. 9/6/18 at 6:14 PM - wandering around unit and to (another) unit as usual this shift. To dining room at times. Attempted to go into other rooms off/on. Urinated in floor in own room. 1:1 initiated. 9/6/18 at 6:36 PM - phone call to MD to increase [MEDICATION NAME] back to 1.5 mg. Called resident contact and discussed medication change with him/her. Stated to the nurse that his/her brother is having an issue with another resident and s/he stated that this resident looks identical to a woman that s/he has had a lot of problems with in years past. S/he states that this other woman has been to this facility with a family member to visit other residents and has attempted to speak to her/him. S/he states that s/he gets very upset when s/he sees him/her and that this other resident must remind her/him of that other woman. 9/6/18 at 6:40 PM - physician note that indicated MD addendum - resident has been seen and discussed with staff several times. Already on therapeutic approach with medications for her/his unpredictable combativeness/behavior issue mainly due to dementia related. 9/6/18 at 8:25 PM - note by the DON indicates this nurse spoke to the medical director regarding recently identified behavioral issues. Medical Director gave order to discontinue [MEDICATION NAME]. New order received to send to MUSC for psychiatric evaluation. Medical Director to be contacted upon resident return and recommendations reviewed. MDS: Quarterly 8/17/18 - ST and LT memory problem with severely impaired cognitive skills for daily decision making Care Plan: Review of the resident's care plan revealed resident at risk for adverse consequences related to receiving antipsychotic medication with a problem start date of 7/19/18. Review of resident's care plan revealed behavioral symptoms, resident was observed wandering into other resident's room(s). The wandering is related to a dementia [DIAGNOSES REDACTED]. The evaluation note on 8/18/18 indicated the resident has begun to wander more frequently lately. Review of resident's care plan revealed behavioral symptoms, resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) with a problem start date of 4/23/18. The evaluation note on 8/18/18 indicated the resident curses and strikes out at staff and others at times. On [MEDICATION NAME] for restlessness and agitation. Social services and psych referrals as needed. Review of the resident's care plan revealed psychosocial well-being, resident expresses sadness as evident by the following statement I don't want to live anymore with a problem start dated of 2/20/18. Approaches included staff will make referral psychiatric nurse practitioner. Evaluation notes on 5/18/18 indicated resident is very confused and gets agitated at the TV, furniture, etc., and history of roommate issues. Social services and psych referrals as needed. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., excessive and/or continually urinating and/or defecating in her/his room trashcan and/or in the A/C unit in her/his room, smearing bodily wastes on the wall(s), etc.) S/He fusses at the TV and becomes agitated and aggressive at times with a problem start dated of 12/1/17. Review of the resident's care plan revealed behavioral symptoms, resident has behavioral symptoms not directed to others (e.g., throwing or smearing food or bodily wastes on walls/floor, etc.) with a problem start date of 2/6/17. The evaluation note on 5/18/18 indicated resident defecates and urinates in inappropriate places at times, pulls drawers out of furniture and curses at TV. Psych and social services referrals as needed. Issue with roommates and was moved to private room. Review of the care plan revealed there was no care plan for the resident's physical behavior with Resident #6, neither incident was documented on the care plan. Review of resident's Progress Notes from 5/2/18-9/7/18 revealed there were no Progress Notes documented by Social Services. The surveyor requested Social Service documentation for the resident and was provided with a Social Service review completed 8/21/18. Behavior indicators were noted as wandering, verbally abusive, and physically abusive. Resident will cuss and yell at other residents, making threatening statements, wanders in/out of other residents' rooms. There was no additional documentation by Social Services. In an interview with the surveyor on 9/6/18 at approximately 12:15 PM, CNA #1 stated s/he has been at the facility 6 years. CNA #1 stated Resident #5 has been at the facility 2 years. CNA #1 has been working with the resident since s/he was admitted . CNA #1 stated Resident #5 is losing his/her focus and vision. CNA #1 stated the resident is going down fast. When the resident came in, s/he was alert and would hold conversation. Now the resident is not alert and can't have conversation. Resident #5 did not have behaviors when they were admitted to the facility. CNA #1 stated they have 6 sections and they rotate resident assignments every day. CNA #1 stated they have been rotating assignments for about a month. CNA #1 stated before Resident #5 would have little behaviors, the resident would relax if approached her/him calmly. Resident #5 would have tantrums, knock stuff off the table. Resident #5 would get in a rage, you would have to wait for him/her to calm down. Resident #5 has had a big change in the last 6 months and his/her behaviors have really increased. Resident #5 has knocked a paper towel dispenser off the wall, and the television. CNA #1 stated s/he just learned the resident is going in other resident rooms. Resident #5 is touching things and s/he has used the bathroom in another resident's room floor. Resident #5 hits at the mirror on the wall, they took the mirror off the wall. Resident #5's outburst will come out of nowhere and have been getting worse over the last 6 months. They put up the gadget board a few weeks ago but the resident doesn't do anything with hit. CNA #1 stated Resident #6 reminds Resident #5 of someone s/he knew when s/he was younger. Resident #5's sister told CNA #1 that. Resident #6 will come stand in between people when they are trying to talk and start talking. Resident #5 gets agitated because Resident #6 is repetitive, s/he will keep asking how you are doing. The facility does behavior training on the computer yearly. CNA #1 stated they complete training on the computer, and no one talks to them about the dealing with resident behaviors/dementia. In an interview with the surveyor on 9/6/18 at approximately 12:45 PM, Unit Manager LPN (Licensed Practical Nurse) #1 stated Resident #5 liked to piddle, take things apart. They could not keep an alarm on him/her because s/he would take it apart. LPN stated s/he has seen Resident #5 decline, s/he has early onset [MEDICAL CONDITION] with behaviors, history of alcohol and drugs. The decline has been gradual over the past year. It was a year ago when LPN #1 started trying to get Resident #5 on the . unit (a separate building). The . unit has more residents with Alzheimer's and behaviors, but the resident has not gone back there. It has been knocked down every time s/he brings it up. One reason was because s/he was defecating on the floors, ac units, urinating in other residents' rooms. That behavior started a year ago. It was bothering other residents on . (unit) that the resident was doing that in their rooms. LPN #1 brought it up to the DON in clinical morning meeting. The response was they were not going to transfer him/her back there because the residents back there might play in his/her feces. LPN #1 stated s/he brings up moving the resident almost monthly, if not more. As Resident #5 has gotten worse, s/he has tried to push it. One response has been that it would be too much stimulation. LPN #1 stated it is always one of those 2 responses when s/he brings up moving the resident to the . unit. The . unit is a locked unit with the day room in front of the nurses' stations. LPN #1 feels Resident #5 could benefit from that environment. Right now s/he just sits beside their nurses' station most of the day and does not get that stimulation. LPN #1 stated . (unit) is considered an Alzheimer's unit. The DON usually decides who to send to the . unit. Since June, Resident #5's behaviors have increased. The resident no longer has a TV in his/her room because s/he ripped it off the wall. S/he ripped the paper towel holder off the wall in his/her bathroom, they had to take the mirror out the bathroom because s/he was going to punch it. Resident #5 tried to take the bathroom door down and broke the metal door frame. Resident #5's vision has gotten worse, s/he thought someone else was there and was going to punch them and that is why they took the mirror down. Resident #5 will go to other residents' rooms on both . (unit) and . (another) unit. Resident #5 will defecate on the floor, go through their things, and rummage through their room. The resident has thrown a box of colored pencils on a resident lying in bed. They put a stop sign on the door to one room for him/her to not enter, that did not deter the resident for long. Resident #5 just took it down and went in. LPN #1 stated s/he does not understand why Resident #5 goes after Resident #6 aggressively, that is the only resident s/he is aggressive with. Resident #5 will cuss at him/her when s/he is walking down the hall, says s/he is going to kill him/her, calls him/her names. When Resident #5 struck Resident #6 on Friday ([DATE]), the resident told Resident #6 s/he was going to kill him/her. Resident #5 will try to get to Resident #6, s/he will get up and chase the resident down the hall. Staff will intervene, they are almost always there and are [MEDICAL CONDITION]. All the staff on the unit are aware of the behavior. Resident #5 is on 15 minute checks since the incident on Friday [DATE]. The weekend before when s/he grabbed Resident #6's arm and left a bruise s/he was put on 1:1 until Monday morning. The incident occurred on 8/25/18, Saturday. Resident #5 came off 1:1 because the DON discontinued it because there were no further behaviors. LPN #1 stated the problem with Resident #6 exacerbated the first part of August, and that is when the documented aggression started toward him/her. Resident #5's sister told one of the nurses' that s/he and Resident #6 knew each other in the community. Resident #5 was sent out to the hospital on [DATE] after striking Resident #6. The DON said s/he wanted the resident sent out and LPN #1 got the order from the physician. The ER physician summary indicated that the facility had sent 2 residents around the same time, they did not have any findings. LPN #1 reported to the hospital s/he had been aggressive with another resident. LPN #1 stated the resident is not seen by psych. They have a psych NP (Nurse Practitioner) that comes once a month, or once every other month. The resident has a busy board in his/her room, installed in July. They wanted to try to give him/her more activities to do, s/he does not use the board. The administrator and DON made the decision to put the board in place. Other than removing things from the resident's room, there have not been any interventions put in place. The sister told the facility about the resident's previously knowing each other this past Saturday, 9/1/18. LPN #1 talked with the Resident #5's sister and son (RP) about transferring the resident to . unit a year ago and they were okay. Resident #6's family comes in a lot and knows Resident #5 is the aggressor. LPN #1 stated s/he has fought moving Resident #6 because s/he feels it will be detrimental to the resident. Resident #6 is confused, but knows where his/her room is. LPN #1 stated Resident #5 has been in a private room for several months. When s/he had roommates before, s/he would be staring over them at 3 in the morning, stand and cuss at them. They would feel threatened and so the resident was put in a private room. LPN #1 stated s/he thinks they went through 3 residents before they put Resident #5 in a private room. LPN #1 stated s/he feels since . (unit) is an Alzheimer's unit, they would be able to work with Resident #5 better. They have activities in the open dayroom where s/he could participate. In an interview with the surveyor on 9/6/18 at approximately 3:15 PM, LPN #2, . Unit Manager, stated s/he has been at the facility since 2009 and . Unit Manager for 2 years. They have mostly wanderers and exit seekers on the unit, they can see all the doors with the layout of the unit. They have more resident's on their unit that have [MEDICAL CONDITION]. LPN #2 stated there are 6 empty beds on the . unit. They have one private room that is occupied. In an interview with the surveyor on 9/6/18 at approximately 4:05 PM, the administrator stated the Social Services director was part of an investigation and is out on suspension related to the investigation. In an interview with the surveyor on 9/6/18 at approximately 4:35 PM, the DON (Director of Nursing) stated Resident #5 has Alzheimer's dementia and they have tried several different approaches. The DON stated s/he is looking at Resident #5's chart and Resident #6's chart to see a trend. The DON stated s/he knew they had an incident last week. The DON stated Resident #6's wandering has increased since mid-August. Since mid-August Resident #6 has had problems sleeping. The physician ordered [MEDICATION NAME] on 8/22/18, it helped some and now the resident is back up in the middle of the night. Resident #5 has been wandering into the doorway of Resident #6's room and yelling get up in the wee hours of the morning. The first episode of Resident #6 going to Resident #5's room is August 13th. Since 8/25/18 there has been an increase in Resident #6 going to Resident #5's room. Resident #5 would go after Resident #6 if s/he came up close to him/her, that started the first of August. They are trying to keep the residents away from each other. They spoke today and last week about room changes. The DON talked with Resident #6's family about a room change and they were worried about the resident falling. They have looked into changing Resident #5's. The resident will get set off if there is a loud noise. Family is very adamant they don't want Resident #6 moved. The DON stated they don't have another room they can put Resident #5 in. The DON stated the problem with roommates is the noise and roommates don't like being in the bathroom with a resident who makes a mess. He has been on every 15 minute checks since s/he came back from theER on Friday. Resident #5 was on 1:1 with the prior incident on 8/25/18 until the following Monday, there was no further incident. He was on 1:1 form 8/25/18-8/27/18. 1:1 is a nursing intervention and does not require a physician order. There is no documentation in the chart about assessing for 1:1. The ADON and unit manager decided to do the 15 minute checks when he came back from the hospital on [DATE]. Reviewed documentation from hospital to see if any psych done and confirmed there was none. The DON called the facility on Saturday and talked with the nurse to see if there was any further agitation. The DON had not been made aware of any increase in behaviors until the first part of August. The DON stated most of the behavior discussion they have had about Resident #5 have been about his/her toileting. The DON stated the Psych NP usually comes once a month and anyone who has had an incident will be on the list for the NP to see. The DON stated they assumed the reason Resident #5 was hitting things is because of noises. The DON stated care plans should be updated with approaches. Social services updates the care plan for interventions and incidents. The DON stated that someone at the meeting with Resident #6's family and the ombudsman today said they knew each other out in the community. The DON stated that today is the first s/he heard of them knowing each other before the facility. In an interview with the surveyor on 9/7/18 at approximately 9:20 AM, the ADON (Assistant Director of Nursing) stated Resident #5 has not been seen by psych at the facility. In an interview with the surveyor on 9/7/18 at approximately 9:40 AM, the administrator stated that they have been monitoring and are aware of the situation between Resident #5 and Resident #6, they have not documented any of what they have talked about or done. They moved Resident #6 to a private room, which was next to Resident #6. The administrator reviewed Resident #5's Progress Notes last night and noticed that there were no social service notes in the resident's medical record. On September 6, 2018 at approximately 6:00 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F0[AGE]5 at a scope and severity of K. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on July 19, 2018.",2020-09-01
2686,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2018-09-07,842,E,1,0,4EIF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to maintain accurate and/or complete medical records for 2 of 3 records reviewed for neglect. Resident #1 and #2's medical record had conflicting or incomplete information. The findings included: Cross refer to F6[AGE] Quality of care The facility admitted resident #2 on 8/22/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident had a Baseline Care Plan: New admission admitted from hospital with pneumonia. Further review of the medical record revealed Progress Notes (Nurses Notes). On 8/24/18: 2:03 AM Resident up in w/c (wheelchair), took meds whole without difficulties. Resident was trying to get out of wheelchair at time of medication pass, was advised to stay in chair or if s/he wanted to get in bed. Resident stated not ready to go to bed. Nurse went into hallway to get roommates medication and resident fell out of w/c. Assisted by nurse and CNA (Certified Nursing Assistant) back into chair and then into bed. Neuro checks initiated. 03:15, neuro check was performed, vital signs were stable. Resident attempted to pull arm away as this nurse placed blood pressure cuff on wrist. VS (Vital Sign) stable. 3:45 AM, nurse went to answer call light of roommate and found resident unresponsive, ashen in color, pupils fixed, eyes moving left to right involuntarily, frothy sputum from mouth, VS stable, BS (Blood Sugar) -82. MD (Medical Doctor) called without success, DON (Director of Nursing) called and nurse was advised to get order from MD to send out. Doctor was reached and order received to send resident to ER (emergency room ). Resident sent to ER for eval (evaluation). There was no documentation the resident had been assessed for injury following the resident's fall. There was no documentation of the actual fall or what position the resident was found in from the fall. No documentation was available in the medical record of any safety interventions that were put into place to prevent further fall. No times were documented as to what time the physician or the Director of Nursing was initially called or when the physician was actually contacted. No documentation was available as to when the resident was transferred out to the hospital. Review of the facility's Incident/Accident Report of the fall had the resident [DIAGNOSES REDACTED]. The baseline care plan did not speak to the resident's amputations, although it spoke to risk of falls. The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed on 8/15/18: At approximately 0105, resident was found on the floor beside his/her bed, lying on his left side, head on the floor, left arm under his/her body. RD (resident) was assisted off the floor and back into bed. Resident complained of pain in the left rib cage area, lethargic, and hard to arouse. Attempts made to contact physician. Assistant Director of Nursimg (ADON) called. Resident was sent out to emergency room for evaluation. On 8/15/18 at 6:44 PM. Resident in bed and easily awakens. Meds crushed in applesauce. Bed is in low position. No attempts noted per staff with trying to get out of bed per him/herself. There was no documentation of when the resident returned from the emergency room . There was no evidence the resident was assessed upon return or what the emergency room findings were. The medical record did not have the family notification documented.",2020-09-01
2687,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,578,D,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident the right to formulate an advanced directive for 1 of 3 sampled residents reviewed for advanced directives. Resident #82 was not certified as incompetent to consent by two physicians prior to resident representative signing for resident's code status, as per the South [NAME]ina Adult Consent Law. Upon review of the South [NAME]ina Adult Consent law, it states, A patients' inability to consent must be certified by two licensed physicians, each of whom has examined the patient. The findings included: Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Surveyor attempted to interview Resident #82 on 9/17/19 at 2:40 PM. Upon greeting Resident #82, Resident #82 rambled incoherently. When surveyor asked questions, Resident #82's answers were inappropriate. Record Review on 9/18/19 at 11:30 am showed that Resident #82 was a full code. Advanced directive was signed by spouse as the resident representative. Record review revealed one psychiatric evaluation indicating that resident has dementia along with [MEDICAL CONDITION], anxiety, confusion, paranoia, and delusions with noted cognitive impairment; however, no physician certifications were found to certify that the resident was deemed incapable of making healthcare decisions. An interview was conducted with facility consultant on 9/18/19 at 3:18 PM to request further documentation on Resident #82's certification of inability for consent for advanced directive. Facility consultant stated, S/he was never certified as incapable of making healthcare decisions. On 9/19/19 at 8:30 am, surveyor noted that facility consultant brought in a physician certification into conference room prior to survey team arrival. The certification of inability to consent for Resident #82 that was dated 9/19/19 stated that Resident #82 would not be able to provide informed consent due to his/her cognitive inability. This certification was dated after the original request from surveyor for certification. Only one certification was provided. Two physician certifications to certify the patient's inability to consent were not provided by the facility, as per the South [NAME]ina Adult Consent Law.",2020-09-01
2688,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,640,B,0,1,TX1R11,"Based on record review and interview, the facility failed to ensure the timely transmission of Comprehensive Assessments for 2 of 2 Resident Assessments listed on facility reports. The findings included: Record review of the Missing OBRA Assessment report revealed Resident #1's comprehensive Minimum Data Set (MDS) assessment with a target date of 4/13/19 and Resident #2's comprehensive MDS assessment with a target date of 4/11/19 were not submitted. In an interview on 09/16/19 at approximately 12:30 PM, the MDS Coordinator reviewed the Missing OBRA Assessment report and stated s/he researched the submissions but could not provide a reason as to why the reports were not transmitted timely but would re-attempt.",2020-09-01
2689,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,645,D,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer a resident to an appropriate mental health entity for further evaluation after admitting the resident to the facility with a positive Pre-Admission Screening and Resident Review (PASARR) evaluation level I for 1 of 1 residents reviewed for PASARR (Resident #68). The findings included: The facility admitted Resident #68 on 7/25/19 with [DIAGNOSES REDACTED]. The resident's medical record reviewed on 9/18/19 at 10:42 AM revealed that a PASARR level I was reviewed on 6/6/19. The resident stated s/he thought s/he had been hospitalized for [REDACTED]. The evaluating physician recommended further evaluation based on mental illness indicators. The physician's orders [REDACTED].#68 related to [MEDICAL CONDITION] with Mania. The resident care plan reviewed on 9/18/19 at 1:00 PM stated that Resident #68 had a history of [REDACTED]. Resident #68 was also care planned for tending to fabricate and was put on the Buddy System for that reason. Interview with the clinical consultant on 9/18/19 at 2:45 PM revealed the facility had not yet referred Resident #68 for a PASARR level II or a psychiatry evaluation.",2020-09-01
2690,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,677,D,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide the necessary services to maintain proper grooming and personal hygiene. Resident #68 was not provided adequate personal care for 1 of 3 residents reviewed for activities of daily living. The findings included: The facility admitted Resident #68 on 7/25/19 with [DIAGNOSES REDACTED]. On 9/16/19 at 12:35 PM, Resident #68 was observed in his/her wheelchair in his/her room. S/he had long, greasy, and unkempt hair, facial hair, and long dirty fingernails. The care plan reviewed on 9/17/19 at 2:00 PM revealed that Resident #68 had limited ability to maintain grooming and personal hygiene due to left [MEDICAL CONDITION] after s/he suffered a stroke. The resident was observed on 9/19/19 at 2:14 PM in the same condition with long, greasy, and unkempt hair, facial hair, and long dirty fingernails. In an interview with the Director of Nursing on 9/19/19 at 4:23 PM, s/he stated that the facility did not track care of hair, nails, and facial hair.",2020-09-01
2691,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,684,D,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, staff failed to complete neurological checks as required following falls for Residents #74 and #122 (2 of 5 sampled residents reviewed for accidents). The findings included: The facility admitted Resident #74 with [DIAGNOSES REDACTED]. Record review on 09/18/19 at approximately 8:34 AM revealed an incident report dated 07/30/19 stating Resident #74 was found on the floor. After assisting the resident back into bed, vitals were taken and neurological checks were begun. Subsequent review of the sheet entitled Neurological (neuro) Evaluation Flow Sheet revealed nursing staff did not conduct the checks as evidenced by blanks on the sheet. In an interview on 09/18/19 at approximately 10:25 AM the Director of Nursing (DON) reviewed the Neurological (neuro) Evaluation Flow Sheet and confirmed that it was not complete. The facility admitted Resident #122 with [DIAGNOSES REDACTED]. Record review on 09/18/19 at approximately 3:37 PM revealed Resident #122 sustained an unwitnessed fall on 07/05/19 and neuro checks were initiated by facility staff. The neuro check flow sheet was incomplete. In an interview on 09/18/19 at approximately 3:42 PM the DON confirmed the neuro checks for Resident #122 were not completed as per policy. Review of facility policy entitled Neurological (Neuro) Checks revealed #1. Neurological checks are to be performed following any type of actual or suspected head injury or change in level of consciousness per physician ordered frequency OR: [NAME] Initially, then B. Every 15 minutes for 1 hour, then C. Every 30 minutes for 2 hours, then D. Every 1 hour for 2 hours, then E. Every shift for 72 hours. Also, 3. Documentation is completed on the Neurological Evaluation Flow Sheet, via the Glasgow Coma Scale. Follow directions on the form and reference for accurate scoring. Review of facility policy entitled Fall Management revealed #6. Any unwitnessed fall will have neuro checks completed per policy regardless of the resident's cognitive status at the time of the incident.",2020-09-01
2692,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,690,D,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of the facility policy titled Catheter-Urinary Catheter, Cleaning and Maintenance, the facility failed to provide appropriate catheter care for 1 of 1 reviewed for catheter care (Resident #112). During catheter care, the labia was not maintained in an open position. The findings included: The facility admitted Resident #112 with [DIAGNOSES REDACTED]. Record review on 9/18/19 at 12:17 PM revealed Resident #112 had a urinary catheter. Review of the care plan dated 8/5/19 revealed an approach listed was to perform catheter care every shift and as needed. Observation of catheter care on 9/19/19 at approximately 10:30 AM revealed Certified Nursing Assistant (CNA) #1 released the labia and did not maintain the position of his/her hand during the catheter care. During an interview with CNA #1 on 9/19/19 at 3:10 PM, s/he confirmed the labia was released during the catheter care. Review of the facility policy titled Catheter-Urinary Catheter, Cleaning and Maintenance revealed under the procedure section the following: 9. With non-dominant hand: [NAME] Female: Gently retract labia to fully expose urethral meatus and catheter insertion site. Maintain position of hand throughout procedure.",2020-09-01
2693,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,695,D,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure all emergency items were in the resident's room related to [MEDICAL CONDITION] (trach) care. In addition, the humidifier bottle was observed empty and the humidity setting was incorrect for 1 of 1 resident with a [MEDICAL CONDITION] (Resident #90). The findings included: The facility admitted Resident #90 with [DIAGNOSES REDACTED]. Record review on 9/18/19 at 11:15 AM revealed a current physician's orders [REDACTED].#4 Shiley. Review of Resident #90's care plan listed under the approach section to administer oxygen as MD (Doctor of Medicine) ordered; observe oxygen precautions; humidified air as MD ordered; spare Shiley disposable #4 to be kept in room as spare and easy access. Observation of Resident #90 on 9/16/19 at 12:29 PM revealed the humidifier bottle was empty and dated 9/7/19, no replacement #[MEDICAL CONDITION] was observed, and the oxygen setting was 8 liters at 28% humidity. Observation on 9/18/19 revealed the humidification was at 35% as ordered. During an interview with Registered Nurse #4 on 9/16/19, s/he confirmed there was no #4 [MEDICAL CONDITION] the resident's room and the humidifier bottle was empty.",2020-09-01
2694,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,732,C,0,1,TX1R11,"Based on observation and interview, the facility failed to follow Nurse Staffing Posting requirements. On all days of the survey, the resident census was not documented on the posting. In addition, all three shifts were completed at the beginning of the day. The findings included: On all days of the survey, the resident census was not documented on the posting. In addition, all staffing was documented at the beginning of the day instead of at the beginning of each shift. During an interview with the Director of Nursing on 9/19/19 at 5:00 PM, s/he confirmed there was no census documented and the form was completed for all shifts with nursing/certified nursing assistant information.",2020-09-01
2695,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,758,D,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure end dates for PRN (as needed) [MEDICAL CONDITION] medications and documentation of non-pharmacological interventions for [MEDICAL CONDITION] medications for 2 of 7 residents reviewed for unnecessary medications. Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #111 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The findings included: On 9/1719 at approximately 8:31 PM during medication pass reconciliation for Resident #135 on 9/17/19 a random observation revealed an order for [REDACTED]. Further review of the MARs (medication administration records) from (MONTH) 2019 through (MONTH) 2019 revealed that no doses had been administered for March, April, May, June, (MONTH) and August, but five doses had been administered in (MONTH) on (MONTH) 8, 10, 11, 12, and 14. Of these five doses, non-pharmacological interventions were not documented on (MONTH) 8, 12, and 14. On 9/18/19 at approximately 10:25 AM, a review of the facility's Pharmacy Services P&P (policy and procedure) for [MEDICAL CONDITION] Drugs Section 6, Subject 6.6 provided revealed the following: 2. D. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days. Except as provided in 483.45 (e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the residents medical record and indicate the duration for the PRN order. On 09/18/19 at approximately 10:41 AM this finding was confirmed by the Director of Nursing (DON) as not having been reordered within 14 days by the physician and that non-pharmacological interventions were not being documented according to the P&P for [MEDICAL CONDITION] Drugs. On 9/18/19 at approximately 11:04 AM a medical record review for Resident #111 revealed two orders for [MEDICATION NAME] ([MEDICATION NAME]). The first order for [MEDICATION NAME] 0.5 mg (milligrams) bid (two times daily) PRN for restlessness and agitation was written 8/14/19 and discontinued on 9/5/19 for a total of 23 days. The second order for [MEDICATION NAME] 1 mg bid prn for restlessness and agitation written on 9/5/19 was open ended with no stop date and was in effect on 9/19/19 for a total of 15 days. Further review of the MARs for (MONTH) 2019 and (MONTH) 2019 failed to show that non-pharmacological interventions were being documented prior to administering prn doses of [MEDICATION NAME]. On 9/18/19 at approximately 11:59 AM this finding was confirmed by the DON as not having been reordered with 14 days by the physician and that non-pharmacological interventions were not being documented according the P&P for [MEDICAL CONDITION] Drugs.",2020-09-01
2696,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,761,E,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to properly store drugs in 1 of 3 med rooms and 2 of 9 med carts. Medications were stored at the wrong temperature and sterile products were not being discarded after use. The findings included: On 9/16/19 at approximately 12:20 PM inspection of the [MEDICATION NAME] Wing Medication Room revealed one unopened 2 ml (milliliter) bottle [MEDICATION NAME] Ophthalmic Sulfate 1 % (percent) by Akorn in the refrigerator belonging to Resident # 4. The manufacturer label stated Store 68-77 degrees F (Fahrenheit) and the refrigerator temperature was 44 degrees F. On 9/16/19 at approximately 12:25 PM this finding was verified by Registered Nurse # 1 who stated that even though the medication was not being used, it should not have been stored in the refrigerator. On 9/17/19 at approximately 11:06 AM inspection of the Magnolia Treatment Cart revealed one opened bottle of Sterile 0.9 % Normal Saline, USP (United States Pharmacopoeia) 250 ml by Medline, dated by the facility as opened 9/1/19. The manufacturer label states Contents sterile unless container is opened or damaged. On 9/17/19 at approximately 11:11 AM, LPN (Licensed Practical Nurse) # 1 verified the manufacturer labeling and acknowledged that the bottle had been opened, dated and stored in the treatment cart. On 9/17/19 at approximately 11:19 AM inspection of the [MEDICATION NAME] Treatment Cart revealed one opened container of TheraHoney Gel 1.5 oz. (ounce) by Medline dated by facility as opened 11/1/18 and labeled by the manufacturer Sterile and Single Use Only. On 9/17/19 at approximately 11:23 AM, LPN # 2 verified the manufacturer labeling and that it had been opened, dated and placed in the treatment cart.",2020-09-01
2697,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,777,D,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to promptly notify the physician of abnormal lab results for 1 of 3 residents reviewed for infection. Resident #121's lab results were verified positive for extended-spectrum B-lactamase (ESBL) on 9/14/19 and were not received, reviewed, or addressed by the physician until 9/16/19. The findings included: The facility admitted resident #121 on 5/20/19 with [DIAGNOSES REDACTED]. During the initial tour of the facility on 9/16/19 at approximately 11:45 AM, observation revealed that Resident #121 had isolation precaution equipment in front of his/her room. In an interview with Registered Nurse #2 on 9/16/19 at approximately at 2:00 PM, s/he stated that Resident #121 was put on isolation precautions the morning of 9/16/19 related to a urinary tract infection. Record review of labs on 9/17/19 at approximately 9:45 AM revealed that Resident #121 had urine collected on 9/11/19 for a urinalysis and urine culture. The urinalysis result was received by the facility on the same day. The urine culture result was obtained and reviewed by the physician two days after the result was verified. The urine culture was verified on 9/14/19, but the doctor received and reviewed it on 9/16/19. In an interview with the unit manager on 9/19/19 at 4:07 PM, s/he confirmed that the abnormal lab result was not provided to the physician on 9/14/19, which delayed treatment.",2020-09-01
2698,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,812,F,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure kitchen dishware was dried and stored according to standard practice. In addition, the facility was unable to maintain the kitchen and its equipment clean and free from insects. Also, the facility failed to ensure all food items were labeled and dated appropriately, and that expired foods were removed from use in 1 of 1 kitchen reviewed. The findings included: On [DATE] at 10:41 AM, the kitchen observation, conducted with the dietary manager present, revealed the following: There were eight large and two medium stainless steel wet nesting pans. Grease build-up was on and around the stove. The food processor was not thoroughly cleaned. French toast and seasoning was observed strewn on the kitchen countertops. Trash was observed on the kitchen floor. Three houseflies were hovering over the cooked food. Food was splattered on the microwave. Also, a dietary staff was wearing a stained, long sleeve [NAME]et that covered most parts of his/her hands. The surveyor noticed two bags of chicken in a freezer and four small stainless steel small pans containing a variety of cooked meats in a refrigerator unlabeled and undated. The entire emergency water supply (3 gallons per day for residents and staff) was expired. Apple juice was opened and stored at room temperature instead of refrigerated after opening per labeling. On [DATE] at 3:43 PM, observation of the [MEDICATION NAME] nutrition room revealed an unlabeled drink was observed in the refrigerator. In addition, the microwave was observed with food splatters. At the time of the observation, Licensed Practical Nurse #3 confirmed the findings.",2020-09-01
2699,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2019-09-19,880,E,0,1,TX1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow appropriate infection control practices. Wound care items were placed on the bedside table prior to placing them on a barrier for 1 of 3 observed for pressure ulcer care (Resident #127). A basket of respiratory supplies was observed directly on the floor for 1 of 1 reviewed for [MEDICAL CONDITION] care (Resident #90). After providing catheter care, a staff member was observed to touch items with a soiled gloved hand for 1 of 1 reviewed for catheter (Resident #112). A staff member was observed to pick up a television remote from the floor and place it on the over the bed table for Resident #112 who was on precautions (1 of 1 reviewed for catheter care). The findings included: The facility admitted Resident #127 with [DIAGNOSES REDACTED]. On 9/18/19 at 3:20 PM, Registered Nurse (RN) #3 was observed to place packaged wound care items on the bedside table prior to placing them on a barrier on the over the bed table. During an interview with RN #3 on 9/19/19 at 2:45 PM, s/he confirmed it was not best practice to place wound care items on the bedside table. The facility admitted Resident #90 with [DIAGNOSES REDACTED]. Observation on 9/16/19 at approximately 12:29 PM of Resident #90's room revealed a basket of respiratory supplies sitting directly on the floor. On 9/16/19 after the observation, RN #4 confirmed the basket was sitting on the floor of the room. The facility admitted Resident #112 with [DIAGNOSES REDACTED]. Record review on 9/18/19 at 12:17 PM revealed Resident #112 was on contact precautions due to Extended Spectrum Beta-Lactamase in the urine. After pressure ulcer care on 9/18/19 at 11:25 AM, RN #3 reached down and picked up a remote which had fallen off of the resident's bedside table. RN #3 placed the remote directly on the over the bed table without cleaning the remote. During an interview with RN #3 on 9/19/19 at 2:45 PM, RN #3 confirmed the remote was placed on the over the bed table and not cleaned prior to placing the remote on the table. After catheter care was completed for Resident #112 on 9/19/19 at 10:30 AM, Certified Nursing Assistant (CNA) #1 was observed to touch the resident's leg, pull the resident's gown down, reposition the resident's legs, and pull the covers over the resident using his/her soiled gloved hands. During an interview with CNA #1 on 9/19/19 at 3:19 PM, s/he confirmed the resident, the gown, and the covers were touched with his/her soiled gloved hands.",2020-09-01
4480,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,241,D,0,1,KH4711,"Based on observation, interview and review of the facility policy titled Resident Dignity & Privacy, the facility failed to provide an environment to promote dignity of residents during the dining experience. During random observations of the lunch meal, staff were observed placing clothing protectors on residents without asking the resident's permission. (1 of 3 units observed during dining) The findings included: On 5/9/16 at approximately 12:30 PM, observation of the lunch meal revealed Certified Nursing Assistants(CNA's) #1, #2 and #3 placed a clothing protector on residents without asking the resident's permission prior to the application. On 5/12/16 at 12:17 PM, CNA #4 was observed to place a clothing protector on a resident without asking the resident's permission. On 5/1216 at 2:56 PM, during an interview, CNA #2 confirmed he/she did not ask the resident's permission prior to the placement of the clothing protector. On 5/12/16 at 2:44 PM, during an interview, CNA #3 confirmed he/she did not ask the resident's permission prior to the placement of the clothing protector. He/she further stated prior to placing the clothing protector, the resident should be asked if they would like a clothing protector. On 5/12/16 at 2:49 PM, during an interview, CNA #4 stated he/she did not realize the resident should be asked if they would like a clothing protector prior to placing one on the resident. Review of the facility policy titled Resident Dignity & Privacy states under the Fundamental Information the following: Dignity means that when interacting with residents, staff carry out activities which assist the resident in maintaining and enhancing his or her self-esteem and self-worth.",2020-01-01
4481,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,274,D,0,1,KH4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and policy review, the facility failed to ensure a significant change assessment was completed in a timely manner for 1 of 2 residents reviewed for significant change in Activities of Daily Living. Resident #186 had an improvement in 3 areas of Activities of Daily Living. The findings included: The facility admitted Resident #186 with [DIAGNOSES REDACTED]. Review on 05/11/2016 at 3:02 PM of Resident #186 Minimum Data Set (MDS) assessment dated [DATE] under Section C Brief Interview for Mental Status (BIMS) -Section C0500 Summary Score 5. Section G Functional Status-Section G0110A1: Bed Mobility: Self Performance is coded as 0: Independent-no help or staff oversite at any time. G0110G1: Dressing: Self Performance is coded as 3: Extensive assistance-resident involved in activity, staff provide weight-bearing support. G0110H1: Eating: Self-performance is coded as 0. G I1: Toilet use: self -performance is coded as 3. Personal hygiene: self-performance is coded as 3 Review on 5/11/2016 at 3:02 PM of Resident #186 MDS assessment dated [DATE] under Section C BIMS-Section C0500 Summary Score 8. Section G Functional Status-Section G0110A1: Bed Mobility: Self Performance is coded as 1: Supervision-oversight encouragement or cueing G0110G1: Dressing: Self Performance is coded as 1. G0110H1: Eating: Self-performance is coded as 2. G I1: Toilet use: self -performance is coded as 1. Personal hygiene: self-performance is coded as 3. Further review of the MDS assessment confirmed a significant change assessment had not been completed to reflect the improvement in functional status for Resident #186. Review on 05/12/2016 at 3:15 PM of the facility ' s policy Resident Assessment Instrument (RAI) Process Operations 4: Clinical Operations under Procedure 2. The Facility conducts a comprehensive assessment (Significant Change in Status) within 14 days after the facility determines that there has been a significant change in the resident ' s physical or mental condition. An interview on 05/12/2016 at 5:56 PM with the MDS/Care Plan Coordinator confirmed that a significant change assessment had not been completed for Resident #186 for improvement in functional status. S/he stated They normally do a significant change when a decline is involved not for improvement.",2020-01-01
4482,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,279,D,0,1,KH4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a care plan for Resident #224 related to behaviors.(1 of 1 reviewed for behaviors) In addition, the facility failed to develop a care plan for Resident #167 related to interventions prior to administration of a [MEDICAL CONDITION] medication. (1 of 6 reviewed for unnecessary medications) The findings included: The facility admitted Resident #224 with [DIAGNOSES REDACTED]. Record review of the nurse's notes on 5/12/16 revealed Resident #224 refused medications, treatments and care multiple times. Further review of the medical record revealed Resident #224 was not care planned for refusal of care. On 5/13/16 at 11:04 AM, during an interview with the Care Plan Coordinator(CPC) #1, he/she confirmed the resident had not been care planned for behaviors and stated all information from all disciplines was not available at the time of the assessment. He/she continued by stating the care plan had not been developed later after all disciplines submitted the information due to an oversight. The CPC #1 was asked who could update the care plans and he/she stated at the present only the Minimum Data Set(MDS) staff could update care plans. The facility admitted Resident #167 with [DIAGNOSES REDACTED]. Record review on 5/12/16 revealed Resident #167 previously had a physician's orders [REDACTED]. Further review of the resident's Medication Administration Record [REDACTED]. Review of the resident's care plan revealed there was no care plan for non-pharmacological interventions to be implemented prior to the administration of the as needed anti-anxiety medication. During an interview on 5/12/16 at 6:13 PM, the Director of Nursing confirmed there was no documentation related to interventions implemented prior to receiving the as needed medication.",2020-01-01
4483,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,282,D,0,1,KH4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to follow the care plan for 2 of 6 sampled residents reviewed for unnecessary meds (Resident #36 and #186). Resident #36 and #186's care plan was not followed related to non-medicated interventions. The findings included: The facility admitted Resident #36 with [DIAGNOSES REDACTED]. Record review on 5/11/2016 at 11:39 AM revealed Resident #36's care plan for pain revealed problem start date 10/22/2015. The approach stated, use non-medicated pain measure: (e.g. repositioning, application of heat/cold, massage, and etc.). Monitor effectiveness. Record review on 5/11/2016 at 3:40 PM revealed Resident #36 was administered [MEDICATION NAME] every six hours as needed for pain on 4/20/2016, 4/24/2016, 4/25/2016, 4/29/2016, 5/2/2016, 5/7/2016, 5/8/2016, and 5/12/2016. Further record review revealed in the Nurses Notes no documentation of non-medicated pain measure used prior to giving [MEDICATION NAME]. During an interview on 5/12/2016 at 6:06 PM, LPN #1 verified the care plan approach, use non-medicated pain measures with no documentation of the approach being used prior to administering [MEDICATION NAME]. The facility admitted Resident #186 with [DIAGNOSES REDACTED]. Record review on 5/11/2016 at 3:50 PM revealed Resident #186 care plan for pain revealed problem start date 5/2/2016. The approach stated, use non-medicated pain measure: (e.g. repositioning, application of heat/cold, massage, and etc.). Monitor effectiveness. Record review on 5/11/2016 at 4:00 PM revealed Resident #186 was administered [MEDICATION NAME] every six hours as needed for pain on 5/3/2016, 5/5/2016, and 5/6/2016. Further record review revealed in the Nurses Notes no documentation of non-medicated pain measure used prior to giving [MEDICATION NAME], During an interview on 5/12/2016 at 6:10 PM, LPN #1 verified the care plan approach for use non-medicated pain measures with no documentation of the approach being used prior to administering [MEDICATION NAME].",2020-01-01
4484,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,314,D,0,1,KH4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policy Clean Dressing Change, the facility failed to ensure necessary care and treatment were provided to promote healing for 1 of 2 pressure ulcers reviewed.(Resident #88) The findings included: The facility admitted Resident #88 with [DIAGNOSES REDACTED]. Record review on 5/11/16 revealed an order for [REDACTED]. During observation of pressure ulcer care on 5/11/16 at 3:48 PM, Licensed Practical Nurse(LPN)#5 was observed after cleansing the area to place the [MEDICATION NAME] Calcium Alginate Dressing. Prior to placing the dressing, LPN #5 was asked if the package had previously been opened and part of the dressing used. LPN #5 stated the package had been opened previous to the treatment and no date had been placed on the package. After providing the treatment and removing his/her gloves, LPN #5 exited the room without washing his/her hands. The [MEDICATION NAME] dressing package was placed back into the treatment cart and the Treatment Administration Record was signed. During an interview with LPN #5 on 5/12/16 at 6:00 PM, he/she confirmed his/her hands were not washed prior to leaving the resident's room. Review of the [MEDICATION NAME] Calcium Alginate Dressing information states for single use only. Review of the facility policy Clean Dressing Change revealed, after application of the dressing, remove gloves; place in bag for disposal and wash hands.",2020-01-01
4485,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,318,D,0,1,KH4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 1 of 3 sampled residents with limited range of motion received services to prevent further decline. Resident #114's restorative nursing program did not start in a timely fashion and range of motion was not done three times a week as recommended. The findings included: The facility admitted Resident #114 with [DIAGNOSES REDACTED]. Record review on 5/12/16 revealed Resident #114 had been evaluated on 3/14/16 and recommended to receive the Restorative Nursing Program for the upper extremities three times per week. Review of the restorative notes revealed there was no documentation Resident #114 received restorative nursing until (MONTH) 6, (YEAR). In April, during the week of the 10th, Resident #114 received restorative nursing twice. Review of the (MONTH) (YEAR) restorative documentation, no documentation was noted for the week of the 8th. During an interview with the Director of Nursing on 5/12/16 at 6:15 PM, he/she confirmed the findings.",2020-01-01
4486,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,322,D,0,1,KH4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and review of the facility policy titled Enteral Feeding: Pump Method, the facility failed to ensure appropriate treatment for 1 of 1 sampled resident reviewed for Percutaneous Endoscopic Gastrostomy(PEG). Observation of the PEG revealed the tube feeding was set at an incorrect rate. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the current physician's orders on 5/12/16 revealed an order for [REDACTED]. Observation of the resident's tube feeding on 5/11/16 at 10:37 AM and 5/12/16 at 12:22 PM revealed the rate of the tube feeding was 70 cc per hour. On 5/12/16 at 1:20 PM, the Director of Nursing along with the surveyor observed the tube feeding setting at 70 cc per hour. During an interview with the Director of Nursing on 5/12/16 at 6:12 PM, he/she confirmed the tube feeding had been set on the incorrect rate. Review of the facility policy titled Enteral Feeding: Pump Method revealed under the Purpose statement the following: A pump is used to administer enteral feeding at a constant, controlled infusion rage per physician's orders. Under the Procedure section #9 the facility policy states to turn on pump and set proper rate per pump's instructions.",2020-01-01
4487,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,329,E,0,1,KH4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled [MEDICAL CONDITION] Medication Assessment & Monitoring, the facility failed to use non pharmacological interventions prior to administering as needed medications to 2 of 5 residents reviewed for unnecessary medications. Resident #36 was administered a pain medication and Resident #167 was administered an anti-anxiety medication without attempting non pharmacological interventions. The findings included: The facility admitted Resident #167 with [DIAGNOSES REDACTED]. Record review on 5/12/16 revealed Resident #167 previously had a physician's order for [MEDICATION NAME] .5 milligrams three times a day as needed for Anxiety Disorder. Further review of the resident's Medication Administration Record(MAR) revealed the resident had received doses of [MEDICATION NAME] .5 mg thirteen times during the month of (MONTH) (YEAR). Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Per a written statement by the Unit Manager on 5/12/16, staff attempts to redirect him with no effects noted. Snacks are offered, but generally continues to request more and repositioning is ineffective. During the survey process, no documented evidence was presented these interventions were attempted prior to each dosage of medication given. During an interview on 5/12/16 at 6:13 PM, the Director of Nursing confirmed there was no documentation related to interventions implemented prior to receiving the as needed medication. Review of the facility policy titled [MEDICAL CONDITION] Medication Assessment & Monitoring did not address attempting non-pharmacological interventions prior to administering an as needed medication. The facility admitted Resident #36 with [DIAGNOSES REDACTED]. Record review on 5/11/2016 at 9:59 AM revealed Physician ' s Orders for [MEDICATION NAME] Schedule IV tablet; 50 mg; Amount to Administer: 1 tab; oral every 6 hours PRN (as needed). - Resident #36 was administered [MEDICATION NAME] every six hours as needed for pain on 4/20/2016, 4/24/2016, 4/25/2016, 4/29/2016, 5/2/2016, 5/7/2016, 5/8/2016, and 5/12/2016. Further record review revealed in the Nurse Notes no documentation of non-medicated pain measure used prior to giving [MEDICATION NAME]. Record review on 5/11/2016 at 11:39 AM revealed Resident #36's care plan for pain a problem start date 10/22/2015. The approach stated, use non-medicated pain measure: (e.g. repositioning, application of heat/cold, massage, and etc.). Monitor effectiveness. During an interview on 5/12/2016 at 6:06 PM, LPN #1 verified [MEDICATION NAME] was administered with the care plan approach for use non-medicated pain measures and no documentation of the approach being used prior to administering [MEDICATION NAME].",2020-01-01
4488,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,332,D,0,1,KH4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of manufacture recommendations, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 29 opportunities for error, resulting in a medication error rate of 6.8%. The findings included: Error #1 On 5/11/16 at approximately at approximately 9:02 AM, Licensed Practical Nurse (LPN) #4 administered Resident #192 ' s [MEDICATION NAME] Patch 24 hour (4.6milligram/24hour) to the residents left back (site #1). Following the observation a review of Resident #192 ' s Medicine Administration Record (MAR) revealed that on 5/2/16 an [MEDICATION NAME] Patch was administered to Resident 192 ' s lb (left back) no site number identified. LPN #4 was asked, Was the left back site used in the last 14 days. s/he stated, Yes. Review of the facility [MEDICATION NAME] Patch Administration Record states, DO NOT use the same site within a 14 day period, Particularly when changing months!. Review of the Rivastagmine ([MEDICATION NAME]) Patch manufactures box insert recommendations in section, How do I use Rivastigmine Patch? under bullet (10) states, Change your application site every day to avoid skin irritation. You can use the same area, but do not use the exact same spot for at least 14 days after your last application. Error #2 On 5/11/16 at approximately 9:50 AM, during an observation of Resident #156 ' s medication administration, Licensed Practical Nurse (LPN) #3 attempted to crush (1) Klor Con M20 (potassium Chloride) ER (Extended Release) 20 milliequivalent (meq.) tablet and administer the medication. Following the observation LPN #3 reviewed the pharmacy bubble pack recommendations and confirmed the Klor Con ER tablet should not have been crushed. Review of the Resident #156 ' s Klor Con M20 medication bubble pack card reveals stamped instructions, Not to be chewed or crushed.",2020-01-01
4489,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,333,D,0,1,KH4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of manufacture recommendations, the facility failed to administer the correct amount medication for 1 of 1 residents reviewed for TB [MEDICATION NAME], Purified Protein Derivative (PPD) medication administration and 1 of 1 residents reviewed for [MEDICATION NAME] Patch administration. Resident #177 did not receive the correct amount of physician ordered PPD during medication administration and Resident #192 did not receive the correct amount of physician ordered [MEDICATION NAME] during medication administration. The findings included: The facility admitted Resident #177 with [DIAGNOSES REDACTED]. On 5/09/16 at 12:20 PM, an observation of the medication refrigerator in the [MEDICATION NAME] unit medication storage room revealed (1) vial of TB [MEDICATION NAME], Purified Protein Derivative (PPD), Diluted /[MEDICATION NAME] 5TU/0.1 ML (Lot Number 3), with an opened date or puncture date of 3/12/16. Following the observation Licensed Practical Nurse (LPN) #1 verified that the PPD was being used past the manufactures recommendations and indicated the PPD should have been discarded. On 5/10/16 at approximately 10:00 AM, review of Resident #177 ' s Medication Administration Record [REDACTED]. During an interview on 5/10/16 at 10:05 AM, Licensed Practical Nurse (LPN) #1 verified the PPD from vial (Lot Number) 3 was administered to Resident #177 on 04/15/16. Review of the TB [MEDICATION NAME], Purified Protein Derivative (PPD), Diluted/[MEDICATION NAME] 5TU/0.1 ml package insert product information under section Dosage and Administration, states Vials in use for more than 30 days should be discarded. Also, under Storage, the insert states Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. The facility admitted Resident #192 with [DIAGNOSES REDACTED]. On 5/11/16 at approximately 9:00 AM, review of Resident #192 ' s Medication Administration Record [REDACTED] On 5/11/16 at approximately at approximately 9:02 AM, during an observation of Resident #192 ' s medication administration, Licensed Practical Nurse (LPN) #4 removed an [MEDICATION NAME] Patch (24 hour) dated 5/3/16 from the residents right back and another [MEDICATION NAME] Patch (24 hour) dated 5/10/16 was removed from the residents right arm. Following the observation Licensed Practical Nurse (LPN) #4, indicated the [MEDICATION NAME] Patches are ordered to be removed every 24 hours prior to the next administration. Review of the Rivastagmine ([MEDICATION NAME]) Patch manufactures box insert recommendations in section, Instructions for Use, under bullet (2) states, Only 1 Rivastigmine Patch should be worn at a time. Do not apply more than 1 Rivastigmine Patch at a time to the body. Also, under How do I use Rivastigmine Patch bullet states (15) Always remove the old Rivastigmine Patch from the previous day before you apply a new one. Furthermore, under bullet (16) Having more than 1 Rivastagmine Patch on your body at the same time can cause you to get too much medicine.",2020-01-01
4490,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,334,D,0,1,KH4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled Pneumonia, the facility failed to provide documented evidence a Pneumococcal Vaccine was offered and given for 2 of 5 residents reviewed for immunizations.(Residents #22 and #114) The findings included: The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Record review on 5/10/16 revealed no documented evidence a Pneumococcal Vaccine was administered to Resident #22. The facility admitted Resident #114 with [DIAGNOSES REDACTED]. Record review on 5/10/16 revealed no documented evidence a Pneumococcal Vaccine was administered to Resident #114. During an interview with the Admission Director on 5/13/16, he/she stated upon admission the history of the resident is checked in the Meditech System. If there is no documentation the resident received the vaccine, it is offered to the resident. This information goes to nursing and once scanned into the system it is then the nursing department's responsibility. During the survey process, documentation of whether the resident had previously received the Pneumococcal Vaccine, declined the vaccine or received the vaccine at the facility was not presented. Review of the facility policy titled Pneumonia states under the procedure section #1 the following: Offer pneumococcal vaccine to residents on admission",2020-01-01
4491,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,371,E,0,1,KH4711,"Based on observation, interview and review of facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchens and has the potential to effect 131 of 131 residents with ordered diets as evidenced by failing to do the following: Wear hair restraints, removing cracked and chipped plates, and drying dishes and pans. The findings included: On 5/9/16 at 11:20 AM, during the Initial Tour an observation of the dish washing and drying area of the kitchen revealed 5 pans stacked wet and several plates that were chipped and cracked. On 5/11/16 at 11:00 AM, an observation with the Dietary Manager (DM) of the kitchen revealed (2) kitchen staff in the food preparation/steam table/stove area without (1) facial beard hair restraint and (1) head hair restraint. Also, in the plate warmer at the lunch serving line revealed all the plates were stacked wet and 23 chipped and cracked. Furthermore, in the dish washing/drying area 16 pans were stacked wet. Following the observations the DM confirmed hair restraints were not worn around food, dishes and pans were stacked wet, and plates were chipped and cracked. Review of the facility policy titled, Hair care states under bullet (1) Hair completely restrained including beard restraints. (2) Wear hair net or cap covering all hair. Also, policy Storage states under bullet (2) Everything must be thoroughly air dried prior to storage. Furthermore, under Nutrition Policies And Procedures Subject: Dinner[NAME]Replacement Policy: The facility will monitor dinner ware for cracks, chips and other imperfections and replace when found. Procedure: Employees will monitor during washing, storage and meal service for any such imperfections and discard when found.",2020-01-01
4492,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,372,D,0,1,KH4711,"Based on observations, interview, and review of the facility's policy, the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpster's reviewed for garbage disposal. Dumpster was open and overflowing with trash. The findings included: On 5/9/16 at approximately 11:20 AM, during the Initial Tour an observation of two dumpster's outside behind the dietary department revealed the left dumpster door was open and overflowing with trash (bagged and card board). On 5/10/16 at approximately 12:16 PM, an observation of the two dumpster's outside behind the dietary department revealed the left dumpster door was open and overflowing with trash (bagged and card board). Also, debris was scattered between and behind the dumpster's. On 5/11/16 at approximately 11:00 AM, an observation with the Dietary Manager (DM) of the two dumpster's outside behind the dietary department revealed the left dumpster door was open and overflowing with trash (bagged and card board). Also, debris continued to be scattered between and behind the dumpster's. Following the observation the DM confirmed that dumpster door was open and trash was overflowing with some on the ground around the dumpster. Review of the facility policy titled Maintenance of Dumpster(s), revealed under Policy: Facility will arrange to have dumpster's scheduled for routine pick up on Thursdays. In the event dumpster becomes full before routine pick up, facility will contact (Refuse Company #) prior to scheduled day for additional pick up.",2020-01-01
4493,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-05-13,431,E,0,1,KH4711,"Based on observation, interview, and review of manufacture recommendations, the facility failed to follow a procedure to ensure that expired medications were removed from medication storage on 2 of 3 units. Expired medications were found on the Palmetto and Magnolia units. The findings included: On 5/09/16 at 12:20 PM, an observation of the medication refrigerator in the Palmetto unit medication storage room with Licensed Practical Nurse (LPN) #1 revealed (1) vial of TB Tuberculin, Purified Protein Derivative (PPD), Diluted /Aplisol 5TU/0.1 ML (Lot Number 3), with an opened date or puncture date of 3/12/16. Also, (1) vial Novolin N (CZF0547) with and expiration date of 02/2016 and (1) vial of Novolin N (CZF0553) with an expiration date of 03/2016. Following the observation LPN #1 verified the medications were expired and indicated the medications should have been discarded. On 5/09/16 at 12:30 PM, an observation of the medication refrigerator in the Magnolia unit medication storage room with LPN #2 revealed (1) vial of Novolin R (Lot Number DZF0107) with an expiration date of 04/2016. Also, on the Magnolia front hall medication cart (1) Lantus (Solo Star) 100 unit/3 milliter (Lot Number 5F2471A) administration pen was opened without an open date and had 220 units remaining. Following the observation Licensed Practical Nurse (LPN) #2 verified that the Novolin R insulin was expired and the Lantus insulin pen did not have and open date and indicated the pen should have dated upon opening. Review of the facility policy titled, Drug &Biological Storage reveals under procedure (4 a.) No discontinued, outdated, or deteriorated drugs or biological's may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with the procedure governing the destruction of medication.",2020-01-01
5192,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-03-28,223,G,1,0,L0UB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure each resident was free from mental abuse. Resident #1 was found with his/her sheets tightly tucked around his/her body. Certified Nurse Aide (CNA) #1 admitted to tucking the resident so s/he could not get to his/her brief. One of one resident reviewed for allegation of abuse. The findings included: The facility submitted a reportable incident to the state survey agency on 10/1/15. The reportable was related to an allegation of mental abuse for Resident #1 by CNA #1 that occurred on 9/30/15. The reportable indicated Resident #1 was found in bed visibly distressed and shouting untangle me, untangle me. The resident was wrapped tightly in his/her sheets. The resident alleged that his/her CNA did it. Review of the facility's Summary Report of Facility Investigation dated 10/8/16 indicated the investigation revealed that Resident #1 was mentally abused by his/her assigned CNA (CNA #1) on the evening of 9/30/15. CNA #1 admitted to Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 that s/he tucked Resident #1's sheet under him/her, but did not know that s/he could not do that. Resident #1, who is alert and oriented, told RN #1 and LPN #1 that CNA #1 was the one that wrapped me up. Resident #1 pleaded to RN #1 and LPN #1 that CNA #1 not do that again. The nurses reported that Resident #1 was anxious and agitated throughout the entire incident. RN #1 and LPN #1 failed to report the incident to their Supervisor/ Director of Nursing and/or the facility Administrator in a timely manner. The incident was observed on 9/30/15 at approximately 7:00 PM. RN #1 and LPN #1 did not report the incident until the next day, 10/1/15 at 7:00 AM. Resident #1 was noted to reside on the Unit (#1) in the facility. Review of the Unit (#1) Assignment Sheet for 9/30/15 revealed CNA #1 worked the 3:00-11:00 PM shift and was assigned to Resident #1's room. CNA #1 had a notation that s/he would be on the Unit (#2) at 11:00 PM. Review of the Unit (#2) Daily Assignment Sheet dated 9/30/15 revealed CNA #1 worked the 11:00 PM - 7:00 AM shift. Neither sheet was updated to indicate there were any staffing changes. Review of Resident #1's medical record revealed the resident's [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Progress Note dated 10/1/15 at 1:28 AM revealed During walking rounds found resident in bed, visibly distressed. Shouting, 'untangle me . untangle me .' Pulled back covers to find resident wrapped tightly in (his/her) sheets. Unwrapped resident and tried to redirect by speaking in low calm voice. Attempts unsuccessful to redirect. Resident continued to yell out, shaking noted and resident asking for staff to not leave (him/her) alone. Scheduled [MEDICATION NAME] given along with other HS (hours of sleep) meds, with somewhat positive effects noted. This nurse sat at the bedside of the resident in attempts to keep the resident calm. Resident did become more quite, but agitation remains. PRN (as needed) [MEDICATION NAME] given at 1800 and 0130, rd (resident) stating that (s/he) is just miserable and hurts all over. Resident was able to find some broken sleep . Further review of the resident's Progress Notes revealed a Body Audit was completed on 10/1/15 at 1:38 PM. The body audit noted Resident #1 had 3 bruised to his/her left arm that were blue/reddish in color. Resident #1 also had 2 bruises on his/her right tibia that were blue/yellow in color and 2 areas of discoloration on the left tibia that were reddish in color and non blanchable. A small bluish bruise was noted on the inner left knee. Review of the resident's Body Audit dated 9/25/15 revealed the resident had a bruise on his/her right leg and also a bruise on his/her right arm and a bruise on the left arm. Review of the Time Card Report dated 9/30/15 revealed CNA #1 worked from 3:06 PM - 3:06 AM that day. Review of the facility's Abuse & Neglect Prohibition Policy revealed the facility will protect residents from harm during the investigation of any alleged abuse. Review of Resident #1's Psychiatry Progress Note dated 10/12/15 completed by the Psychiatry Nurse Practitioner indicated the resident's chief complaint was anxiety, excessive worry, paranoia and confusion. .Staff have noted patient to be tearful lately and cries in his/her room. Patient is worried about having to leave facility and states it is because s/he was rude to someone . Further review of the Psychiatry Progress Note dated 10/12/15 revealed no documentation related to Resident #1's allegation of mental abuse. The Nurse Practitioner listed current psychiatric medications as [MEDICATION NAME] 10 milligrams daily for depression and [MEDICATION NAME] 1 milligram daily and as needed. In an interview with the surveyor on 3/9/16 at approximately 7:15 PM, RN #1 stated s/he worked 7 PM-7 AM on 9/30/15. S/he was doing walking rounds with LPN #1. RN #1 stated Resident #1 was alert and oriented with some confusion. When they arrived at Resident #1's room s/he was saying I can't breathe, turning his/her head back and forth, and respirations were heightened. When s/he got to the bedside s/he noticed the resident had his/her arms by his/her side and the sheet was wrapped tightly around him/her and tucked underneath him/her. RN #1 and LPN #1 pulled the sheet to release the resident. RN #1 noticed the resident's brief was on backwards. Resident #1 was trapped and s/he felt trapped. The resident was saying s/he couldn't breathe. Resident #1 said they don't want me to dig in my poop. S/he would pull at his/her brief and would dig in his/her poop. RN #1 tried to comfort the resident and sat with him/her for 2.5 hours to calm him/her down. That was not something s/he normally had to do. CNA #1 was assigned to the resident on 9/30/15. Resident #1 was scared but did calm down, RN #1 gave him/her as needed anxiety medication to help calm him/her down. RN #1 and LPN #1 reported the incident to the Unit Manager the next morning at shift change. CNA #1 continued to work that night and RN #1 did not talk with the nurse on Unit (#2) to let him/her know about the incident with CNA #1. In an interview with the surveyor on 3/10/16 at approximately 9:35 AM, Director of Social Service stated s/he talked with Resident #1 on 10/1/15. The resident stated (s/he) tied me up. Resident #1 was more anxious than usual that day. Resident #1 was consistent in his/her story about what happened. In an interview with the surveyor on 3/10/16 at approximately 10:40 AM, LPN #1 stated s/he and the night nurse were doing rounds. They heard Resident #1 saying help me, help me. They went into his/her room and pulled the sheets back and his/her arms were pinned. Resident #1 said s/he did it, CNA #1 walked in the room behind them and the resident said s/he did. CNA #1 said I did it, I was stopping him/her from sticking his/her hands in his/her brief. LPN #1 told the CNA s/he couldn't do that and CNA #1 said s/he didn't know that and left out of the room. LPN #1 and RN #1 got the resident untucked and straightened sheets and left the room. There was one sheet over the tucked sheet so you couldn't see until removed. LPN #1 stated s/he could tell how the resident was positioned that s/he couldn't move his/her arms and that is when they removed the sheet. Resident #1 was very upset when they got to the room. The resident was still upset when they left but not as upset. LPN #1 contacted the Unit Manager the next morning and told him/her about the situation and asked if that was abuse. The Unit Manager said yes and s/he would follow up. In an interview with surveyor on 3/10/16 at approximately 3:55 PM, the facility Administrator stated s/he was not at the facility at the time of incident. The Administrator stated staff is trained to notify the nursing administrator on call at the time of the event. They should have sent CNA #1 home immediately. As licensed nurses they are responsible for suspending immediately. The nurses did not follow policy or procedure. The DON (director of nursing) called him/her to let her know about the incident at 7 AM the next morning on 10/1/15. The Administrator stated s/he talked with CNA #1 and s/he said s/he tucked Resident #1 in tight. CNA #1 stated s/he did not know that was considered a restraint. The facility Administrator stated CNA #1 worked on Unit (#1) until 11 PM and then went to Unit (#2) and worked until 3:06 AM. CNA #1 said s/he tucked the resident in tight because s/he was digging in his/her brief. The Administrator stated s/he did not know of any notification of the psychiatry nurse practitioner after incident and there was no documentation in the resident's computer medical chart. In an interview with the surveyor on 3/10/16 at approximately 5:45 PM, the facility administrator stated CNA #1 did not take care of Resident #1 after 7:00 PM. The facility administrator stated assignment sheets should be updated to reflect any staff change of who is providing care for residents.",2019-03-01
5193,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-03-28,226,G,1,0,L0UB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to implement written policies and procedures that prohibit abuse of residents. Resident #1 was found with his/her sheets tightly tucked around his/her body. Certified Nurse Aide (CNA) #1 admitted to tucking the resident so s/he could not get to his/her brief. CNA #1 continued to work after the incident was identified by two nurses. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 failed to report the allegation of abuse timely to facility administration. One of one resident reviewed for allegation of abuse. The findings included: The facility submitted a reportable incident to the state survey agency on 10/1/15. The reportable was related to an allegation of mental abuse for Resident #1 by CNA #1 that occurred on 9/30/15. The reportable indicated Resident #1 was found in bed visibly distressed and shouting untangle me, untangle me. The resident was wrapped tightly in her/his sheets. The resident alleged that her/his CNA did it. Review of the facility's Summary Report of Facility Investigation dated 10/8/16 indicated the investigation revealed that Resident #1 was mentally abused by her/his assigned CNA (CNA #1) on the evening of 9/30/15. CNA #1 admitted to RN #1 and LPN #1 that s/he tucked Resident #1's sheet under him/her, but did not know that s/he could not do that. Resident #1, who is alert and oriented, told RN #1 and LPN #1 that CNA #1 was the one that wrapped me up. Resident #1 pleaded to RN #1 and LPN #1 that CNA #1 not do that again. The nurses reported that Resident #1 was anxious and agitated throughout this entire incident. RN #1 and LPN #1 failed to report the incident to their Supervisor/ Director of Nursing and/or the facility Administrator in a timely manner. The incident was observed on 9/30/15 at approximately 7:00 PM. RN #1 and LPN #1 did not report the incident until the next day, 10/1/15 at 7:00 AM. Resident #1 was noted to reside on Unit (#1) in the facility. Review of the Unit (#1) Assignment Sheet for 9/30/15 revealed CNA #1 worked the 3:00-11:00 PM shift and was assigned to Resident #1's room. CNA #1 had a notation that s/he would be on the Unit (#2) at 11:00 PM. Review of the Unit (#2) Daily Assignment Sheet dated 9/30/15 revealed CNA #1 worked the 11:00 PM - 7:00 AM shift. Neither sheet was updated to indicate there were any staffing changes. Review of Resident #1's medical record revealed the resident's [DIAGNOSES REDACTED]. Review of the facility's Abuse & Neglect Prohibition Policy revealed the facility will protect residents from harm during the investigation of any alleged abuse. In an interview with surveyor on 3/10/16 at approximately 3:55 PM, the facility Administrator stated she was not at the facility at the time of incident. The Administrator stated staff is trained to notify the nursing administrator on call at the time of the event. They should have sent CNA #1 home immediately. As licensed nurses they are responsible for suspending immediately. The nurses did not follow policy or procedure. The DON called him/her to let her know about the incident at 7 AM the next morning on 10/1/15. The Administrator stated s/he talked with CNA #1 and s/he said s/he tucked Resident #1 in tight. CNA #1 stated s/he did not know that was considered a restraint. The facility Administrator stated CNA #1 worked on Magnolia until 11 PM and then went to [MEDICATION NAME] unit and worked until 3:06 AM. CNA #1 said s/he tucked the resident in tight because s/he was digging in his/her brief. The Administrator stated s/he did not know of any notification of the psychiatry nurse practitioner after incident and there was no documentation in the resident's computer medical chart.",2019-03-01
5194,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2016-03-28,309,G,1,0,L0UB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest physical and psychosocial well-being. Resident #1 was noted to have increased behavior problems and recommendations by the psychiatry nurse practitioner were not implemented. The psychiatry progress notes dated 10/12/15 recommended to restart [MEDICATION NAME] to 25 milligrams daily to address depression and anxiety; this recommendation was not followed up. One of three residents reviewed for behaviors. The facility also failed to implement an antibiotic timely. The findings included: Review of Resident #1's medical record revealed the resident's [DIAGNOSES REDACTED]. Review of Resident #1's Nursing Progress Note dated 10/1/15 at 1:28 AM revealed During walking rounds found resident in bed, visibly distressed. Shouting, 'untangle me . untangle me .' Pulled back covers to find resident wrapped tightly in (his/her) sheets. Unwrapped resident and tried to redirect by speaking in low calm voice. Attempts unsuccessful to redirect. Resident continued to yell out, shaking noted and resident asking for staff to not leave (him/her) alone. Scheduled [MEDICATION NAME] given along with other HS (hours of sleep) meds, with somewhat positive effects noted. This nurse sat at the bedside of the resident in attempts to keep the resident calm. Resident did become more quite, but agitation remains. PRN (as needed) [MEDICATION NAME] given at 1800 and 0130, rd (resident) stating that (s/he) is just miserable and hurts all over. Resident was able to find some broken sleep . Further review of the resident's Progress Notes revealed a Body Audit was completed on 10/1/15 at 1:38 PM. The body audit noted Resident #1 had 3 bruised to his/her left arm that were blue/reddish in color. Resident #1 also had 2 bruises on his/her right tibia that were blue/yellow in color and 2 areas of discoloration on the left tibia that were reddish in color and non blanchable. A small bluish bruise was noted on the inner left knee. Review of the resident's Body Audit dated 9/25/15 revealed the resident had a bruise on his/her right leg and also a bruise on his/her right arm and a bruise on the left arm. Further review of Resident #1's Nursing Progress Notes revealed on 10/10/15 the resident was yelling for help at shift change over. Resident found to have a high level of anxiety. Resident continually presses the call light, call light answered, immediately after exiting the room, call light pressed again. On 10/12/15 the resident was seen talking to people who were not in the room. On 10/14/15 Resident #1 was noted in bed at shift change with obvious signs of anxiety. The resident was talking fast, and jumping from topic to topic. Resident was pulling at his/her hair and when the nurse turned the resident to change brief found hair all about the bed. Resident stated that s/he was pulling his/her hair out. On 10/15/15 the resident was noted in bed during walking rounds in a high state of anxiety. The resident was calling out for help, asking for medications, yelling that his/her back hurt, side hurt etc. Resident didn't want the nurse to leave the room, each time the nurse attempted to leave the resident would give a reason to not leave. The resident was mashing the call light while the nurse was standing at the bedside providing care, the nurse asked the resident why s/he was mashing the call light while staff was in the room providing care and the resident stated s/he didn't know guessed it was a force of habit. Review of Resident #1's Psychiatry Progress Note dated 9/14/15 completed by the psychiatry nurse practitioner revealed the resident's anxiety level was becoming .increasingly uncontrollable at nights and his/her as needed [MEDICATION NAME] was not effective in calming him/her down. Patient yells out constantly for help, cries out. Paranoia noted in statements that people are going to do harm to her. Staff report s/he is extremely difficult to redirect . Recommendations included to taper and discontinue [MEDICATION NAME] related to no improvement. Review of the resident's Medications Administration History revealed [MEDICATION NAME] 10 mg (milligrams) three time a day was administered throughout the month of (MONTH) and October. [MEDICATION NAME] was discontinued on 11/2/15. The Psychiatry Progress Note dated 10/12/15 completed by the Psychiatry Nurse Practitioner indicated the resident's chief complaint was anxiety, excessive worry, paranoia and confusion. Staff have noted patient to be tearful lately and cries in his/her room. Patient is worried about having to leave facility and states it is because s/he was rude to someone. Further review of the Psychiatry Progress Note dated 10/12/15 revealed no documentation related to Resident #1's allegation of mental abuse and the incident that occurred on 9/30/15. The Nurse Practitioner listed current psychiatric medications as [MEDICATION NAME] 10 milligrams daily for depression and [MEDICATION NAME] 1 milligram daily and as needed. The recommendations included to restart [MEDICATION NAME] to 25 milligrams daily to address depression and anxiety. Further review of Resident #1's Psychiatry Progress Notes revealed a 4/6/15 note that stated the reason for follow-up was noted as medication check. Recommendations included to continue medication as prescribed, the patient was stable at current dose and/or needs more time to see beneficial effects. Dose reduction attempted and/or reduction will cause decompensation of patient. Will consider dose reduction in [MEDICATION NAME] in the future due to multiple antidepressant treatment. Current psychiatric medications were listed as [MEDICATION NAME] 5 mg as needed for anxiety, [MEDICATION NAME] 10 mg TID for anxiety, [MEDICATION NAME] 10 mg for depression and [MEDICATION NAME] 50 mg for depression/sleep. Review of Resident #1's Physician's Telephone Orders revealed and order dated 4/20/15 to discontinue [MEDICATION NAME]. On 11/2/15 the Psychiatry Progress Note revealed the current psychiatric medications were listed as [MEDICATION NAME] 10 mg daily, [MEDICATION NAME] 10 mg three times a day and [MEDICATION NAME] 1 mg daily and as needed. The psychiatry nurse practitioner evaluated Resident #1 per pharmacy consultation regarding a gradual dose reduction for [MEDICATION NAME]. The psychiatry nurse practitioner recommended to taper and discontinue [MEDICATION NAME] since no improvement was noted. Review of Resident #1's Physician's Telephone Orders revealed no order to restart the [MEDICATION NAME] 25 milligrams daily. Review of Resident #1's (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records revealed no order for [MEDICATION NAME] 25 milligrams (mg) daily. In an interview with the surveyor on 3/10/16 at approximately 5:45 PM, the facility administrator stated the psychiatry nurse practitioner enters his/her medication orders into the computer, the order goes into the resident's electronic medical record and is transmitted to the pharmacy. The Assistant Director of Nursing reviewed orders and was not able to locate an order for [REDACTED]. In a telephone interview with the surveyor on 3/25/16 at approximately 2:35 PM, the psychiatry nurse practitioner stated s/he is usually at the facility every week. The Psychiatry Nurse Practitioner stated s/he enters orders for medications into the computer. S/he confirmed that she did not see [MEDICATION NAME] listed on the resident's medication list in (MONTH) (YEAR). The Psychiatry Nurse Practitioner stated s/he would have documented in the progress note if s/he had been told about Resident #1's allegation of mental abuse related to the incident of 9/30/15 . Review of Resident #1's Specimen Inquiry dated 10/6/15 revealed a preliminary urine culture result with gram negative rods that was verified at 8:02 on 10/7/15. At the bottom of the form was a note dated 10/7/15 for [MEDICATION NAME] 100 milligrams twice a day x 7 days. The note was signed by the nurse practitioner. Review of the Concerns from Unit (#1) form completed for Resident #1 dated 10/8/15 revealed the resident was continuously yelling out help, help, attention seeking behaviors, throwing remote call light to floor, being very demanding with staff. The nurse practitioner completed the form on 10/8/15 and commented that the resident was diagnosed with [REDACTED]. Review of the Prescription Order from for Resident #1 revealed [MEDICATION NAME] 100 milligrams twice a day x 7 days was entered on 10/9/15 at 4:48 PM. Review of Resident #1's Medication Administration History for (MONTH) (YEAR) revealed [MEDICATION NAME] was started on 10/9/15 at the 9:00 PM medication administration. In an interview with the surveyor on 3/10/16 at approximately 5:45 PM, the Director of Nursing stated Resident #1 had a preliminary lab on 10/7/15 and was awaiting culture that came on 10/8/15. In a telephone interview with the surveyor on 3/16/16 at approximately 11:15 AM, the Nurse Practitioner stated s/he would expect the order for [MEDICATION NAME] to have started on 10/7/15. S/he signs the lab report and gives it to the Unit Manager or nurse and they enter the order for the medication. There is no set policy for how the orders are processed.",2019-03-01
5621,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2015-01-15,155,D,0,1,JQ1711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were afforded the opportunity to formulate an Advance Directive for 1 of 18 residents reviewed for Advance Directives. (Resident #9) The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the Advance Directives section of the medical record revealed that the Medical Intervention Guideline form was not signed by the resident. Information on this form indicated, It is your right to make important decisions regarding life-sustaining treatment. This Medical Intervention Guideline Form provides you the opportunity to inform us of your desires regarding treatment. Further record review revealed there was no determination by two physicians to indicate that Resident #9 was unable to make his/her own healthcare decisions as required under Section 44-66-20 of the Adult Health Care Consent Act. During an interview on 1/15/15 at approximately 2:15 PM, the facility's Social Worker stated that it was his/her process to interview residents to determine their ability to sign an Advance Directive; and if unable to sign, two physicians would certify that the resident was unable to make healthcare decisions, and a representative would sign the Advance Directive. The Social Worker reviewed Resident #9's record and verified that the form attesting to Resident #9's decision-making capacity was missing from the record. The Social Worker stated that he/she would provide the form when located. On 1/15/15 at approximately 3:26 PM, the surveyor was informed that the form had not been located. No form was provided prior to exit from the facility.",2018-11-01
7174,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-05-30,152,D,0,1,2OTX11,"On the days of the survey, based on record review and interviews the facility failed to provide evidence that 2 physicians had deemed Resident #4 lacked capacity to make his/her own healthcare decisions for 1 of 24 residents reviewed for Code status. The findings included: During record review on 5/21/13 at approximately 9:15 AM a DNR (Do Not Resuscitate) form was found on Resident #4's Medical Record and signed by his/her daughter. Further review of Resident #4's Medical Record revealed the healthcare decisional capacity form which is to be signed by 2 Physicians to determine if a resident has capacity to make his/her own decisions was not found. Also, a POA (Power of Attorney) giving his/her daughter authority to make health care decisions for him/her could not be located in the Medical Record for Resident #4. On 5/21/13 at approximately 10:20 AM, an interview with the Licensed Social Worker, revealed that no healthcare decisional capacity form had been completed. S/he stated the facility was in the process of a comprehensive assessment and the attending Physician was waiting for the results before deeming the resident's capacity to make healthcare decisions. During an interview with Resident #4's daughter, s/he verified s/he did not have a Power of Attorney for making medical decisions for his/her family member.",2017-05-01
7175,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-05-30,166,E,0,1,2OTX11,"On the days of the survey, based on review of the Residents' Council Minutes and interviews, the facility failed to actively seek a resolution and keep the residents' apprised of its progress toward resolution. The findings included: On 05/19/2013 at 2:30 PM, this surveyor obtained permission from the Resident's Council President to read the minutes from the Resident's Council Meeting. Review of the minutes for the months of February, March, and April 2013 revealed the residents' complained of Cold food, Call light problem, Missing phone calls, phone is not available some residents hog the phone. Further review of the Residents' Council Minutes revealed that there were no documentation regarding resolutions by the facility or any documentation that the residents' were appropriately apprised of the facility's progress towards a resolution. On 05/20/2013 at 10:00 AM during the Group Interview, the residents' stated that they were not sure that the facility followed up on their complaints because there has been no response from anyone regarding their complaints. On 05/23/2013 at 2:15 PM, during an interview with the Administrator, when asked if there were documentation responding to the residents' complaints expressed during the Resident's Council Meetings, he/she stated that there were no documentation, but s/he has spoken to the residents. He/she stated I receive all the minutes from the Residents' Council Meeting and I was under the impression that the Activities Director was informing the residents regarding resolution to to their complaints. The Administrator spoke to the Dietary Manager and the Activity Director in the presence of this surveyor. The Dietary Manager verified that he/she met with some of the residents on 04/18/2013 and on 04/25/2013. However, there were no resolution presented at either meeting. The Activity Director verified that there were no resolution presented to the residents regarding their complaints, nor were the residents appropriately apprised of the facility's progress toward resolution.",2017-05-01
7176,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-05-30,271,D,0,1,2OTX11,"**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 the physician's orders for routine care of [MEDICAL CONDITION] at the time of readmission from hospital for Resident #16 . The findings included: Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. On 05/22/2013 at 12:00 PM, record review revealed that Resident #16 was admitted into the hospital on [DATE] and 05/05/2013 relating to the [MEDICAL CONDITION] and readmitted into the facility on 04//27/2013 and 5/14/2013 respectively. Further record review revealed that upon Resident #16's readmission to the facility, the facility received the Universal Medication Form from the hospital, written orders that identified the necessary medications for Resident #16 to receive. However, there were no written orders that addressed the routine care for the [MEDICAL CONDITION]. On 05/22/2013 at 1:00 PM during an interview with the Director of Nursing (DON), he/she reviewed and verified that there were no orders to address the routine care of the [MEDICAL CONDITION]. When asked about a policy regarding readmission of residents, he/she stated that there was no policy, but the nurses should have called the MD (Medical Doctor) to clarify orders.",2017-05-01
7177,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-05-30,281,D,0,1,2OTX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based upon observations, record reviews and interviews the facility failed to ensure that the care of 1 of 8 residents observed during medication pass met professional standards of quality relevant to medication documentation and administration. Resident D was observed with multiple medication patches and the Medication Administration Record [REDACTED] The findings include: On 5/20/13 at approximately 9:15 AM during medication pass to Resident D, Licensed Practical Nurse (LPN) # 4 discovered an undated [MEDICATION NAME] Patch attached to the right arm of the resident's wheelchair. LPN # 4 checked behind both ears and removed another [MEDICATION NAME] from behind the left ear bearing a smeared/partially legible date of 5/17 or 5/19 and an undated [MEDICATION NAME] from behind the right ear. LPN # 4 checked the MAR (medication administration record) and discovered that a [MEDICATION NAME] was scheduled to be applied on 5/19/13, but the MAR indicated [REDACTED]. On 5/20/13 at approximately 9:25 AM LPN # 4 applied a new and dated patch behind the right ear of Resident D and corrected the MAR indicated [REDACTED]. During medication reconciliation, the physician order [REDACTED]. This was verified by LPN # 4 on 5/20/13 at approximately 9:30 AM who stated that based on the MAR (medication administration record) and his/her findings that he/she was unclear as to what had happened with the [MEDICATION NAME]es.",2017-05-01
7178,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-05-30,309,D,0,1,2OTX11,"**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 physicians orders for a nutritional supplement were accurately performed. On 5/20/13 at approximately 8:12 AM, during medication pass, LPN (Licensed Practical Nurse) # 2 administered 120 ml (milliliters) of Med Pass 2.0 to Resident B. During medication reconciliation, the 5/15/13 physician's orders [REDACTED]. Medpass 240 ml BID (two times daily). On 5/20/13 at approximately 10:40 AM, LPN # 2 checked the physician's orders [REDACTED]. He/she checked the MAR (medication administration record) and verified that the change to 240 ml BID had been previously entered.",2017-05-01
7179,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-05-30,329,D,0,1,2OTX11,"**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 address the Pharmacy Consultation Report recommendation for a gradual dose reduction of a sedative/hypnotic medication that is routinely administered to Resident #12. The finding included: On 05/20/2013 at 3:00 PM review of the Consultation Report Comment: (Issued on 03/21/2013) revealed Resident [MEDICATION NAME] mg at bedtime except Sundays for [MEDICAL CONDITION] since 10/29/12. Recommendation : Please consider reducing the dose [MEDICATION NAME] the eventual goal of discontinuation, if possible .If therapy is to continue at the current dose, please provide rationale describing a dose reduction as clinically contraindicated. Further record review revealed that the physician's response was not addressed on the Consultation Report and on 4/25/2013 the MD wrote another prescription [MEDICATION NAME] mg 1 tab M (Monday)-Sat (Saturday) po (by mouth). 05/21/2013 at 11:30 AM during an interview with the Unit Manager, he/she reviewed and verified that the physician's response regarding the Consultation Report recommendations were not addressed. On 5/22/2013 at 1:00 PM during interview with the Director of Nursing (DON), when asked how is the physician made aware of the Pharmacist's Consultation Report, he/she stated that The Consultation Report is placed in the physician's box for review.",2017-05-01
7180,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-05-30,332,F,0,1,2OTX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews, Facts and Comparisons (updated monthly) and the ISMP (Institute of Safe Medication Practice) list of Oral Dosage Forms That Should Not Be Crushed (updated biannually) the facility failed to ensure that it was free of a medication error rate of five percent or greater. The medication error rate was 13.2 (percent). There were 7 errors out of 53 opportunities for error and these occurred on 4 of 6 medication carts located on 3 of 3 residents halls. Substandard Quality of Care was cited at 483.25 (m)(1) F332 related to a Medication of Error rate of 13.2 % at a scope and severity of F. The findings included: ERROR # 1: On 5/19/13 at approximately 3:55 PM during observation of medication pass on the 100 Hall (Indigo), RN (Registered Nurse) # 1 administered two drops of [MEDICATION NAME] B/[MEDICATION NAME] Ophthalmic Solution to the right eye of Resident # 9. These two drops were administered in rapid succession (approximately 1 second between drops) which caused a considerable amount of the ophthalmic solution to run down the side of the resident's face. During medication reconciliation on 5/19/13 at approximately 4:15 PM, the physicians orders and MAR (medication administration record) for May, 2013 stated [MEDICATION NAME] Eye Drops 2 drops to right eye four times daily. On 5/19/13 at approximately 4:34 PM RN # 1 verified that he/she did not wait between administering the the 2 drops to the right eye. Facts & Comparisons, topical ophthalmics section, states 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 is not diluted by the first. ERROR # 2: On 5/20/13 at approximately 7:50 AM during observation of medication pass on 200 Hall ((Magnolia), LPN (Licensed Practical Nurse) # 1 crushed one tablet of [MEDICATION NAME] 24 hour ER (extended release) 30 mg (milligram) along with with other medications being administered to Resident A. Prior to administration on 5/20/13 at approximately 7:53 AM LPN # 1 verified that he/she had crushed the [MEDICATION NAME] 24 hour ER and was asked not to administer since it is an extended release medication. LPN # 1 verified that the medication should not have been crushed, then redid and administered the medication pass without crushing [MEDICATION NAME] 24 hour ER. During medication reconciliation, the physician orders [REDACTED].*[MEDICAL CONDITION]*DO NOT CRUSH OR CHEW*. ERROR # 3: On 5/20/13 at approximately 8:12 AM, during observation of medication pass on 200 Hall (Magnolia), LPN # 2 crushed a Multivitamin with Iron tablet and mixed along with other crushed medications in approximately 1-1/2 teaspoons of applesauce. When these medications/applesauce were administered to Resident B he/she swallowed the medications/applesauce, but spit out a piece of the Multivitamin with Iron tablet. LPN # 2 placed this piece in the trash can beside the resident's bed and stated that Resident A spits out any medication that isn't crushed finely and that vitamins were often a problem to crush. During medication reconciliation, the physicians order and MAR indicated [REDACTED]*DX NUTRITIONAL SUPPLEMENT , There was no record on the MAR indicated [REDACTED]. ERROR # 4: On 5/20/13 at approximately 8:45 AM during observation of medication pass on 300 Hall ([MEDICATION NAME]) LPN # 3 administered one tablet of Calcium 600 mg with Vitamin D 200 IU (International Units) to Resident C. During medication reconciliation on 5/20/13 at approximately 11:00 AM, the physician order [REDACTED].*DX NUTRITIONAL SUPPLEMENT On 5/20/14 at approximately 11:05 AM, LPN # 4 checked the stock bottle from which the dose had been taken and verified that it did not match the physicians order. ERRORS: On 5/20/13 at approximately 9:12 AM during observation of medication pass on Hall 100 (Indigo) LPN # 4 crushed all oral medication, except fish oil for Resident D These crushed medications were mixed with approximately 2 teaspoons of applesauce and included: # 5-one tablet of Klor Con M 20 mEq (milliequivalents) SR (sustained release) # 6-one tablet of donepezil 10 mg # 7-one tablet of [MEDICATION NAME] 5 mg On 5/20/13 at approximately 9:14 AM prior to administration to Resident D LPN # 4 verified that the Klor Con M 20 mEq had been crushed and that she had previously checked with pharmacy and had been told that it was permissible to crush. On 5/20/13 at approximately 9:22 AM, LPN # 4 administered all crushed medications to Resident D. During medication reconciliation on 5/20/14 at approximately 9:35 AM, review of the physicians order and MAR for May, 2013 revealed an order for [REDACTED]. LPN # 4 verified he/she had administered the [MEDICATION NAME] and Donepezil and failed to sign for administration, that these medications had been discontinued by the physician on 5/13/13 and that D/C (discontinued) 5/13/13 had been entered on the MAR (medication administration record). LPN # 4 stated that he/she was accustomed to seeing discontinued orders highlighted on the MAR. The ISMP list of Oral /Dosage Forms That Should Not Be Crushed (updated April, 2012) page 8 states that Klor Con M should not be crushed.",2017-05-01
7181,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-05-30,371,E,0,1,2OTX11,"On the days of the survey, based on observation, interviews, and review of the facilities policies, the facility failed to prepare, distribute, and serve food under sanitary conditions. Dietary staff failed to calibrate the Fahrenheit food temperature probe (thermometer) accurately, clean the can opener, and ice scoop holder. Also, disposable towels were not available at the sink area and the three compartment sink did not have adequate chemical solution for sanitization. The findings included: During initial tour of the kitchen on 5/19/13 at approximately 4:00 PM, and again on 5/20/13 at 10:55 AM observations were of the common sink area were observed with no disposable towels available. Also, the can opener had a large build up of a dark substance and food debris present on the blade. Furthermore, the ice scoop holder tray had a brown/gray substance on the bottom of the tray. On 5/20/13 at approximately 11:00 AM, during an observation of the lunch meal serving line. Dietary Cook #1 calibrated the Fahrenheit food temperature probe to 20 degrees in a cup of ice water, then began to test the temperature of foods on the steam table. The surveyor then asked Dietary Cook #1, what is the correct temperature for calibration of a Fahrenheit thermometer in ice water?, Dietary Cook #1 stated, 30, then observed the probe and stated 20 or 22. Dietary Cook #1 was then asked to calibrate the Fahrenheit temperature probe to 32 degrees and was unable to do so. On 5/21/13 at approximately 10:00 AM, during an observation of the three compartment sink with the Dietary Manager (DM), a PHydrion Papers QT-10 test strip with lot # 2 was used to test the sanitizing sink. The test strip after being submerged in the water read 0 parts per million. The DM verified that there was not adequate sanitizing solution in the water. On 5/21/13 at approximately 10:30 AM, during an interview with the DM, the cleaning logs were reviewed. The DM stated that the ice scoop holder and can opener had not been recently cleaned nor were they scheduled on a regular basis to maintain sanitary conditions. Also, s/he verified that disposable towels were not available at the common sink area. On 5/21/13 at approximately 2:45 PM, review of the facilities policy titled Proper Use of Thermometers, revealed under Procedure: 3.) All thermometers are checked daily prior to each meal. The accuracy is checked by the following procedure: Place the thermometer in the ice water and wait three minutes stirring occasionally. After three minutes the thermometer should read 32 degrees Fahrenheit. If the temperature does not read 32 degrees Fahrenheit it should be calibrated prior to use. Also, review of the facility policy Pot and Pan Washing, revealed under Procedure 2.) A three compartment sink is used. The first sink is used for washing, the second for rinsing, and the third for sanitizing. Procedure 5.) The third sink should contain hot water with adequate chemical solution. All items should be completely submersed in the water and be allowed to soak for one minute. A test strip should be used to determine if the sanitizer is appropriate. Further review of the facility policy Cleaning & Maintaining Ice Machines, revealed under subtitle Ice Scoops, Procedure 3.) The tray and scoop should be run through the dishwasher every day.",2017-05-01
7182,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-05-30,428,D,0,1,2OTX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based upon a random observation, the facility, the pharmacy and the consultant pharmacist failed to indicate a correct [DIAGNOSES REDACTED]. Calcitonin Salmon Nasal Spray (Miacalcin), 200 Unit/spray for Resident E was noted to bear a [DIAGNOSES REDACTED].>The findings include: On 5/19/13 at approximately 4:55 PM during inspection of the 200 Hall (Magnolia) medication room refrigerator, the pharmacy dispensing label on a container of Calcitonin Salmon Nasal Spray (Miacalcin), 200 Unit/spray for Resident E was noted to bear a [DIAGNOSES REDACTED].>On 5/20/13 at approximately 12:15 PM, LPN # 1 stated that Resident E had been sent to the hospital on [DATE] at approximately 11:00 AM due to breathing problems On 5/20/13 at approximately 11:20 AM, the Consultant Pharmacist stated that the facility identifies diagnoses associated with each medication and communicates that information to the pharmacy for review. He/she stated that the consultant pharmacist, during monthly MRR (medication regimen review) checks for [DIAGNOSES REDACTED]. On 5/20/13 at approximately at approximately 2:20 PM, a review active and thinned records for Resident E showed that the medication had been initially ordered on [DATE] and ordered again in subsequent months including May, 2013. During the period from 1/7/11 to May, 2013 all physician orders [REDACTED].*DX (diagnosis) allergies [REDACTED]. Further review of the Consultant Pharmacist MRR (Medication Regimen Review) for Resident E from 1/21/11 through 4/23/13 failed to show a [DIAGNOSES REDACTED]. Further review of the physicians orders, January, 2011 through May, 2013, for Resident E showed multiple diagnosed including: [DIAGNOSES REDACTED].>",2017-05-01
7183,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-05-30,502,E,0,1,2OTX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On days of the survey, based on record review and interviews the facility failed to obtain laboratory services when ordered by the attending Physician. Labs were not obtained for Residents #5, #6, #8 and #12 as ordered by the Physician. (4 of 14 residents reviewed for laboratory services) The findings included: The facility admitted Resident #5 with a [DIAGNOSES REDACTED]. anxiety, and [MEDICAL CONDITION]. On 5/21/13 at approximately 10:14 AM during record review of Resident #5's medical record revealed an order by the attending Physician for a [MEDICATION NAME] Level every 6 months, and a [MEDICATION NAME] level to be drawn once a month, and a TSH ([MEDICAL CONDITION] Stimulating Hormone) level every 6 months, HFP (Hepatic Function Panel) every 6 months, CBC (Complete Blood Count) every 6 months, BMP (Basic Metabolic Panel) every 6 months, and a PAB ([MEDICATION NAME]) level very 6 months. No results were found for the monthly [MEDICATION NAME] level for 11/2012, 12/2012, 1/2013, 2/2013, 3/2013. No TSH level, HFP level, CBC level, or BMP levels were found in Resident #5's medical record for 2/2013. An interview on 5/21/13 at approximately 10:14 AM with the RN (Registered Nurse) Unit Manager on Magnolia Hall verified that the labs had not been done for the dates listed. The facility admitted Resident #6 to the facility with a [DIAGNOSES REDACTED]. During review of Resident #6's medical record on 5/21/13 at approximately 10:50 AM revealed an order by the attending Physician for a H&H (Hemoglobin and Hematocrit) level every month, a HgbA1c (Glycosylated Hemoglobin) every 3 months, CBC (Complete Blood Count) every 3 months, and a CMP (Complete Metabolic Panel) every 3 months No results were found in Resident #6's medical record for the HgbA1c for 12/2012 and 3/2013. No results were found for the H&H for 8/2012, 11/2012, 1/2013, 2/2013, and 3/2013. No results were found for the CMP for 3/2013 and no results were found for a CBC for 3/2013. An interview on 5/21/13 at approximately 10:50 AM with the RN Unit Manager on Magnolia Hall verified that the labs had not been done for the dates listed. On 5/20/2013 at 1:00 PM, record review of Resident #12's cumulative physician's orders [REDACTED].**LABS** CBC (Complete Blood Count), CMP (Complete Metabolic Panel), TSH ([MEDICAL CONDITION] Stimulating Hormone), and Liver Function Test (LFT) every 6 months (Dec/Jun). Further record review revealed that the mentioned labs were not drawn in December as ordered. On 5/20/2013 at 4:15 PM, this surveyor shared with the Unit Manager that the December labs could not be found in Resident #12's record. He/she stated I will look for the labs. On 5/21/2013 at 11:30 AM during an interview with the Unit Manager, he/she reviewed and verified that the labs were not drawn in December as ordered. However, he/she presented this surveyor with a Physician's Telephone Order dated 5/20/13 that states Obtain CBC, CMP, TSH, and LFT in am and Q 6 months. On 5/21/2013 at 1:00 PM, record review of Resident #8's cumulative physician's orders [REDACTED].>for the month of May 2013 revealed Lipid Panel Q (Every) 6 months, Hemoglobin A1C (HgBAIC) Q 3 months, CBC (Complete Blood Count) and Complete Metabolic Panel (CMP) Q3 months. Further record review revealed that the above mentioned labs were not drawn as ordered. On 05/21/2013 at 3:00 PM during an interview with the Assistant Director of Nursing (ADON), he/she reviewed and verified that the CMP and the HgAIC were last drawn on 12/27/2012,the CBC was last drawn on 09/28/2012 and that there were no lab results for the Lipid Panel.",2017-05-01
7184,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2014-05-01,281,J,1,0,PSP611,Deficiency Text Not Available,2017-05-01
7185,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2014-05-01,309,J,1,0,PSP611,Deficiency Text Not Available,2017-05-01
7186,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2014-05-01,314,E,1,0,PSP611,"**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 ensure that necessary treatment and services were provided to promote healing for 1 of 4 residents reviewed for pressure ulcers (Resident #8). The facility also failed to monitor and provide a consistent turning schedule for 4 of 4 residents reviewed for pressure ulcers (Residents #1, #6, #7, and #8). The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed a physician's orders [REDACTED]. Start cleanse with wound cleanser, apply [MEDICATION NAME] fluffed gauze and wrap with kerlix BID (twice a day). Review of the [DATE] Treatment Administration Record (TAR) on [DATE] revealed the new order had not been added to the treatment sheet. Further review of the TAR revealed the resident received skin prep to the left heel twice a day for fifteen days. No order was written or found by the facility for the skin prep to the left heel. No further treatment was documented for the left heel from [DATE]-[DATE]. No treatment was documented as provided to the right heel from [DATE]-[DATE]. Review of the nurse's notes revealed there was no documentation related to the change in treatment or implementation of the treatment ordered on [DATE]. During an interview with the Assistant Director of Nursing (ADON) on [DATE], s/he confirmed the order written on [DATE] had not been implemented. S/he confirmed there was no order for the skin prep to the left foot. On [DATE] at 3:27 PM s/he confirmed a clarification order was written on [DATE] to discontinue treatment to the right heel and cleanse left heel with wound cleanser, apply [MEDICATION NAME] fluffed gauze and wrap with kerlix twice a day until healed. The ADON confirmed the treatment was not done on [DATE] and could offer no explanation. On [DATE] at 3:15 PM, during an interview the resident's physician, s/he stated that the resident's pressure areas were not observed each time s/he made a visit. S/he continued by stating s/he was not aware the order for [DATE] had not been carried through and that the facility may have faxed (facsimile) information to his/her office but at this time s/he was unaware. S/he further stated that all orders should be done and the facility had guidelines and certainly needed to follow the guidelines. When discussing Resident #8, s/he stated that even if the resident had received the treatment as ordered, s/he did not think it would have made a whole lot of difference due to the resident's condition. Observation of Resident #8 on [DATE] at 11:45 AM revealed the resident was lying on his/her back. At 2:30 PM the resident was out of the facility. Resident #8 was observed at 4:30 PM and 5:45 PM lying on his/her back. Observation of the resident's right heel on [DATE] revealed a healed area. Observation of the left heel revealed a healing .3cm x 1 cm (centimeter) dark area. The facility self-reported an allegation of neglect to the State Agency on [DATE] after a Licensed Practical Nurse (LPN) #1 did not initiate CPR. Review of the facility obtained statements revealed a statement by Certified Nurse Aide #1 that stated s/he picked up the roommates breakfast tray and Resident #1 was sleeping. The last time I saw him after that was during lunch when the nurse notify me that he had past . In an interview with the surveyor on [DATE] at approximately 1:25 PM, Certified Nurse Aide (CNA) #1 stated that s/he was assigned to Resident #1 on [DATE] on the 7:00 AM - 3:00 PM shift. CNA #1 stated that s/he provided incontinent care to Resident #1 at approximately 7:30 AM. CNA #1 saw the resident again at approximately 9:30 AM when s/he went into the room to get Resident #1's roommate's meal tray; s/he did not provide care to Resident #1 at that time. CNA #1 stated that the only time s/he provided care for Resident #1 was at 7:30 AM. Review of Resident #1's closed medical record indicated s/he was admitted with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded as having a short-term and long-term memory problem with severely impaired cognitive skills for daily decision-making. Resident #1 at the time of the reported incident had a stage II pressure ulcer on his/her left hip. The facility admitted Resident #6 with diagnoses, which included but not limited to Advanced Alzheimer's Dementia and [MEDICAL CONDITION]. Observation of the resident on [DATE] at 12:40 PM revealed the resident was lying on his/her back in bed with the head of the bed elevated approximately 30 degrees. Resident #6 was observed at 4:30 PM and 5:40 PM lying on his/her back. The facility admitted Resident #7 with diagnoses, which included but not limited to [MEDICAL CONDITIONS] related to [MEDICAL CONDITIONS], Diabetes Mellitus and Decubitus. Observation on [DATE] of the resident revealed at 2:35 PM, the resident was sitting up in bed at a 45 degree angle, at 4:35 PM and 5:30 PM; the resident was lying on his/her back. During an interview with the Administrator on [DATE], s/he stated that due to malfunctioning air mattresses, they had all been discontinued. When asked what was the facility doing instead, s/he stated aggressive turning. The facility could not provide any documentation related to how the aggressive turning was monitored however; the Administrator stated the nurse's pay close attention to whether or not the resident's are turned. An interview on [DATE] with CNA (Certified Nursing Assistant)#1 revealed a turning log was kept at the desk and we write it down daily before we start work. We keep referring to the information in the log and turn the resident when the two hour time frame is up. An interview on [DATE] with CNA #2 revealed the CNA's just check on the resident's every two hours and turn them. It is not written down anywhere.",2017-05-01
7187,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2014-05-01,520,E,1,0,PSP611,"**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 and implement appropriate plans of action to correct identified quality deficiencies. The findings included: Cross refers to F314 as it relates to the failure of the facility to ensure that necessary treatments and services were provided to promote healing for 1 of 4 residents reviewed for pressure ulcers (Resident #8). The facility also failed to monitor and provide a consistent turning schedule for 4 of 4 residents reviewed for pressure ulcers (Residents #1, #6, #7, and #8). During the complaint and extended survey, problems with ordered pressure sore treatments not done and treatment provided without a physician's orders [REDACTED]. Also, per the Administrator due to malfunctioning air mattresses, an aggressive turning schedule was implemented. An in-service was provided on 2/28/14 to Nurses and CNA's (Certified Nursing Assistants) on turning and repositioning q (every) 2 hours. No documentation was provided related to the monitoring of the turning of residents. Residents were observed in the same position on multiple observations.",2017-05-01
8269,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2012-07-25,318,D,0,1,QHNN11,"**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 1 sampled resident with limited range of motion received appropriate services to prevent further decline. Resident #3 did not receive Restorative Nursing as recommended by Occupational Therapy. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set((MDS) dated [DATE] revealed the resident had range of motion limitations of the upper and lower extremities on one side. Review of the Occupational Discharge Note dated 6/22/12 revealed a recommendation for Restorative Nursing for left upper extremity range of motion and to continue with a rolled washcloth in the left hand at all times as tolerated except for patient care. Further review of the medical record revealed no restorative notes on the record. On 7/24/12 the Unit Manager was asked if she could locate documentation related to restorative services. The Unit Manager stated that Restorative Nursing had not been initiated. Further interview with Administrative Staff revealed that Restorative had not been started due to failure of therapy not initiating the paperwork.",2016-06-01
8270,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2012-07-25,325,D,0,1,QHNN11,"**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 maintain acceptable nutritional status as evidence by not following Physicians order for mighty shake to prevent weight loss for 1 of 5 residents reviewed for nutritional status (Resident #13). The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review of the medical record on 7/23/12 at approximately 6 PM revealed Resident #13 was dependent on others for all ADL's (Activities of Daily Living) which includes eating. Reviewing the medical record for Resident #13 revealed a Physicians order for Mighty Shakes TID (Three times a day) with meals. Review of the Registered Dietitian Nutritional Care Monitoring Notes dated 6/7/12 revealed a problem of involuntary weight loss with a recommended intervention of Shake tid with meals. The RD documented the resident had an [MEDICATION NAME] level of 2.5. Observations of the lunch and supper meal on 7/24/12 revealed that Resident #13 did not receive a mighty shake with either meal. During an interview on 7/24/12 with the Unit Manager for [MEDICATION NAME], she verified that resident did not receive nutritional supplement with meal because the Physicians order for mighty shake for Resident #13 was never sent to Dietary for the weight loss intervention to be implemented.",2016-06-01
8271,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2012-07-25,367,D,0,1,QHNN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, and interviews, the facility failed to provide a physician ordered diet in the appropriate form for 1 of 2 residents reviewed receiving a Puree diet. Resident #3 continued to receive whole sandwiches after the diet was changed to pureed. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 7/23/12 revealed a physician's orders [REDACTED]. During observation of the lunch meal on 7/24/12, a staff member delivering the tray was asked what diet the resident was receiving. The staff member stated that the resident was receiving a Puree diet. The staff member was asked if a whole sandwich was on a Puree diet and she stated that she did not think she would feed the sandwich to the resident. Observation of the evening meal revealed LPN(Licensed Practical Nurse)#2 feeding the resident. LPN #2 was asked what diet the resident was on and she responded after reading the tray card that she was on a Puree diet. LPN #2 confirmed a whole sandwich on the resident's tray. Review of the tray card revealed a sandwich was still listed. An interview with the Dietary Manager on 7/25/12 revealed that the sandwich had remained on the tray card after the diet change and that after it had been brought to her attention, it was removed. An interview with the Registered Dietician on 7/25/12 at 11:45 AM revealed that the sandwich was listed as a preference of the resident and when reviewing the resident's diet, she did not review the tray card for accuracy.",2016-06-01
8272,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2012-07-25,425,D,0,1,QHNN11,"On the days of the survey, based on observation, manufacturer package insert, Facts and Comparisons (Updated Monthly) and interview, the facility failed to follow a procedure to ensure that expired medications were not stored in 1 of 3 medication rooms. The findings included: On 7/23/12 at approximately 1:10 PM, inspection of the Indigo Medication Room refrigerator revealed the following: Two opened vials of Tuberculin PPD (Purified Protein Derivative), 5 TU (Test Units)/0.1 ml (milliliter/vial, lots 3 and 7, labelled House Stock had not been labeled as to date opened. The manufacturer (JHD Pharmaceuticals) package insert and Facts and Comparision, page 2001 state, Discard vials in use for more than 30 days because of possible oxidation and degradation that may affect potency. This finding was verified by LPN (Licensed Practical Nurse #1 on 7/23/12 at approxiamtely 1:20 PM.",2016-06-01
8587,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-02-10,272,D,1,0,1X6M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, observation and limited record review, the facility failed to conduct periodic assessment of the resident's functional capacity related to needed assistance with transfer and toileting for Resident #1, 1 of 2 residents reviewed for falls. The findings included: Cross-refer to F-282 as it relates to the failure of the facility to follow Resident #1's care plan related to her/his need for assistance with transfer and toileting. Cross-refer to F-323 as it relates to the failure of the facility to adequately supervise the Certified Nurse Aide (CNA) staff in assisting with the transfer and toileting of Resident #1. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] coded the resident with a BIMS of 14/15 the resident was alert, oriented and made decision of daily living independently. S/he was coded as requiring the assistance of 2 persons for transfer and toilet use. Review of the Interdisciplinary Progress Notes dated 1/10/2013 stated the resident was assisted to the bathroom by a CNA, that when the resident's knee/legs got weak and gave out s/he went to the floor. The resident sustained [REDACTED]. Resident #1 interviewed by the surveyor on 2/10/2013 at 7:25 PM stated s/he walked a short distance to the dining room almost daily using her/his walker with a nursing aide walking beside her/him. S/he also stated that s/he could get around pretty good by her/himself in the wheelchair. A wheelchair and walker was observed on the resident's side of the room. The resident confirmed that s/he had a fall on 1/10/2013 and that one CNA was assisting her/him to the bathroom. S/he stated that when s/he went down s/he was holding to the rail in the bathroom with her/his left hand and somehow it twisted and s/he hurt her/his finger. Review of the Care Plan initiated 12/31/2008 revised 12/18/2012 identified a history of falls related to unsteady gait and poor safety awareness approaches included 2 assist with RW (rolling walker) for txf's (transfers). The Care Plan documented falls on 5/20/2011 with a fracture to the right humerus. Review of the CNA Kardex/care plan in use at the time of the incident revealed a section headed Transfers that indicated Assist 2 Other: with R.W. (rolling walker) leave R.W. in BR (bathroom). The section headed Continence indicated incontinent at night, bowel, bladder, commode 3-1 commode, Other: prompted toileting. Under the Safety heading it indicated please move w/c (wheelchair) to hall when in bed @ night. The Activity/Mobility section indicated walker RW in BR. The Kardex was not dated. Review of the ADL (activities of daily living) Flow Record for Transfers and Toilet Use for November, December 2012 and January 1-10, 2013 showed the resident transferred and used the toilet with the assistance of 1 staff member on all shifts. In a face-to-face interview with the surveyor on 2/10/2013 at 7:45 PM CNA #2 stated s/he was in the room when Resident #1 fell in the bathroom. S/he stated that s/he and CNA #1 went in the room to provide care for Resident #1 and her/his roommate; that CNA #1 helped her/him with Resident #1's roommate who was transferred with the lift and when they finished with the roommate CNA #1 helped Resident #1 to the bathroom. CNA #2 confirmed s/he was in the room when Resident #1 fell and saw her/him on the floor in the bathroom and that CNA #1 was standing behind her/him between the toilet and the resident holding her/him by the shoulder. At 8:10 PM (2/10/2013) CNA #2 confirmed the wheelchair and walker in Resident #1's room belonged to the resident. CNA #2 stated that s/he had assisted Resident #1 by her/himself before. In a face-to-face interview with the surveyor on 2/10/2013 at approximately 11:05 PM the Director of Therapy stated that currently Resident #1 was followed by Restorative Therapy; that Physical Therapy saw the resident regarding the splint ordered following the fall on 1/10/2013. The last time s/he was assessed by therapy was late in 2011 when s/he was in rehab following her/his last fracture. The Director of Therapy stated that Resident #1 needed two people on each side when s/he was using the walker with a wheelchair following behind. During an interview with the Administrator and Director of Nurses on 2/10/2013 at approximately 11:30 PM the surveyor referred them to the November, December 2012 and January 1-10, 2013 ADL (activities of daily living) Flow Record and confirmed the documentation by the CNA's that showed Resident #1 transferred and used the toilet with the assistance of 1 staff member on all shifts.",2016-02-01
8588,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-02-10,282,D,1,0,1X6M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, observation and limited record review the facility failed to implement interventions to prevent falls for Resident #1, 1 of 2 residents reviewed for falls. The facility failed to ensure that 2 staff members as documented on the resident's care plan and Certified Nurse Aide (CNA) Kardex assisted Resident #1 with transfers and toilet use. The findings included: Cross-refer to F-272 as it relates to the failure of the facility to conduct periodic assessment of the resident's functional capacity related to needed assistance with transfer and toileting for Resident #1, 1 of 2 residents reviewed for falls. Cross-refer to F-323 as it relates to the failure of the facility to adequately supervise the Certified Nurse Aide (CNA) staff in assisting with the transfer and toileting of Resident #1. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] coded the resident with a BIMS of 14/15 the resident was alert, oriented and made decision of daily living independently. S/he was coded as requiring the assistance of 2 persons for transfer and toilet use. Review of the Interdisciplinary Progress Notes dated 1/10/2013 stated the resident was assisted to the bathroom by a CNA, that when the resident's knee/legs got weak and gave out s/he went to the floor. The resident sustained [REDACTED]. Review of the Care Plan initiated 12/31/2008 revised 12/18/2012 identified a history of falls related to unsteady gait and poor safety awareness approaches included 2 assist with RW (rolling walker) for txf's (transfers). The Care Plan documented falls on 5/20/2011 with a fracture to the right humerus. Review of the CNA Kardex/care plan in use at the time of the incident revealed a section headed Transfers that indicated Assist 2 Other: with R.W. (rolling walker) leave R.W. in BR (bathroom). The section headed Continence indicated incontinent at night, bowel, bladder, commode 3-1 commode, Other: prompted toileting. Under the Safety heading it indicated please move w/c (wheelchair) to hall when in bed @ night. The Activity/Mobility section indicated walker RW in BR. The Kardex was not dated. Review of the ADL (activities of daily living) Flow Record for Transfers and Toilet Use for November, December 2012 and January 1-10, 2013 showed the resident transferred and used the toilet with the assistance of 1 staff member on all shifts. In a face-to-face interview with the surveyor on 2/10/2013 at 7:45 PM CNA #2 confirmed s/he was in the room when Resident #1 fell and saw her/him on the floor in the bathroom and that CNA #1 was standing behind her/him between the toilet and the resident holding her/him by the shoulder. CNA #2 stated that s/he had assisted Resident #1 by her/himself before. During an interview with the Administrator and Director of Nurses on 2/10/2013 at approximately 11:30 PM the surveyor referred them to the November, December 2012 and January 1-10, 2013 ADL (activities of daily living) Flow Record and confirmed the documentation by the CNA's that showed Resident #1 transferred and used the toilet with the assistance of 1 staff member on all shifts.",2016-02-01
8589,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2013-02-10,323,D,1,0,1X6M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, observation and limited record review, the facility failed to adequately supervise the nursing staff to ensure that interventions to prevent falls were adequate and appropriate for Resident #1, 1 of 2 residents reviewed for falls. The findings included: Cross-refer to F-272 as it relates to the failure of the facility to conduct periodic assessment of the resident's functional capacity related to needed assistance with transfer and toileting for Resident #1, 1 of 2 residents reviewed for falls. Cross-refer to F-282 as it relates to the failure of the facility to follow Resident #1's care plan related to her/his need for assistance with transfer and toileting. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Annual Minimum (MDS) data set [DATE] coded the resident with a BIMS of 14/15 the resident was alert, oriented and made decision of daily living independently. S/he was coded as requiring the assistance of 2 persons for transfer and toilet use. Review of the Interdisciplinary Progress Notes dated 1/10/2013 stated, Res (resident) was being assisted to bathroom per CNA @2025 when her knee/legs got weak and gave out, Res. went to the floor and CNA was standing behind her to assist to floor . She was also using walker @ the time . Assessed, V/S (vital signs) taken, O2 placed. No visible injuries noted. Res c/o discomfort to (R) knee and (L) hand, no swelling or bruising noted . monitoring. On 1/11/2013 the physician was notified of bruising to the resident's left pinky finger and pain; the physician ordered an x-ray to the left hand. The x-ray revealed a fracture to the 5 metacarpal on the left hand. The physician ordered a splint applied to the left hand per physical therapy and an orthopedic consult was made for the 1/13/2012. Review of the preliminary x-ray report dated 1/11/2013 stated, .Bone demineralized - transverse fracture at base of 5th metacarpal (left hand) . Review of the Care Plan initiated 12/31/2008 and revised 12/18/2012 identified a history of falls related to unsteady gait and poor safety awareness approaches included 2 assist with RW (rolling walker) for txf's (transfers). The Care Plan documented falls on 5/20/2011 with a fracture to the right humerus. Review of the CNA Kardex/care plan in use at the time of the incident revealed a section headed Transfers that indicated Assist 2 Other: with R.W. (rolling walker) leave R.W. in BR (bathroom). The section headed Continence indicated incontinent at night, bowel, bladder, commode 3-1 commode, Other: prompted toileting. Under the Safety heading it indicated please move w/c (wheelchair) to hall when in bed @ night. The Activity/Mobility section indicated walker RW in BR. The Kardex was not dated. Review of the ADL (activities of daily living) Flow Record for Transfers and Toilet Use for November, December 2012 and January 1-10, 2013 showed the resident transferred and used the toilet with the assistance of 1 staff member on all shifts. Resident #1 interviewed by the surveyor on 2/10/2013 at 7:25 PM stated s/he walked a short distance to the dining room almost daily using her/his walker with a nursing aide walking beside her/him. S/he also stated that s/he could get around pretty good by her/himself in the wheelchair. A wheelchair and walker was observed on the resident's side of the room. The resident confirmed that s/he had a fall on 1/10/2013 and that one CNA was assisting her/him to the bathroom. S/he stated that when s/he went down s/he was holding to the rail in the bathroom with her/his left hand and somehow it twisted and s/he hurt her/his finger. In a face-to-face interview with the surveyor on 1/10/2013 at 7:45 PM CNA #2 stated s/he was in the room when Resident #1 fell in the bathroom. S/he stated that s/he and CNA #1 went in the room to provide care for Resident #1 and her/his roommate; that CNA #1 helped her/him with Resident #1's roommate who was transferred with the lift and when they finished with the roommate CNA #1 helped Resident #1 to the bathroom. CNA #2 confirmed s/he was in the room when Resident #1 fell and saw her/him on the floor in the bathroom and that CNA #1 was standing behind her/him between the toilet and the resident holding her/him by the shoulder. At 8:10 PM (2/10/2013) CNA #2 confirmed the wheelchair and walker in Resident #1's room belonged to the resident. In a face-to-face interview with Licensed Practical Nurse #1 on 2/10/2013 at 9:30 PM s/he stated s/he observed the CNA's to make sure they were transferring residents appropriately. S/he stated that s/he was often asked by the CNA's to assist with the Hoyer lift. In a face-to-face interview with Registered Nurse #1 on 2/19/2013 at 10:55 PM s/he stated that s/he would use the ADL sheet as a way to make sure the CNA's were doing their jobs. S/he stated that s/he observed the CNA's when s/he was giving meds or providing care. During an interview with the Administrator and Director of Nurses on 2/10/2013 at approximately 11:30 PM the surveyor referred them to the November, December 2012 and January 1-10, 2013 ADL (activities of daily living) Flow Record and confirmed the documentation by the CNA's that showed Resident #1 transferred and used the toilet with the assistance of 1 staff member on all shifts.",2016-02-01
9063,PRINCE GEORGE HEALTHCARE CENTER,425295,901 MAPLE STREET,GEORGETOWN,SC,29440,2012-05-23,323,G,1,0,F9OU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review, observations, interviews, and review of facility injury investigation files, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident who sustained injury from an improper transfer from bed to chair on 4/30/12 (#1). Certified Nursing Assistant (CNA) #1 used a manual assist of one person to transfer the resident from bed to wheelchair. The resident, however, needed mechanical lift with the assist of two persons for transfer. A statement from CNA #2 as part of the facility's investigation, revealed CNA #1 confused Resident #1 for her roommate, who was an assist of one person for transfer. The findings included: Resident #1 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instrument (assessment reference date of 10/23/11) and the latest quarterly Minimum Date Set (assessment reference date of 4/8/12) revealed the resident required the total assistance of two people for transfer from bed to chair. The annual assessment notes stated the resident needed the assist of two people with a mechanical lift for transfer. The quarterly assessment showed a BIMS (Brief Interview for Mental Status) score of 12/15, indicating moderate cognitive impairment Review of the medical record revealed the resident's drug regimen included the antiplatelet agent, Aggrenox, increasing the risk for bleeding. Review of the resident's plan of care revealed ""Needs dependent assistance of 2 with hoyer (sic) (total mechanical lift) for transfers."" The Kardex for nursing assistants also showed the resident needed mechanical lift for transfers. Review of the facility's policy for Resident Transfer: Mechanical Lift showed "" ... Mechanical lifts require at least a 2-person assist. ..."" The policy also stated under Training: ""All staff should be in-serviced on use of a mechanical lift, and Demonstrate his/her competency with the device to his/her supervisor. ..."" Review of the Nurse's Notes showed an entry on 4/30/12 at 0700 stating the resident complained of pain in her left shoulder and left knee after being put back to bed that morning. Review of the facility's injury report revealed the resident's left shoulder was swollen. The physician ordered portable x-rays which were negative for fracture. The resident filed a grievance report on 4/30/12 stating that the CNA (#1) that got her out of bed that morning hurt her left shoulder and her left heel. Resident #1 told the Social Worker that the CNA picked her up by the arm and put her in her wheelchair. She heard her arm crack and thought her shoulder was out of place. The resident also stated that in the process of the transfer, the CNA hit her heel on something on the wheelchair. Resident #1 said when she was put back to bed, the CNA slammed her hard on the bed. A Nurse's Note on 5/1/12 at 1630 said the resident had significant bruising to the anterior part of her left upper arm. There was bruising to the right chest spreading from the breast to under the axilla. Observation of the resident on 5/23/12 at 10:45 AM revealed she still showed evidence of extensive bruising. A large dark bruise extended down her left anterior/inner upper arm from axilla level to just above the elbow. Another large dark bruise was observed from the elbow to above the wrist on the left outer forearm. A round, dark bruise was noted on the left chest wall under the axilla. Approximately one half of the resident's right breast was darkly bruised. The resident complained of left arm pain and left knee pain when visited by the physician at 12:40 PM. The resident was unwilling to speak about the incident on the day of the complaint inspection. Review of the facility's investigative materials revealed a written statement from CNA #2, who was on duty 11-7 on 4/29-30/12. She said the resident was up in her wheelchair by the nurses' station early on 4/30/12. The resident wanted to go back to bed. She did not have the mechanical lift pad underneath her. CNA #2 assisted CNA #1 to put the resident back to bed using a 2 person lift. CNA #2 was on the resident's right side and CNA #1 was on the left. CNA #2 wrote in her statement that CNA #1 confused the two residents in the room, she thought Resident #1 was on her assignment but she should have attended the roommate instead of Resident #1. Review of the CNA Assignment Sheet for the 11-7 shift on 4/29-30/12 clearly showed CNA #1 was assigned to Resident #2 in the B bed, and not Resident #1 in the A bed. A written statement from the Unit Manager dated 4/30/12 said she called CNA #1 to ask if the CNA had assisted the resident out of bed that morning. CNA #1 responded ""yes I sure did."" CNA #1 declined to provide a written statement for the facility's file. Review of CNA #1's employee file failed to show evidence, per the facility's Resident Transfer: Mechanical Lift policy, that CNA #1 had been trained in using a mechanical lift and had completed a return demonstration showing competency.",2015-08-01
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
1116,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2017-01-26,272,D,0,1,90VE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled Comfort Care, the facility failed to ensure Resident #249 was reassessed and monitored after a documented change in condition and decline for 1 of 1 residents reviewed for death. The findings included: The facility admitted Resident #249 with [DIAGNOSES REDACTED]. Review on 1/24/2017 at approximately 3:27 PM of the nurses notes for Resident #249 revealed a note on 1/12/2017 at 11:46 AM which states, Resident resting in bed. Bed is locked and in lowest position. Call light within reach. Change in condition noted. Resident is showing signs and symptoms of pain and agitation. PRN (as needed) meds given. RP (responsible party) made aware. Unable to obtain vital signs at this time. Further review of the nurses notes on 1/24/2017 at approximately 3:30 PM revealed the very next note dated 1/12/2017 at 5:23 PM reads, Late entry: Resident assessed at 4:00 PM. No blood pressure, no pulse and no respirations. Pupils fixed and dilated. Physician pronounced death at 4:00 PM. RP made aware. No documentation of reassessments or monitoring was found in Resident #249's nurses notes to ensure Resident #249 was reassessed or monitored after a change in condition with a decline. Review on 1/25/217 at approximately 12:40 PM of the physician progress notes [REDACTED]. The medical record did not include any progress notes by the physician. A physician's order was faxed into the facility on [DATE] at 1:00 PM that reads, Notified at 11:50 AM on 1/12/2017 that resident was declining due to [MEDICAL CONDITION] and nearing death. Advised to continue aggressive comfort measures. Review on 1/25/2017 at approximately 2:00 PM of a document titled, Discharge Summary, states under, Problem: Resident Requires Palliative Care. Goal #1: Resident will be kept as comfortable as possible, as evidenced by no verbal/nonverbal indications of distress/discomfort and or dissatisfaction. The following approaches are listed, Obtain vital signs as indicated. Obtain 02 saturation as indicated with vital signs. Assist with turning and repositioning approximately every 2 hours or as needed for comfort. Check for incontinence at regular intervals and provide thorough incontinence care as needed. Administer meds as ordered. Monitor for nonverbal signs of dissatisfaction, discomfort, distress. Assess and meet needs accordingly. No documentation could be found in the medical record to ensure Resident #249 was afforded the required Palliative Care measures listed on the discharge summary. During an interview on 1/26/2017 at approximately 10:42 AM with Licensed Practical Nurse (LPN) #1, the nurse caring for Resident #249 at the time of the decline, stated, We were in and out of the resident's room all day checking on him/her. LPN #1 confirmed at this time that he/she had not documented in the medical record for Resident #249 any reassessment or monitoring of his/her condition during the decline and death of this resident. Review on 1/26/2017 at approximately 11:00 AM of the facility policy titled, Comfort Care. states, Policy: Physicians may order comfort measures (end of life care) for dying residents. This type of care focuses on providing palliative care to the resident with resident comfort as the main goal. The Purpose: reads, 1. The vital signs should be taken as indicated. 2. The resident should be turned and repositioned as indicated or as needed for comfort. 3. The resident should receive incontinence care, including skin care with turning or as needed. 4. The resident should be observed for signs/symptoms of pain and pain control measures utilized such as: [NAME] Turing and repositioning. B. Relaxation techniques. C. Medication as ordered by the physician. 5. Food/fluids should be offered as ordered. If resident is NPO (nothing by mouth) then oral care should be given as indicated.",2020-09-01
1117,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2017-01-26,371,E,0,1,90VE11,"Based on observation and interview the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. The food preparation area and bulk food containers were observed with splashes, the meat slicer had a build up on and around the blade and a Certified Nursing Aide was observed holding a cup to be used by a resident inside the brim with bare hands. The findings included: During a meal observation on 1/23/17 at 12:02 PM, Certified Nursing Aide (CNA) #1 touched the brim (inside edge of the cup where a person's mouth touches) of the 2 coffee cups with her bare fingers and then served coffee in the cups to two residents; and touched the inside of a coffee cup with her bare fingers and served the coffee in the cup to one other resident. During an interview on 1/26/17 at 2:26 PM, CNA #1 states she served the coffee to the residents in the dining room on 1/23/17. She stated the sanitary way to serve coffee is to hold the cup by either the bottom or the handle of the cup. She stated she wouldn't hold the cup by the brim. She stated she was not aware she had picked up the cups by the brim with bare fingers; and she was not aware her bare fingers had touched the inside of a coffee cup. She stated she was rushing and that she knows the right place to hold the cup. During an interview on 1/26/17 at 3:23 PM, the Infection Prevention Coordinator stated that staff should not touch with bare hands any piece of equipment that will make contact with a resident's mouth. She stated they have tried to avoid touching the brim of a cup with bare hands and that bare fingers should not have touched the brim or inside of a cup. During the Initial Tour of the Main Kitchen on 1/23/17 at 11:05 AM, bulk food containers for rice and sugar were observed with visible splashes on them. The Food Service Director verified the splashes and stated these containers are cleaned every day. The meat slicer was observed with buildup on and around the blade, the Food Service Director verified this and stated the slicer was not supposed to look like that, it needed to be cleaned, and it had not been used that day. A maintenance box above the dessert preparation table was observed with dust buildup, the Food Service Director stated she noticed the buildup after the surveyor pointed it out to her. The bakers oven was observed with visible splashes on the doors and on the floor surrounding thee oven. The Food Service Director verified the splashes and stated the oven is cleaned once a week. The Policy for Dietary Department, last updated 1/2017, stated all equipment must be cleaned at all times and all food preparation equipment, dishes and utensils must be maintained in a clean, sanitary, and safe manner .",2020-09-01
1118,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2017-01-26,502,D,0,1,90VE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Laboratory Services, the facility failed to ensure physician ordered lab services were obtained for Resident #93 for 1 of 6 residents reviewed with lab services ordered. A [MEDICATION NAME] level was not obtained as ordered for Resident #93. The findings included: The facility admitted Resident #93 with [DIAGNOSES REDACTED]. Review on 1/26/2017 at approximately 2:30 PM of the medical record for Resident #93 revealed a [MEDICATION NAME] level that was ordered every 6 months by the physician had not been drawn for 9/2016. During an interview on 1/26/2017 at approximately 4:30 PM with the Director of Nursing, he/she confirmed that the [MEDICATION NAME] level ordered by the physician ever 6 months had no been drawn for (MONTH) (YEAR). Resident #93 continued to take the ordered dose of [MEDICATION NAME] for a [MEDICAL CONDITION] Disorder. Review on 1/26/2017 at approximately 4:45 PM of the facility policy titled, Laboratory Services. states. Policy: Lab services will be provided per physician's/ Nurse Practitioner's order. The Procedure: states, 1. The physician/NP must order all laboratory services. 2. If the lab order does not specify the laboratory service is an emergency, it may be carried out on the next scheduled lab date. 3. Emergency requests must be labeled stat to assure that prompt action is taken. 4. MD/NP will be notified immediately of critical lab values. 5. Abnormal lab values will be faxed or reviewed by MD/NP on next visit dependent on resident status/condition.",2020-09-01
1119,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2018-04-20,550,D,0,1,6TP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide privacy during toileting for 1 of 1 random observation. The findings included: Resident #429 was admitted to the facility with [DIAGNOSES REDACTED]. On 4/16/18 at approximately 12pm, Resident #429 was observed to be toileting inside of the room with a housekeeping attendant present. The curtain was not pulled and the door was not closed. At this point, the Surveyor asked for permission to enter the room, and once permission was granted, asked Resident #429 if the privacy curtain could be pulled. At this point, the housekeeping attendant stopped cleaning, stepped out of the room and continued down the hallway. On 4/18/18 at approximately 4pm, Resident #429 was interviewed and stated staff members were often present whenever toileting took place. Resident #429 also stated that it doesn't make her/him uncomfortable. An interview with the Housekeeping Supervisor (HS) on 4/20/18 at approximately 12pm revealed that it is the expectation of staff to knock on the resident's door and wait for permission before entering. HS then states that if a resident is observed to be using the restroom, the expectation of staff members is to excuses themselves until the resident is finished. HS states that education and training on resident dignity is given to staff, but was unable to provide any documentation.",2020-09-01
1120,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2018-04-20,623,E,0,1,6TP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Notice Before Transfers, the facility failed to ensure Resident #113, #85, #83, #55, #94, #113 and Resident #109 and their Personal Representatives received in writing and in a language they could understand of the reason for the transfer/discharge to the hospital for 6 of 6 residents reviewed for hospitalization . The findings included: The facility admitted Resident #55 with [DIAGNOSES REDACTED]. Review on 4/19/2018 at approximately 2:04 PM of the medical record for Resident #55 indicated that Resident #55 was admitted to the hospital on [DATE] and discharged back to the facility on [DATE]. No documentation could be found in the medical record for Resident #55 to ensure that he/she and the Personal Representative received in writing and in a language they could understand of the reason for the discharge/transfer to the hospital prior to the the transfer/discharge to the hospital. The facility admitted Resident #83 with [DIAGNOSES REDACTED]. Review on 4/18/2018 at approximately 8:34 AM of the medical record for Resident #83 revealed a hospital stay from 3/17/2018 until 3/22/2018 and then readmitted into the nursing facility. No documentation could be found in the medical record for Resident #83 to ensure he/she or the Personal Representative for Resident #83 receiving in writing in a language they could understand of the reason for the transfer/discharge to the hospital. The facility admitted Resident #94 with [DIAGNOSES REDACTED]. Review on 4/20/2018 at approximately 10:55 AM of the medical record for Resident #94 indicated a hospital stay from 1/25/2017 and returned to the facility on [DATE]. A hospital stay on 1/26/2018 and returned to the facility on [DATE] and a third hospital stay from 2/16/2018 and returned to the facility on [DATE]. No documentation could be found in the medical record to indicate that Resident #94 nor his/her Personal Representative received in writing and in a language they could understand of the reason for the transfer/discharge to the hospital. The facility admitted Resident #109 with [DIAGNOSES REDACTED]. Review on 4/20/2018 at approximately 4:34 PM of the medical record for Resident #109 revealed a hospital stay on 3/16/2018 and returned to the facility on [DATE] and out to the hospital in 3/31/2018 and returned to the hospital on [DATE]. No documentation could be found in the medical record for Resident #109 to ensure he/she or the Personal Representative for Resident #109 receiving in writing and in a language they could understand of the reason for the transfer/discharge to the hospital. During an interview on 4/18/2018 at approximately 10:00 AM with the DON (Director of Nursing) and he/she stated, we call the personal representative and let them know what is going on with the resident and we send a discharge summary with them. If the resident is a Medicare recipient then we send an ABN (Advance Beneficiary Notice), and if a Medicaid recipient then we notify the personal representative, If Medicare recipient then we send a bed hold. Review on 4/20/2018 at approximately 6:00 PM of the facility policy titled, Notice Before Transfers, states, Before a resident is transferred, the facility will notify the resident and/or resident representative of the transfer or discharge. The notice shall be in a language and manner they understand. This notice shall be in writing and shall include the reason for the transfer or discharge. The notice will be made either 30 days before the resident is transferred or discharged or as soon as practicable depending on the reason for the transfer or discharge. A copy of the notice will be sent to the Office of the State Long Term Care Ombudsman. The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Record review on 4/18/18 revealed Resident #113 was discharged to the hospital on [DATE]. Further review of the nurse's notes and the social services noted revealed there was no documentation written information of the reason for the transfer was distributed to the resident and the resident's representative. In addition, there was no documented evidence the Ombudsman was sent information related to the discharge. The facility admitted Resident #85 with [DIAGNOSES REDACTED]. Resident #85 was admitted to Lexington Medical Center 01/31/18 and returned to the facility on [DATE] there was no evidence that the Transfer and Bedhold information was distributed to the Resident/Responsible Party and/or Ombudsman.",2020-09-01
1121,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2018-04-20,625,D,0,1,6TP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Notification of Bed Hold, the facility failed to ensure Resident #113, #83, #94 and Resident #109 and or their personal representative received the Bed Hold Policy and the bed payment policy prior to a transfer/discharge to the hospital for 4 of 6 residents reviewed for hospitalization . The findings included: The facility admitted Resident #83 with [DIAGNOSES REDACTED]. Review on 4/18/2018 at approximately 8:34 AM of the medical record for Resident #83 revealed a hospital stay from 3/17/2018 until 3/22/2018 and then readmitted into the nursing facility. No documentation could be found in the medical record for Resident #83 and or the personal representative received the Bed Hold Policy with the reserve payment policy upon discharge/transfer to the hospital The facility admitted Resident #94 with [DIAGNOSES REDACTED]. Review on 4/20/2018 at approximately 10:55 AM of the medical record for Resident #94 indicated a hospital stay from 1/25/2017 and returned to the facility on [DATE]. A hospital stay on 1/26/2018 and returned to the facility on [DATE] and a third hospital stay from 2/16/2018 and returned to the facility on [DATE]. No documentation could be found in the medical record to indicate that Resident #94 and/or nor his/her Personal Representative received the Bed Hold Policy and the reserve payment policy upon transfer/discharge to the hospital. The facility admitted Resident #109 with [DIAGNOSES REDACTED]. Review on 4/20/2018 at approximately 4:34 PM of the medical record for Resident #109 revealed a hospital stay on 3/16/2018 and returned to the facility on [DATE] and out to the hospital in 3/31/2018 and returned to the hospital on [DATE]. No documentation could be found in the medical record for Resident #109 to ensure he/she or the Personal Representative for Resident #109 received the Bed Hold Policy upon discharge/transfer to the hospital. Review on 4/18/2018 at approximately 11:09 AM of the facility policy titled, Bed Hold Policy, states, Notification of Bed Hold, 1. Notice before Transfer: Before a resident is transferred to a hospital or goes on therapeutic leave the facility will provide written information to the resident and or resident representative specifying the duration of the bed-hold policy under the state plan, during which resident is permitted to return and resume residence in the facility. Number 2. states, Bed Hold Notice Upon Transfer, If a resident requires transfer to an acute hospital, the facility will offer the resident the opportunity of electing to have the bed held for 10 days. Upon admission, the facility will notify the resident or the representative of the bed hold option. The resident or the resident's representative is liable to pay reasonable charges, not to exceed the resident's daily room rate, for the bed hold period. Insurance may not cover such costs, Medicaid provides payment for a bed hold up to 10 days. The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Record review on 4/18/18 revealed Resident #113 was discharged to the hospital on [DATE]. Further review of the medical record revealed a Bed Hold Status form with a date of 3/5/18 was signed 3/6/18. There was no documentation the bed hold policy was given to the resident upon discharge to the hospital.",2020-09-01
1122,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2018-04-20,656,D,0,1,6TP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record Review, Observation and Interview the facility failed to develop a comprehensive Care Plan related to the use of a Communication Assistance Device for 1 of 3 sampled Residents reviewed for Communication/Sensory. The findings included: The facility admitted Resident #92 with [DIAGNOSES REDACTED]. Observation and interview of Resident #92 on 04/18/18 at approximately 9:57 AM revealed a picture/word book that was made by his/her family to assist with communication between the resident and staff. When asked if the book was helpful the resident indicated it was. Further review of the book revealed pictures and words related to simple questions, items the resident may want or need including staff, food, medications, toiletries and activities. Record review on 04/18/18 at approximately 12:16 PM revealed the Care Plan for Resident #92 did not include the use of the communication device. In an interview on 04/18/18 at approximately 12:16 PM the Minimum Data Set (MDS) Coordinator stated s/he thought the book was included in the care plan.",2020-09-01
1123,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2018-04-20,657,D,0,1,6TP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy titled Care Plans, the facility failed to ensure all required disciplines were involved with the care plan process for 3 of 28 care plans reviewed.(Resident #55,#87 & #113) In addition, the facility failed to update the care plans for Resident #128 for weight loss and Resident #87 for code status.(2 of 28 care plans reviewed) The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Record review on 4/20/18 of the Care Plan Conference Signature Sheets dated 3/29/17 and 6/21/17 revealed a Certified Nursing Assistant(CNA) did not participate in the care plan process. In addition, on 12/13/17 the dietary department was not represented in the care plan process. The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Record review on 4/20/18 of the Care Plan Conference Signature Sheets dated 4/19/17 and 7/5/17 revealed a CNA did not participate in the care plan process. Further review of the care plan revealed the code status for Resident #87 had not been updated to reflect a Do Not Resuscitate request by the resident representative which went into effect on 2/14/18. During an interview with the Director of Nursing on 4/20/18 at 10:43 AM, s/he confirmed Resident #87's care plan had not been updated to reflect the current code status. S/he continued by stating Social Services would ensure information related to code status is correct and at that time, the Care Plan Coordinator would update the care plan. Review of the facility policy titled Care Plans revealed the following under the Procedure section: 5. The Care Plan is reviewed and updated as necessary, but not less than quarterly or when there is a change in the resident's condition. 10) Other revisions/updates will be made by hand as indicated. The facility admitted Resident #55 with [DIAGNOSES REDACTED]. Review on 4/19/2018 at approximately 2:04 PM of the form titled, Care Plan Conference Signature Sheet, dated 1/30/2018 for Resident #55 indicated the CNA (Certified Nursing Assistant) most closely involved with the care for Resident #55 did not have input into the care planning process for this resident. The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Review on 4/19/2018 at approximately 10:15 AM of the weights for Resident #128 revealed an admission weight on 3/7/2018 of 89.8 pounds and on 3/28/2018 a weight loss of 9.2 pounds in 21 days. Further review on 4/19/2018 at approximately 10:15 AM of the weights for Resident #128 revealed a continued weight loss from 3/28/2019 until 3/17/2018 of 12 pounds. No documentation could be found in the medical record for Resident #128 to ensure he/she was reweighed to ensure accuracy of the weights. Review on 4/19/2019 at approximately 10:19 AM of the Plan of Care for Resident #128 revealed no review and no revision to ensure the weight stabilized or any interventions to prevent further weight loss for Resident #128. During an interview on 4/19/2018 at approximately 12:30 PM with the RD (Registered Dietician ) he/she stated. the resident would certainly need to be seen today. The RD agreed and verified that Resident #128 did have a huge weight loss but did not verbalize that interventions were added to stabilize Resident #128's weight or to prevent further weight loss. Review on 4/19/2018 at approximately 2:20 PM of the facility policy titled, Weight Protocol, states under, Policy:, Resident experiencing undesirable weight loss or gain will receive appropriate interventions. Number 8. states, The CDM (Certified Dietary Manager) and/or Registered Dietician will review the plan of care and document nutritional assessment and recommendations/interventions as indicated for the individual resident.' Number 9 states, Nursing will communicate dietary recommendations to the MD (Medical Doctor) and obtain MD orders as indicated and approved by the MD. Number 12. states, If all interventions are unsuccessful and weight loss continues, a tube feeding may be recommended per the MD. If the resident or RP (Responsible Party) decide against a tube feeding, the resident should continue to be evaluated per CDM or RD and interventions recommended and implemented as indicated.",2020-09-01
1124,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2018-04-20,679,D,0,1,6TP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #94 was afforded an ongoing program of activities designed to meet the interest, and the physical, mental and psychosocial well-being for 1 of 6 residents reviewed for Activities. The findings included: The facility admitted Resident #94 with [DIAGNOSES REDACTED]. Review on 4/20/2018 at approximately 1:18 PM of the activity attendance sheets dated 1/29/2018 through 4/20/2018 revealed family visits and bringing him/her a newspaper. No other activities were documented for Resident #94. Review on 4/20/2018 at approximately 1:35 PM of the Activity assessment dated [DATE] revealed activity preferences as enjoying pets, being outdoors and working with tractors. No activities pertaining to the assessed interests for Resident #94 were documented as offered. During an interview on 4/19/2018 at approximately 1:50 PM with the Activity Director, he/she verified the documented activities offered, and stated, I do go in and talk to the resident but, he/she is not on 1 to 1 visits from the Activity Department. The Activity Director confirmed that activities pertaining to Resident #94's interests have not been offered.",2020-09-01
1125,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2018-04-20,690,D,0,1,6TP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview and facility policy titled Perineal Care Policy(Female), the facility failed to ensure proper incontinent care was provided for Resident #113. (One of One reviewed for incontinent care) Staff was observed to release the labia during care and touched items in the resident's room with soiled gloves. The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Observation of incontinent care on 4/18/18 at 3:07 PM revealed Certified Nursing Assistant(CNA)#3 released the labia three times during cleansing. CNA #3 assisted with turning Resident #113, cleansed the buttocks, placed a brief on the resident, pulled the resident's pants up, placed the blanket onto the resident and closed the container of wipes and then removed the soiled gloves. During an interview with the Unit Manager on 4/20/18 at 3:00 PM, s/he confirmed the above findings and stated the CNA who had provided the care had been re-educated. Review of the facility policy titled Perineal Care Policy(Female) revealed the following under the Procedure section: 12. Open labia with thumb and finger of non-dominant hand and maintain the position of this hand throughout the procedure.",2020-09-01
1126,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2018-04-20,695,D,0,1,6TP911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the oxygen concentrator was adequately cleaned for 1 of 2 residents reviewed for respiratory care. The findings included: Resident #429 was admitted to the facility with [DIAGNOSES REDACTED]. During initial observation on 4/18/18, the vent of the oxygen concentrator (O2 concentrator) in Resident #429's room appeared to have an accumulation of grey substance that resembled dust. An interview with the Rehab Director (RHD) on 4/19/18 at 925am confirmed the grey substance on the vent of the O2 concentrator. An interview with the DON on 4/19/18 revealed that cleanliness of O2 concentrators was identified seven days prior to the discovery of the issue with Resident #429 and had already been added to the facilities quality analysis (QA) plan. The QA was reviewed on 4/19/18 at 935am and the audits and education were requested for review. At 10am, DON stated that QA hasn't been started yet, so audits and education have not been completed. Review of the facility's policy on Oxygen Therapy states 7. If using an oxygen concentrator, check and clean filter on outside of the concentrator weekly as indicated by washing the foam filter with soap and water to prevent dust from entering concentrator.",2020-09-01
1127,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2019-05-02,550,D,1,1,1Y9911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner that promoted enhancement of quality of life. During dining observations, staff was observed to knock and enter resident rooms without permission. The findings included: On 5/2/19 at approximately 1:10 PM, observation of the meal tray delivery revealed three staff members knocking and entering rooms before residents gave their permission to enter. During an interview immediately after the meal tray delivery on 5/2/19, the Director of Nursing (DON) stated the staff knew the residents well and knew when to enter the resident's rooms. During the interview, the DON confirmed since this was the resident's home, staff should knock, introduce self, and ask permission prior to entering the resident's room. During an observation 4/29/2019 at approximately 1:11 PM during the lunch meal service on the 300 Unit staff was observed knocking on resident room doors to deliver the lunch meal tray and not waiting for a reply, just walking in without permission to do so. An additional observation during the lunch meal service on the 300 hall on 4/2/2019 at approximately 1:11 PM revealed a staff member knocking on the door of room [ROOM NUMBER] and shouted, Hey Sweetie. and walked in room and did not wait for permission to enter. In room [ROOM NUMBER], the staff member cleansed his/her hands and entered the room without permission. The Certified Nursing Assistant rearranged the over the bed table and placed a bed pillow behind the resident in bed.",2020-09-01
1128,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2019-05-02,812,E,1,1,1Y9911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to maintain the kitchen reach-in cooler, dry food storage, and nourishment refrigerator free from expired food items. The findings included: A kitchen tour conducted on [DATE] at 11:03 AM revealed three 36 ounce chocolate milk containers in the reach-in cooler and four 32 ounce bags of pure cane sugar in the dry food storage that were expired. In the nourishment room of the 100 unit, there were two 8 ounce of expired and four 8 ounce dented therapeutic nutrition supplements. At the time of discovery, the Certified Dietary Manager confirmed the expired food in the kitchen, and Registered Nurse #1 confirmed the expired supplements in the nourishment refrigerator.",2020-09-01
4994,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2016-02-25,309,E,0,1,RHQG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure each resident received the necessary care and services to maintain the highest practicable, physical and psychosocial well-being. Resident #5 was admitted with a skin condition that had a red scalded appearance. The facility had been applying the same medication since ordered by the physician on 4/9/2015 with no improvement for 1 of 1 resident reviewed for non pressure skin conditions. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. An observation on 2/24/2016 at approximately 11:15 AM of [MEDICAL CONDITION] care for Resident #5 revealed a red, scalded area around the stoma. The area continued horizontally down his/her right side to where his/her body met the mattress and was approximately 8 to 10 inches wide. The left side of the abdomen was free of any redness or blisters. Marathon, a skin barrier was applied around the stoma and Abram's Formula (a pharmacy compound of Vitamin A & D Ointment, Zinc Oxide, and [MEDICATION NAME] CV) was applied on the remaining skin to cover the area on the right side. Review on 2/24/2016 at approximately 12:45 PM of the medical record for Resident #5 revealed a physician's orders [REDACTED]. Apply Abram's Formula TID (three times a day) as directed until resolved. The area around the stoma and horizontally down Resident #5's torso remains red, tortuous and has a scalded appearance. During an interview on 2/25/2015 at approximately 9:15 AM with the Medical Director, he/she stated, I think the area is fungal caused from warmth. It should not spread but may linger. He/she went on to say that he/she had assessed the area about a week ago. The medical director did not make any recommendations.",2019-06-01
4995,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2016-02-25,371,E,0,1,RHQG11,"Based on observation, interview and review of facility policy titled Left Over Policy, the facility failed to ensure safe dietary practices for 1 of 1 kitchen and has the potential for affecting all residents with ordered diets. Outdated items were found in the reach-in refrigerator and deli meats were observed in a container with fluid noted in the bottom of the container. In addition, during the temping of the food service line, a piece of paper was observed to fall in a food item and the dietary cook's glove was noted touching another food item. The findings included: Initial tour of the kitchen on 2/22/16 at 9:30 AM revealed the following all with an expiration date of 2/19/16: (1) container of cantaloupe; (1) container of green grapes; deli meat; and (1) container of pimento cheese. (1) container was observed in the reach-in refrigerator with bologna, salami, chicken breast and ham dated 2/12/16 and visible liquid was observed in the bottom of the container which the items were stored. At the time of the observation, the Food Service Assistant confirmed the findings and removed the items from the reach-in refrigerator. On 2/25/16 at approximately 11:00 AM, after calibrating the food thermometer, the Dietary Cook was observed to take temperatures of the food items. During the taking of the temperatures of the foods, a small piece of paper off of the alcohol covering was observed to fall in the collards. During the temperature taking of the smothered pork chops, the cook's gloved finger was observed touching the gravy of the smothered pork chops. After the temperatures were taken, the Dietary Cook covered all items and did not removed the two items off of the serving line. During an interview with the Registered Dietician at the time of the above observation, he/she stated the two food items were possibly cross-contaminated and instructed the Dietary Cook to remove the two items. On 2/25/16 at 11:26 AM, the Dietary Cook stated he/she did not realize the gloved hand had touched the gravy on the smothered pork chops. Review of the facility policy titled Left Over Policy revealed the following: 3. All leftovers must be discarded if not used within 72 hours of the preparation date.",2019-06-01
4996,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2016-02-25,431,E,0,1,RHQG11,"Based on observations, record reviews and interviews the facility failed to ensure that four medications were properly stored and/or dated in 2 of 6 medication carts. The findings include: On 2/22/16 at approximately 10:27 AM inspection of the Rehab (Rehabilitation) Center medication cart # 2 revealed: -One ampule of Budesonide Inhalation Suspension 0.5mg/2ml Suspension by Sandoz stored in the right top drawer lying on its side without foil covering. The manufacturer labeling states Store unopened ampules in the foil envelope placed upright in the carton. Protect from light. -One vial of Brovana (arformeterol tartrate) Inhalation Solution 15mcg/2ml by Sunovion was stored in the right top drawer without foil overwrap and without date removed from refrigerator. The manufacturer labeling states: Protect from light. Store unopened pouched unit-dose vials in refrigerator. Unopened pouched unit-dose vials can also be stored at room temperature for up to 6 weeks. Do not use past the expiration date or after 6 weeks storage at room temperature. On 2/22/16 at approximately 10:32 AM, RN (Registered Nurse) # 1 verified that Budesonide had not been stored correctly and that Brovana had not been dated when removed from the refrigerator. 02/22/2016 10:32:19 AM On 2/22/2016 at approximately 10:37 AM inspection of the Rehab Center medication cart # 1 revealed: -One opened and in-use Advair Diskus 100-50 by GlaxoSmithKline with doses remaining, but not dated when opened. The manufacturer states: The device should be discarded 1 month after removal from the moisture-protective overwrap or after all blisters have been used (when the indicator reads 0), whichever comes first. -One opened and in-use bottle of Calcitonin-Salmon Nasal Spray by Apotex lying on its side. The manufacturer states Store bottle in use at room temperature .in an upright position. On 2/22/16 ay approximately 10:42 AM, RN # 2 that the Advair Diskus had not been dated when opened and that the Calcitonon-Salmon Nasal Spray had not been stored in an upright position.",2019-06-01
6090,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2014-11-06,279,D,0,1,Z53O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a care plan and implement interventions for 2 of 2 residents reviewed for urinary incontinence. Resident #163 and #79 had a change in urinary continence status and no interventions were developed to improve or prevent a decline in bladder functioning. The findings include: The facility admitted Resident #163 with the [DIAGNOSES REDACTED]. Review of the resident's Admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident was always continent. Resident #163's Quarterly MDS statement noted a change in the resident's continent status from always continent to occasionally incontinent. Review of the resident's Comprehensive Care Plan on 11/5/14 at approximately 9:30 AM revealed no care plan to address the resident's occasional urinary incontinence. Per review of the medical record there are no nurses notes or physicians notes indicating any treatment plans, toileting schedules or intervention's related to assisting Resident #163 with his/her occasional urinary incontinent episodes. Review of the nurses notes on 11/5/14 at approximately 9:52 AM revealed noted entries where it stated that the resident is continent with occasional incontinent episodes. Nurses notes dated 6/12/14 stated Resident requires extensive assistance x 2 with transferring on and off of toilet and personal hygiene after elimination. 6/13/14 Resident is continent of bowel and bladder with frequent incontinence of bladder noted. 6/17/14 Continent of bowel and bladder with occasional incontinent episodes noted. Uses bedside commode. Observation of the resident was made on 11/5/14 at approximately 11:25 AM sitting in the room. No bed side commode was observed in the room at time. Further observation of the room revealed the bedside commode in the resident's restroom. Review of Resident #163's Bowel and Bladder assessment dated [DATE] noted resident has 2-6 incontinence episodes per week. Resident has a history of Urinary Tract Infections [MEDICAL CONDITION]. Completion of assessment specified resident as not appropriate for retraining related to continent of bowel and bladder. During an interview with Certified Nursing Assistant #1 on 11/5/14 at approximately 2:42 PM s/he stated the resident does wear pads in case of incontinent episodes. The resident is able to use bed side commode with assistance. CNA #1 stated there was no toileting schedule in place for the resident, further stating if the resident has to use the bathroom s/he can press the call light. During an interview with the MDS Coordinator on 11/5/14 at approximately 2:47 PM s/he stated if a resident went from always continent to occasional incontinence the care plan should have been developed for the resident to address the change in urinary continent status. Further during the interview the MDS Coordinator stated the resident's bedside commode should have been in the resident's room in reach rather than the resident's restroom. The facility admitted Resident #79 with [DIAGNOSES REDACTED]. Review of Resident #79's medical record on 11/6/2014 at approximately 2:50 PM revealed a Minimum Data Set (MDS) Section A 2300 with an observation end date of 6/13/2014. Section 500 of the MDS revealed a Brief Interview for Mental Status (BIMS) score of 12, the range being 00-15. Section H, the assessment of Bowel and Bladder function revealed Resident #79, under section H0300 coded as 1, Occasionally incontinent of bowel and bladder. Section H200 is coded as O, not scheduled for a toileting program. Further review of the MDS dated [DATE] revealed a Care Area Assessment Summary which included urinary incontinence as a triggered area to be care planned with interventions to restore or improve continence. Additional review of the MDS on 11/6/2014 at approximately 3:00 PM revealed, on 6/19/2014, Section H was again coded as occasionally incontinent of bowel and bladder. The MDS dated [DATE] was coded as always incontinent, the MDS dated [DATE] was coded as frequently incontinent and the MDS dated [DATE] was coded as frequently incontinent of bowel and bladder. Review of Resident #79's Comprehensive Plan of Care on 11/6/2014 at approximately 3:30 PM, no mention of incontinence or interventions to reduce incontinence or improve continence could be found on the plan of care. During an interview on 11/6/2014 at approximately 3:35 PM with the MDS/Care Plan Coordinator, he/she verified that a Comprehensive Plan of Care had not been developed to address interventions to restore and or improve continence.",2018-05-01
6091,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2014-11-06,315,D,0,1,Z53O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop a care plan and implement interventions for 2 of 2 residents reviewed for urinary incontinence. Resident #163 and #79 had a change in urinary continence status and no interventions were developed to improve or prevent a decline in bladder functioning. The findings include: The facility admitted Resident #163 with the [DIAGNOSES REDACTED]. Review of the resident's Admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident was always continent. Resident #163's Quarterly MDS statement noted a change in the resident's continent status from always continent to occasionally incontinent. Review of the resident's Comprehensive Care Plan on 11/5/14 at approximately 9:30 AM revealed no care plan to address the resident's occasional urinary incontinence. Per review of the medical record there are no nurses notes or physician's notes indicating any treatment plans, toileting schedules or intervention's related to assisting Resident #163 with his/her occasional urinary incontinent episodes. Review of the nurses notes on 11/5/14 at approximately 9:52 AM revealed entries where it stated that the resident is continent with occasional incontinent episodes. Nurses notes dated 6/12/14 stated Resident requires extensive assistance x 2 with transferring on and off of toilet and personal hygiene after elimination 6/13/14 Resident is continent of bowel and bladder with frequent incontinence of bladder noted. 6/17/14 Continent of bowel and bladder with occasional incontinent episodes noted. Uses bedside commode. Observation of the resident was made on 11/5/14 at approximately 11:25 AM sitting in the room. No bedside commode was observed in the room at the time. Further observation of the room revealed the bedside commode in the resident's restroom. Review of Resident #163's Bowel and Bladder assessment dated [DATE] noted resident has 2-6 incontinent episodes per week. Resident has a history of Urinary Tract Infections [MEDICAL CONDITION]. Completion of assessment specified resident as not appropriate for retraining related to continence of bowel and bladder. During an interview with Certified Nursing Assistant #1 on 11/5/14 at approximately 2:42 PM s/he stated the resident does wear pads in case of incontinent episodes. The resident is able to use bed side commode with assistance. CNA #1 stated there was no toileting schedule in place for the resident, further stating if the resident has to use the bathroom s/he can press the call light. During an interview with the MDS Coordinator on 11/5/14 at approximately 2:47 PM s/he stated if a resident went from always continent to occasional incontinence the care plan should have been developed for the resident to address the change in urinary continent status. Further during the interview the MDS Coordinator stated the resident's bedside commode should have been in the resident room in reach rather than the resident's restroom. During an interview with the Director of Nursing on 11/5/14 at approximately 3:00 PM s/he stated Residents who are able to call for assistance, and who are having episodes of incontinence the facility would do a bowel and bladder pattern assessment to determine if there is a certain time of day the resident needs to void. Residents who are having accidents and that are alert will also be a candidate for bladder training. The facility admitted Resident #79 with [DIAGNOSES REDACTED]. Review of Resident #79's medical record on 11/6/2014 at approximately 2:50 PM revealed a Minimum Data Set (MDS) Section A 2300 with a observation end date of 6/13/2014. Section 500 of the MDS revealed a Brief Interview for Mental Status (BIMS) score of 12, the range being 00-15. Section H, the assessment of Bowel and Bladder function revealed Resident #79, under section H0300 coded as 1, Occasionally Incontinent of bowel and bladder. Section H200 is coded as O, not scheduled for a toileting program. Further review of MDS dated [DATE] revealed a Care Area Assessment Summary which included urinary incontinence as a triggered area to be care planned with interventions to restore or improve continence. Additional review of the MDS on 11/6/2014 at approximately 3:00 PM revealed, on 6/19/2014, Section H was again coded as occasionally incontinent of bowel and bladder. The MDS dated [DATE] was coded as always incontinent, the MDS dated [DATE] was coded as frequently incontinent and the MDS dated [DATE] was coded as frequently incontinent of bowel and bladder. No further assessments could be found in resident #79's medical record for bowel and bladder incontinence or the mention of a bladder training program. Review of Resident #79's Comprehensive Plan of Care on 11/6/2014 at approximately 3:30 PM, no mention of incontinence or interventions to reduce or improve continence could be found on the plan of care. During an interview on 11/6/2014 at approximately 3:35 PM with the MDS/Care Plan Coordinator, he/she verified that a Comprehensive Plan of Care had not been developed to address interventions to restore and or improve continence.",2018-05-01
6092,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2014-11-06,333,D,0,1,Z53O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the [MEDICATION NAME] manufacturers' recommendations, the facility failed to administer insulin consistent with manufacturers' recommendations for 1 of 2 residents reviewed for insulin administration. Resident #98 insulin was administered via a [MEDICATION NAME] after the discard date. The findings included: The facility admitted Resident #98 with [DIAGNOSES REDACTED]. On 11/3/14 at 5:55 PM, an observation with LPN #1 of the Green wing medication cart #1 revealed Resident #98's [MEDICATION NAME] (Lot #DZF0266) had an open date of 9-24-14 and discard date of 10-21-14. Also, there was another of Resident #98's [MEDICATION NAME] (Lot #DZF0266) that had an open date of 9-23-14 and discard date of 10-20-14. Following the observations LPN #1 verified the [MEDICATION NAME] were Resident 98's and indicated that the medications were being used beyond the discard dates and should have been removed from the cart after the discard date. On 11/5/14 at 2:45 PM, review of Resident #98's Physicians Orders revealed Resident #98 was ordered [MEDICATION NAME] SYRINGE FINGERSTICK BLOOD SUGAR TWICE DAILY COVER FOR 151-200 = 2 UNITS, 201-250 = 4 UNITS, 251-300 = 6 UNITS, 301-350 = 8 UNITS, 351-400 = 10 UNITS, 401-450 = 12 UNITS, LESS THAN 60 OR GREATER THAN 450 NOTIFY MD. Further review of Resident #98's Medication Administration Record [REDACTED]. On 11/5/14 at approximately 4:20 PM, review of the [MEDICATION NAME] manufacturers' recommendations/box package insert product information (Date of issue April 25, 2014, Version 22) under section 16.2 Recommended Storage states Once a cartridge or [MEDICATION NAME] Flex Pen or [MEDICATION NAME] Flex Touch is punctured, it should be kept at temperatures below 30 degrees of Celsius (86 degrees Fahrenheit) for up to 28 days, but should not be exposed to excessive heat or sunlight. Also, under Instructions for Use: Preparing your [MEDICATION NAME]: bullet #4 states Do not use [MEDICATION NAME] past the expiration date printed on the label or 28 days after you start using the Pen.",2018-05-01
6093,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2014-11-06,371,E,0,1,Z53O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility policy Supplement Protocol, the facility failed to prepare, distribute, and serve food under sanitary conditions for 2 of 3 dietary supplement storage rooms. The facility failed to remove expired nutritional supplements from the diet kitchen/supplement storage area. The facility also failed to properly calibrate the thermometer prior to taking food temperatures. The findings included: On 11/3/14 at 4:28 PM, an observation of the Green wing diet kitchen/supplement storage area with RN #1 revealed 24 (8 Fluid Oz.) unopened cans of [MEDICATION NAME] with carb Steady Therapeutic Nutrition Vanilla (Lot # RAO 1442), with an expiration date of 6/1/2014. Following the observation RN #1 verified the 24 unopened cans of [MEDICATION NAME] with carb Steady Therapeutic Nutrition Vanilla (Lot # RAO 1442) were expired and indicated that they should have been removed. Also, RN #1 was asked if the supplement was being used. RN #1 stated Yes. On 11/3/14 at 4:58 PM, an observation of the Blue wing diet kitchen/supplement storage area with RN #2 revealed 14 (8 Fluid Oz.) unopened cans of [MEDICATION NAME] with carb Steady Therapeutic Nutrition Vanilla (Lot # RAO 1014), with an expiration date of 11/1/2014. Following the observation RN #2 verified the 14 unopened cans of [MEDICATION NAME] with carb Steady Therapeutic Nutrition Vanilla (Lot # RAO 1014) were expired and indicated that they should have been removed. On 11/5/14 at 4:10 PM, review of the facility policy entitled Supplement Protocol, revealed under Procedure (4.) Supplements are stocked by Purchasing and replaced as indicated. On 11-05-14 at approximately 11:45 AM, prior to the temping of foods for the lunch meal with the Certified Dietary Manager (CDM) present, observation of Dietary Assistant #1 revealed he/she had not known the correct temperature for calibration of a Fahrenheit food temperature thermometer in ice water. The Surveyor asked Dietary Assistant #1 the following, What is the correct temperature for calibration of a Fahrenheit thermometer in ice water? Dietary Assistant #1 stated, 22 degrees. When the Surveyor instructed Dietary Assistant #1 to ask the CDM, the CDM stated, 32 degrees, and proceeded to calibrate the Fahrenheit food temperature thermometer in ice water. During an interview on 11-06-14 at approximately 12:12 PM with Dietary Assistant #1, he/she, when asked what was the correct temperature for calibration of a Fahrenheit food temperature thermometer in ice water, responded, 42 degrees. Review on 11-06-14 of the Carolina Nutrition Consultants, Incorporated Food Safety Management Tool Kit revealed in the section titled Ice-Point Method for Calibrating a Thermometer revealed i.e 3.) Hold the calibration nut securely with the wrench and rotate the head of the thermometer until it reads 32 degrees. Review on 11-06-14 of the facility Dietary Inservice/ Training dated 05-23-14 and titled, Sanitation Safety, Hazard Analysis and Critical Control Points (HACCP), Temperature Regulations Made Practical, Thermometer Calibration revealed Dietary Staff #1 attended the inservice.",2018-05-01
6094,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2014-11-06,428,D,0,1,Z53O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Responsibilities/Job Description of Consultant Pharmacist, the facility failed to ensure a monthly medication review was completed for 2 of 6 residents reviewed for unnecessary medications. Resident #85 and #30. The findings included: The facility admitted Resident #85 with [DIAGNOSES REDACTED]. Review of Resident #85's medical record on 11/5/14 at approximately 11:53 AM revealed an admitted [DATE]. Further review of Resident #85's medical record revealed a Medication Administration Record [REDACTED]. No documentation could be found to ensure the Pharmacist had conducted a monthly review of Resident #85's medications. An interview on 11/5/2014 at approximately 12:06 PM with the Unit Manager of the Blue Wing confirmed the medications for Resident #85 had not been reviewed by the Pharmacist since admission. An interview on 11/6/2014 at approximately 4:00 PM with the Pharmacist, he/she verified that a review of the medications for Resident #85 and Resident #30 had not been completed, and stated, I have been out of town for a week. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Review of Resident #30's medical record revealed a MAR for October 2014. No documentation could be found to ensure the Pharmacist had conducted a monthly review of Resident #30's medications for October 2014. Review of the Comprehensive Plan of Care for Resident #85 under Problem: Potential for undesirable side effects related to psychoactive drug therapy included an approach that states, Pharmacy consultant review drug regimen per policy and make recommendations, reductions, etc. Review of the Comprehensive Plan of Care for Resident #30 under Problem: Potential for undesirable side effects related to psychoactive drug therapy also included an approach which states, Pharmacy consultant review drug regimen monthly and make recommendations. Review of a form titled,Responsibilities/Job Description of Consultant Pharmacist, states, The consultant pharmacist is responsible to the Executive Director for the development, coordination and supervision of pharmaceutical activities, which may include but not limited to: #1. Visiting each facility on a monthly basis. #4. Medication reviews shall be conducted monthly and evidence of review documented within the resident's chart.",2018-05-01
6095,MORRELL NURSING CENTER,425111,900 NORTH MARQUIS HWY,HARTSVILLE,SC,29551,2014-11-06,431,D,0,1,Z53O11,"Based on observations, interview and review of the manufacturers' recommendations. The facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 2 of 7 medication carts. Three NovoLog FlexPens were on the medication cart after the discard date. The findings included: On 11/3/14 at 5:55 PM, an observation with LPN #1 of the Green wing medication cart #1 revealed NovoLog FlexPen (Lot # DZF0266) with an open date of 9-24-14 and discard date of 10-21-14. Also, on cart #1 there was another NovoLog FlexPen (Lot # DZF0266) with an open date of 9-23-14 and discard date of 10-20-14. Following the observation LPN #1 verified the NovoLog FlexPens were being used and should have been removed from the cart after the discard date. On 11/3/14 at 6:06 PM, an observation with LPN #2 of the Green wing medication cart #2 revealed a NovoLog FlexPen (Lot #DZF0250) with an open date of 8-24-14 and discard date of 9-20-14. Following the observation LPN #2 indicated that the NovoLog Flex Pen should have been removed from the cart after the discard date. On 11/5/14 at approximately 4:20 PM, review of the NovoLog FlexPen manufacturers' recommendations/box package insert product information (Date of issue April 25, 2014, Version 22) under section 16.2 Recommended Storage states Once a cartridge or NovoLog Flex Pen or NovoLog Flex Touch is punctured, it should be kept at temperatures below 30 degrees of Celsius (86 degrees Fahrenheit) for up to 28 days, but should not be exposed to excessive heat or sunlight. Also, under Instructions for Use: Preparing your NovoLog FlexPen: bullet #4 states Do not use Novolog past the expiration date printed on the label or 28 days after you start using the Pen.",2018-05-01
1051,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-01-31,600,G,1,0,50EK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident remained free from neglect. Resident #1 was noted to receive a laceration while being transferred by CNA (certified nurse aide) #1. CNA #1 did not use the appropriate transfer method while transferring Resident #1 at the time the laceration occurred. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 11/29/17. Review of the facility's Five-Day Follow-Up Report dated 12/4/17 indicated Resident #1 was being transferred from the wheelchair to the bed for care. The resident's left leg caught on the bracket of the wheelchair leg rest, causing a laceration. Resident #1 was sent to the emergency room for evaluation and treatment. The resident's laceration was approximately 2 cm x 0.5 cm. Review of Resident #1's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 6. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with 2+ person physical assist. Review of the care plan revealed requires two assistance to/from bed/chair, use mechanical lift to assist as necessary was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide gait belt and assistance of two as necessary for transfers/mechanical lift with two as necessary depending on ability. Review of the SBAR Communication Form dated 11/29/17 indicated the CNA stated that during transfer from the bed to the wheelchair after ADL (activities of daily living) care, the resident's lower left leg was caught on a metal piece of the wheelchair causing a laceration. The resident had a deep laceration that required sutures. CNA #1's facility-obtained statement dated 11/29/17 indicated s/he was transferring Resident #1 from the bed back to the chair. The resident's leg got caught on the inside of the wheelchair. When CNA #1 saw blood, s/he notified the nurse immediately. In an interview with the surveyor on 1/30/18 at approximately 2:10 PM, CNA #1 stated s/he was assigned to Resident #1 at the time of the incident. S/he was transferring the resident from the bed to the wheelchair and his/her leg got caught inside the wheelchair. CNA #1 stated s/he transferred Resident #1 by him/herself, CNA #1 transferred the resident as a stand and pivot. CNA #1 stated the shoes Resident #1 had on did not have grip and they slid. The resident's leg got caught on a groove on the inside of the wheelchair. CNA #1 notified the nurse when it happened. CNA #1 stated s/he transferred the resident by him/herself. CNA #1 stated the transfer information for each resident is on the kardex on the kiosk. CNA #1 stated s/he did not look at the kardex prior to transferring the resident, s/he did go back and look at the information after the incident and the resident was listed as a 2 person transfer. CNA #1 stated s/he usually works days and is usually assigned to Resident #1. CNA #1 has worked on the same unit for [AGE] years. LPN (Licensed Practical Nurse) Unit Coordinator's facility-obtained statement dated 11/29/17 indicated a description of action taken in regards to CNA #1. A verbal warning was giving to CNA #1 for not following the Kardex plan of care on Resident #1's transfer status. Also, discussion as to importance of checking the Kardex on all residents prior to caring for them to see how they transfer, eat, toilet, how they do with ADL's and any other safety concerns or issues that are listed in each individual Kardex. In an interview with the surveyor on 1/30/18 at approximately 2:20 PM, RN #1 stated s/he was working on 11/29/17 and s/he was assigned to Resident #1. RN #1 was passing medications and s/he heard an aide looking for him/her. They told RN #1 to bring the treatment cart. Resident #1 was sitting in his/her wheelchair and his/her leg was bleeding. RN #1 cleaned the area because there was a lot of blood. S/he saw the laceration and sent for the unit manager. The resident's leg kept bleeding. The unit manager came and looked at the leg and went and got the DON (Director of Nursing). The DON said the resident needed sutures and needed to go out to the hospital. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the DON stated s/he completed the reportable and investigation for Resident #1 because it was a significant injury. They checked the kardex and the care plan to make sure they matched and Resident #1's did match. Resident #1 was a 2 person stand/pivot transfer at the time of the incident. CNA #1 had a coaching and s/he was re-educated on the kardex and looking at the kardex to safely transfer a resident. Review of the facility's Abuse & Neglect Prohibition policy revealed each resident has the right to be free from neglect. Neglect was defined as failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.",2020-09-01
1052,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-01-31,607,G,1,0,50EK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse/neglect. Resident #1 was noted to receive a laceration while being transferred by CNA (certified nurse aide) #1. CNA #1 did not use the appropriate transfer method while transferring Resident #1 at the time the laceration occurred. This incident was an allegation of neglect and CNA #1 was not suspended during the investigation. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 11/29/17. Review of the facility's Five-Day Follow-Up Report dated 12/4/17 indicated Resident #1 was being transferred from the wheelchair to the bed for care. The resident's left leg caught on the bracket of the wheelchair leg rest, causing a laceration. Resident #1 was sent to the emergency room for evaluation and treatment. The resident's laceration was approximately 2 cm x 0.5 cm. Review of Resident #1's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 6. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with 2+ person physical assist. Review of the care plan revealed requires two assistance to/from bed/chair, use mechanical lift to assist as necessary was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide gait belt and assistance of two as necessary for transfers/mechanical lift with two as necessary depending on ability. Review of the SBAR Communication Form dated 11/29/17 indicated the CNA stated that during transfer from the bed to the wheelchair after ADL (activities of daily living) care, the resident's lower left leg was caught on a metal piece of the wheelchair causing a laceration. The resident had a deep laceration that required sutures. CNA #1's facility-obtained statement dated 11/29/17 indicated s/he was transferring Resident #1 from the bed back to the chair. The resident's leg got caught on the inside of the wheelchair. When CNA #1 saw blood, s/he notified the nurse immediately. In an interview with the surveyor on 1/30/18 at approximately 2:10 PM, CNA #1 stated s/he was assigned to Resident #1 at the time of the incident. S/he was transferring the resident from the bed to the wheelchair and his/her leg got caught inside the wheelchair. CNA #1 stated s/he transferred Resident #1 by him/herself, CNA #1 transferred the resident as a stand and pivot. CNA #1 stated the shoes Resident #1 had on did not have grip and they slid. The resident's leg got caught on a groove on the inside of the wheelchair. CNA #1 notified the nurse when it happened. CNA #1 stated s/he transferred the resident by him/herself. CNA #1 stated the transfer information for each resident is on the kardex on the kiosk. CNA #1 stated s/he did not look at the kardex prior to transferring the resident, s/he did go back and look at the information after the incident and the resident was listed as a 2 person transfer. CNA #1 stated s/he usually works days and is usually assigned to Resident #1. CNA #1 has worked on the same unit for [AGE] years. LPN (Licensed Practical Nurse) Unit Coordinator's facility-obtained statement dated 11/29/17 indicated a description of action taken in regards to CNA #1. A verbal warning was giving to CNA #1 for not following the Kardex plan of care on Resident #1's transfer status. Also, discussion as to importance of checking the Kardex on all residents prior to caring for them to see how they transfer, eat, toilet, how they do with ADL's and any other safety concerns or issues that are listed in each individual Kardex. In an interview with the surveyor on 1/30/18 at approximately 2:20 PM, RN #1 stated s/he was working on 11/29/17 and s/he was assigned to Resident #1. RN #1 was passing medications and s/he heard an aide looking for him/her. They told RN #1 to bring the treatment cart. Resident #1 was sitting in his/her wheelchair and his/her leg was bleeding. RN #1 cleaned the area because there was a lot of blood. S/he saw the laceration and sent for the unit manager. The resident's leg kept bleeding. The unit manager came and looked at the leg and went and got the DON (Director of Nursing). The DON said the resident needed sutures and needed to go out to the hospital. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the DON stated s/he completed the reportable and investigation for Resident #1 because it was a significant injury. They checked the kardex and the care plan to make sure they matched and Resident #1's did match. Resident #1 was a 2 person stand/pivot transfer at the time of the incident. CNA #1 had a coaching and s/he was re-educated on the kardex and looking at the kardex to safely transfer a resident. Review of CNA #1's Time Detail Report revealed s/he worked in the facility from 7:09 AM until 3:10 PM on 11/29/17. CNA #1 worked the 7:00 AM - 3:00 PM shift on 11/30/17, 12/1/17, and 12/4/17. CNA #1 was employed at the facility on the days of the survey and was interviewed while on duty. Review of the facility's Abuse & Neglect Prohibition policy revealed the facility will timely conduct an investigation of any alleged abuse/neglect. Any employee alleged to be involved in an instance of abuse and/or neglect will be suspended immediately and will not be permitted to work unless and until such allegations of abuse/neglect are unsubstantiated.",2020-09-01
1053,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-01-31,610,G,1,0,50EK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to prevent further potential abuse/neglect while an investigation was in progress. Resident #1 was noted to receive a laceration while being transferred by CNA (certified nurse aide) #1. CNA #1 did not use the appropriate transfer method while transferring Resident #1 at the time the laceration occurred. CNA #1 continued to work the rest of his/her shift on the day of the incident and was not suspended during the investigation. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 11/29/17. Review of the facility's Five-Day Follow-Up Report dated 12/4/17 indicated Resident #1 was being transferred from the wheelchair to the bed for care. The resident's left leg caught on the bracket of the wheelchair leg rest, causing a laceration. Resident #1 was sent to the emergency room for evaluation and treatment. The resident's laceration was approximately 2 cm x 0.5 cm. Review of Resident #1's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 6. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with 2+ person physical assist. Review of the care plan revealed requires two assistance to/from bed/chair, use mechanical lift to assist as necessary was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide gait belt and assistance of two as necessary for transfers/mechanical lift with two as necessary depending on ability. Review of the SBAR Communication Form dated 11/29/17 indicated the CNA stated that during transfer from the bed to the wheelchair after ADL (activities of daily living) care, the resident's lower left leg was caught on a metal piece of the wheelchair causing a laceration. The resident had a deep laceration that required sutures. CNA #1's facility-obtained statement dated 11/29/17 indicated s/he was transferring Resident #1 from the bed back to the chair. The resident's leg got caught on the inside of the wheelchair. When CNA #1 saw blood, s/he notified the nurse immediately. In an interview with the surveyor on 1/30/18 at approximately 2:10 PM, CNA #1 stated s/he was assigned to Resident #1 at the time of the incident. S/he was transferring the resident from the bed to the wheelchair and his/her leg got caught inside the wheelchair. CNA #1 stated s/he transferred Resident #1 by him/herself, CNA #1 transferred the resident as a stand and pivot. CNA #1 stated the shoes Resident #1 had on did not have grip and they slid. The resident's leg got caught on a groove on the inside of the wheelchair. CNA #1 notified the nurse when it happened. CNA #1 stated s/he transferred the resident by him/herself. CNA #1 stated the transfer information for each resident is on the kardex on the kiosk. CNA #1 stated s/he did not look at the kardex prior to transferring the resident, s/he did go back and look at the information after the incident and the resident was listed as a 2 person transfer. CNA #1 stated s/he usually works days and is usually assigned to Resident #1. CNA #1 has worked on the same unit for [AGE] years. LPN (Licensed Practical Nurse) Unit Coordinator's facility-obtained statement dated 11/29/17 indicated a description of action taken in regards to CNA #1. A verbal warning was giving to CNA #1 for not following the Kardex plan of care on Resident #1's transfer status. Also, discussion as to importance of checking the Kardex on all residents prior to caring for them to see how they transfer, eat, toilet, how they do with ADL's and any other safety concerns or issues that are listed in each individual Kardex. In an interview with the surveyor on 1/30/18 at approximately 2:20 PM, RN #1 stated s/he was working on 11/29/17 and s/he was assigned to Resident #1. RN #1 was passing medications and s/he heard an aide looking for him/her. They told RN #1 to bring the treatment cart. Resident #1 was sitting in his/her wheelchair and his/her leg was bleeding. RN #1 cleaned the area because there was a lot of blood. S/he saw the laceration and sent for the unit manager. The resident's leg kept bleeding. The unit manager came and looked at the leg and went and got the DON (Director of Nursing). The DON said the resident needed sutures and needed to go out to the hospital. A review of the Time Detail report dated 11/29/17 revealed CNA #1 was in the facility from 7:09 AM to 3:10 PM on that date. CNA #1 worked the 7:00 AM - 3:00 PM shift on 11/30/17, 12/1/17, and 12/4/17. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the DON stated s/he completed the reportable and investigation for Resident #1 because it was a significant injury. They checked the kardex and the care plan to make sure they matched and Resident #1's did match. Resident #1 was a 2 person stand/pivot transfer at the time of the incident. CNA #1 had a coaching and s/he was re-educated on the kardex and looking at the kardex to safely transfer a resident. Review of the facility's Abuse & Neglect Prohibition policy revealed each resident has the right to be free from neglect. Neglect was defined as failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.",2020-09-01
1054,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-01-31,656,G,1,0,50EK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to implement a comprehensive person-centered care plan for each resident. Resident #1 was noted to receive a laceration while being transferred by CNA (certified nurse aide) #1. CNA #1 did not use the appropriate transfer method while transferring Resident #1 at the time the laceration occurred per the resident's plan of care. Resident #1's care plan for [MEDICAL CONDITION] medication was not followed related to attempted gradual dose reductions. One of three residents reviewed for care plans. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 11/29/17. Review of the facility's Five-Day Follow-Up Report dated 12/4/17 indicated Resident #1 was being transferred from the wheelchair to the bed for care. The resident's left leg caught on the bracket of the wheelchair leg rest, causing a laceration. Resident #1 was sent to the emergency room for evaluation and treatment. The resident's laceration was approximately 2 cm x 0.5 cm. Review of Resident #1's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 6. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with 2+ person physical assist. Review of the CNA Kardex for Resident #1 revealed under transfer status to provide gait belt and assistance of two as necessary for transfers/mechanical lift with two as necessary depending upon ability. Provide mechanical lift as necessary for transfers depending on resident ability: full body lift. Review of Resident #1's care plan revealed impaired ability to transfer self due to weakness was identified as a problem area on the care plan. Resident was noted to require 2 assistance to/from bed/chair, use mechanical lift to assist as necessary. Interventions and approaches to the problem were listed on the care plan and included provide gait belt and assistance of two as necessary for transfers/ mechanical lift with two as necessary depending upon ability. Provide mechanical lift, as necessary for transfers depending on resident ability: full body lift. Review of the SBAR Communication Form dated 11/29/17 indicated the CNA stated that during transfer from the bed to the wheelchair after ADL (activities of daily living) care, the resident's lower left leg was caught on a metal piece of the wheelchair causing a laceration. The resident had a deep laceration that required sutures. CNA #1's facility-obtained statement dated 11/29/17 indicated s/he was transferring Resident #1 from the bed back to the chair. The resident's leg got caught on the inside of the wheelchair. When CNA #1 saw blood, s/he notified the nurse immediately. In an interview with the surveyor on 1/30/18 at approximately 2:10 PM, CNA #1 stated s/he was assigned to Resident #1 at the time of the incident. S/he was transferring the resident from the bed to the wheelchair and his/her leg got caught inside the wheelchair. CNA #1 stated s/he transferred Resident #1 by him/herself, CNA #1 transferred the resident as a stand and pivot. CNA #1 stated the shoes Resident #1 had on did not have grip and they slid. The resident's leg got caught on a groove on the inside of the wheelchair. CNA #1 notified the nurse when it happened. CNA #1 stated s/he transferred the resident by him/herself. CNA #1 stated the transfer information for each resident is on the kardex on the kiosk. CNA #1 stated s/he did not look at the kardex prior to transferring the resident, s/he did go back and look at the information after the incident and the resident was listed as a 2 person transfer. CNA #1 stated s/he usually works days and is usually assigned to Resident #1. CNA #1 has worked on the same unit for [AGE] years. LPN (Licensed Practical Nurse) Unit Coordinator's facility-obtained statement dated 11/29/17 indicated a description of action taken in regards to CNA #1. A verbal warning was giving to CNA #1 for not following the Kardex plan of care on Resident #1's transfer status. Also, discussion as to importance of checking the Kardex on all residents prior to caring for them to see how they transfer, eat, toilet, how they do with ADL's and any other safety concerns or issues that are listed in each individual Kardex. In an interview with the surveyor on 1/30/18 at approximately 2:20 PM, RN #1 stated s/he was working on 11/29/17 and s/he was assigned to Resident #1. RN #1 was passing medications and s/he heard an aide looking for him/her. They told RN #1 to bring the treatment cart. Resident #1 was sitting in his/her wheelchair and his/her leg was bleeding. RN #1 cleaned the area because there was a lot of blood. S/he saw the laceration and sent for the unit manager. The resident's leg kept bleeding. The unit manager came and looked at the leg and went and got the DON (director of nursing). The DON said the resident needed sutures and needed to go out to the hospital. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the DON stated s/he completed the reportable and investigation for Resident #1 because it was a significant injury. They checked the kardex and the care plan to make sure they matched and Resident #1's did match. Resident #1 was a 2 person stand/pivot transfer at the time of the incident. CNA #1 had a coaching and s/he was re-educated on the kardex and looking at the kardex to safely transfer a resident. Review of Resident #1's medical record revealed the pharmacist's Medication Regimen Review on 12/17/17 indicated irregularities and/or recommendations. Review of the Consultation Report dated 12/17/17 revealed Resident #1 received two [MEDICAL CONDITION] medications: [REDACTED]. The recommendation was to please evaluate if a gradual dose reduction of either of the medications was possible at the time, perhaps decreasing [MEDICATION NAME] to 2.5 milligrams three times daily, while monitoring for re-emergence of target and/or withdrawal symptoms. If this therapy is to continue it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; AND b) the facility interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences. Further review of the Consultation Report dated 12/17/17 revealed there was no response or signature from the physician. The Consultation Report contained an area for the physician to sign to accept the recommendations and an area for the physician to sign to decline the recommendations. Review of the Doctor's Progress Notes revealed no documentation between 12/17/17 and 1/31/18 related to the pharmacist recommendations for a gradual dose reduction. Review of the pharmacist's Gradual Dose Reduction Tracking Report dated 1/22/18 indicated the last gradual dose reduction request for Resident #1 for [MEDICATION NAME] and [MEDICATION NAME] was on 12/17/17. The report indicated there was no current documentation of clinical contraindications. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the Director of Nursing stated the physician would look at the pharmacy consultation report but may not sign it. S/he stated they print out a copy of the report and put it in the physician's mailbox. Review of Resident #1's care plan revealed the resident required administration of psychoactive medications was identified as a problem area on the care plan. Interventions and approaches to the problem were listed on the care plan and included periodic reviews of medications by the interdisciplinary team to determine potential dose reductions.",2020-09-01
1055,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-01-31,689,G,1,0,50EK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was noted to receive a laceration while being transferred by CNA (certified nurse aide) #1. CNA #1 did not use the appropriate transfer method while transferring Resident #1 at the time the laceration occurred. One of three residents reviewed for incidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 11/29/17. Review of the facility's Five-Day Follow-Up Report dated 12/4/17 indicated Resident #1 was being transferred from the wheelchair to the bed for care. The resident's left leg caught on the bracket of the wheelchair leg rest, causing a laceration. Resident #1 was sent to the emergency room for evaluation and treatment. The resident's laceration was approximately 2 cm x 0.5 cm. Review of Resident #1's medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 6. The Quarterly MDS coded Resident #1 as requiring extensive assistance for transfers with 2+ person physical assist. Review of Resident #1's Transfer Evaluation forms dated 9/7/17 and 12/5/17 revealed the resident's transfer evaluation score was a category 3, caregiver performs 50% or more of task. Equipment was indicated as mechanical lift (total body/sling or stand assist as appropriate). Review of the Nursing Monthly Summary dated 9/26/17 revealed the nurse indicated Resident #1 required extensive assistance with one person physical assist for transfers. Review of the Nursing Monthly Summaries dated 11/24/17 and 12/25/17 revealed Resident #1 was also coded as requiring extensive assistance with one person physical assist for transfers. Review of the Nursing Daily Skilled Charting note dated 12/5/17 revealed Resident #1's transfer status was documented as requiring extensive assistance with two+ persons physical assist. Review of the care plan revealed requires two assistance to/from bed/chair, use mechanical lift to assist as necessary was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to provide gait belt and assistance of two as necessary for transfers/mechanical lift with two as necessary depending on ability. Review of the SBAR Communication Form dated 11/29/17 indicated the CNA stated that during transfer from the bed to the wheelchair after ADL (activities of daily living) care, the resident's lower left leg was caught on a metal piece of the wheelchair causing a laceration. The resident had a deep laceration that required sutures. CNA #1's facility-obtained statement dated 11/29/17 indicated s/he was transferring Resident #1 from the bed back to the chair. The resident's leg got caught on the inside of the wheelchair. When CNA #1 saw blood, s/he notified the nurse immediately. In an interview with the surveyor on 1/30/18 at approximately 2:10 PM, CNA #1 stated s/he was assigned to Resident #1 at the time of the incident. S/he was transferring the resident from the bed to the wheelchair and his/her leg got caught inside the wheelchair. CNA #1 stated s/he transferred Resident #1 by him/herself, CNA #1 transferred the resident as a stand and pivot. CNA #1 stated the shoes Resident #1 had on did not have grip and they slid. The resident's leg got caught on a groove on the inside of the wheelchair. CNA #1 notified the nurse when it happened. CNA #1 stated s/he transferred the resident by him/herself. CNA #1 stated the transfer information for each resident is on the kardex on the kiosk. CNA #1 stated s/he did not look at the kardex prior to transferring the resident, s/he did go back and look at the information after the incident and the resident was listed as a 2 person transfer. CNA #1 stated s/he usually works days and is usually assigned to Resident #1. CNA #1 has worked on the same unit for [AGE] years. LPN (Licensed Practical Nurse) Unit Coordinator's facility-obtained statement dated 11/29/17 indicated a description of action taken in regards to CNA #1. A verbal warning was giving to CNA #1 for not following the Kardex plan of care on Resident #1's transfer status. Also, discussion as to importance of checking the Kardex on all residents prior to caring for them to see how they transfer, eat, toilet, how they do with ADL's and any other safety concerns or issues that are listed in each individual Kardex. In an interview with the surveyor on 1/30/18 at approximately 2:20 PM, RN #1 stated s/he was working on 11/29/17 and s/he was assigned to Resident #1. RN #1 was passing medications and s/he heard an aide looking for him/her. They told RN #1 to bring the treatment cart. Resident #1 was sitting in his/her wheelchair and his/her leg was bleeding. RN #1 cleaned the area because there was a lot of blood. S/he saw the laceration and sent for the unit manager. The resident's leg kept bleeding. The unit manager came and looked at the leg and went and got the DON (director of nursing). The DON said the resident needed sutures and needed to go out to the hospital. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the DON stated s/he completed the reportable and investigation for Resident #1 because it was a significant injury. They checked the kardex and the care plan to make sure they matched and Resident #1's did match. Resident #1 was a 2 person stand/pivot transfer at the time of the incident. CNA #1 had a coaching and s/he was re-educated on the kardex and looking at the kardex to safely transfer a resident. The DON stated CNAs can decide if they need to use a lift or the nurse may make the call and let the CNAs know to use a lift. The Nursing Monthly Summary is completed by the nurse assigned to the resident and the DON was not sure what their thought process was for assessing Resident #1 as a 1 person assist for transfer status. The nurses should have assessed the resident as a 2 person assist since that is what was on the care plan. The DON stated the Transfer Evaluations are completed by MDS (minimum data set) nurses and they look at the plan of care documentation from the CNAs to complete the evaluation. If Resident #1 was coded as a Category 3, s/he would require a lift unless therapy assessed that s/he did not require a lift for transfers. In an interview with the surveyor on 1/31/18, Occupational Therapist #1 stated s/he started working with Resident #1 on 12/1/17, after the incident. They assess residents on the therapy case load for transfer status, they do not assess all residents in the facility.",2020-09-01
1056,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-01-31,758,D,1,0,50EK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. The pharmacist recommended Resident #1 be reviewed for a gradual dose reduction on 12/17/17. There had been no response to the recommendation when the surveyor was at the facility 1/30-1/31/18. One of one residents reviewed for gradual dose reductions. The findings included: Review of Resident #1's medical record revealed the pharmacist's Medication Regimen Review on 12/17/17 indicated irregularities and/or recommendations. Review of the Consultation Report dated 12/17/17 revealed Resident #1 received two [MEDICAL CONDITION] medications: [REDACTED]. The recommendation was to please evaluate if a gradual dose reduction of either of the medications was possible at the time, perhaps decreasing [MEDICATION NAME] to 2.5 milligrams three times daily, while monitoring for re-emergence of target and/or withdrawal symptoms. If this therapy is to continue it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; AND b) the facility interdisciplinary team ensure ongoing monitoring for effectiveness and potential adverse consequences. Further review of the Consultation Report dated 12/17/17 revealed there was no response or signature from the physician. The Consultation Report contained an area for the physician to sign to accept the recommendations and an area for the physician to sign to decline the recommendations. Review of the Doctor's Progress Notes revealed no documentation between 12/17/17 and 1/31/18 related to the pharmacist recommendations for a gradual dose reduction. Review of the pharmacist's Gradual Dose Reduction Tracking Report dated 1/22/18 indicated the last gradual dose reduction request for Resident #1 for [MEDICATION NAME] and [MEDICATION NAME] was on 12/17/17. The report indicated there was no current documentation of clinical contraindications. In an interview with the surveyor on 1/31/18 at approximately 11:30 AM, the Director of Nursing stated the physician would look at the pharmacy consultation report but may not sign it. S/he stated they print out a copy of the report and put it in the physician's mailbox. Review of the facility's [MEDICAL CONDITION] Management policy revealed the facility will use [MEDICAL CONDITION] medication therapy only when clinically indicated to enhance the quality of life, while maximizing functional potential and well-being of the resident. Gradual dose reductions of [MEDICAL CONDITION] medications and behavioral or non-pharmacological interventions are attempted, unless clinically contraindicated, in an effort to discontinue the medications, if appropriate. [MEDICAL CONDITION] medications include the following categories: anti-psychotic, anti-depressant, anti-anxiety, and sedative/hypnotic.",2020-09-01
1057,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-01-31,943,D,1,0,50EK11,"> Based on review of facility files and interview, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property. CNA (certified nurse aide) #1 was noted not to receive yearly education on abuse and neglect. One of one CNAs reviewed for in-service education. The findings included: Review of CNA #1's in-service education records revealed s/he last received training on Understanding Abuse and Neglect on 10/1/15. The facility was unable to provide documentation that CNA #1 received in-service training on abuse/neglect from 10/1/15 until 11/30/17. CNA #1 completed a packet of training courses that included information on abuse. The only date on the paperwork completed by the CNA #1 indicated the paperwork was completed on 11/30/17. The surveyor reviewed CNA's employee file related to an allegation of neglect by CNA #1 during care of Resident #1 that occurred on 11/29/17. In an interview with the surveyor on 1/31/18 at approximately 11:05 AM, the administrator stated CNA #1 had in-service training on abuse/neglect on 10/1/15 and again on 11/30/17. They could find no additional in-service documentation for CNA #1.",2020-09-01
1058,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,156,D,1,1,G1PJ11,> Based on record review and interview the Center for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (CMS -NOMNC) issued to Resident #5 did not include all required information . The facility failed to complete the services end date section of the notice of pending expiration of Medicare Part A eligibility for 1 of 3 residents reviewed for Liability Notices. The findings include: Record review on 04/07/17 at 9:47 am revealed that the facility did not include all required information on the Notice of Medicare Non-coverage (CMS - -NOMNC) provided to Resident #5. Further review revealed it could not be determined what option Resident #5 selected on the CMS - because the decision section was not completed. In an interview on 04/07/17 at 9:47 am the Social Worker stated that the previous worker was completing the forms incorrectly.,2020-09-01
1059,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,157,G,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to immediately inform the resident's physician when there was a significant change in the resident's physical status. Resident #92 was noted with complaints of pain and his/her arm was observed to be red and swollen on 12/18/16 at approximately 9:00 PM. The resident's physician and responsible party were not notified until 12/19/16. One of resident reviewed for notification. The findings included: The facility submitted an allegation of physical abuse for Resident #92 on 12/19/16. Resident #92 was noted to have a painful, swollen, reddened left elbow. Review of the Radiology Report dated 12/19/16 revealed Resident #92 had a supracondylar elbow fracture. Review of the medical record revealed the Quarterly Minimum Data Set ((MDS) dated [DATE] coded Resident #92 as having a Brief Interview for Mental Status score of 6. Review of the Incident/Accident Report revealed the resident's physician was notified at 8:40 AM and the resident's responsible party was notified at 9:20 AM. The report was signed but not dated. The Incident/Accident Report indicated the date of incident was 12/18/16 at 9:00 PM, the resident complained of pain and his/her left elbow was discolored and swollen. Review of Resident #92's Nurses' Notes revealed no entries between 12/5/16 and 12/19/16. A SBAR Summary was completed on 12/19/16 at 10:28 AM that indicated the resident was noted to have a swollen red elbow. Review of the SBAR dated 12/19/16 at 10:28 indicated resident was noted to have a swollen red elbow to the left and discoloration to the left heel. Resident's left elbow observed to be swollen, painful to touch, and discolored. Verbal order received per MD for x-ray of left elbow, apply skin prep to left heel. Tylenol 325 mg 2 tablets was administered for pain on 12/19/16 at 9:00. CNA # 3's facility-obtained statement dated 12/19/16 indicated on 12/18/16 at 9:00 PM s/he went to check on Resident #92. As s/he went to turn the resident, the resident said ouch my arm my arm. CNA #3 went to get LPN #1 and s/he came in to talk with the resident. LPN #1's facility-obtained statement indicated on 12/18/16 at approximately 9:00 PM, CNA #3 told him/her that Resident #92 complained of arm pain. LPN #1 stopped what s/he was doing and went to the resident's room. LPN #1 observed both arms and noted the left elbow was red and a little bigger than the right. LPN #1 indicated s/he went to the medication cart and administered 325 mg Tylenol. LPN #1 then continued with his/her medication pass. In an interview with the surveyor on 4/4/16 at approximately 6:10 PM, the ADON (Assistant Director of Nursing) reviewed Resident #92's nurses' notes and confirmed there was no documentation related to the resident's arm on 12/18/16. The ADON stated LPN #1 should have notified the physician at the time the arm was noted to be red and swollen. Review of the facility's policy on Changes in Resident Condition indicated the attending physician and resident's legal representative are notified when changes in the resident's condition occur. The policy indicated prompt notification is required when there is a significant change in the resident's physical status.",2020-09-01
1060,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,159,F,1,1,G1PJ11,"> Based on information provided by the facility and interview, the facility failed to manage resident monies in a way that prevented misappropriation of the monies for 7 of 7 identified residents with discrepancies in their trust accounts. Residents A, B, C, D, E, F and [NAME] The findings included: November (YEAR) the facility identified 7 residents who had discrepancies in their trust fund accounts. The residents or their family members questioned the withdrawals from the accounts. The facility verified the resident trust accounts were inaccurate. The facility review of the resident trust accounts revealed the resident accounts had inaccuracies since 2014. Resident A had withdrawals made on their account on 12/9/15, 1/8/16, 2/10/16, 3/3/16, 4/6/16, 5/23/16, 7/1/16, and 8/3/16, for increments of $60 each time. The amount withdrawn should have been for $30 dollars each time. On 6/7/16 and 9/9/16 a withdrawal was made for $100.00, that should have been for $30.00. A total of $360.00 discrepancy was withdrawn from resident A's account. Resident B's withdrawals were made from the resident's account on 8/10/16, 2/9/15, 3/31/15, and 6/19/15 for $60.00 each withdrawal. The amounts withdrawn should have been for $30 each withdrawal. A total of $120.00 discrepancy. Resident C' had a withdrawal on 6/13/16 for $60.00. The amount should have been for $30. There was a $30 dollar discrepancy. Resident D had withdrawals on his/her account on 4/5/16, 4/20/16, 5/23/16, 6/13/16 and 2/25/2014 for $60.00. The amounts withdrawn should have been $30.00 each withdrawal. A total of $150 discrepancy. Resident [NAME] had a withdrawal on 4/20/2016 for $60.00 which should have been for $30.00. A total of $30.00 difference. Resident F had a withdrawal on 5/23/2016 for $60.00 which should have been for $30.00. A difference of $30.00. Resident G had withdrawals of 7/8/2016 for $80.00 that should have been for $25.00. A withdrawal was made on 9/20/2016 for 50 dollars that should have been for $30.00. A second withdrawal was made on 9/20/16 for $100.00 that should have been for $50.00. A total of $125.00 difference. Cross refer to F224- Abuse/Neglect/Misappropriation as it relates to the facility management of resident trust funds and the inaccuracy of the accounting of the money.",2020-09-01
1061,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,221,G,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure each resident remained free from physical restraints imposed for purposed of convenience, and not required to treat the resident's medical symptoms. Resident #142 was noted to been restrained in his/her wheelchair with a gait belt. One of 1 resident reviewed for restraints. The findings included: The facility reported an allegation of physical abuse for Resident #142 on 9/17/16. Review of the facility's Five-Day Follow-Up Report dated 9/21/16 revealed a nurse was walking through the unit on 9/16/16 at approximately 11:35 PM and Resident #142 asked the nurse if s/he had a pair of scissors. The nurse asked the resident what s/he needed scissors for. Resident #142 said to cut this thing off of me. The nurse examined the chair and noticed the gait belt around the resident. The nurse called the ADON (Assistant Director of Nursing) to report. When the ADON and the DON arrived at the facility around midnight, Resident #142 was in the bed. CNA #2 was assigned to Resident #142 on the 11-7 shift. When CNA #2 took Resident #142 to his/her room s/he noticed the gait belt around him/her. CNA #2 removed the gait belt and asked the nurse, LPN #4, if s/he knew anything about the situation. LPN #4 said (CNA #1) must have put it on him/her. The 3-11 shift CNA, CNA #1, stated that s/he put his/her gait belt around Resident #142 to prevent him/her from falling. CNA #1 told LPN #4 and brought the resident to the nurses station where s/he could be closely monitored. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #142 as having a Brief Interview for Mental Status score of 6. The Initial MDS coded Resident #142 as requiring extensive assistance for transfers, dressing, hygiene and bed mobility with no behaviors coded as occurring during the assessment period. The Initial MDS coded Resident #142 as having no restraints. Review of the care plan revealed resident exhibits behavioral symptoms as evidenced by yelling out, resists care, and verbally/physically abusive to staff/others at times was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to modify environment to minimize external stressors. Review of Resident #142's (MONTH) (YEAR) Physician order [REDACTED]. Review of the Nurses' Notes dated 9/15/16 indicated resident made several attempts to stand and get up out of wheelchair unassisted. Alert alarm intact and functioning. Resident refuses to be redirected, yells at staff and is very aggressive. LPN #2's facility-obtained statement dated 9/16/16 indicated at approximately 11:25 PM, s/he saw Resident #142 sitting in the wheelchair at the nurses' station. Resident #142 asked him/her for scissors because s/he was tied to his/her chair. LPN #2 said you are not tied, then looked closer to find resident tied to wheelchair with a gait belt and covered up with a fitted bedsheet. LPN #2 called the ADON. CNA #1's facility-obtained statement dated 9/17/16 indicated s/he was assigned to Resident #142 on 9/16/16 on the 3-11 shift. Resident #142 kept trying to get up out of bed and his/her alarm kept going off. CNA #1 put Resident #142 in the wheelchair around 9:30 PM and the resident was trying to get up out of the wheelchair. At about 10:00 PM, the resident continued to try to get out of the chair so CNA #1 decided to put his/her gait belt around him/her to keep them from getting up out of the chair so s/he would not fall. When CNA #1 took the resident to the front of the nurses' station s/he told LPN #4 that s/he had put the gait belt on the resident. Resident #142 was saying s/he was cold so the CNA took a draw sheet off the bed and draped it around the resident. CNA #1 stated s/he did not tie the sheet around the resident and did not put the sheet on the wheelchair handles. CNA #1 meant to take off the gait belt before s/he left but forgot. CNA #1 did not know how the resident got a fitted sheet wrapped around him/her or hooked to the wheelchair handles. In an interview with the surveyor on 4/4/17 at approximately 7:15 PM, CNA #1 stated Resident #142 was following him/her around in the hallway. CNA #1 put the resident in the wheelchair so s/he could go up and down the hall. Then the resident started getting up from the wheelchair and walk around the hall. CNA #1 took his/her gait belt and put it around Resident #142 in the wheelchair. S/he used the hook on the gait belt to secure it. CNA #1 fastened the gait belt behind the wheelchair seat. That was around 10:00 PM. CNA #1 worked the 3-11 PM shift. CNA #1 told the nurse, LPN #4, that s/he put the gait belt around the resident in the chair because s/he couldn't watch the resident and care for the other residents. LPN #4 didn't say anything, but CNA #1 stated s/he knows s/he heard him/her. CNA#1 meant to remove the belt when s/he left at 11:00 but got busy and forgot. CNA #1 stated Resident #142 followed him/her around that night. Resident #142 would knock on a resident's door and ask CNA #1 when s/he was going to be done. Resident #142 CNA tell CNA #1 to hurry up. CNA #1 stated Resident #142 did not usually follow him/her around like they did that night. CNA #2's facility-obtained statement dated 9/16/16 indicated at approximately 11:00 PM s/he observed Resident #142 in the wheelchair at the nurses' station with a sheet wrapped over him/her. At around 12:30 AM, the resident said s/he was tired and ready to go to bed. CNA #2 took the resident to his/her room and assisted him/her to bed. When CNA #2 was putting the resident to bed s/he noticed that the resident had a gait belt on as s/he removed the sheet that was over the resident's waist and legs. When s/he finished putting the resident to bed, she took the gait belt to the nurses' station and asked the nurse if s/he knew that it was on the resident. The nurse said CNA #1 must have placed it on the resident to avoid him/her from falling. In an interview with the surveyor on 4/4/16 the Interim DON (Director of Nursing) stated s/he would not expect the nurse to document the incident. When asked about LPN #2 finding the resident restrained at approximately 11:25 PM and the resident still being tied with a gait belt at 12:30 AM per CNA #2's statement, the Interim DON stated s/he would expect the nurse who called the ADON to follow the ADON's direction as to what to do. Review of the facility's Abuse & Neglect Prohibition policy revealed each resident has the right to be free from mistreatment, neglect, abuse, exploitation, involuntary seclusion, corporal punishment, physical or chemical restraint not required to treat the resident's medical symptoms, injuries of unknown origin, and misappropriation of resident property.",2020-09-01
1062,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,224,F,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to maintain resident funds in a way that prevented misappropriation of residents' monies. Seven of 7 residents identified by the facility had discrepancies in their resident funds. Residents A, B, C, D, E, F, and [NAME] This system failure in their accounting practices resulted in Substandard Quality of Care and an Extended survey. The findings included: In response to a reported incident of resident discrepancies in their trust funds an investigation was initiated. On 4/3/2017, at the time of the Recertification/Complaint Survey, the facility had no information regarding the facility investigation of the reported incident. Administration staff at the facility at the time of the incident were no longer employed. The present Administration including the Administrator, the Director of Nursing, The Business Office Manager, and Corporate Personnel were all new to the facility. An interview with the Corporate Nurse, Interim Administrator and Director of Nurses revealed the investigation was conducted by the Compliance Office. They were unable to produce the investigation or evidence of a complete investigation. Review of the Initial and the 5 day Report revealed the office clerk was terminated for failure to follow protocols and make timely deposits. After the Office Clerk was no longer an employee the potential for theft was identified when collection calls were made to facility families and amounts were disputed. The 5 day report included that the books were audited and families and residents were contacted- monies were reimbursed. During the Recertification survey the facility provided a list of 7 residents with discrepancies of their trust accounts, which was obtained from the Corporate Office. The discrepancies were found when the residents/families questioned the resident accounts. Resident A had withdrawals made on their account on 12/9/15, 1/8/16, 2/10/16, 3/3/16, 4/6/16, 5/23/16, 7/1/16, and 8/3/16, for increments of $60 each time. The amount withdrawn should have been for $30 dollars each time. On 6/7/16 and 9/9/16 a withdrawal was made for $100.00, that should have been for $30.00. A total of $360.00 discrepancy was withdrawn from resident A's account. Resident B's withdrawals were made from the resident's account on 8/10/16, 2/9/15, 3/31/15, and 6/19/15 for $60.00 each withdrawal. The amounts withdrawn should have been for $30 each withdrawal. A total of $120.00 discrepancy. Resident C' had a withdrawal on 6/13/16 for $60.00. The amount should have been for $30. There was a $30 dollar discrepancy. Resident D had withdrawals on his/her account on 4/5/16, 4/20/16, 5/23/16, 6/13/16 and 2/25/2014 for $60.00. The amounts withdrawn should have been $30.00 each withdrawal. A total of $150 discrepancy. Resident [NAME] had a withdrawal on 4/20/2016 for $60.00 which should have been for $30.00. A total of $30.00 difference. Resident F had a withdrawal on 5/23/2016 for $60.00 which should have been for $30.00. A difference of $30.00. Resident G had withdrawals of 7/8/2016 for $80.00 that should have been for $25.00. A withdrawal was made on 9/20/2016 for 50 dollars that should have been for $30.00. A second withdrawal was made on 9/20/16 for $100.00 that should have been for $50.00. A total of $125.00 difference. On 4/14/17, the Director of Nurses not available at the time of the complaint survey was interviewed by phone regarding the facility investigation. The complete investigation was again requested including any statements, audits, police reports and termination paperwork of the alleged perpetrator. Review of the information provided revealed their were no actual statements by the residents/families. There was no statement from the alleged perpetrator or termination papers. A Police Report was available. The incident date was documented as 3/31/2015. The date of the report was 11/30/2016. The police responded to the facility in reference to Breach of Trust. The report stated the Business Office Manager (BOM) stated the alleged perpetrator was stealing money out of several resident's accounts. The alleged perpetrator had worked in the business office over financial transactions dealing with payments. The BOM stated that several residents started complaining about unpaid items and not received the right amount of cash that was stated on their receipts. The BOM stated the facility had conducted an internal investigation which revealed an estimated amount of $845.00 in cash stolen. The Alleged perpetrator had worked at the facility over [AGE] years. The information that was provided revealed the audit the facility conducted contained information the discrepancies in the resident accounts went back to (MONTH) 2014, two and 1/2 years of inaccurate funds accounting.",2020-09-01
1063,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,225,F,1,1,G1PJ11,"> Based on record review and interview, the facility failed to provide evidence of conducting a thorough investigation of 1 of 1 reported allegation of misappropriation of resident funds. No information was available related to an investigation of the allegation, findings or actions on the part of the facility. The findings included: Cross-refer to F224- Abuse/Neglect/Misappropriation as it relates to failure of the facility to provide evidence of a thorough investigation of inaccuracies in the accounting of resident funds. The facility reported to the State Agency an alleged Misappropriation of resident funds. At the time of the team entrance for the Recertification/Complaint Survey, on 4/3/2017, the facility did not have evidence of conduction of a thorough investigation. On the Initial and 5 day Report, the Alleged Perpetrator was documented to be at risk of taking residents monies. There was no evidence that the facility obtained a statement from the person accused. This was confirmed in an interview by the surveyor of the alleged perpetrator on (MONTH) 6, (YEAR). At the time of the survey no investigation was provided by the facility. No evidence was provided of an audit of all resident funds or a plan of action implemented in response to the allegation/findings. Administration persons that were at the facility at the time of the incident were no longer at the facility. The present Administration who included the Administrator, the Director of Nursing, The Business Office Manager, and Corporate Personnel were all new to the facility. An interview with the Corporate Nurse, Interim Administrator and Interim Director of Nurses revealed the investigation was conducted by the Corporate Compliance Office. They were unable to produce the investigation or evidence of the investigation.",2020-09-01
1064,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,241,D,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and review of the facility policy titled Resident Dignity & Personal Privacy the facility failed to care for residents in a manner that respected and enhanced each resident's dignity for 2 of 2 residents observed. Resident #197 was observed with only a tee shirt and brief on visible from the hallway. One random observation after knocking on a resident's door of a Certified Nursing Assistant(CNA) saying enter while assisting the resident. The findings included: The facility admitted Resident #197 with [DIAGNOSES REDACTED]. Observation on 4/6/17 at 9:40 AM revealed Resident #197 was up in the wheelchair in his/her room dressed in a tee shirt and a brief. The resident could be seen from the hallway as the room door was open. During a random observation on the environmental tour on 4/7/17 at 10:15 AM, after knocking on room [ROOM NUMBER] in the West Building, the staff member assisting the resident stated to come into the room. Upon opening the door, the resident was lying flat in the bed and the CNA appeared to be assisting the resident. The privacy curtain was not pulled. The Director of Operations closed the door and stated Well I guess you saw that. Review of the facility policy titled Resident Dignity & Personal Privacy states under the procedure section the following:1. Care for residents in a manner that maintains dignity and individuality: Dress in appropriate and desired clothing .2. Examine and treat residents in a manner that maintains their privacy. a. Use a closed door, a drawn curtain, or both, to shield the resident during all personal care and treatment procedures.",2020-09-01
1065,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,247,D,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility's policy entitled Room and Roommate Assignment, the facility failed to provide prior notice of a change in roommate for 1 of 1 resident reviewed for Admission, Transfer and Discharge. The findings included: The facility admitted Resident #136. During an interview on 04/07/17, Resident #136 stated after returning from [MEDICAL TREATMENT] s/he learned s/he had a new roommate. In a follow up interview, the Admissions Director revealed that Resident #136 had two roommate changes on (MONTH) 10th and 25th of (YEAR). Review of the Social Services Notes on 04/07/17 revealed there was no evidence of notification of Resident #136 or the responsible party In a subsequent interview, the Director of Social Services stated that Resident #136 was not notified because the new roommates were new admissions. Review of the facility's policy entitled Room and Roommate Assignment, revealed that when there is a change all parties involved will be provided with a 48-hour advance notice of the change whenever possible.",2020-09-01
1066,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,248,D,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental and psychosocial well being of Resident #180 and #188 for 2 of 3 residents reviewed for activities. The findings included: The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 4/5/2017 at approximately 2:32 PM of a form, Activity Assessment/History, revealed current interest as cards, games, watching TV, music and reading, Also included was walking/wheeling outdoors, trips, shopping, writing, talking/conversing, exercise and parties and social events. No documentation could be found to ensure Resident #180 was offered any of these activities. Review on 4/6/2017 at approximately 9:00 AM of a form titled, Individual Activity Participation Record, for January, (MONTH) and (MONTH) (YEAR) included only 2 activities which included talking/conversing/telephone and relaxation. No other activities were offered in accordance to Resident #180's activity preferences. During an interview on 4/6/2017 at approximately 9:14 AM the Activity Director stated, this resident is now very active and asked us to get him/her up for activities. The Activity Director verified that Resident #180 had other interests but he/she had a difficult time getting to all the residents that the care plan did not include activity interest for Resident #180. The facility admitted Resident #188 with [DIAGNOSES REDACTED]. Record Review of the Activity assessment dated [DATE] revealed Resident #188's current interests were listed as music, reading, education, trips, shopping, writing, talking/conversing, spiritual/religious, exercise, citizenship/voting and parties/social events. Review of the Preferences for customary routine and activities for Minimum Data Set 3.0 listed preferences that were very important as books, newspapers, magazines, listening to music, keeping up with the news, going outside to get fresh air when the weather was good and to participate in religious services. Review of the individual activity participation record for (MONTH) and (MONTH) (YEAR) revealed few activities nor a variety of activities were offered to Resident #188. Review of the resident's care plan dated 3/15/17 revealed Resident #188 was at risk for social isolation with interventions to allow the resident to select his/her choice of activities and frequent visits by staff. During the survey, Resident #188 was not observed in activities. During an interview with the Activity Director on 4/5/17 at approximately 5:04 PM, after reviewing the participation records for Resident #188, he/she confirmed there was not many stimulating activities offered to the resident.",2020-09-01
1067,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,253,E,1,1,G1PJ11,"> Based on observations, interview, an environmental round with the Administrator and Director of Operation, the facility failed to provide housekeeping and maintenance services as necessary to maintain a sanitary, orderly, and comfortable interior in 2 of 2 buildings. The facility had uncovered/unmarked bedpans/urinals,toilet paper holder damaged, wheelchair with torn arm rests, light missing on callbell plate, rough edges on over the bed tables, shower room with chipped tile, debris on the shower trolley, dining room with chairs damaged or with dust build-up, over the bed table with spillage, scraped walls, table cloths stained, debris in tub. In addition throughout the building there were door frames and doors with scrapes. The findings included: Random observations were made in the facility during the survey process as follows: East Building -shower room 100/200/300 Hall with chipped tile and debris under the mattress of the shower trolley; -dining room with five chairs with damage and/or dust build-up; -dayroom on the 100/200/300 Hall with an over the bed table with spillage, a red table with a small piece of veneer missing and the wall of the dayroom noted with scrapes, tablecloth stained; -dayroom on the 400/500/600 hall with an over the bed table with damage and a tablecloth stained. -Room 403B-wheelchair with cracked armrests. West Building -Room 206-uncovered bedpan; -Room 210-light missing on callbell plate, toilet paper holder in disrepair and over the bed table with rough edges; -[RM #]5D-toilet paper holder in disrepair; -[RM #]8-brown matter on privacy curtain; -West Shower room with cracked tile and debris in tub. -West shower room Strong urine smell in area around commode to right of door; wet floor surface extending n~18 around this commode with very strong smell of urine Commode to left of entry door with feces in bowl and shredded toilet paper on floor; cracked ceramic floor tile and cracked patches to tile which were raised above other surface ~ 1/4; ground-in dirt around commode base .commode base had shifted approximately 1 from original installed position debris in massage tub (oak leaves and coat hanger) Throughout the East and West buildings there were scraped door frames and room doors. Environmental rounds were made on 4/7/17 at approximately 10:15 AM with the Administrator and the Director of Operations. No policies regarding the environment or facility room rounds were provided during the survey process.",2020-09-01
1068,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,276,D,1,1,G1PJ11,"> Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments for Resident #245, #246 and #247 were transmitted to the State Agency in a timely manner without error for 3 of 3 residents with missing MDS 3.0 OBRA Assessments reviewed. The findings included: Review on 4/5/2017 at approximately 4:45 PM of the missing assessment report from the facility revealed Resident #245, #246 and #247 has missing MDS 3.0 OBRA Assessments and or errors during transmission. During an interview on 4/5/2017 at approximately 5:00 PM with the MDS Consultant confirmed the missing assessments and stated, We have had an inservice on making sure the MDS assessments have been accepted. He/she went on to say that the identification number had changed for Resident #245, #246 and #247 and the facility will contact the State RAI to request a merge.",2020-09-01
1069,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,280,D,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to review and revise the plan of care with interventions to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests, and the physical, mental and psychosocial well being of Resident #180 for 1 of 3 residents reviewed for activities. The findings included: The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 4/5/2017 at approximately 2:32 PM of a form, Activity Assessment/History, revealed current interest as cards, games, watching TV, music and reading, Also included was walking/wheeling outdoors, trips, shopping, writing, talking/conversing, exercise and parties and social events. No documentation could be found to ensure Resident #180 was offered any of these activities. Review on 4/6/2017 at approximately 9:00 AM of a form titled, Individual Activity Participation Record, for January, (MONTH) and (MONTH) (YEAR) included only 2 activities which included talking/conversing/telephone and relaxation. No other activities were offered in accordance to Resident #180's activity preferences. During an interview on 4/6/2017 at approximately 9:14 AM the Activity Director stated, this resident is now very active and asked us to get him/her up for activities. The Activity Director verified that Resident #180 had other interests but he/she had a difficult time getting to all the residents and that the care plan did not include activity interest for Resident #180.",2020-09-01
1070,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,281,G,1,1,G1PJ11,"> Based on review of facility files and interview, the facility failed to ensure services provided by the facility meet professional standards of care. Resident #92 was noted with complaints of pain and observed to have a swollen red elbow on 12/18/16 at 9:00 PM. There was no follow up to the resident's condition until 12/19/16 at approximately 9:00 AM. One of resident reviewed for professional standards. The findings included: The facility submitted an allegation of physical abuse for Resident #92 on 12/19/16. Resident #92 was noted to have a painful, swollen, reddened left elbow. Review of the Radiology Report dated 12/19/16 revealed Resident #92 had a supracondylar elbow fracture. Review of the Incident/Accident Report revealed the resident's physician was notified at 8:40 AM and the resident's responsible party was notified at 9:20 AM. The report was signed but not dated. The Incident/Accident Report indicated the date of incident was 12/18/16 at 9:00 PM, the resident complained of pain and his/her left elbow was discolored and swollen. Review of Resident #92's Nurses' Notes revealed no entries between 12/5/16 and 12/19/16. A SBAR Summary was completed on 12/19/16 at 10:28 AM that indicated the resident was noted to have a swollen red elbow. There were no entries on 12/18/16 when Resident #92's arm was noted to be swollen and red, with the resident complaining of pain. There was no documentation that the resident's condition was monitored. Review of the SBAR dated 12/19/16 at 10:28 indicated resident was noted to have a swollen red elbow to the left and discoloration to the left heel. Resident's left elbow observed to be swollen, painful to touch, and discolored. Verbal order received per MD for x-ray of left elbow, apply skin prep to left heel. Tylenol 325 mg 2 tablets was administered for pain on 12/19/16 at 9:00. Review of Resident #92's Medication Administration Record revealed the resident was not administered Tylenol 325 mg for pain on 12/18/16. The resident received Tylenol 325 mg for pain on 12/19/16 at 9:00 AM. CNA #3's facility-obtained statement dated 12/19/16 indicated on 12/18/16 at 9:00 PM s/he went to check on Resident #92. As s/he went to turn the resident, the resident said ouch my arm my arm. CNA #3 went to get LPN #1 and s/he came in to talk with the resident. LPN #1's facility-obtained statement indicated on 12/18/16 at approximately 9:00 PM, CNA #3 told him/her that Resident #92 complained of arm pain. LPN #1 stopped what s/he was doing and went to the resident's room. LPN #1 observed both arms and noted the left elbow was red and a little bigger than the right. LPN #1 indicated s/he went to the medication cart and administered 325 mg Tylenol. LPN #1 then continued with his/her medication pass. In an interview with the surveyor on 4/4/16 at approximately 6:10 PM, the ADON (Assistant Director of Nursing) reviewed Resident #92's nurses' notes and confirmed there was no documentation related to the resident's arm on 12/18/16. The ADON stated LPN #1 should have notified the physician at the time the arm was noted to be red and swollen. The ADON stated the nurse should have monitored and documented the resident's condition in the nurses' notes. The ADON reviewed Resident #92's (MONTH) (YEAR) MAR and confirmed there was no documentation that the nurse administered Tylenol for pain on 12/18/16. The ADON reviewed the nurses' notes and confirmed there was no documentation related to Resident #92's arm on 12/18/16. Review of the facility's policy on Changes in Resident Condition indicated the attending physician and resident's legal representative are notified when changes in the resident's condition occur. The policy indicated prompt notification is required when there is a significant change in the resident's physical status. The policy also indicated the SBAR Communication Form and the Progress Note are used to: assess and document changes in condition in an efficient and effective manner, provide assessment information to the physician, and provide clear comprehensive documentation.",2020-09-01
1071,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,314,D,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, interviews and review of the facility policy titled, Wound Care Procedure For Major Wounds, the facility failed to provide care and services to promote the healing of pressure ulcers and to prevent or treat an infection for Resident #180 and Resident #63 for 2 of 2 residents reviewed with pressure ulcer treatments. The findings included: The facility admitted Resident #180 with [DIAGNOSES REDACTED]. An observation during wound care on 4/5/2017 at approximately 1:18 PM revealed a physician's order to clean the sacrum with wound cleanser, apply Mesalt and a dry dressing daily and as needed. The Registered Nurse (RN) #3 performed the dressing change for Resident #180. RN #3 knocked on Resident #180's door, was asked to come in. This surveyor asked the resident if it was ok for this survey to observe the treatment and he/she stated, yes. RN #3 washed his/her hands and left the room and went out to the treatment cart and came back in the room with a small piece of wax paper and placed it on the over bed table. He/she did not clean the overbed table before applying the wax paper. The nurse then applied gloves and used the same gloved hands to lower the head of the bed. The head of the bed would not go down without hesitation so he/she used the same gloved hands to move the bedside straight chair so the head of the bed would go down easier. RN #3 went back to the bed controls and continued lowering the head of the bed. Then RN#3 went over to the sink and retrieved the trash can using the same gloved hands and removed the call bed from the bed, he/she then used the same gloved hands to unfasten the resident's brief and rolled the resident over and removed the soiled dressing and the packing from the wound and grabbed the bed sheet and covered the resident with the same gloved hands. RN #3 then removed the gloves and washed his/her hands. He/she then left the resident's room to get wound cleanser, Mesalt and a dry dressing. The nurse then came back in the room wearing gloves he/she had gotten off the treatment cart, pulled the sheet covering the resident and used the same gloved hands to cleanse around the outside of a wound, with x 2 and never cleansed the wound bed. RN #3 then removed the gloves and applied gloves and opened the packages of Mesalt and the dry dressing and pulled down the bedsheet with the same gloved hand and packed the wound with Mesalt and covered the area with a dry dressing and took of the glove off his/her right hand and dated and initialed the clean dressing and fastened the brief. He/she removed the gloves and washed his/her hands and applied gloves, elevated the bed and made the resident comfortable. He/she then bagged the trash and carried it to a trash can against the wall in front of the nurse's desk and deposited it. The nurse then went into the soiled utility room removed the gloves and washed his//her hands and proceeded to chart the treatment. During an interview on 4/5/2017 at approximately 3:10 PM with RN #3, the concerns were reviewed with him/her and RN #3 would not confirm that the dressing change went as this surveyor described. Review on 4/5/2017 at approximately 3:30 PM of the facility policy titled, Wound Care Procedure for Major Wounds, under Procedure states: [NAME] Take a well stocked treatment cart down the hall and park it outside the resident's room. B. Remove the supplies needed and Lock the cart. C. Set up the supplies on a clean surface at the bedside (cover the surface with a clean impervious barrier before putting the supplies out.) D. Provide privacy for the resident: Put a Procedure in Progress sign on the door, close the door and pull the curtain, E. Wash your hands. F. Explain the procedure to the resident. [NAME] Cut the tape with your clean scissors. H. Put on gloves. I. Remove the soiled dressing and place in a bag at the bedside. Place the soiled scissors on one corner of your setup not touching supplies. [NAME] Remove gloves and discard in the bag. K. Clean the scissors with 60 seconds of contact with alcohol and place on a clean corner of your setup. L. Wash your hands M. Put on clean gloves. N. Clean the wound according to the order. Clean from the center outward. O. Place soiled gauze used for cleaning in the bag. P. Remove gloves and place in bag. Q. Put on new gloves. R. Apply clean dressing as ordered. S. Remove gloves and place in bag. T, Initial, date and time dressing. U. Make resident comfortable. V. Close the bag and place in the large plastic bag attached to the cart. W. Wash your hands X. Document the treatment on the treatment book on the cart. The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Record review on 4/5/17 revealed Resident #63 had a healing Stage IV decubitus to the sacrum. During wound observation on 4/5/17 at 2:25 PM, Registered Nurse(RN)#3 was observed to wash hands but use no barrier to turn the faucet off. He/she then obtained supplies, left the cart unlocked and entered resident's room. He/she came out of the resident's room obtained more items and locked the cart. After positioning the resident, it was discovered that Resident #63 did not have a dressing to the wound. RN #3 removed his/her gloves and washed his/her hands but did not use a barrier to turn the faucet off. During the cleansing of the wound, RN #3 was observed to swipe over the area several times with the same normal saline soaked 4 x 4's. The resident was observed to turn over on his/her back after the cleansing. Again, RN #3 did not use a barrier after washing his/her hands. After donning of gloves, RN #3 opened the mesalt and balled it up and placed in his/her left hand and continued by opening the dressing package. At this point, RN #3 stated he/she needed to initial and date the dressing. He/she reached into his/her pocket, placed the top of the pen in his/her left hand which was holding the mesalt. After dating dressing, took dressing and placed the mesalt on the dressing and then placed the items over the sacral wound. He/she adjusted the resident and placed personal items on the over the bed table and adjusted the table. After removal of gloves, he/she washed his/her hands and did not use a barrier to turn the faucet off. During an interview with RN #3 on 4/6/17 at 3:29 PM, he/she did not dispute the above findings. He/she stated if a dressing comes off of a wound, Certified Nursing Assistants should notify the nurse. Review of the facility policy titled Wound Care procedure for Major Wounds states under the procedure section the following: B. Remove the supplies needed and lock the cart. N. Clean the wound according to the order. Clean from the center outward.",2020-09-01
1072,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,328,D,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to provide respiratory care as ordered for 1 of 1 resident observed. Resident #188 was observed in the hallway with a portable oxygen tank which was observed empty. The findings included: The facility admitted Resident #188 with [DIAGNOSES REDACTED]. On 4/7/17 at 12:32 PM, during a random observation of Resident #188 up in the wheelchair in the hallway revealed the resident's portable oxygen tank dial indicated the tank needed replacing. At the time of the observation, the Unit Manager was informed and confirmed the tank needed replacing. Review of the policy titled Use of Oxygen did not contain any information related to observing the portable oxygen tank to ensure it was functioning correctly and contained oxygen.",2020-09-01
1073,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,333,E,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and interviews the Facility failed to ensure that it was free of significant medication errors. Expired [MEDICATION NAME] PPD (Purified Protein Derivative) was administered to 7 of 7 residents receiving the [MEDICATION NAME] PPD and 1 of 1 resident received 9 doses of expired [MEDICATION NAME] R (Regular) Insulin (Refer to F431). The findings include: On 4/4/17 at approximately 5:06 PM (subsequent to West Building Hall 100/200 medication room refrigerator inspection) a review of the Facility Immunization Report revealed that 7 of 7 residents had been administered doses of expired [MEDICATION NAME] PPD, Lot C5035aa which had been opened by the facility on 1/28/17 and was still in use 30 days (2/29/17) passed the manufacturer's expiration date for opened (in-use) vials. Expired [MEDICATION NAME] PPD had been administered as follows: Resident 125 on 3/1/17, Resident 245 on 3/4/17, Residents 241 and 244 on 3/15/17, Resident 246 on 3/15/17, Resident 243 on 3/25/17 and Resident 247 on 3/30/17. RN (Registered Nurse) #1 verified on 4/3/17 at approximately 3:58 PM that [MEDICATION NAME] PPD Lot C5035aa was expired and in-use. On 4/4/17 at approximately 5:47 PM a review of the (MONTH) and April, (YEAR) Physicians Orders for Resident 186 revealed an order for [REDACTED]. RN # 1 had verified on 4/3/17 at approximately 3:58 PM that the [MEDICATION NAME] R Insulin dated as opened 1/31/17 was expired and in-use. On 4/5/17 at approximately 10:39 AM these findings were reviewed with the Director of Nursing who stated that he/she had not been made aware of the expired medications by the facility staff.",2020-09-01
1074,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,371,F,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, interview and review of facility policies titled Equipment, Food Storage: Cold, Food: Preparation and Authorized Kitchen Personnel, the facility failed to follow proper sanitization and food handling practices for 2 of 2 kitchens which has the potential to affect all residents with ordered diets. Food items in dry storage observed opened and not sealed, fruit observed brown, vegetable turning brown, frozen items open not sealed, improperly thawing nutritional shakes, Left overs in refrigerator past three days, air condition vent with dust, incorrect sanitization concentration in red buckets, staff entered kitchen without hair restraint, during temping of food items thermometer handle fell into food and staff touching bread with gloved hand, pieces of food placed on serving line with gloved hand, staff failed to sanitize thermometer between temping of food items, food item obtained out of freezer and started prep then placed food item back into box to be placed into freezer, staff did not know correct parameters for dishwasher, unit nutrition kitchen with spillage in refrigerator, crumbs in microwave with no glass plate in microwave, expired supplement in nutrition kitchen on unit, ice machines with build-up and [MEDICAL TREATMENT] snacks sent in plastic bag with ice-no cooler. The findings included: During the initial tour of the West kitchen on 4/3/17 at 3:30 PM the following was observed: (1) partial bag of Barilla pasta opened not sealed; (1) partial bag of cereal opened not sealed; (3) partially brown bananas noted on rack; (1) bag of slaw with brown cabbage observed in bag; (1) partial package of frozen beef patties opened not sealed; (1) partial bag of biscuits opened not sealed. (1) box of chocolate nutritional shakes thawing on counter; (1) container of macaroni and cheese cooked 4/3/17 with expiration date of 4/10/17. During an interview with the evening cook on 4/3/17, he/she stated thawing of the shakes on the counter was not the correct way to thaw the nutritional shakes. During an interview with the Registered Dietician(RD) on 4/3/17, he/she removed the items from the counter and checked the temperature of the items which was 30 degrees. He/she also confirmed items left on counter was not the correct thawing method. The RD also stated he/she was told items could be kept in refrigerators for seven days. Observation of the nutrition kitchen in the West building revealed (1) 8 ounce Glucerna supplement with an expiration date of 11/20/16. This was confirmed by the Unit Manager at the time of the finding. At the time of the observation two residents were receiving Glucerna on the unit. On 4/6/17 at approximately 12:15 PM, observation of the West kitchen revealed the following: -the air condition above the dry storage door was observed with dust on the vent; (1) red bucket without the correct concentration of sanitizer which was confirmed by the District Manager; (1) staff member entered into the kitchen without a hair restraint. During the temping of food items on 4/6/17 at approximately 12;15 PM in the West building kitchen, the cook was observed to reach his/her gloved hand into the pan and pick up particles of fried okra and place them into the container on the serving line. The RD was informed of the observation and the cook was asked to remove the okra from the serving line and to cook more. During the plating of food, Kitchen staff #1 was observed to pick up rolls and place them on the resident's plate. The District Manager was informed of this method and removed the rolls from the plates and instructed Kitchen staff #1 to use tongs when serving the rolls. Leftovers were observed in the reach in cooler with the following dates: -Cream of chicken soup in 4/5/17 remove 4/11/17; -pinto beans in 4/4/17 remove 4/10/17; -jelly in 4/4/17 remove 4/10/17; -Cream of mushroom soup in 4/3/17 remove 4/9/17; -Cream of potato soup in 4/3/17 remove 4/9/17; -Tuna fish in 4/5/17 remove 4/11/17; -Noodles in 4/5/17 remove 4/11/17; -mashed potatoes in 4/5/17 remove 4/11/17; -chicken salad in 4/3/17 remove 4/10/17; -sausage gravy in 4/6/17 remove 4/12/17. During an interview with the RD on 4/6/17 at 1:00 PM, he/she stated when he/she came to South [NAME]ina he/she was informed leftovers could be refrigerated for seven days. Observation of temping of foods in the East building on 4/6/17 at 5:40 PM revealed the following: The evening cook had to be reminded to sanitize the thermometer between food items. During the temping of the puree meat the thermometer handle fell into the meat. The cook did not immediately remove the food item. This surveyor asked what would you do since the thermometer handle fell into the food item. At that time the food item was pulled from the line. During the temping of the gravy, the thumb of the oven mitt entered into the gravy. The evening cook was unaware of the incident and was told to look on the oven mitt which had the gravy stain on the thumb. This item was then pulled from the line. Meat patties were obtained out of the freezer and as the cook started to prepare the meat patties, the RD removed several cans of puree meat and stated this would be used. The evening cook placed the meat patties back into the box to be placed back into the freezer. This surveyor notified the Dietary Manager that the meat patties had been placed in the box and at that time, he/she discarded them. On 4/6/17, the red bucket in the East kitchen did not contain the proper amount of sanitizer. During the operation of the dish machine on 4/6/17, the temperature of the machine was observed at 80 degrees. Dietary staff member #1 was asked if she could test the sanitizer in the machine and he/she stated he/she had never tested the sanitizer before. The Dietary Manager was notified of the dish machine and after running the machine several times, the temperature was at 124 degrees and contained the correct level of sanitizer. During finial tour of the East building nutrition kitchens on 4/5/17 the following was observed: Halls 100/200/300-chipped grate on the corner of the ice machine; the ice machine with gray build-up Halls 400/500/600-(1) unlabeled, undated item in refrigerator, refrigerator with spillage observed, crumbs in the microwave, no turntable in the microwave and white/gray buildup on the ice machine. Staff was notified of the concerns in the nutrition kitchen and the food item was removed. Review of the facility policy titled Equipment revealed It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order. Action step 5 states the Food Services Director will submit requests for maintenance or repair it to the Administrator and/or Maintenance Director as needed. Review of the facility policy titled Food Storage: Cold the following: .all perishable foods will be maintained at temperature of 41 degrees or below except during necessary periods of preparation and service. 5.all food items are stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. 6 thaws frozen items requiring defrosting, before preparation, under refrigeration, in a microwave for immediate use, or in a sealed container immersed in cold running water. Review of the facility policy titled Food: Preparation revealed under 11. All staff will use serving utensils appropriately to prevent cross contamination. 13. All time/temperature control for safety(TCS) foods that are to be held for more than 24 hours at a temperature of 41 degrees or less will be labeled and dated with a prepared date(Day 1) and a use by date (Day 7). Review of the facility policy titled Authorized kitchen personnel states under the action step 2. All authorized personnel must wear appropriate head covering while in the kitchen or production area.",2020-09-01
1075,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,372,D,1,1,G1PJ11,"> On the days of the survey, based on observation and interview, the facility failed to ensure the grease traps were located on a non-porous surface for 2 of 2 grease traps observed. The findings included: On 4/6/17 at approximately 10:00 AM, the grease trap for the West Building was observed on wheels located partially over a grassy area. On 4/7/17 at approximately 10:30 AM, the grease trap for the East Building was observed on wheels located over a grassy area. On 4/7/17 at approximately 10:30 AM, the above findings were confirmed with the Administrator. No policy was provided during the survey process related to the grease traps and how they are stored.",2020-09-01
1076,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,431,D,1,1,G1PJ11,"> Based on observations, record reviews, interviews and manufacturer package inserts the facility failed to assure that expired medications were not in-use in 1 of 4 medication rooms and that 1 of 4 medication room refrigerators were kept free of water dripping onto medications (Refer to F333). The findings include: Inspection of the West Building Hall 100/200 Medication Room refrigerator at approximately 4:53 PM revealed: - One opened vial of Tuberculin Purified Protein Derivative (Mantoux) Tubersol 5 TU (test units)/0.1 ml (milliliter) 5 ml (50 tests) by Sanofi-Pasteur, Lot C5035aa, dated as opened by the facility on 1/28/17. The manufacturer package insert states to discard a vial which has been entered and in-use after 30 days. -One opened vial of Humulin R (Regular) Insulin by[NAME]Lilly, belonging to Resident 186 dated by the facility as opened 1/13/17. The manufacturer package insert states that opened (in-use) vials are to be used within 28 days of opening. -The bottom shelf of the refrigerator contained medication packaging saturated with water and standing water was on the bottom shelf. These findings were verified on 4/3/17 at approximately 5:22 PM by RN (Registered Nurse) # 1 who stated that both the Tuberculin Purified Protein Derivative and Humulin R Insulin were still in-use. RN # 1 was unable to explain the presence of standing water and wet medication packaging in the refrigerator.",2020-09-01
1077,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,441,D,1,1,G1PJ11,"> Based on observations, interviews and review of the facility policy titled, Wound Care/Treatment Guidelines, and Laundry Services, the facility failed to ensure soiled dressings were disposed of properly after wound care for 1 of 2 residents reviewed for pressure ulcers. In addition the facility failed to ensure soiled linen was not thrown on the floor on the clean side of the laundry room and the soiled heavy duty gloves and gown for sorting were not stored on the clean side of the laundry room next to clean clothes and linens. The facility further failed to ensure soiled linen and resident clothes were sorted with as little agitation as possible and away from the body and face during the sorting of soiled linen/laundry in 1 of 2 laundry rooms. The findings included: An observation on 4/5/2018 at approximately 1:18 PM revealed Registered Nurse (RN) #3 performing wound care for Resident #180. After completing wound care RN #3 bagged the trash and carried it to a trash can against the wall in front of the nurse's desk and deposited it. The nurse then went into the soiled utility room removed the gloves and washed his//her hands and proceeded to chart the treatment. Review on 4/5/2017 at approximately 3:30 PM of the facility policy titled Wound Care/Treatment Guidelines, states under Purpose: To provide excellent wound care to promote healing. Number X1 states,Trash is bagged in the room and again in the bag on the cart. This bag is disposed in the soiled utility room. An observation on 4/7/2017 at approximately 11:00 AM in the West Building laundry room revealed a large bundle of soiled table clothes and napkins piled on the floor on the clean side of the laundry room. Further observation revealed the soiled heavy duty gloves and gown used for sorting soiled linen and laundry were stored on the clean laundry room side next to clean linens. During an interview on 4/7/2017 at approximately 11:15 AM with Laundry Worker #1 confirmed that the soiled table clothes and the napkins should not have been placed on the floor of the clean side of the laundry room. He/she also confirmed that the soiled gloves and gown should not have been stored on the clean side of the laundry room. An observation on 4/7/2017 at approximately 11:55 AM revealed Laundry Worker #1 sorting soiled linen outside the West Building laundry room. He/she used the heavy duty gloves and a gown for protection, but was observed holding the soiled linen above eye level and shaking it out very close to his/her exposed face. An interview on 4/7/2017 at approximately noon with Laundry Worker #1 confirmed that he/he had held the soiled linen up and close to his/her face while shaking it out. Review on 4/7/2017 at approximately 12:40 PM of the facility policy titled, Laundry Services, states under the Purpose: To assure a clean supply of linens and to protect employees who handle and process the laundry. Under Policy: 1 [NAME] states, Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and of persons handling the linen. Standard precautions will be used by clinical and laundry staff handling the linen. Section III, Separating Clean from Dirty in the Laundry, states, In the laundry, dirty linen should be moved from the dirtiest to the cleanest areas as it is being processed; dirty linen should be clearly separated from areas where clean linen is handled. .",2020-09-01
1078,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,460,D,1,1,G1PJ11,"> Based on observation, interview and review of the facility policy titled Resident Dignity & Personal Privacy , the facility failed to equip each resident room to assure full visual privacy for each resident in 2 of 2 buildings. The findings included: During room rounds on 4/4/17 and 4/5/17, the following rooms were not equipped with a privacy curtain which ensured full visual privacy: Room N403; Room N407; Room N502; Room N508; Room F204. During environmental rounds on 4/7/17 at 10:15 AM with the Environmental Consultant and the Administrator, the above rooms were confirmed with short curtains that did not provide full visual privacy. Review of the facility policy titled Resident Dignity & Personal Privacy states under the Procedure section the following: 2. Examine and treat residents in a manner that maintains their privacy. a. Use a closed door, a drawn curtain, or both, to shield the resident during all personal care and treatment procedures. No room rounds were provided during the survey process to indicate how often privacy curtains were observed to ensure full visual privacy.",2020-09-01
1079,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,463,D,1,1,G1PJ11,"> Based on observation and interview, the facility failed to adequately equip residents with a functioning call bell system in 2 of 2 buildings. The findings included: During room observations the call bell system was not adequately functioning in the following rooms: 4/4/17 at 9:52 AM Room N403-confirmed by Certified Nursing Assistant #5; 4/4/17 at 10:23 AM Room B308C-confirmed by the Nurse Consultant; 4/4/17 at 4:21 PM the restroom callbell for Room F107-confirmed by the Minimum Data Set Coordinator. No policy related to callbells was provided during the survey process. No schedule as to how often callbells are tested was provided during the survey process. (",2020-09-01
1080,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,490,F,1,1,G1PJ11,"> Based on record review and interview the facility failed to maintain resident funds in a way that prevented misappropriations of residents' monies and the administration failed to conduct a thorough investigation of the allegations of misappropriation of resident property. Administrative staff at the time of the survey had little knowledge of the misappropriation of resident funds, the investigation of the allegation was limited and was not available for review. Seven of 7 residents were found to have discrepancies in their resident funds. The findings included: Cross refer to F159- Management of Personal Funds, F224- Abuse/Neglect/Misappropriation, F225- Failure to conduct a thorough investigation of allegations of Abuse/Neglect/Misappropriation of resident funds. The facility was unable to produce evidence of a thorough investigation of the allegation of mishandling of the resident trust fund. The Administration staff at the time of the incident was no longer at the facility. The present Administration including the Administrator, the Director of Nursing, the Business Office Manager, and the Corporate Personnel were new to the facility. An interview with the Corporate Nurse, Interim Administrator and Interim Director of Nurses revealed the investigation was conducted by the Corporate Compliance Office. They were unable to produce the investigation or evidence of the investigation at the time of the Recertification/Complaint Survey. During the survey the Interim Administrator had no knowledge of the issue or investigation. The acting Director of Nursing (DON) stated the issue was investigated by the Corporate Compliance Office and she would contact them for the investigation report. One employee was terminated but there was no interview noted in the facility investigation. Efforts were made by the surveyor to contact the employee were successful on (MONTH) 6, (YEAR). The employee denied any knowledge of the incident, only that it was being investigated and s/he was advised by an attorney to refer any questions to him. The survey and complaint investigation was completed on (MONTH) 6, (YEAR) after contact was made with the terminated employee and the limited amount of facility investigation was reviewed.",2020-09-01
1081,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,502,D,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility admitted Resident #63 with [DIAGNOSES REDACTED]. Record review on 4/7/17 revealed a physician's orders [REDACTED]. Further review of the medical record revealed the laboratory tests were not drawn as ordered. During an interview on 4/7/17 at 5:08 PM with the Nurse Consultant, he/she confirmed the laboratory tests could not be found and had not been done as ordered. The facility admitted Resident #183 with [DIAGNOSES REDACTED]. Record review on 4/6/17 revealed an order on 3/29/17 to have a Urinalysis collected and conduct a Culture and Sensitivity. The Urinalysis was obtained on 4/6/17 but no culture was started. During an interview with the Registered Nurse for Admissions on 4/7/17 at 5:22 PM, he/she stated a Culture and Sensitivity had not been started. No policy was provided during the survey process related to Laboratory tests. Based on record reviews and interviews, the facility failed to ensure that lab services were done as ordered for 3 of 3 residents reviewed for Lab Services. Labs samples were not collected per Physician order [REDACTED]. The findings included: The facility admitted Resident #47 with [DIAGNOSES REDACTED]. Record Review on 04/05/17 on 11:25 am, revealed a physician's orders [REDACTED]. The review revealed lab results in the file dated 04/13/16. In an interview on 04/06/17 at 11:25 am, Licensed Practical Nurse #3 reviewed the lab book at the nurse's station but could not locate any results for Resident #47. In an interview on 04/06/17 at 11:58 am the Director of Nursing stated the facility did not have a Lab Policy or tracking system.",2020-09-01
1082,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,514,D,1,1,G1PJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews the facility failed to ensure meal consumption was documented after Resident #180 had eaten and not before for 1 of 3 residents reviewed for Nutrition. The facility further failed to ensure hand splints ordered by the physician were in use for the ordered amount of time for Resident #180 for 1 of 2 residents reviewed for Contractures. In addition the facility failed to ensure medical records were accurately documented for Resident #92, 1 of 1 resident reviewed for an injury. The findings included: The facility admitted Resident #180 with [DIAGNOSES REDACTED]. Review on 4/6/2017 at approximately 12:45 PM of the meal consumption documentation for Resident #180 for January, (MONTH) and (MONTH) revealed meal percentages charted/recorded prior to the resident eating the meal. An interview on 4/6/2017 at approximately 1:00 PM with Registered Nurse (RN) #2 verified that meal consumption had been charted by staff prior to the Resident #180 eating the meal. Review on 4/6/2017 at approximately 2:40 PM of the Treatment Administration Record for Resident #180 revealed no documentation for the left wrist, hand, finger orthotic device nor the right hand palm protector being worn by Resident #180 for the physician ordered amount of time. The left wrist, hand, finger othotic device daily for 4-6 hours and the right hand palm protector daily for 6-8 hours. During an interview on 4/6/2017 at approximately 3:10 PM with the Director of Nurses, he/she verified the findings. The facility submitted an allegation of physical abuse for Resident #92 on 12/19/16. Resident #92 was noted to have a painful, swollen, reddened left elbow. Review of the Radiology Report dated 12/19/16 revealed Resident #92 had a supracondylar elbow fracture. Review of the Incident/Accident Report revealed the resident's physician was notified at 8:40 AM and the resident's responsible party was notified at 9:20 AM. The report was signed but not dated. The Incident/Accident Report indicated the date of incident was 12/18/16 at 9:00 PM, the resident complained of pain and his/her left elbow was discolored and swollen. Review of Resident #92's Nurses' Notes revealed no entries between 12/5/16 and 12/19/16. A SBAR Summary was completed on 12/19/16 at 10:28 AM that indicated the resident was noted to have a swollen red elbow. There were no entries on 12/18/16 when Resident #92's arm was noted to be swollen and red, with the resident complaining of pain. There was no documentation that the resident's condition was monitored. Review of the SBAR dated 12/19/16 at 10:28 indicated resident was noted to have a swollen red elbow to the left and discoloration to the left heel. Resident's left elbow observed to be swollen, painful to touch, and discolored. Verbal order received per MD for x-ray of left elbow, apply skin prep to left heel. Tylenol 325 mg 2 tablets was administered for pain on 12/19/16 at 9:00. Review of Resident #92's Medication Administration Record revealed the resident was not administered Tylenol 325 mg for pain on 12/18/16. The resident received Tylenol 325 mg for pain on 12/19/16 at 9:00 AM. CNA #3's facility-obtained statement dated 12/19/16 indicated on 12/18/16 at 9:00 PM s/he went to check on Resident #92. As s/he went to turn the resident, the resident said ouch my arm my arm. CNA #3 went to get LPN #1 and s/he came in to talk with the resident. LPN #1's facility-obtained statement indicated on 12/18/16 at approximately 9:00 PM, CNA #3 told him/her that Resident #92 complained of arm pain. LPN #1 stopped what s/he was doing and went to the resident's room. LPN #1 observed both arms and noted the left elbow was red and a little bigger than the right. LPN #1 indicated s/he went to the medication cart and administered 325 mg Tylenol. LPN #1 then continued with his/her medication pass. In an interview with the surveyor on 4/4/16 at approximately 6:10 PM, the ADON (Assistant Director of Nursing) reviewed Resident #92's nurses' notes and confirmed there was no documentation related to the resident's arm on 12/18/16. The ADON stated LPN #1 should have notified the physician at the time the arm was noted to be red and swollen. The ADON stated the nurse should have monitored and documented the resident's condition in the nurses' notes. The ADON reviewed Resident #92's (MONTH) (YEAR) MAR and confirmed there was no documentation that the nurse administered Tylenol for pain on 12/18/16. The ADON reviewed the nurses' notes and confirmed there was no documentation related to Resident #92's arm on 12/18/16. Review of the facility's policy on Changes in Resident Condition indicated the attending physician and resident's legal representative are notified when changes in the resident's condition occur. The policy indicated prompt notification is required when there is a significant change in the resident's physical status. The policy also indicated the SBAR Communication Form and the Progress Note are used to: assess and document changes in condition in an efficient and effective manner, provide assessment information to the physician, and provide clear comprehensive documentation.",2020-09-01
1083,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-08-10,578,E,0,1,0H3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to offer alert and oriented residents the opportunity to formulate an advance directive and/or failed to ensure that residents were examined and deemed to lack the capacity for decision making by 2 physicians before allowing a resident representative to formulate the advance directive for Residents # 2, 93. 303, 61, and 139, 5 of 9 residents reviewed for advance directives. The findings included: The facility admitted Resident #2 on 6/1/16 with [DIAGNOSES REDACTED]. On 08/07/18 at 04:19 PM, record review revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt form dated 6/2/16 that was signed by the daughter of Resident #2. The form noted the resident was a full code per Social Services. There was no evidence that the resident had been examined by 2 physicians and deemed to lack the capacity to make informed decisions for her/himself. On 08/09/18 at 09:58 AM, review of the MDS (Minimal Data Set) Assessments revealed a 5/6/18 Significant Change in Status Assessment and a 8/1/18 Quarterly Assessment that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact for decision making. At 10:05 AM, review of the Social Services Notes revealed an Initial Social Services Assessment and History indicating the resident was alert and oriented to self, family, time, place and situation. There was no documentation that code status was discussed with Resident #2. The facility admitted Resident #93 on 01/10/17 with [DIAGNOSES REDACTED]. No documentation could be located in the medical record. On 08/07/18 at 04:50 PM, review of the monthly cumulative orders revealed Resident #93 had an advance directive for a code status of DNR. Further review on 08/10/18 at 10:06 AM revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt form dated 01/10/17 indicating a code status of Full Code. Review of a History and Physical dated 3/19/18 from the Hospital stated the resident was a DNR per wishes of the resident's niece and power of attorney. The facility admitted Resident #303 on 08/02/17 with [DIAGNOSES REDACTED]. On 08/07/18 at 04:40 PM, review of the record revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt form dated 08/02/17 and signed by the resident's representative indicating a code status of DNR. Further review revealed only 1 physician had certified the resident lacked the inability to consent. Review of the Annual MDS assessment indicated the resident had a BIMS score of 12. There was no evidence in the record that advance directives was discussed with the resident. During an interview on 08/10/18, the District Director of Clinical Services confirmed the findings as above. The facility admitted Resident #61 on 9/21/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident's Representative signed the Advance Directive/Medical Treatment Decisions Acknowledgment of Receipt form dated 9/22/17. Further record review revealed the Resident's Brief Interview Mental Status (BIMS) score was 11 which indicated the resident was alert and oriented. Record review revealed there was no form in the record with 2 physician's signatures attesting that the resident was not capable of making his/her own healthcare decisions. The documentation was reviewed and confirmed by the Social Services Director on 8/10/18 at approximately 11:30 am. The facility admitted Resident #139 on 1/26/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident's Representative signed the Advance Directive. The record did not contain a form with 2 physician's signatures attesting that the resident was incapable of making his/her own healthcare decisions. The documentation was reviewed and confirmed by the Social Services Director on 8/10/18 at approximately 11:30 am. Review of the facility's policy entitled Advance Directives stated that The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with State and Federal Law. The policy further indicated that, Capacity to Make Health Care Decisions means the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a health care decision.",2020-09-01
1084,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-08-10,607,D,0,1,0H3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy entitled Abuse & Neglect Prohibition, the facility failed to implement its Abuse/Neglect policies related to reporting allegations of Abuse for 1 of 1 resident reviewed for misappropriation of property. (Resident #13) The findings included: The facility admitted Resident #13 on 2/7/17 with [DIAGNOSES REDACTED]. Record review revealed the facility submitted an Initial 2/24-Hour Report of an allegation of Misappropriation of Resident Property concerning Resident #13 by fax to the State Agency on 5/23/18. When asked for a copy of the Five-Day Follow-Up Report and documentation of the date submitted to the State Agency, the facility informed the surveyor that the report was not submitted. During an interview on 8/10/18 at approximately 9:45 AM, the Administrator confirmed this finding. Review of the facility's policy entitled, Abuse & Neglect Prohibition indicated under Reporting and Response 1. STATE REPORTING OBLIGATIONS: 5. The facility will submit a summary of its investigation to the appropriate State agency within 5 days of its initial report or within whatever time frame required by the State Agency.",2020-09-01
1085,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-08-10,609,D,0,1,0H3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy entitled Abuse & Neglect Prohibition, the facility failed to report the results of its investigation of an allegation of abuse to the State Survey Agency in a timely manner for 1 of 1 resident reviewed for misappropriation of resident property. (Resident #13) The findings included: The facility admitted Resident #13 on 2/7/17 with [DIAGNOSES REDACTED]. Record review revealed the facility submitted an Initial 2/24-Hour Report of an allegation of Misappropriation of Resident Property concerning Resident #13 by fax to the State Agency on 5/23/18. When asked for a copy of the Five-Day Follow-Up Report and documentation of the date submitted to the State Agency, the facility informed the surveyor that the report was not submitted. During an interview on 8/10/18 at approximately 9:45 AM, the Administrator confirmed this finding. Review of the facility's policy entitled, Abuse & Neglect Prohibition indicated under Reporting and Response 1. STATE REPORTING OBLIGATIONS: 5. The facility will submit a summary of its investigation to the appropriate State agency within 5 days of its initial report or within whatever time frame required by the State Agency.",2020-09-01
1086,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-08-10,625,D,0,1,0H3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's Bed Hold / Leave of Absence policy, the facility failed to provide a copy of the bed hold policy at the time of transfer for Residents # 107, 1 of 3 residents reviewed for hospitalization s. The findings included: The facility admitted Resident #107 on 08/24/17 with [DIAGNOSES REDACTED]. On 08/07/18 at 02:50 PM, review of the Progress Notes revealed Resident #107 was hospitalized from [DATE] to 04/09/18 and from 04/26/18 to 05/09/18. Further review of the Progress Notes revealed no documentation that a copy of the Bed Hold Policy was provided to the resident and/or the resident representative at the time of transfer for either hospitalization . Review of the Bed Hold / Leave of Absence policy on 08/09/18 revealed the facility provides written notification of the bed hold/leave of absence policy to all residents and/or responsible parties upon admission, and at the time of leave of absence or transfer, in accordance with Federal and State Regulations. During an interview on 08/09/18 at 11:28 AM, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) provided documentation of a Performance Improvement Plan (PIP) dated 8/2/18 related to providing transfer notices to Residents and/or Resident Representatives and the Ombudsman. On 08/09/18 at 11:37 AM, the DON confirmed there was no documentation in the record that the bed hold policy had been provided for the 3/30/18 or 4/26/18 transfer to the hospital but stated that the Business Office Manager (BOM) might have a paper trail and would check with the BOM. During an interview at 11:51 AM, the DON provided a blank copy of a Bed Reservation form that was provided to residents on admission. The DON further stated But (the Resident) was Medicaid so the bed was automatically held for 10 days and confirmed a copy of the bed hold policy was not provided for either hospitalization . The DON also stated that a copy of the bed hold policy would be provided if a resident was hospitalized beyond the 10 days bed hold. The DON then confirmed that the resident exceeded the 10 day bed hold when he was hospitalized from 4/26 to 5/9/18 and that a copy of the bed hold policy was not provided.",2020-09-01
1087,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-08-10,657,C,0,1,0H3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to have evidence that a Certified Nursing Assistant participated in the care plan conference for residents sampled for review of the care plan. Residents #2, #87, #93, #95, #107, #131 and #303. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. At 02:55 PM on 08/10/18, review of the Interdisciplinary Care Conference Attendance Record dated 05/30/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Care Conference Attendance Record dated 04/17/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. There was no documentation of a care plan conference since 04/17/18. The facility admitted Resident #93 with [DIAGNOSES REDACTED]. At 2:57 PM on 08/10/2018, review of the Interdisciplinary Care Conference Attendance Record dated 07/19/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. On 08/10/18 at 02:22 PM, review of the Interdisciplinary Care Conference Attendance Record dated 04/17/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. There was no documentation of a care plan conference since 04/17/18. The facility admitted Resident #107 with [DIAGNOSES REDACTED]. At 2:17 PM on 08/10/2018, review of the Interdisciplinary Care Conference Attendance Record for Resident #107 dated 08/01/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. The facility admitted Resident #131 with [DIAGNOSES REDACTED]. On 08/10/18 at 02:20 PM, review of the Interdisciplinary Care Conference Attendance Records dated 5/30/18 and 08/02/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. The facility admitted Resident #303 with [DIAGNOSES REDACTED]. At 02:52 PM on 08/10/2018, review of the Interdisciplinary Care Conference Attendance Record dated 04/17/18 revealed no documentation that a Certified Nursing Assistant was included in the Interdisciplinary Team and participated in the development of the care plan. There was no documentation of a care plan conference since 04/17/18. During interviews on 08/10/18, the Social Services Director and the Director of Nursing confirmed the lack of Certified Nursing Assistant participation in the care plan meetings and the lack of documentation of care plan meetings as noted above.",2020-09-01
1088,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-08-10,658,D,0,1,0H3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide nursing services according to professional standards of practice for 2 of 2 residents reviewed for a change in condition. Nursing staff failed to document a complete and accurate assessment of a change in condition for Resident #107 and Resident #155. The findings included: The facility admitted Resident #155 on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nursing Progress Note dated [DATE] which indicated, Resident expired at 5:51 a.m.; family and MOD notified. There was no further documentation related to the assessment of the resident or of the condition of the resident prior to the [DATE] notation. The notation prior to [DATE] was dated [DATE]. The surveyor requested additional documentation from the Director of Nursing (DON) concerning the resident's condition. During an interview on [DATE] at approximately 2:30 PM, the DON confirmed that there was no documentation related to the resident's condition prior to when the resident expired and confirmed that there was no documentation of the resident being assessed by an Registered Nurse. The facility admitted Resident #107 on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 01:57 PM, record review revealed an SBAR (Situation Background Appearance Request) form timed and dated 07:26 AM [DATE] stating Blood Sugar HI' after 2 readings. The vital signs recorded on the form were from ,[DATE] (respirations), ,[DATE] (temperature), and ,[DATE] (pulse and blood pressure). There was no documentation of an assessment of the resident's condition at 07:26 AM. At 11:03 PM on [DATE], the nurse documented the resident was resting in bed in no acute distress, there was no documentation that the blood sugar had been re-checked. Continued review of the Nursing Progress Notes revealed on [DATE] at 13:54 the nurse documented LTC MD notified of res. (resident's) increased FSBS (finger stick blood sugar), [MEDICATION NAME] 15 (units) administered this a.m. with no effective results. New order to send to ER (emergency room ) for evaluation. (Ambulance) contacted for transport to ER. Further record review revealed an order for [REDACTED]. On [DATE] at 02:07 PM, review of the Medication Administration Record [REDACTED]. There was no documentation that the blood sugar was re-checked after administration of the insulin and there was no documentation how the nurse determined the insulin was ineffective. Review of the hospital History and Physical dated [DATE] at 18:53 revealed the resident's blood glucose was 841 at the emergency department. Review of the facility's policy entitled Diabetic Management revealed Residents are monitored for signs/symptoms of complications. For [MEDICAL CONDITION] the complications listed included: breathing difficulties and increased respirations, sweet or fuity breath, flushed skin, loss of appetite, nausea and vomiting, increased thirst and dry tongue, dry skin, increased urination, and loss of consciousness. None of the documentation indicated the resident was assessed for the presence or absence of any of the complications listed. During an interview on [DATE] at approximately 4:40 PM, the Director of Nursing (DON) confirmed the resident's blood sugar read high at 7:26 AM and that insulin was administered at 7:41 AM. The DON stated the nurse documented the insulin was ineffective. When informed that the documentation was timed at 1:54 PM, the DON stated it was probably a late entry but confirmed that was not documented. When asked if the physician would have sent the resident out earlier if the nurse had re-checked the FSBS and notified the physician the insulin had been ineffective earlier in the shift, the DON stated I see what you're saying. During an interview at 5:13 PM, the DON confirmed the SBAR was timed and dated at 13:54 PM and that neither the SBAR or the Nursing Progress Notes contained an assessment of the resident at the time the blood sugar was Hi. The DON also confirmed there was no documentation or assessment of the resident at 7:26 AM or at 13:54 PM when the nurse documented the [MEDICATION NAME] administered at 7:41 AM was not effective and that there was no documentation of a FSBS result.",2020-09-01
1089,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2018-08-10,761,D,0,1,0H3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the pharmacy and the facility failed to assure that medications were correctly stored in 3 of 4 medication rooms and in 1 of 8 medication carts. The findings included: On 8/07/18 at approximately 9:25 AM inspection of East Building South (Halls 100, 200 and 300) Medication Room refrigerator revealed: -a refrigerator thermometer reading of 40 degrees F (Fahrenheit) -2 unopened vials of [MEDICATION NAME] Ophthalmic Drops 0.2% (percent), 5 ml (milliliter) (dispensed 8/5/18 and dispensed 7/27/18) -1 unopened vial of Oflaxacin Ophthalmic Drops 0.3%, 5 ml (dispensed 8/6/18) -1 unopened vial of [MEDICATION NAME] Ophthalmic Drops 0.2%-0.5%, 5 ml (dispensed 6/30/18) -1 unopened vial of Dorzolamide Ophthalmic Drops 2%, 5 ml (dispensed 7/31/18) These findings were confirmed on 8/07/18 at approximately 9:46 AM LPN (Licensed Practical Nurse) # 1 who contacted pharmacy for further direction, On 8/07/18 at approximately 10:32 AM inspection of the West Building Front (Halls 100 and 200) Medication Room revealed: -a refrigerator thermometer reading of 38 degrees F -1 unopened vial of [MEDICATION NAME] Ophthalmic Drops 0.5% 5 ml (dispensed 4/27/18) -1 unopened vial of [MEDICATION NAME] Ophthalmic Drops 0.2%-0.5% 5 ml (dispensed 7/16/18) -Multiple insulin [MEDICATION NAME], in plastic bags were stored on a plastic tray full of water sitting beneath freezer compartment. These findings were confirmed by RN (Registered Nurse) # 1 on 8/7/18 at approximately 10:38 AM who stated that she would contact pharmacy for further guidance regarding the ophthalmic medications and that he/she had just adjusted temperature of refrigerator and that's why there was water in the storage tray. On 8/07/18 at approximately 11:40 AM inspection of the West Building Back (Halls 300 and 400) Medication Room revealed: -a refrigerator thermometer reading of 40 degrees F -1 unopened vial of Dorzalamide Ophthalmic Drops 2%, 5 ml (dispensed 8/3/18) These findings were confirmed on 8/07/18 at approximately 11:46 AM by RN # 2. In each of the above medication rooms, other ophthalmic medications that require refrigeration according to the manufacturer, such as Latanoprost Ophthalmic 0.005%, were also in the refrigerator. None of the ophthalmic medications had been labeled by Pharmacy as requiring refrigeration and the manufacturer's storage requirement had been covered by a pharmacy applied label bearing the resident's name. The manufacturer of the incorrectly stored medication requires storage at room temperature (50-86 degrees), not at refrigerator temperature (36-46 degrees F). On 8/07/18 at approximately 11:54 AM inspection of the West Building Back (Hall 300) Medication Cart revealed the following: 1 - opened bottle of Acidophilus Lactobacillus by Optimum. The manufacturer's label states Refrigerate after opening. This finding confirmed on 8/07/18 at approximately 11:44 AM by LPN # 2.",2020-09-01
1090,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2019-10-31,550,D,0,1,5QMT11,"Based on observation, interview, and review of the facility policy titled Resident Dignity & Personal Privacy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes enhancement of his or her quality of life. During dining observations, staff was observed to knock and enter resident rooms without the resident's permission and/or enter resident rooms without knocking for 1 of 1 dining observation observed. The findings included: During the delivery of lunch trays on 10/28/19 at approximately 1:00 PM, multiple staff members were observed to knock and enter resident rooms and/or enter resident rooms without knocking. During an interview with Certified Nursing Assistant (CNA) #1 on 10/31/19 at 1:30 PM, s/he confirmed s/he did not knock on the resident's door and should have knocked. During an interview with CNA #2 on 10/31/19 at 1:25 PM, s/he confirmed s/he did not knock prior to entering resident rooms. Review of the facility policy titled Resident Dignity & Personal Privacy, revealed the following under the Procedure section: 1 . Knock on doors before entering; announce your presence.",2020-09-01
1091,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2019-10-31,578,D,0,1,5QMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Residents #33 and #117 were afforded the opportunity to formulate their own advance directives (2 of 3 sampled residents reviewed for advance directives). The findings included: The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Record review on 10/30/19 at approximately 9:25 AM revealed that on 11/02/2017 Resident #33 filed paperwork with the facility stating the Power of Attorney in effect at the time of his/her admission was revoked and s/he was assuming responsibility for making his/her own healthcare decisions. No paperwork related to Resident #33 being provided the opportunity to formulate an advance directive was available in the medical record. In an interview on 10/30/19 at approximately 12:18 PM the Director of Nursing confirmed an advance directive was not completed by Resident #33 upon resuming responsibility for making his/her healthcare decisions. Review on 10/30/19 of Resident#117's medical records reveal resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of facility admitted for Resident #117 was 04/12/2019. Resident #117's facility Advance Directives/Medical Treatment Decisions Acknowledgment of receipt was signed by Resident #117's sister-in-law dated 04/12/2019. Review on 10/30/19 of Resident #117's durable power of attorney for Property, Financial, and Healthcare dated (MONTH) 17 (YEAR) revealed that Resident #117's son would have executive power when Resident #117 was deemed incompetent. During an interview with Social Worker #1 on 10/30/19 at approximately 1:30 PM, s/he acknowledged that the sister-in law should have not have signed the Advanced Directives/Medical Treatment Decisions Acknowledgment of receipt and that Resident #117 should have signed the Advance Directives/Medical Treatment Decisions Acknowledgment of receipt because Resident #117 had a Brief Interview for Mental Status of 14 and was considered competent.",2020-09-01
1092,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2019-10-31,657,D,0,1,5QMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the comprehensive Care Plan was reviewed and revised by an interdisciplinary team composed of residents who have knowledge about themselves for 2 out of 24 residents (Residents #33 and #117). The findings included: Review of Medical Book revealed that Residents #33 and #117 were not present at any Care Plan meetings to help compose or make decisions to develop their Care Plans. During an interview with Social Worker #2 on 10/30/19 at approximately 9:35 AM, he/she stated that s/he started his/her position about fours months ago. Further interview revealed that Resident #117 loves staying in bed and will not participate in any activities or participate in any Care Plan meetings. ''That is what Resident #117 likes to do. S/he also stated that there are no written notes about Resident #117 being asked to attend any care plan meetings or refusing to attend any care plan meetings. The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Record review on 10/30/19 at approximately 9:25 AM revealed that a Minimum Data Set (MDS) assessment for Resident #33 was submitted with the date of 05/26/19. No information related to a Quarterly review of the Comprehensive Care Plan by the Interdisciplinary Team could be located in the medical record. In an interview on 10/30/19 at approximately 12:18 PM, the Director of Nursing stated the Care Plan conference was not held.",2020-09-01
1093,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2019-10-31,758,E,0,1,5QMT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure that a [MEDICAL CONDITION] medication was properly prescribed and administered relevant to PRN (as needed) requirements for 1 of 7 residents reviewed for unnecessary medications (Resident #121). The findings included: The facility admitted Resident #121 with [DIAGNOSES REDACTED]. On 10/30/19 at approximately 8:00 AM, a review of the medical record for Resident #121 revealed a physician's orders [REDACTED]. Further review of the October, 2019 Medication Administration Record [REDACTED]. In an interview on 10/30/19 at approximately 1:00 PM, the Director of Nursing verified that the [MEDICATION NAME] 0.5 mg q 6 hr prn anxiety had been prescribed on 10/8/19 with no end date or record of physician evaluating the resident, that this medication had been given past the 14-day limit without a new order and had been administered since 10/8/19 without prior non-pharmacological interventions.",2020-09-01
1094,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2019-10-31,908,D,0,1,5QMT11,"Based on observation, record review, and interview, the facility failed to maintain laundry equipment in safe operating condition in 1 out 2 laundry facilities. The findings included: On 10/31/2019 at approximately 8:40 AM, observation in one laundry facility revealed the outside of the back of the dryer area had several clumps of lint. The clumps were about 2 x 3 each. On 10/31/2019 at approximated 8:45 AM, the Administrator did observe the back of the dryer where several clumps of lint could be seen. The Administrator stated, it looks like they missed that area. On 10/31/2019 at approximately 8:55 AM, interview with the Laundry Worker revealed that the back of the dryer area was cleaned every hour when in use. On 10/31/2019 at approximately 9:00 AM, review of the facility's laundry room cleaning log revealed that the last cleaning was at 8:00 AM.",2020-09-01
4453,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,156,C,0,1,W3VQ11,"Based on record review and interview, the facility failed to provide the amount of time required for notification on Liability and Appeals Notice to 1 of 3 sampled residents who had been discharged from Medicare Part A Services with days of eligibility remaining for Resident #51. Additionally, the facility failed to post contacts and phone numbers to contact outside of the facility in 2 of the 2 buildings and Resident #70 was unaware of the Ombudsman position. The findings included: A review of Liability and Appeals Notice with the Business Office Coordinator (B[NAME]) on 6/19/16, revealed Resident #51 was discharged from Medicare Part A Services on 4/15/16 without the forty eight hour notification with Medicare eligibility days remaining. During the review of these notices, the B[NAME] verified that the Notice of Medicare Non-Coverage -CMS form had The Effective Date Coverage of Your Current Services Will End: 4/14/16. The B[NAME] indicated if the resident is in the facility and able to sign he/she would have the resident sign the Notice of Medicare Non-Coverage -CMS . The B[NAME] was unaware of the forty eight hour notification requirement. A review of the minutes from the Resident Council meetings in the past year, revealed no written discussion about Facility rules, available Ombudsman support or DHEC Survey results. When asked about the state surveys, the Resident Council President stated that s/he was not aware of available survey results, because no one had explained it to her/him. When asked if s/he knew what an Ombudsman does, s/he was not familiar with the position of the Ombudsman. On 06/08/16 at approximately 2:30 pm, during an interview with the Activity Director (AD), the AD stated that s/he had been with the facility for over four years. The AD was asked about the last time s/he went over the facility rules and the results from the last DHEC survey. The AD stated that it had been way over a year. Also, s/he could not remember the last time an Ombudsman came to a Resident Council meeting, and s/he did not know who the current Ombudsman was for the facility.",2020-01-01
4454,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,157,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the residents' physician and/or responsible party were notified for a change in condition for 1 of 3 residents reviewed for notification. There was no evidence of notification to Resident #199 's physician for the resident's refusal of [MEDICATION NAME]. The findings included: The facility admitted Resident #199 with [DIAGNOSES REDACTED]. Record review on 6/8/15 at 8:55 PM revealed a care plan dated 6/2/16 Problem Exhibition of Behavioral Symptoms as evidenced by Resists Care. Approach: Notify Medical Doctor (MD) as needed. Record review of the Physician 's Order on 06/09/2016 at 7:35 AM revealed that the resident was receiving [MEDICATION NAME] solution 40mg/0.4ml ([MEDICATION NAME] Sodium) inject 0.4ml subcutaneously one time a day for preventative treatment. Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Record review on 06/09/2016 at approximately 8:00 AM of the Progress Notes revealed Resident #199 refused 0.4ml subcutaneously on 6/1/16, 6/3/16, 6/4/16, 6/5/16 and 6/6/16. During an interview with Director of Nursing (DON) on 06/09/2016 at approximately 6:45 PM, after reviewing the chart, he/she confirmed there was no documentation the physician was notified and the physician should have been notified of the refusal.",2020-01-01
4455,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,159,C,0,1,W3VQ11,"Based on interview, record review, and review of the facility 's policy Resident Trust Accounts , the facility failed to ensure that 3 of 4 sampled residents received quarterly statements. Resident #57, Resident #70's Responsible Party and Resident #92 stated they were not given quarterly statements. The Findings included: During a family interview on 6/7/16 at approximately 12:44 PM with Resident #70's Responsible party, individual interview with Resident #57 on 6/7/16 at 1:42 PM, and individual interview with Resident #92 on 6/7/16 revealed they had not received quarterly statements. Review of the facility policy on Resident Trust Accounts: Quarterly Procedures: 3. Trust statements for residents who have been properly declared incompetent to make health care/financial decisions are sent to the resident 's legal representative. During an interview with Accounts Receivable Coordinator (ARC) on 6/9/15 at 5:15 PM, he/she stated the statements are usually mailed out by Corporate. He/she stated there is no documentation when the statement is mailed to responsible party. He/she also stated the resident can request their account statement through the nurse or social worker. ARC confirmed he/she did not give out quarterly statements to the residents that stay in the facility.",2020-01-01
4456,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,170,C,0,1,W3VQ11,"Based on interview, the facility failed to ensure mail would be sent out or delivered promptly to residents whenever there was regularly scheduled postal delivery and pick-up service. Findings included: On 06/08/2016 at approximately 5:15 pm, a phone interview was conducted with the weekend office manager. The office manager stated that she had been with the facility for three years and s/he did not check the Saturday mail on a regular basis. However, if a resident did tell that he or she was expecting mail, s/he would get the mail for that resident. The rest of the mail sits on the AR Coordinator 's desk until Monday morning when s/he comes in. The weekend office manager further stated that if there were no requests for mail, s/he would not get the mail. On 06/08/2016 at approximately 5:25pm, interview with the AR Coordinator revealed that there are some Monday mornings when the mail box was full or there would be a stack of mail on the desk. The AR Coordinator also stated that part of the Monday morning routine was to give the mail to the Activity Director. The Activity Director would then deliver the mail to the residents.",2020-01-01
4457,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,241,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his/her individuality for Resident #59 for 1 of 5 residents reviewed for dignity. Staff failed to answer call lights in a timely manner resulting in Resident #59 having incontinent episodes. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. During an interview on 6/6/2016 at approximately 5:00 PM, Resident #59 reported that staff do not answer call lights in a timely manner resulting in incontinent episodes. He/she stated, Right after breakfast I have to go to the bathroom and no one comes when I call. He/she went on to say that it is frequently during the night, that staff does not answer the call lights. Review on 6/6/2016 at approximately 5:20 PM of the Minimum Data Set ((MDS) dated [DATE] for Resident #59 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Further review of the MDS for Resident #15 revealed in Section G - Functional Status - I. Toilet Use is coded as 3 under self performance as resident needs extensive assistance. And 2. under support is coded as a 2 for one person to physically assist. During an interview on 6/8/2016 at approximately 3:20 PM with Licensed Practical Nurse (LPN) #5 stated, we know we have some problems with the call lights but it is at night usually that the call lights are not getting answered.",2020-01-01
4458,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,242,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility policy titled, Resident Rights, the facility failed to ensure Resident #59 and Resident #203 were afforded the right to choose activities, schedules and health care consistent with his or her interests and to make choices about aspects of his/her life in the facility that are significant to the resident for 2 of 4 residents reviewed for choices. Resident #59 and Resident #203 were not afforded his/her choice to choose the type of bath nor how often he/she would like to bathe. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. During an interview on 6/6/2016 at approximately 8:36 AM with Resident #59, he/she stated,I do not get to choose what kind of bath I want, they just put me on a schedule and I don't know how I got on that schedule. I only get to shower on Tuesday, Thursday and Saturday. Review on 6/8/2016 at approximately 5:20 PM of the Minimum Data Set ((MDS) dated [DATE] for Resident #59 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Further review of the MDS for Resident #15 revealed in Section G - Functional Status - under bathing is coded as 4 totally dependent on staff for bathing and support provided is coded as a 2 which indicates Resident #59 requires the assistance of one person. Further review of the MDS dated [DATE], Section F, Preferences for Customary Routine and Activities, C. asks, While you are in this facility how important is it to you to choose between a tub bath, shower, bed bath or a sponge bath? This question is coded with a 1 as, Very Important. No documentation could be found to indicate his/her preference as to the frequency of bathing. During an interview on 6/8/2016 at approximately 2:08 PM with the Director of Nursing, he/she stated, they ask the preference of what type of bath the resident would like to have, but not the preference for the frequency of baths. During interviews on 6/8/2016 at approximately 2:20 PM with Certified Nursing Assistant (CNA) #2 and CNA #3, both revealed that the facility had a shower schedule and it depended on the room number. That's how it is determined what days they get a shower. Review on 6/8/2016 at approximately 3:45 PM of the facility policy titled, Resident Rights, states, The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. The section under,Fundamental Information, states, Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety. During an interview on 6/8/16 at 10:43 AM with Resident #203 stated, Depends on the weather, prefer to take one in the morning and one in the evening. During an interview on 6/8/16 at 11:26 AM, The Director of Social Services was asked, How do you determine when a newly admitted resident gets a bath? He/she stated, The nurse on the unit will complete an assessment. During an interview on 6/8/16 at 11:40 AM with LPN #5 was asked, How do you determine when a newly admitted resident gets a bath? He/she stated The particular room the resident is in receive showers on the days that are listed. He/she showed the Shower Schedule that lists the rooms and days showers are permitted. Review of the facility 's policy Resident ' s Rights under Federal Law: 29. The Resident has a right to choice activities, schedules, and health care consistent with his or her own interest, assessments, and plan of care.",2020-01-01
4459,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,248,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interview and review of the activity participation record, the facility failed to provide an ongoing program of activities designed to meet the interests, and the physical, mental and psychosocial well being for Resident #57 for 1 of 1 resident reviewed for activities. The findings included: The facility admitted resident # 59 with [DIAGNOSES REDACTED]. Random observations made on 6/6/2016 and 6/7/2016, the first 2 days of the survey, Resident #57 was not provided any type of activities in or outside of his/her room. An observation on 6/7/2016 at approximately 5:15 PM revealed Resident #57 lying in bed, fully dressed in street clothes, sleeping at intervals. Review on 6/7/2016 at approximately 5:28 PM of the activity attendance sheets dated from 3/29/2016 through 5/30/2016 revealed no specific activities for Resident #57 according to his/her preferences. Review on 6/8/2016 at approximately 7:06 AM of the Plan of Care for Resident #57 revealed a need which reads Resident needs continued interaction/socialization and or help adjusting to facility placement with weekly 1 to 1 visits. The goal for Resident #57 included, Resident will continue to have opportunities for socialization, interaction and participate in daily activities as able. The interventions included, Activities of choice as tolerated. Movies and or TV and Music. Other interventions included, resident prefers to have meals in her room, he/she enjoys having his/her mail read to him/her, he/she enjoys visits from friends, family and staff. He/she enjoys touch and or music therapy. He/she also enjoys having books, the Bible, The Daily Bread Devotion and the newspaper read to him/her. No documentation could be found where the above mentioned activities were provided for Resident #57. Review on 6/8/2016 at approximately 8:00 AM of the activity participation record for Resident #57 revealed no specific activities that were being offered to include his/her preferences. During an interview on 6/9/2016 at approximately 10:28 AM with the Activity Director, he/she provided a progress note dated 5/16/2016 which states, continues to be out of bed as tolerated at times, sitting in a large chair in room or at the nurse's station. He/she has family visits almost daily. The family will wheel him/her in the hallway and sometimes outside the facility. Activity staff will continue to invite and encourage him/her to sit in on social group activities . No documentation could be found where activities were being provided for Resident #57.",2020-01-01
4460,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,274,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, the facility failed to complete a SCSA (Significant Change in Status Assessment) within 14 days as required for Resident #160, 1 of 1 resident reviewed receiving Hospice services. The findings included: The facility admitted Resident #160 with [DIAGNOSES REDACTED]. On 06/08/2016 at 2:24 PM, record review revealed the resident was admitted to Hospice on 5/18/16. At 11:37 AM on 06/10/2016, review of the record revealed a SCSA (Significant Change in Status Assessment (Minimum Data Set) with an Assessment Reference Date (ARD) of 6/6/16, which was the 20th day after Resident #160 was admitted to Hospice. Review of the CMS RAI Manual, Chapter 2, page 2-21 revealed A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election . During an interview 2:59 PM 06/10/2016, Registered Nurse (RN) #1 confirmed the Hospice conversion date of 5/18/16. The RN further confirmed that the SCSA was done with an ARD of 6/6/16. When asked when it should have been done, the RN stated we did it within 14 days after we found out. At 3:33 PM, upon review of the RAI Manual, the RN stated that the ARD had been set based on when the MDS office was notified the resident had been admitted to Hospice, not when the resident was admitted to Hospice.",2020-01-01
4461,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,279,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, and review of the facility policy titled, Referral to Outside Agencies, the facility failed to ensure a Plan of Care was developed with measurable goals and interventions to address the care and treatment related to dental/oral health for Resident #102 for 1 of 1 resident reviewed for Dental Status and Services. The findings included: The facility admitted Resident #102 with [DIAGNOSES REDACTED]. An observation on 6/6/2016 at approximately 4:29 PM revealed Resident #102 with his/her top teeth missing. During an interview with Resident #102 on 6/7/2016 at approximately 9:11 AM, he/she stated the he/she did have problems with his/her teeth. Resident #102 went on to say that, X-rays had been taken and the Dentist had visited a time or two, but that was last year and nothing has been done since. Review on 6/9/2016 at approximately 7:01 PM of the Plan of Care for Resident #102 revealed no mention of his/her problems with his/her teeth. The care plan did mention a concern which read, Potential for weight loss/Nutritional Risk. Review on 6/10/2016 at approximately 12:54 PM of the medical record for Resident #102 revealed an oral examination on 8/4/2015 by Senior Dental Care. The notes and recommendations included ,Patient is a candidate for max. partial. He/she would need root tip #9 removed first, then the impression taken. Refer out for extraction of #9 root tip. Further review on 6/10/2016 at approximately 12:54 revealed another dental visit by Senior Dental Care on 9/26/2015 which states, #9 root tip needs extracting, starting to be symptomatic at times . Needs consent form signed by his/her medical doctor and personal representative before the extraction can be done. The consent form was sent to the Social Services Director. No documentation could be found in the medical record where the consent was signed by the doctor nor the personal representative for Resident #102. Resident #102 was seen again on 12/2/2015, and still no one had addressed the #9 root tip extraction. The next appointment was scheduled for (MONTH) (YEAR), and Resident #102 stated that he/she had not been to the dentist this year. No documentation could be found to ensure Resident #102 had been seen for the (MONTH) (YEAR) appointment, and no documentation to ensure Resident #102's dental work had been completed. During an interview on 6/10/2016 at approximately 2:19 PM with the Social Services Director stated, I think this resident went to the dentist for the extraction. I am not sure if he/she has upper teeth or not. The social service director could not ensure Resident #102 attended the follow up appointments as ordered nor could he/she ensure the extraction was done. The social services director could not provide documentation or paper work to ensure the matter was taken care of for Resident #102. During a second interview on 6/10/2016 at approximately 2:30 PM with Resident #102 he/she stated, I have not been to the Dentist this year. I was told once they removed one of my teeth, they could do the impression and get me some top teeth, but they have not removed the tooth yet. Review on 6/10/2016 at approximately 3:45 PM of the facility policy titled, Referral to Outside Agencies, Under Procedure, #3 states, The Social Service Director makes an appointment for the resident with the appropriate outside agency. Number 7 reads, Service providers' recommendations are to be integrated into the resident's plan of care.",2020-01-01
4462,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,280,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the care plan to include a left elbow extension splint for Resident #41, 1 of 3 residents reviewed for care plans. The facility also failed to revise the care plan to reflect the change of a Foley catheter to a suprabubic catcher for Resident #117, 1 of 2 residents reviewed for catheters. The care plans were not revised related to weight loss for Residents #6 and #33, 2 of 4 reviewed for nutrition and the care plans did not include wound doctor visits for Residents #139, #145 and #182, 3 of 5 residents reviewed for pressure ulcers. The findings included: Resident #41 was admitted to the facility with [DIAGNOSES REDACTED]. At 1:34 PM on 06/09/2016, review of the Physician Order Summary Report for May, (YEAR) revealed an order that stated Restorative Nursing Splint Order: L (left) elbow Extension Splint to be worn Mon (Monday)-Sat (Saturday), as tolerated by the resident. Further review revealed an order dated 3/23/16 for Occupational Therapy 5 times a week from 3/23/16 through 4/23/16. Therapeutic interventions included Therapeutic Exercises and Activities, Diathermy and splinting. No order was noted to discontinue the left elbow extension splint. At 3:03 PM on 06/09/2016 review of the Care Plan revealed Risk for decline in Range of Motion was identified as a problem area. Interventions included Restorative PROM (Passive Range of Motion) 3-5 times per week for 8 weeks. The PROM was not reordered upon return from the hospital as the resident was receiving Occupational Therapy. The care plan was not updated to include the left elbow extension splint ordered on [DATE]. During an interview on 06/09/2016 6:00:29 PM, the Director of Nursing (DON) confirmed the left elbow extension splint was not listed on the care plan. The DON further stated that the therapist had reported that no referral had been made to Restorative and no education provided for splint application. The DON did also confirm the resident had an order for [REDACTED]. The facility admitted Resident #117 with a Foley catheter due to [MEDICAL CONDITION] status [REDACTED]. Review of the Discharge summary revealed the hospitalist stated Resident #117 would need a chronic Foley due to being unresponsive to [MEDICATION NAME] and Advodart therapy, Recurrent UTI (Urinary Tract Infection) and Recurrent Acute [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. Record review revealed the resident was sent to the hospital for evaluation and to have the Foley replaced with a suprapubic due to penile erosion on 3/21/16. At 4:45 PM on 06/10/2016, review of the care plan revealed a problem dated 12/17/15 for a #16 French Indwelling Foley catheter. Interventions included but were not limited to, catheter care and changes per physician orders. The care plan was not updated to reflect the change from a Foley catheter to a suprapubic catheter. During an interview on 06/10/2016 at 5:09 PM, the Director of Nursing confirmed confirmed the resident had a suprapubic catheter and that the care plan had not been updated. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. During the Stage I Census Record Review, Resident #6 weights were noted as 117 pounds on 05/11/201; Weight 30 days prior to current weight (04/08/2016): 128 (which is 11 lbs. less than on the first date or a 9.4% loss); Weight 90 days ago (02/01/2016): 137 (which is 20 lbs. less than on the first date or a 17.1% loss; and Weight 180 days ago (11/15/2015): 140 (which is 23 lbs. less than on the first date or a 19.7% loss) At 5:51 PM on 06/10/2016, review of the Care Plan revealed Potential for weight loss related to Chronic Disease: [MEDICAL CONDITION] Reflux, [MEDICAL CONDITION], Hypertension, Chronic Obstructive Heart Failure, [MEDICAL CONDITIONS] Embolism, and Acute [MEDICAL CONDITION] was identified as a problem area. The goal was that the resident's weight would be stabilized through the next review period. The care plan was reviewed on 6/1/16 and continued but was not updated to reflect actual weight loss. During an interview 06/10/2016 6:51:47 PM, Licensed Practical Nurse (LPN) #5 confirmed the weight loss as documented. The LPN also confirmed the care plan was not updated to reflect the actual weight loss. The facility admitted Resident # 182 with [DIAGNOSES REDACTED]. Review on 6/8/2016 at approximately 1:40 PM of the medical record for Resident #182 revealed visits by a wound care specialists contracted by the facility to care for pressure ulcers. The wound care specialists visits were from 4/12/2016 to present date. No physicians order could be found in Resident #182's medical record for the Wound Specialist to evaluate and treat Resident #182. Review on 6/9/2016 at approximately 7:10 AM of Resident #182's Plan of care revealed no mention of the wound care specialist. The facility admitted Resident # 139 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 1:53 PM of Resident #139's medical record revealed visits made the by the wound care specialists with no physician's order found in the the medical record for the wound care specialists to evaluate and treat Resident #139. Review on 6/9/2016 at approximately 2:00 PM of the Plan of Care for Resident #139, revealed no mention of the wound care specialists visits or treatment. The facility admitted Resident #145 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 6:54 PM of Resident #145's medical record revealed visits from the wound care specialists dated from 5/10/2016 through 5/31/2016. No physician's order could be found in the medical record for the would care specialists to evaluate and treat the wounds for Resident #145. Review on 6/9/2016 at approximately 6:54 PM of the Care Plan for Resident #145 revealed no mention of visits or treatment from the wound care specialists. Further review of the Plan of Care for Resident #145 revealed the ordered trunk wedge, knee spreader/flexion block cushion and the bilateral heel/ankle protectors were in place for resident use, but the Plan of Care did not include the devices. An interview on 6/9/2016 at approximately 3:00 PM with the Director of Nursing confirmed that there was not a Physician's order for the wound care specialists and also confirmed that there was not mention on the Plan of Care for Residents #182, #139 and #145. The physician's order for the wound care specialists was obtained during the survey on 6/9/2016. During an interview on 6/10/2016 at approximately 2:33 PM with the Care Plan Coordinator, Registered Nurse #1 he/she confirmed that the wound care specialists was not on the Plan of Care for the above mentioned residents. The facility admitted Resident #33 which included but not limited to [MEDICAL CONDITION] Vascular Disease ([MEDICAL CONDITION]), Type 2 Diabetes Mellitus with [MEDICAL CONDITION] (DM-II), and [MEDICAL CONDITION]. During dining observation on 6/8/16 at 12:36 PM revealed the resident's meal consisted of smothered steak, bread, greens, sweet potatoes, water and ginger ale. He/she only consumed a small portion of sweet potatoes, collards and drank the water and ginger ale. During an interview with Resident #33 on 6/8/16 at 12:49 PM was asked, Why they did not eat their lunch? He/she stated I asked for a piece of chicken and the Certified Nurse Aide (CNA) stated I had to eat what was on the paper. During an interview with CNA #4 on 6/8/16 at 1:12 PM, he/she stated Past her tray and made sure she had what she needed. Resident #33 saw another resident had chicken and asked for some. I was only allowed to give the resident what was on the paper. I asked if he/she wanted a sandwich. Review of the Care Plan on 6/8/16 at 9:54 PM revealed the care plan dated 3/28/16 Weight Loss/Nutritional risk related to Chronic Disease, [MEDICAL CONDITION] Reflux Disease (GERD), Diabetes Mellitus (DM), [MEDICAL CONDITION] Disease [MEDICAL CONDITION], and Hypertension (HTN). The Approach for the care plan included offer preferred food and determine individual likes and dislikes. During an interview with Dietary Manager on 6/9/16 at 12:09 PM, he/she stated the Resident is on a cardiac diet that consist of no fried food. The foods are baked and not fried except for the chicken. He/she also stated the resident is offered a diet free holiday or may have menu of the month. Record review on 6/9/16 at 2:57 PM revealed Resident#33 weight for 4/28/16 was 183 and 5/11/16 was 173. During an interview with the Director of Nursing (DON) on 6/9/16 at 6:31 PM, he/she confirmed the care plan was not revised for the significant weight loss that occurred in the month (MONTH) (YEAR).",2020-01-01
4463,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,281,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the facility policy and Potter, P.[NAME], & Perry Fundamentals of Nursing , the facility failed to meet professional standard of quality for 1 of 5 residents reviewed for subcutaneous administration. Staff used a gauge needle inconsistent with a subcutaneous injection. The findings included: The facility admitted Resident #205 with [DIAGNOSES REDACTED]. On 6/8/16 at 8:51 AM, during Resident #205's medication administration LPN #3 withdrew units of [MEDICATION NAME] Solution (Epoetin) into a 21 gauge, 1 inch needle. Prior to administration LPN #3 was asked to review Resident #205 Physicians Orders that stated [MEDICATION NAME] Solution UNIT/ML (Epoetin Alfa) inject 1 dose subcutaneously Weekly every Wed. Following the observation LPN#3 verified s/he was going to administer Epoetin units subcutaneously with a 21 gauge, 1 inch needle. Review of the facility policy Administration of Medications, subtitle: Subcutaneous Injections under Equipment, states Safety Needle 25 or 27 gauge, 1/2 - 7/8 inch length. Review of Potter, P.[NAME], & Perry Fundamentals of Nursing (6th edition), states under Subcutaneous injections, Do not administer more than 1 ml with a single SubQ (subcutaneous) injection. Use a 25-to-30 gauge, 3/8-to 5/8- inch needle.",2020-01-01
4464,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,282,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure the Comprehensive Plan of Care was followed for Resident # 57, #199 and Resident #59. Resident #57's Plan of care not followed related to activities and activity preferences for 1 of 1 resident reviewed for activities. Resident #59's care plan not followed related to a physician ordered fluid restriction, monitoring the Thrill and Bruit and for ensuring [MEDICAL TREATMENT] communication is sent to [MEDICAL TREATMENT] with Resident #59 and returned after the appointment is complete for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The facility further failed to follow a Plan of Care for Resident #199 related to notification for 1 of 1 resident reviewed for Notification. The findings included: The facility admitted resident # 57 with [DIAGNOSES REDACTED]. Review on 6/7/2016 at approximately 5:28 PM of the activity attendance sheets dated from 3/29/2016 through 5/30/2016 revealed no specific activities for Resident #57 according to his/her preferences. Review on 6/8/2016 at approximately 7:06 AM of the Plan of Care for Resident #57 revealed a need which reads Resident needs continued interaction/socialization and or help adjusting to facility placement with weekly 1 to 1 visits. The goal for Resident #57 included, Resident will continue to have opportunities for socialization, interaction and participate in daily activities as able. The interventions included, Activities of choice as tolerated. Movies and or TV and Music. Other interventions included, resident prefers to have meals in her room, he/she enjoys having his/her mail read to him/her, he/she enjoys visits from friends, family and staff. He/she enjoys touch and or music therapy. He/she also enjoys having books, the Bible, The Daily Bread Devotion and the newspaper read to him/her. No documentation could be found where the above mentioned activities were provided for Resident #57. Review on 6/8/2016 at approximately 8:00 AM of the activity participation record for Resident #57 revealed no specific activities that were being offered to include is/her preferences. During an interview on 6/9/2016 at approximately 10:28 AM with the Activity Director, he/she provided a progress note dated 5/16/2016 which states, continues to be out of bed as tolerated at times, sitting in a large chair in room or at the nurse's station. He/she has family visits almost daily. The family will wheel him/her in the hallway and sometimes outside the facility. Activity staff will continue to invite and encourage him/her to sit in on social group activities . No documentation could be found where the mentions activities were being provided for Resident #57. The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Review on 6/8/2016 at approximately 11:43 AM of the medical record for Resident #59 revealed a physician's orders [REDACTED]. Notify the physician if not present. Review on 6/8/2016 at approximately 1:25 PM of the Plan of Care for Resident #59 revealed a Problem/strength which states, Receives [MEDICAL TREATMENT] 3 times weekly. The interventions included, fluid restriction as ordered, 1500 milliliters daily. A second intervention/approach was listed and read, After return from [MEDICAL TREATMENT], check for thrill and bruit two times per shift on days returned from [MEDICAL TREATMENT], and then daily. The plan of care also included in approaches/interventions which reads, [MEDICAL TREATMENT] Communication Record is sent to the [MEDICAL TREATMENT] center with each appointment, and return of the form is ensured after each appointment is completed. No documentation could be found in Resident #59's medical record to ensure the care plan was followed. Review on 6/8/2016 at approximately 4:31 PM of he Treatment Record for Resident #59 revealed that the thrill and bruit had not been monitored per the physician's orders [REDACTED].>During interviews on 6/8/2016 at approximately 4:31 PM with the Director of Nursing and the Unit Manager, Licensed Practical Nurse #5 confirmed that the Care Plan was not followed related to a physician ordered fluid restriction, for checking the thrill and bruit daily and before and after [MEDICAL TREATMENT] nor was it followed to ensure the [MEDICAL TREATMENT] communication records were sent to [MEDICAL TREATMENT] with Resident #59 and were returned after the appointment was completed to coordinate care between the [MEDICAL TREATMENT] center and the facility. The facility admitted Resident #199 with [DIAGNOSES REDACTED]. Record review on 6/8/15 at 8:55 PM revealed care plan dated 6/2/16 Problem Exhibition of Behavioral Symptoms as evidenced by Resists Care. Approach: Notify Medical Doctor (MD) as needed. Record review on the physician's order [REDACTED]. Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Record review on 06/09/2016 at approximately 8:00 AM of the Progress Notes revealed Resident #199 refused 0.4ml subcutaneously on 6/1/16, 6/3/16, 6/4/16, 6/5/16, and 6/6/16. During an interview with Director of Nursing (DON) on 06/09/2016 at approximately 6:45 PM, after reviewing the chart, he/she confirmed there was no documentation the physician was notified and the care plan was not followed to notify the physician when the resident refused the [MEDICATION NAME].",2020-01-01
4465,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,309,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and the facility policy titled, Documentation, the facility failed to ensure a physician ordered fluid restriction was consistently documented to reflect the total intake for resident #59. The facility further failed to ensure the thrill and bruit were monitored and verified for Resident #59. The facility additionally failed to ensure coordination of care via a communication sheet was provided to the [MEDICAL TREATMENT] clinic and returned to the facility with each [MEDICAL TREATMENT] visit for Resident #59 for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The facility failed to ensure medications were administered as ordered by the physician as evidenced by blanks on the Medication Administration Record [REDACTED]. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Review on 6/8/2016 at approximately 11:43 AM of the medical record for Resident #59 revealed a physician's orders [REDACTED]. Notify the physician if not present. A second physician's orders [REDACTED]. No documentation could be found in Resident #59 medical record to ensure the physician's orders [REDACTED]. During interviews on 6/8/2016 at approximately 4:31 PM with the Director of Nursing and the Unit Manager, Licensed Practical Nurse #5 confirmed that the physician's orders [REDACTED]. Review on 6/8/2016 at approximately 2:10 PM of the Medication Administration Record [REDACTED]. The [MEDICATION NAME] 0.5 mg tablet to be given by mouth daily at 8:00 AM and [MEDICATION NAME] Sodium 100 mg tablet to be given by mouth at bedtime had not been documented as given on 6/3/2016. The daily fingerstick blood sugar checks to be done daily at 6:00 AM was not documented as done on 6/1/2016, 6/3/2016 nor on 6/4/2016. The [MEDICATION NAME] 5 units to be administered subcutaneously at bedtime and the [MEDICATION NAME] 75 microgram tablet to be given by mouth daily at 6:00 AM was not documented as given on 6/1/2016, 6/3/2016 and 6/4/2016. The [MEDICATION NAME] 10 mg tablet to be given by mouth at bedtime was not documented as given on 6/3/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 20 mg tablet to be given by mouth daily at 8:00 AM was not documented as given. The Prostat 30 milliliters to be given by mouth daily, and Senispar 60 mg tablet to be given daily by mouth was not documented as given on 6/2/2016. The Tab-A-Vite tablet 1 tablet to be given by mouth daily and Vitamin B 6 100 mg to be given by mouth one time daily was not documented as given on 6/2/2016. The [MEDICATION NAME] 50 mg 1 tablet to be given by mouth daily was not documented as given on 6/3/2016. The [MEDICATION NAME] MultiHealth Fiber Powder 58.6 % [MEDICATION NAME] ordered to give 2 teaspoons by mouth two time daily was not documented as given at 8:00 AM on 6/2/2016 and the 8:00 PM dose was not documented as given on 6/3/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 17 grams to be given by mouth 2 times daily and the Sildenafil [MEDICATION NAME] 20 mg tablet to be given 2 times daily was not documented as given on 6/2/2016 at 8:00 AM as ordered. The Vitamin B 1 100 mg tablet to be given two times a day was not documented as given at 8:00 AM on 6/2/2016. The [MEDICATION NAME] 800 mg tablet to be given by mouth three times daily on Sunday, Tuesday, Thursday and Saturday was not documented as given on 6/2/2016 at 8:00 AM and 12 noon. During an interview on 6/8/2016 at approximately 2:15 PM with the Director of Nurses concerning the blanks on the MARs, he/she stated, Me and all my managers came in Sunday to check orders to make sure they were correct and new orders had been entered correctly. The DON verified multiple blanks on the MARs We had training but not everyone attended. During an interview on 6/8/2016 at approximately 2:45 PM with the Nurse Manager, Licensed Practical Nurse (LPN) #5, he/she confirmed the blanks on the MARs and stated, I think it is because the staff did not know how to chart in the computer once the medication was given. The LPN could not verify that the resident's received the medications as ordered. The facility admitted Resident #102 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 9:00 AM of the MAR for Resident #102 revealed the medication Atorvastatin 10 mg tablet to be given by mouth at bedtime was not documented as given on 6//1/2016. The [MEDICATION NAME] 25 mg tablet to be given by mouth one time daily was not documented as given on 6/2/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 100 mg tablet to be given by mouth was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 5 mg tablet to be given by mouth one time daily was not documented as given on 6/1/2016, 6/4/2016 and 6/4/2016. The [MEDICATION NAME] 0.4 mg tablet to be given by mouth daily was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 400 mg tablet to be given by mouth at bedtime was not documented as given on 6/1/2016. The [MEDICATION NAME] 40 units to be given subcutaneously in the evening was not documented as given on 6/1/2016. The Multi Vitamin with Minerals to be given one time daily was not documented as given on 6/4/2016 and 6/5/2016. The Multivital-M tablet to be given by mouth daily was not documented as given on 6/1/2016. The [MEDICATION NAME] 10 mg tablet to be given one time daily by mouth was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] Insulin on 6/2/2016 with 12 units to be administered daily at 12 noon and 5:00 PM was not given on 6/4/2016 and 6/5/2016. The time preprinted on the MAR indicated [REDACTED]. No 5:00 PM doses were given on 6/2/2016, 6/3/2016, 6/4/2016, 6/5/2016, 6/6/2016, 6/7/2016 or 6/8/2016, then the order was discontinued on 6/8/2016 at 7:18 PM. The [MEDICATION NAME] Insulin 15 units to be given at 8:00 AM was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 17 grams to be be given daily was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The Senna Lax 17.2 mg tablet to be given at bedtime was not documented as given on 6/1/2016. The Xarelto 20 mg tablets ordered to be given daily at 5:00 PM was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. Blood pressure checks ordered to done every shift were not documented as done on 6/1/2016 AM nor PM, 6/4/2016 AM, 6/5/2016 AM or 6/10/2016 AM. The Carvedilol 25 mg tablet to be given by mouth 2 times daily was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] Capsule 300 mg to be given 2 times daily was not documented as given on 6/1/2016 at 2:00 PM, 6/2/1016 at 6:00 AM, 6/4/2016 at 2:00 PM and 6/5/2016 at 2:00 PM. The [MEDICATION NAME] 1000 mg to be given 2 times daily by mouth was not documented as given on 6/1/2016, 6/4/2016, or 6/5/2016 at 8:00 AM. The Fingerstick Blood Sugars ordered 3 times daily were not documented as checked on 6/1/2016 at 12 noon and 5:00 PM, 6/2/2016 at 6:00 AM, 6/4/2016 at 12 noon and 5:00 PM, and 6/5/2016 at 12 noon and 5:00 PM. The facility admitted Resident # 139 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 1:19 PM of the MAR for Resident #139 revealed the medication [MEDICATION NAME] 100 mg to be given daily by mouth was not documented as given on 6/2/2016. The [MEDICATION NAME] 20 mg tablet to given by mouth daily was not documented as given on 6/2/2016. The Multivitamin with Minerals 1 tablet to be given by mouth daily was not documented as given on 6/2/2016. The [MEDICATION NAME] 650 mg to be given by mouth 2 times daily was not documented as given on 6/2/2016 at 8:00 AM. The [MEDICATION NAME] 100 mg to be given two times daily by mouth was not documented as given on 6/2/2016 at 8:00 AM. The House Supplement to be given 2 times daily was not documented as given on 6/2/2016 at 8:00 AM. The [MEDICATION NAME] 50 mg to be given 2 times daily by mouth was not documented as given on 6/2/2016 at 8:00 AM. The [MEDICATION NAME]-[MEDICATION NAME] 25-100 mg to be given 3 times daily by mouth was not documented as given on 6/2/2016 at 8:00 AM nor 12 noon. The [MEDICATION NAME] 250 mg capsule to be be given by mouth 3 times daily for 10 days and ordered on [DATE] at 4:50 PM was not documented as given on 6/4/2016, 6/5/2016 and the 9:00 AM dose on 6/6/2016. The House Supplement for Medpass 90 milliliters to be administered by mouth 4 times daily was documented as given on 6/2/2016 at 9:00 AM and 1:00 PM. The facility admitted Resident #145 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 6:54 PM of Resident #145's MAR indicated [REDACTED]. The House Supplement to be given daily at 10:00 AM was not documented as given on 6/2/2016. The Tylenol 650 mg tablets to be given by mouth every 6 hours was not documented as given on 6/4/2016 at 12:00 AM and 6:00 AM. Review on 6/10/2016 at approximately 9:22 AM of the facility policy titled, Documentation, revealed under, Fundamental Information, Aspects of resident care such as observations and assessments, administration of medications, and services and treatments performed must be documented in the medical record according to policy. Under the topic, Procedure, General, number 6 states, Medication and Treatment Records: When a medication or treatment is administered the nurse initials the appropriate box on the Medication Administration Record [REDACTED]",2020-01-01
4466,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,314,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facilty's policies, the facility failed to provide treatments as ordered for Resident #160, stage the ulcer for Resident #182, or obtain an order for [REDACTED]. The findings included: The facility admitted Resident #160 with [DIAGNOSES REDACTED]. On 06/07/2016 at 10:26 AM, review of the nutrition assessment dated [DATE] revealed the resident had a Stage IV to sacrum. At 1:04 PM on 06/10/2016, review of the Treatment Administration Record (TAR) revealed treatment orders to cleanse the wound with wound cleaner, apply calcium alginate, cover with dry gauze and secure with a dry dressing. Further review revealed the treatments were not signed off 5/28/16 and to the 5/29/16 sacrum, coccyx, left heel, and left ankle. Review of the TAR revealed a treatment for [REDACTED]. A treatment ordered for a skin prep to the left ankle and a wet to dry dressing was not done on 6 days in (MONTH) prior to the Left Above Knee Amputation (AKA). A treatment for [REDACTED]. Upon return from the hospital status [REDACTED]. Review of the TAR revealed the dressing change was not done on 5/14, 5/15/16. In addition, review of the medical record revealed no body audits in the medical record. Review of the Body Audit notebook revealed 1 body audit dated 5/28/16. During an interview at 1:58 PM on 06/10/2016, Licensed Practical Nurse (LPN) #6 confirmed the missing treatment documentation in (MONTH) and (MONTH) and that the sacral dressing was done once daily not BID as ordered. The LPN also confirmed there were no body audits in the resident's medical record and only one body audit dated 5/28/16 in the Body Audit notebook. The facility admitted Resident # 182 with [DIAGNOSES REDACTED]. Review on 6/8/2016 at approximately 1:40 PM of the medical record for Resident #182 revealed visits by a wound care specialists contracted by the facility to care for pressure ulcers. The wound care specialists visits were from 4/12/2016 to present date. No physicians order could be found in Resident #182's medical record for the Wound Specialist to evaluate and treat Resident #182. The facility admitted Resident # 139 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 1:53 PM of Resident #139's medical record revealed visits made the by the wound care specialists with no physician's order found in the the medical record for the wound care specialists to evaluate and treat Resident #139. The facility admitted Resident #145 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 6:54 PM of Resident #145's medical record revealed visits from the wound care specialists dated from 5/10/2016 through 5/31/2016. No physician's order could be found in the medical record for the wound care specialists to evaluate and treat the wounds for Resident #145. A physician's order for the wound care specialists was obtained during the survey on 6/9/2016 for Resident #145. An interview on 6/9/2016 at approximately 3:00 PM with the Director of Nursing confirmed that there was not a Physician's order for the wound care specialists even though Resident # 145, #139 and Resident #182 are receiving care and services from the wound care specialists. Review on 6/9/2016 at approximately 4:20 PM of the agreement with the wound care specialists titled, National Wound Care Services Agreement, states under section II, General Duties and Obligations of Provider, [NAME] Services. states, Provider shall ensure that its personnel provides skin and wound care, upon receipt of: the written order of an attending physician and specific authorization to treat the resident.",2020-01-01
4467,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,318,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide a left elbow extension splint for Resident #41 and failed to follow up on Passive Range of Motion exercises for Resident #145 to increase strength and prevent further decrease in range of motion for 2 of 3 residents reviewed for Range of Motion. The findings included: Resident #41 was admitted to the facility with [DIAGNOSES REDACTED]. At 1:56 PM on 06/08/2016, observation of Resident #41 revealed the resident supine in bed with contractures noted of bilateral hands and wrists. Resident was unable to extend wrist upon request and had on no splints. At 11:35 AM and at 2:39 PM on 06/09/2016, observation revealed Resident #41 supine in bed, arms bent at the elbows, hands on chest with noted contractures and no splints in place. At 1:34 PM on 06/09/2016, review of the Physician order [REDACTED]. Further review revealed an order dated 3/23/16 for Occupational Therapy 5 times a week from 3/23/16 through 4/23/16. Therapeutic interventions included Therapeutic Exercises and Activities, Diathermy and splinting. No order was noted to discontinue the left elbow extension splint. Record review revealed no documentation of application of the splint. At 3:03 PM on 06/09/2016 review of the Care Plan revealed Risk for decline in Range of Motion was identified as a problem area. Interventions included Restorative PROM (Passive Range of Motion) 3-5 times per week for 8 weeks. The PROM was not re-ordered upon return from the hospital as the resident was receiving Occupational Therapy. The care plan was not updated to discontinue the PROM or to include the left elbow extension splint ordered on [DATE]. During an interview at 2:48 PM on 06/09/2016, CNA (Certified Nursing Assistant) #1 confirmed the resident did not have on splints and stated s/he uses a pillow for positioning to help extend the resident's elbow. The CNA confirmed the splint was in the resident's room and stated that lately the resident had been refusing the splint. During an interview at 3:29 PM on 06/09/2016, the Director of Nursing confirmed the order for the left elbow splint and stated the referral had never been made to Restorative. The DON further confirmed that Restorative was not applying the splint. The DON also stated that the therapist had informed her/him that the resident had not tolerated the splint but confirmed the documentation provided by the therapist indicated the resident was tolerating the splint well for 3 hours. The DON also confirmed the left elbow extension splint was not listed on the care plan. During an interview at 3:38 PM on 06/09/2016, LPN (Licensed Practical Nurse) #5 stated s/he had been told maybe once or twice that the resident refused to wear the splint but in the last week, no. The facility admitted Resident #145 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 8:45 AM of the medical record for Resident #145 revealed that resident #145 had contractures on admission and was seen by therapy with a decrease in mobility, decreased participation with functional tasks, increased dependency upon caregivers and increased pain due to a motor vehicle accident with multiple back surgeries, weakness and difficulty walking. Review on 6/10/2016 at approximately 8:45 AM of a form titled, Rehabilitation/Restorative Service Delivery Record, dated (MONTH) 2014 included, Passive Range of Motion (PROM) exercises to lower extremities and to do 2 sets of 15 repetitions. Also included were ankle pumps, leg sliders, and leg raises 3 x weekly for strengthening. Random attempts were made 6 times during the month of (MONTH) 2014. No other attempts have been made to ensure Resident #145 did not develop further contractures. No pain medications were documented as given prior to the exercises. No attempts were made to decrease the repetitions of the exercises to determine if Resident #145 could tolerate some portions of the PROM and gradually increase the ROM and prevent Resident #145 from developing further contractures. During an interview on 6/10/2016 at approximately 11:00 AM with the Nurse Manager, Licensed Practical Nurse (LPN) #7, stated the PROM was never attempted for very long with Resident #145. LPN #7 stated PROM is being done with AM care. No documentation could be found in the medical record for Resident #145 to ensure PROM was being done during AM care. Review on 6/10/2016 at approximately 6:54 PM of the Plan of Care for Resident #145 revealed that he/she is at risk for a decline in range of motion. The goals included, Resident to maintain current ROM status by tolerating range of motion. The approaches included Restorative PROM 5 times weekly. No documentation could be found in Resident #145's medical record to ensure any ROM was being done for this resident.",2020-01-01
4468,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,327,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility policy on Fluid Restriction, the facility failed to ensure a physician ordered fluid restriction was followed and documented for Resident #59 for 1 of 1 resident reviewed for [MEDICAL TREATMENT] and any limited fluid intake. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Review on 6/8/2016 at approximately 11:43 AM of the medical record for Resident #59 revealed a physician's order dated 3/8/16 at 3:00 PM which read, Check for bruit and thrill every shift. Notify the physician if not present. A second physician's order was found in Resident's medical record to maintain and monitor a 1500 milliliter fluid restriction. No documentation could be found in Resident #59 medical record to ensure the physician's orders were followed. During interviews on 6/8/2016 at approximately 4:31 PM with the Director of Nursing and the Unit Manager, Licensed Practical Nurse #5 confirmed that the physician's orders for the 1500 milliliter fluid restriction was not followed as evidenced by no documentation to support the monitoring of the fluid restriction Review on 6/9/2016 at approximately 8:45 AM of the facility policy titled, Fluid Restriction, states , To provide residents who have a written physician's order for fluid restriction an appropriate amount of fluid each day while allowing nursing adequate fluid to supply medications, etc. each shift.",2020-01-01
4469,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,329,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy on documentation, the facility failed to ensure a physician's order was followed. Resident #70 (1 of 1 resident sampled for insulin administration) did not receive insulin as originally ordered and did not have an order to decrease the frequency of insulin administration as stated on the Medication Administration Record [REDACTED] Findings include: On 06/10/2016, review of Resident #70's Medication Administration Record [REDACTED]. There was a standing doctor 's order for Novo LOG Flex Pen Solution Pen injector 10 unit subcutaneous with meals. Review of the (MONTH) MAR indicated [REDACTED]. There was also a standing doctor 's order for [MEDICATION NAME] 50 mg tablet given three times a day. Review of the MAR for (MONTH) 1 and (MONTH) 2, (YEAR), revealed that there were blanks for the afternoon and evening time. There was no nurse notation or circles in the boxes and no entry of why it was not given. The (MONTH) MAR further revealed the order for Novo LOG Flex Pen Solution Pen injector 10 unit subcutaneous with meals was changed from 3 x per day to 1 x per day. On 06/10/2016 at 1:37 pm, during interview, the South unit manager stated there were standing doctor 's orders for Novo LOG Flex Pen Solution Pen injector 10 unit subcutaneous with meals. The manager does not know why the (MONTH) MAR for Resident #70 shows an order for [REDACTED]. On 06/10/2016 at approximately 2:01 pm, interview with the Director of Nursing (DON), revealed that if there were blanks on the MAR indicated [REDACTED]. The DON could not locate the physician 's order changing the frequency of the medication.",2020-01-01
4470,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,332,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the manufactures recommendations, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 29 opportunities for error, resulting in a medication error rate of 6.8%. The findings included: Error#1 On 6/7/16 at approximately 4:45 PM, during observation of Resident #71 ' s medication administration, Licensed Practical Nurse (LPN) #2 was observed to administer [MEDICATION NAME] 50 microgram (mcg.) nasal spray to the resident without shaking the bottle prior to administration. Review of the [MEDICATION NAME] manufactures Prescribing Information, state, SHAKE GENTLY BEFORE USE. Error #2 On 6/8/16 at 8:51 AM, during Resident #205's medication administration Licensed Practical Nurse #3 attempted to administer units of [MEDICATION NAME] Solution (Epoetin). Prior to administration LPN #3 was asked to review Resident #205 physicians orders that stated [MEDICATION NAME] Solution UNIT/ML (Epoetin Alfa) inject 1 dose subcutaneously Weekly every Wed. LPN #3 verified s/he was going to administer Epoetin units instead of the physician ordered units.",2020-01-01
4471,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,333,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policy, the facility failed to administer the correct amount of medication resulting in significant medication errors for 2 of 30 residents reviewed for medication administration. Resident #65 did not receive the correct amount of insulin and Resident #205 did not receive the correct amount Epoetin during medication administration. The findings included: The facility admitted Resident #65 with [DIAGNOSES REDACTED]. On 6/7/16 at 4:40 PM, an observation of the East building, North unit (500-600) medication cart with Licensed Practical Nurse (LPN) #1 revealed (1) vial of Resident #65's [MEDICATION NAME] (Lot #5F452A) with a puncture date of 5/3/16, containing 1/10 of insulin. On 6/7/16 at 5:45 PM, review of Resident #65's Medication Administration Record [REDACTED]. On 6/7/16 at 6:00 PM, an interview with the Director of Nursing verified Resident #65's [MEDICATION NAME] vial (Lot # 5F452A) puncture date was 5/3/16 and used past the manufactures recommended discard date of 28 days after opening. Review of the [MEDICATION NAME] 100 Units/ML vial manufactures recommendations states under the section Storage: Discard all containers in use after 28 days, even if there is insulin left. The facility admitted Resident #205 with [DIAGNOSES REDACTED]. On 6/8/16 at 8:51 AM, during Resident #205's medication administration Licensed Practical Nurse (LPN) #3 withdrew 1 milliliter (ml.) from a unit/ml. vial of [MEDICATION NAME] solution (Epoetin) and attempted to administer the medication to Resident #205. Prior to administration LPN #3 was asked to review Resident #205 Physicians orders that stated [MEDICATION NAME] Solution UNIT/ML (Epoetin Alfa) inject 1 dose subcutaneously Weekly every Wed. LPN #3 verified s/he was going to administer Epoetin units instead of the Physician ordered units.",2020-01-01
4472,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,371,F,0,1,W3VQ11,"Based on observation, interviews, and review of facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 2 of 2 kitchens and has the potential to effect 145 of 145 residents with ordered diets as evidenced by failing to do the following: Remove rotted foods, wear hair restraint, reheat food to proper temperature, and have sanitizing buckets containing an adequate chemical solution for sanitization. The findings included: On 6/6/16 at 10:25 AM, during the initial tour of the East kitchen walk-in refrigerator revealed one box cucumbers containing cucumbers with dark green soft areas and areas with a white fuzzy substance. Also, one box of 8 green peppers had areas containing a white fuzzy and black substances. On 6/7/16 at 11:58 AM, an observation of the West kitchen lunch line temping with the Registered Dietician (RD) revealed the mechanically altered/pureed bread on the steam table read 110 degrees. Cook #1 reheated the bread to 131 degrees of Fahrenheit and attempted to serve. Following the observation Cook #1 indicated s/he did not know the correct reheating temperature. Also, a dietary aide in the kitchen food area was observed without a facial hair restraint. Furthermore, no sanitization buckets were observed with a chemical solution for sanitization. On 6/8/16 at 11:49 AM, an observation of the East kitchen walk-in refrigerator with the DM revealed one box cucumbers containing 56 cucumbers with dark green soft areas and a fuzzy white substance. Following the observation the DM verified the cucumbers were in various stages of rotting. On 6/8/16 at 11:58 AM, an observation of the East kitchen lunch line temping with the DM revealed the mechanically altered/pureed chicken on the steam table read 125 degrees. Cook #2 reheated the chicken to 140 degrees of Fahrenheit. Following the observation Cook #2 indicated s/he did not know the correct reheating temperature. Review of the facility policy entitled Food Preparation, states under Action Step (8) Time /Temperature Control for Safety (TCS) hot food items will be heated according to the following guidelines: bullet (5) Mechanically altered foods Reheated to 165 degrees Fahrenheit for 15 seconds. Also, policy Staff Attire, states under Action Step (1) The Food Service Director insures that all staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.",2020-01-01
4473,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,372,E,0,1,W3VQ11,"Based on observations, interviews, and review of the facility policy the facility failed to dispose of garbage and refuse properly for 2 of 4 dumpsters reviewed for garbage disposal. Two dumpster lids were broken and unable to close exposing garbage. The findings included: On 6/7/16 at 1:49 PM, an observation of the East and West building garbage disposal areas with the Dietary Manager (DM) revealed (1) dumpster at the East building and (1) dumpster at the West building had broken lids containing exposed garbage. Following the observation the DM verified the dumpster lids were broken exposing garbage and indicated the dumpster's needed to be replaced. Review of the facility policy Environment, states under Action Step (7) The Food service Director will insure that all trash is properly disposed in external receptacles (dumpsters) and that the area is free of debris.",2020-01-01
4474,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,412,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews and the facility policy titled, Referral to Outside Agencies, the facility failed to provide from an outside resource, routine and emergency dental services including assisting with appointments to meet the needs for Resident #102 for 1 of 1 resident reviewed for Dental Status and Services. The findings included: The facility admitted Resident #102 with [DIAGNOSES REDACTED]. An observation on 6/6/2016 at approximately 4:29 PM revealed Resident #102 with his/her top teeth missing. During an interview with Resident #102 on 6/7/2016 at approximately 9:11 AM, he/she stated the he/she did have problems with his/her teeth. Resident #102 went on to say that, X-rays had been taken and the Dentist had visited a time or two, but that that was last year and nothing has been done since. Review on 6/10/2016 at approximately 12:54 PM of the medical record for Resident #102 revealed an oral examination on 8/4/2015 by Senior Dental Care. The notes and recommendations included ,Patient is a candidate for max. partial. He/she would need root tip #9 removed first, then the impression taken. Refer out for extraction of #9 root tip. Further review on 6/10/2016 at approximately 12:54 revealed another dental visit by Senior Dental Care on 9/26/2015 which states, #9 root tip needs extracting, starting to be symptomatic at times . Needs consent form signed by his/her medical doctor and personal representative before the extraction can be done. The consent form was sent to the Social Services Director. No documentation could be found in the medical record where the consent was signed by the doctor nor the personal representative for Resident #102. Resident #102 was seen again on 12/2/2015, and still no one had addressed the #9 root tip extraction. The next appointment was scheduled for (MONTH) (YEAR), and Resident #102 stated that he/she had not been to the dentist this year. No documentation could be found to ensure Resident #102 had been seen for the (MONTH) (YEAR) appointment, and no documentation to ensure Resident #102's dental work had been completed. During an interview on 6/10/2016 at approximately 2:19 PM with the Social Services Director stated, I think this resident went to the dentist for the extraction. I am not sure if he/she has upper teeth or not. The social service director could not ensure Resident #102 attended the follow up appointments as ordered nor could he/she ensure the extraction was done. The social services director could not provide documentation or paper work to ensure the matter was taken care of for Resident #102. During a second interview on 6/10/2016 at approximately 2:30 PM with Resident #102 he/she stated, I have not been to the Dentist this year. I was told once they removed one of my teeth, they could do the impression and get me some top teeth but they have not removed the tooth yet. Review on 6/10/2016 at approximately 3:45 PM of the facility policy titled, Referral to Outside Agencies, Under Procedure, #3 states, The Social Service Director makes an appointment for the resident with the appropriate outside agency. Number 7 reads, Service providers' recommendations are to be integrated into the resident's plan of care.",2020-01-01
4475,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,431,E,0,1,W3VQ11,"Based on observation, interview, review of manufacture recommendation and facility policy, the facility failed to follow a procedure to ensure that medications were stored properly in 3 of 8 medication carts reviewed for medication storage. (1) Insulin vial was on the medication cart after the discard date and 1 Insulin Pen and (1) vial unopened were stored on the medication cart. The finding included: On 6/7/16 at 4:40 PM, an observation of the East building, North Unit, (500-600) hall medication cart with Licensed Practical Nurse (LPN) #1 revealed (1) vial of Lantus insulin (Lot #5F452A) with a puncture date of 5/3/16. On 6/7/16 at 4:55 PM, an observation of the East building, North Unit, (400-500) hall medication cart with LPN #2 revealed (1) unopened Lantus Solostar 100/unit (Lot # 6F2765A) injection Pen unopened or dated in a pharmacy package stating, Refrigerate Until Opened. LPN #2 verified the Lantus Solostar on the cart and indicated the Pen should be refrigerated until opened. On 6/7/16 at 5:20 PM, an observation of the West building, Back unit, (300) hall medication cart with LPN #4 Rebecca[NAME]revealed (1) vial of Novolog (Lot #FZF0182) unopened or dated in pharmacy packaging stating, Refrigerate Until Opened. LPN #4 verified the Novolog on the cart and indicated the insulin should be refrigerated until opened. Review of the Lantus Solostar 100Units/ML manufacture recommendation under section Storage, states, Store all unopened insulin containers in the refrigerator between 36-46 degrees. Review of the facility policy entitled Storage and Expiration of Medications, Biologicals, Syringes and Needles, revealed under procedure (4) Facility should ensure that medications and biologicals: (4.2) Have not been retained longer than recommended by manufacture or supplier guidelines. Also, procedure (11) states, Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges.",2020-01-01
4476,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-10,441,F,0,1,W3VQ11,"Based on observation, record review, and interview, the facility failed to perform surveillance of infections to track and/or trend causative organisms to prevent development and transmission of disease. The findings included: On 6/8/16, the Infection Control Surveillance logs since the last survey were requested from the Director of Nursing (DON) when s/he delivered the Infection Control Manual and the Surveillance logs for (YEAR). During an interview at that time, 5:17 PM, the Director of Nursing stated that s/he only had surveillance logs since January, (YEAR). The DON stated s/he did not know what the previous DON had done with the (YEAR) surveillance logs. The DON later provided October, November, and (MONTH) (YEAR) surveillance logs and March, April, May, and June, (YEAR) logs. The DON was unable to locate the February, July, August, or September, (YEAR) surveillance logs. At 5:34 PM on 6/8/16, review of the Surveillance logs revealed no tracking or trending of organisms in the 13 months of surveillance logs provided. Further review revealed 41 urinary tract infections in 8 months in (YEAR) with no documentation of whether a culture was done and/or no documentation of the causative organism if the culture was documented. In (YEAR) there were 41 urinary tract infections listed during the first 5 months of the year with no documentation of cultures and/or results. In addition there were 11 infections listed in (YEAR) and 14 infections listed in (YEAR) with the antibiotic listed but not the location of the infection. On 06/10/2016 at 11:15 AM, the Director of Nursing (DON) confirmed there were no organisms listed in the surveillance logs. The DON stated s/he tracked infections as the lab results came in on the fax machine in her/his office but that s/he didn't document them in the surveillance book.",2020-01-01
5552,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-02-06,241,E,0,1,WG2R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the facility policy Resident Dignity & Personal Privacy, the facility failed to promote dignity of residents during the dining experience in 2 of 2 buildings. During observations at meal times, staff were observed placing clothing protectors on residents without asking each resident's permission, not physically knocking on doors and not pulling the privacy curtain during meal time when the roommate was receiving a tube feeding. In addition, the facility failed to provide services to promote resident dignity for one of one resident observed with facial hair (Resident #60). The findings included: During breakfast delivery on 2/2/15 at approximately 8:20 AM, Certified Nursing Assistant (CNA) #4 was observed entering a resident's room without knocking and placing a clothing protector on the resident without asking the resident's permission. CNA #3 was observed placing a clothing protector on a resident without asking the resident's permission. CNA #7 and CNA #2 were observed entering a resident's room without knocking. During an interview on 2/6/15 at 3:00 PM, CNA #4 stated s/he knew the residents who needed clothing protectors and that is why s/he did not ask. During an interview on 2/6/15, CNA #3 stated the resident was not asked due to a daily routine and We know the ones who want them. During an interview on 2/6/15 at 3:02 PM, CNA #2 stated,I remember not knocking and I am suppose to knock. Observation of Resident #60 on all days of the survey revealed several long facial hairs. During an interview on 2/6/15, after speaking with Resident #60, the Social Services Director stated the resident would like the facial hair removed. Review of the facility policy entitled Resident Dignity & Personal Privacy revealed the following: .Knock on doors before entering; announce your presence .Groom appropriately and to resident's desire . The breakfast meal was observed on the 400-600 Unit on 2/4/15 at approximately 8:31 AM. Certified Nursing Assistant (CNA) #5 and CNA #6 were observed applying clothing protectors to residents without first asking if they would like to have one applied. CNA #5 was observed on two occasions not knocking or asking permission before entering resident rooms while distributing meal trays. CNA #6 was observed on one occasion not knocking or asking permission to enter a resident's room. CNA #5 was observed to set up the meal tray for the resident in A bed in a resident room while the resident in B bed, who was receiving a continuous tube feeding, watched consumption of the breakfast meal. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. During an interview with Resident #30 on 2/4/15 at approximately 9:15 AM, Certified Nursing Assistant (CNA) #1 entered the resident's room without knocking and requesting permission to enter. During an interview on 2/4/15 at approximately 9:45 AM, CNA #1 stated that upon entering rooms, s/he knocked on residents' doors. However, the CNA did confirm that s/he did not knock on Resident 30's door and stated, It just slipped my mind.",2018-11-01
5553,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-02-06,242,D,0,1,WG2R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure choices were respected for 1 of 1 sampled resident reviewed for choices of bedtime and wake up time. Resident #30 was not afforded the opportunity to eat breakfast in the dining room due to staff not getting him/her up as requested. The findings include: The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Review of the 1/21/15 Quarterly Minimum Data Set (MDS) assessment revealed the resident had no cognitive impairment. During an interview on 2/4/15 at approximately 9:00 AM, Resident #30 stated s/he could not choose when to wake up or go to bed at night. Resident #30 stated that prior to admission, s/he went to bed early and woke up early in the morning. On 2/6/15 at approximately 12:30 PM, review of the care plan (last updated 1/20/15) revealed for Individual Preferences: (Resident #30) chooses to be highly involved in daily care decisions regarding suggested or recommended interventions and has specific preferences related to bed baths. Approaches included but were not limited to: Honor individual choices and preferences as able within parameters of facility and other individuals safety and choices or preferences. Further review of the care plan revealed Activities of Daily Living (ADL): (Resident #30) requires staff assistance and intervention for completion of ADL needs. Requires Limited assistance, Extensive assistance and total care. Review of Resident #30's Resident Care Specialist Assignment Sheet noted Please get up early-Resident requests to eat breakfast in dining room. On 2/6/14 at approximately 8:07 AM, the resident was observed in bed while staff was setting up the meal tray on the resident's overbed table. During an interview on 2/6/15 at approximately 8:45 AM, Certified Nursing Assistant (CNA) #1 confirmed that the CNA care guide (Resident Care Specialist Assignment Sheet) indicated that the resident preferred to get up early to eat breakfast. The CNA stated that the night shift was supposed to get the resident up because the first shift CNA had other duties in the dining room. During an interview on 2/6/15 at approximately 3:51 PM, the Activity Director stated Resident #30 hadn't been going to activities and/or eating in the dining room as s/he had previously done.",2018-11-01
5554,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-02-06,247,D,0,1,WG2R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy entitled Resident Rights, the facility failed to ensure 2 of 2 sampled residents reviewed were notified prior to room/roommate changes (Resident #15 and #60). The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. During an interview on 2/4/15 at approximately 10:00 AM, Resident #15 stated that s/he had been moved to a different room in the facility but had not been notified where s/he was going prior to the move. Review of Resident #15's medical record on 2/6/15 at approximately 4:30 PM revealed no documentation in the Nurses' Notes or Social Services progress notes related to the resident's room change. During an interview on 2/6/14 at approximately 7:09 PM, Licensed Practical Nurse (LPN) #4 reviewed the record and confirmed there was no documentation of Resident #15 having a room/roommate change or any follow up related to that change. LPN #4 stated that s/he had spoken with the resident's family members related to the room change. The facility admitted Resident #60 with the [DIAGNOSES REDACTED]. Review of Resident #60's 1/6/15 Quarterly Minimum Data Set revealed a Brief Interview for Mental Status Score of 15 indicating that the resident was cognitively intact. During an interview on 2/23/2015 at 10:46 AM, Resident #60 stated that residents were not notified of getting a new roommate prior to the roommate change. Review of Resident #60's medical record on 2/6/15 at approximately 7:20 PM revealed no mention of the resident being notified of a roommate change nor of any follow up related to that change. Review of Social Services notes on 2/6/2015 at approximately 7: 30 PM revealed no mention of Resident #60 or his/her responsible party/family being notified of a roommate change. Review of the facility document entitled Resident Rights revealed the following: Residents of the Company read and sign a Resident Information Handbook, a part of which explains the resident's rights under state law and under federal law .30. The resident has a right to receive advance notice of transfers or discharges of the resident as required by law. The resident has a right to receive notice before the resident's room or roommate is changed .",2018-11-01
5555,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-02-06,253,E,0,1,WG2R11,"Based on observations, interviews and review of the Special Project Schedule and Deep Clean Schedule, the facility failed to ensure housekeeping and maintenance services were adequate to maintain a sanitary environment for 1 of 4 Units. There were multiple housekeeping/maintenance concerns related to the resident rooms, bathrooms, a shower room stretcher and door frames. The findings included: Observations on 2/3/15 at approximately 12:54 PM and on all days of the survey revealed the following: -The resident bathroom for Room 507 had visible dust and debris in all 4 corners of the room. The bathroom door frames (X 4) had multiple scratches and scrapes. The door frame in the resident room just outside the bathroom had 2 large scrapes. -The resident bathroom for Room 508 had a heavy wax build-up in 3 corners and edges of the baseboard. The 4 bathroom door frames had multiple scratches and scrapes. -The resident bathroom for Room 605 had 2 badly scraped door frames and one door frame leading into the bathroom with multiple scrapes. There was a hole in the wall across from the toilet that was approximately 3 inches in diameter. All four corners of the bathroom floor had dust and debris. -The resident's privacy curtain in Room 606 had 4 dark stains and 2 long ink stains around the seam at the edge of the curtain. -The resident bathroom for Room 608 had two corners that had heavy dust and debris. The door frames had multiple scrapes. The ceiling light fixture contained multiple visible dead bugs. -The bathroom (shared by Rooms 610 and 612) floor had 4 corners containing dust and debris. 3 of the 4 door frames had multiple scrapes. -A gurney in the shower across from Room 407 had a dark substance all along the frame under the soft overlay. All of the above findings were observed and confirmed by the facility Administrator during tour on 2/6/15 at 4:45 PM. On 2/6/15 at 5:15 PM, the Housekeeping Supervisor provided a Special Project Schedule which included the following: Mon(day): Clean/Scrub Shower Rooms, Wed(nesday): Corners, Edges, & Door Jams; Thu(rsday): Corners, Edges, & Door Jams, and Fri(day): Clean/Scrub Shower Rooms. A Deep Clean Schedule was also provided for January, (YEAR), with the following: Room 507 deep cleaned on the 9th, Room 508 on the 12th, Room 605 on the 19th, Room 606 on the 20th, Room 608 on the 22nd, Room 610 on the 23rd and Room 612 on the 26th.",2018-11-01
5556,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-02-06,282,D,0,1,WG2R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interview, and review of the facility policy entitled Fall Management (Revision Date: (MONTH) 2012), the facility failed to follow the plan of care for 2 of 4 sampled residents reviewed with a history of falls. Residents #30 and #40 were assessed as high risk for falls and had care plans for placement of personal alarms which were not observed in use. The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of the last comprehensive (5/14) Minimum Data Set (MDS) revealed the resident had sustained one or more non-injury falls . Observations on 2/4/15 at approximately 10:11 AM and at approximately 11:10 AM revealed the resident was lying in bed with a non-functioning alarm in place. During an interview on 2/4/15 at approximately 11:20 AM, the Director of Nursing (DON) confirmed that the resident's personal bed alarm was not functioning and that the battery needed to be replaced. Review of Resident #40's medical record on 2/6/15 at approximately 8:33 AM revealed a 1/22/15 care plan indicating the resident was At Risk for Falls related to his/her mental status, history of previous falls, balance problem/standing, balance problem/walking and [MEDICAL CONDITION]. The approaches included, but were not limited to, bed in low position, provide assistive devices w/c (wheelchair) as indicated and accepted, and place call light within reach. The interdisciplinary care plan did not indicate that the resident had a bed or chair alarm, but review of the Certified Nursing Assistant Care Guide noted the resident should have a bed alarm. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Review of the 1/21/15 Quarterly MDS revealed the resident had sustained 2 falls without injuries since the prior assessment. Review of the 1/15/15 Fall Risk Evaluation revealed a score of 16, with a total score of 10 or above representing high risk for falls. Observations on 2/3/15 at approximately 2:30 PM and on 2/4/15 at 9:26 AM revealed Resident #30 lying in bed with what appeared to be a non-functioning bed alarm. During an interview on 2/4/15 at approximately 10:10 AM, Certified Nursing Assistant (CNA) #1 confirmed the bed alarm was not functioning. S/he stated that the CNA Care Guide (Activity of Daily Living) sheet provided them with information related to care the resident needed and if the resident required any assistive devices. CNA #1 stated that the CNA's were responsible for checking the alarms to ensure they were in place. Review of the CNA Care Guide for Resident #30 revealed the resident was supposed to have a personal alarm on the wheelchair and when in bed. Review of the care plan on 2/6/15 at approximately 7:46 AM revealed the resident was At risk for falls related to mental status, recent fall, history of previous falls, poor vision and bilateral [MEDICAL CONDITION]. The approaches included application of a bed alarm-pressure pad alarm, bed in low position, and a tab alarm. Review of the clinical record on 2/6/15 at approximately 7:50 AM revealed that the resident had sustained non-injury falls on 11/13/14, 11/17/14 and 11/20/14. The facility policy entitled Fall Management Revision Date: (MONTH) 2012 specified: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls A plan of care is developed and implemented, based on this evaluation, with ongoing review. If a fall occurs the Interdisciplinary Team (IDT) conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls",2018-11-01
5557,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-02-06,311,D,0,1,WG2R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide a restorative program to maintain or improve the resident's functional status for 1 of 3 residents reviewed for rehabilitation services. Resident #146 was not provided restorative services as recommended by Physical and Occupational Therapies. The findings included: The facility admitted Resident #146 with [DIAGNOSES REDACTED]. Review of the 11/21/14 Physical Therapy Discharge Status and Recommendations revealed the following: Prognosis to Maintain CLOF (Current Level of Function) = Excellent with participation in RNP (Restorative Nursing Program). The Physical Therapy notes and recommendations were signed 11/24/14 at 3:41:47 PM by the Physical Therapy Assistant and co-signed by the Physical Therapist on 11/24/14 at 4:54:10 PM. Review of the 11/21/14 Occupational Therapy Discharge Status and Recommendations revealed the following: RNP/FMP (Functional Maintenance Program): To facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNPs has been completed with the IDT (Interdisciplinary Team): ambulation, cognition, dressing, grooming and transfers. The Occupational Therapy (OT) Notes and recommendations were signed by Certified Occupational Therapy Assistant on 11/21/14 at 12:54:35 and co-signed by Occupational Therapist on 11/21/14 at 5:41:54. During record review, there were no restorative notes available for review. During an interview on 2/7/15 at 7:30 PM, the Director of Nursing (DON) provided a Rehab to Restorative Transition Record form which s/he stated was the process through which therapy communicated recommendations to nursing. The DON stated s/he had spoken with therapy who had failed to complete this form and communicate their recommendations to the nursing department. S/he also confirmed that no restorative services had been provided to this resident. On 2/5/15 at 11:34 AM, the resident was observed seated in a wheelchair at her/his bedside. The resident stated s/he had been getting therapy and it ran out. Resident #146 stated s/he would like to have more.",2018-11-01
5558,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-02-06,323,E,0,1,WG2R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, review of the facility policy entitled Fall Management (Revision Date: (MONTH) 2012), and review of the Material Safety Data Sheet, the facility failed to ensure the resident environment remained as free of accident hazards as was possible. Two of four sampled residents reviewed for falls had non-functioning personal alarms in use (Resident #30 and #40). An unsecured chemical was observed in 1 of 3 shower rooms. Multiple rooms on 1 of 4 units were noted with elevated water temperatures. The findings included: During initial tour on 2/3/15 at approximately 8:45 AM, observation of the shower room on the 100-300 units in the East Building revealed a 1/2 full quart-size screw-top spray bottle of Quat(ernary) Disinfectant Cleaner in an unlocked cabinet. On 2/3/15 at approximately 8:52 AM, the Unit Manager was informed of the unsecured chemical. Review of the Material Safety Data Sheet for the Quat Disinfectant Cleaner Concentrate revealed that if eye or skin contact was made, to flush the site for at least 15 minutes and obtain immediate medical attention. If inhaled and signs/symptoms occur, place person in fresh air and if symptoms continue call a physician. If swallowed do not induce vomiting. Give two glasses of water and call physician immediately. During an interview on 2/6/15 at 7:43 PM, the Administrator stated rounds are done every morning and if any concerns are noted in a resident's room, they should be reported in the meeting. During resident observations in the East Building on 2/3/15 at approximately 1:13 PM, the following rooms were noted with elevated water temperatures: Room 401-125.2 Room 406-123.9 Room 407-124.9 Room 501-125.7 Room 506-125. On 2/3/15 at 3:28 PM, the Administrator and Director of Nursing (DON) were notified of the elevated temperatures in resident rooms. On 2/3/15 at 3:29 PM, rounds were initiated with the Maintenance Director to check water temperatures with the facility's device. The Maintenance Director used a Laser Temp Gun to test the water in Room 401 which registered 89 degrees. At that time, the surveyor and Maintenance Director left the room to calibrate the thermometers. After calibration of the surveyor's thermometer, the Laser Temp Gun was used to test the same ice bath and several different temperatures were obtained by the Laser Temp Gun. On 2/3/15 at 3:29 PM, testing of the water temperatures was completed with the surveyor's thermometer which revealed the following temperatures: Room 401-115.3 Room 406--123.5 Room 407-115.3 Room 501-115.7 Room 504-116.8 Room 505-118 Room 506-121 During an interview on 2/3/15, the Maintenance Director stated that s/he checked a room on both units every week with the laser thermometer. Review of the log from (MONTH) 2014-February (YEAR) revealed that specific rooms checked were not noted on the log and the temperatures documented were in the range of 88-101 degrees. Review of the information related to the laser thermometer revealed the laser thermometer provided a safe accurate way to measure surface temperature. Review of the accident/incident log from (MONTH) 2014-January (YEAR) revealed there were no incidents of burns or scalds recorded. A review of residents located in the rooms with elevated temperatures revealed that residents in the following rooms used or could access the sink: Room 401-A Room 406-A Room 501 Room 504 Room 505 -A & B Room 506-A Room 507-A & B Room 605-A & B Room 608-B Room 610-B Room 612-A & B. During observations on 2/3/15 at approximately 12:00 PM, the shower room across from Room 407 contained a clear plastic medicine cup with a white creamy substance unlabeled and unsecured. This surveyor took it to Licensed Practical Nurse #7 who looked at it and stated to put it into the medicine cart trash. The Director of Nurses observed the substance at this time and stated, They know better than that! During resident room observation on 2/3/15 at 12:57 PM, the water in the sink in Room 507 felt hot when this surveyor held his/her hand under the running water for less than one minute. The temperature was checked and measured 123.9 degrees Fahrenheit (F). Other resident rooms were checked on this unit and those measuring greater than 120 degrees F were as follows: Room 508 - 123.2 Room 605 - 121.9 Room 606 - 124.1 Room 608 - 123.1 Room 610 - 123.9 Room 612 - 123.4 The shower room across from Room 407 measured 124.7. The Maintenance Director used a laser thermometer to measure the water temperature which only registered 87 degrees F. The surveyor recalibrated his/her thermometer and the maintenance director accompanied him/her throughout the rooms for re-check of the water temperatures with the following results: Room 508 - 121 Room 605 - 119.2 Room 606 - 119.6 Room 608 - 120.4 Room 610 - 120.7 Room 612 - 123.2 The shower room across from room 407 measured 122.2. During an interview on 2/3/15 at 4:47 PM, the Maintenance Director stated s/he had checked the hot water and it was reading 110. S/he said that there were 2 water heaters on that wing. The Maintenance Director stated that the water heater for laundry and the kitchen was set on 120 or 130 and the one for residents was set at 110. The unit water heater did not have a mixing valve or booster but only a circulating pump with a thermostat. He/she stated that the temperature gauge was set at 125 degrees on the circulating pump and the thermostat inside the water heater was set for 110 degrees. The Maintenance Director stated s/he had adjusted the gauge from 110 to 100 and would keep checking 'til we get it down. The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Review of Resident #40's 5/14/14 Annual Minimum Data Set (MDS) Assessment revealed the resident had sustained one or more non-injury falls. Observations on 2/4/15 at approximately 10:11 AM and at approximately 11:10 AM revealed the resident was lying in bed with a non-functioning alarm in place. During an interview on 2/4/15 at approximately 11:20 AM, the Director of Nursing (DON) confirmed that the resident's personal bed alarm was not functioning and that the battery needed to be replaced. Review of Resident #40's medical record on 2/6/15 at approximately 8:33 AM revealed a 1/22/15 care plan indicating the resident was At Risk for Falls related to his/her mental status, history of previous falls, balance problem/standing, balance problem/walking and psychotropics. The approaches included, but were not limited to, bed in low position, provide assistive devices w/c (wheelchair) as indicated and accepted, and place call light within reach. The interdisciplinary care plan did not indicate that the resident had a bed or chair alarm, but review of the Certified Nursing Assistant Care Guide noted the resident should have a bed alarm. The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Review of the 1/21/15 Quarterly MDS revealed the resident had sustained 2 falls without injuries since the prior assessment. Review of the 1/15/15 Fall Risk Evaluation revealed a score of 16, with a total score of 10 or above representing high risk for falls. Observations on 2/3/15 at approximately 2:30 PM and on 2/4/15 at 9:26 AM revealed Resident #30 lying in bed with what appeared to be a non-functioning bed alarm. During an interview on 2/4/15 at approximately 10:10 AM, Certified Nursing Assistant (CNA) #1 confirmed the bed alarm was not functioning. S/he stated that the CNA Care Guide (Activity of Daily Living) sheet provided them with information related to care the resident needed and if the resident required any assistive devices. CNA #1 stated that the CNA's were responsible for checking the alarms to ensure they were in place. Review of the CNA Care Guide for Resident #30 revealed the resident was supposed to have a personal alarm on the wheelchair and when in bed. Review of the care plan on 2/6/15 at approximately 7:46 AM revealed the resident was At risk for falls related to mental status, recent fall, history of previous falls, poor vision and bilateral amputee. The approaches included application of a bed alarm-pressure pad alarm, bed in low position, and a tab alarm. Review of the clinical record on 2/6/15 at approximately 7:50 AM revealed that the resident had sustained non-injury falls on 11/13/14, 11/17/14 and 11/20/14. The facility policy entitled Fall Management Revision Date: (MONTH) 2012 specified: Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls A plan of care is developed and implemented, based on this evaluation, with ongoing review. If a fall occurs the Interdisciplinary Team (IDT) conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls",2018-11-01
5559,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-02-06,431,E,0,1,WG2R11,"Based on observation and interview, the facility failed to ensure expired medications were not stored with other medications available for resident use in 4 of 7 medication carts and 2 of 4 treatment carts. The findings included: Observation of the 600 Hall Medication Cart revealed PDI Sani-Cloth Plus Germicidal Disposable Cloths with an expiration date of 11/13 confirmed by Licensed Practical Nurse (LPN) #6 on 2/5/15. Observation of the 400-500 Hall Medication Cart revealed (1) Geri-Lanta Antacid-Antigas 12 fluid ounce bottle with an expiration date of 1/15 confirmed by LPN #1. Observation of the Back Hall West Building Medication Cart on 2/6/15 at 9:45 AM revealed (1) medication card with 14 caplets of Omeprazole 20 milligrams (mg) DR (Delayed Release) expired 1/31/15. At the time of the observation, LPN #2 confirmed the medication had expired and stated the resident also had another card of Omeprazole which was in date and from which s/he had given the medication. Observation of the medication cart for the Middle Back Hall of the West Building revealed (1) bottle of Acetaminophen 325 mg with an indecipherable expiration date (worn off the bottle). Only the month of 7 was visible. This was confirmed by LPN #7 on 2/6/15 at 10:00 AM. During an interview on 2/6/15 at 7:34 PM, the Director of Nursing stated that nurses were responsible for checking medications each time they were on the cart and that the Pharmacy Consultant or Pharmacy Technician and the Corporate Nurse checked the carts monthly. Observation of the 400-600 Unit Treatment Cart in East Building on 2/5/15 at 11:00 AM revealed a tube of Skintegrity Hydrogel 4 ounces unopened with no expiration date. Licensed Practical Nurse (LPN) #1 confirmed the absence of an expiration date. Observation of the Treatment Cart on the back hall in West Building on 2/6/15 at 10:08 AM revealed a 3 ounce tube of Geritrex: Flex Cream-Trolamine Salicylate 10% Muscular Pain Relieving Cream with approximately 2 ounces left in the tube with no expiration date. LPN #2 examined the tube, confirmed there was no expiration date, and placed it in the trash. During an interview on 2/6/15 at 8:06 PM, the Director of Nurses stated the last Pharmacy med storage audit had been done on 1/12/15.",2018-11-01
5560,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-02-06,441,E,0,1,WG2R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure processes were in place in two of two laundries in East and West Buildings to prevent cross contamination. The laundries were not designed to provide separation between soiled and clean linen. Heavily soiled items were not washed separately. In addition, residents' personal care items were not stored and/or labeled appropriately on 1 of 4 units. The findings included: During observations of resident rooms on 2/3/15, the following items were observed: room [ROOM NUMBER]-A urine container (hat) was noted upside down on the toilet seat. room [ROOM NUMBER]-An uncovered fracture bedpan was noted on the bathroom floor. During observations of resident rooms on 2/4/15 the following items were observed. room [ROOM NUMBER]-An uncovered fracture bedpan was noted on floor in the bathroom. room [ROOM NUMBER]-A nebulizer and uncovered mask were in a chair. Unlabeled/uncovered urinals were on the grab bar in the bathroom and on the floor. room [ROOM NUMBER]-An uncovered fracture bedpan was noted on the bathroom floor. room [ROOM NUMBER]B-An uncovered/unlabeled bedpan was on the bathroom floor. On 2/6/15 at 4:45 PM, environmental rounds were made with the Administrator who observed and confirmed the above. During an interview on 2/7/15 at 7:38 PM, the Director of Nursing stated nebulizer masks were changed every Wednesday night. S/he also stated urinals and fracture bedpans were to be placed in bags and were the responsibility of the RCS. On 2/6/15 at 11:06 AM, observation of sorting of soiled laundry was observed. During the observation, Laundry Worker #1 stated if something was heavily soiled, s/he would wash the item with other whites and use heavy bleach. S/he continued by stating heavily soiled items were not washed alone. After sorting the laundry, Laundry Worker #1 pulled the cart into the laundry room, placed the items in the washer, closed the washer, and started the cycle wearing the same soiled gloves. When asked how often the washers were wiped down, Laundry Worker #1 stated the washers were sanitized once per shift. Clean items were observed uncovered and approximately 1 foot away from the container holding the soiled items with no separation between the clean and dirty sides of the laundry room. Laundry Worker #1 was asked how often the gown s/he was wearing was washed and s/he stated when the gown appeared soiled. Further observation of the laundry revealed there were two racks of clean items positioned on the soiled side of the room. The area between the washer and clean rack was measured at 48-49 inches on 2/6/15 at 3:52 PM with the Housekeeping Supervisor in attendance. Review of the laundry area in the West Building with the Housekeeping Supervisor on 2/6/15 at 11:44 AM revealed there was only one entrance/exit to the laundry area. After sorting the soiled laundry under the breezeway, Laundry Worker #2 opened the door with his/her soiled glove, opened the washer, placed the soiled items into the washer, closed the washer door, started the cycle, and removed the barrel from the room. The entry into the laundry room had a folding table with covered items to the left and a rack of clean clothing to the right. There was no separation between the soiled and clean areas of the laundry. Measurements from the entrance of the room to the clothes rack was approximately 44 inches and from the washer to the dryer was approximately 38 1/2 inches. At the back of the room, clean items such as pillows and mop heads were stored covered. During medication observation on 2/4/15 at approximately 7:15pm, Nurse #3 entered a resident room to provide eye drops. He/she took the drops out of the medicine cart drawer along with a tissue and entered the resident room. She asked the resident to tilt his/her head back and pulled down the right eye lid, dropped one drop into the eye and gave the tissue to the resident. He/she washed his/her hands following the procedure. He/she did not cleanse his/her hands or don gloves prior to the procedure. On 2/7/15 at approximately 3:00pm, the Director of Nursing provided the Eyedrop Administration policy which stated, Explain the procedure to the patient; provide privacy. Perform hand hygiene; then put on gloves. Position the patient . During resident room observations on 2/3/15 at 2:34pm, room [ROOM NUMBER] had a fracture pan on the bathroom floor that was unlabeled or covered. This pan was still there on 2/4/15 at 9:49am observation. During resident room observation on 2/3/15 at 12:35pm and 2/4/15 at 10:01am, room [ROOM NUMBER]A had a soiled glove on the bathroom floor in front of the toilet. On 2/4/15 at 10:01am, the base of the feeding tube pump was rusty and soiled with dried feeding. This was noted on all days of the survey. During resident room observation on 2/3/15 at 12:59pm and 2/4/15 at 10:14am in room [ROOM NUMBER]A, a fracture pan was soiled and unlabeled and stored in the toilet handrail uncovered. A urinal was in plastic hanging on the wall but not labeled. This bathroom was shared by 4 residents. During random rounds on 2/3/15 at approximately 12:00PM, the shower room across from resident room [ROOM NUMBER] contained a soiled brief on the floor behind the door. During an interview with the Director of Nursing at this time, she stated, They know better than that!",2018-11-01
5784,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-09-03,280,D,1,0,FYM811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to revise a care plan to depict the resident's actual care for 1 of 2 residents reviewed for falls. Resident #2's care plan was not revised to remove the self release belt the resident was no longer wearing, nor did the care plan depict the resident's falls in July. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. On 9/3/15 at 12:00 PM the resident was observed in the dining room in a wheelchair with anti-tipsters. No self release belt or alarm was noted on the resident wheelchair, this was confirmed by the nurse in the dining room. Review of the medical record revealed the resident was care planned for falls on 12/17/14, with updates on 3/11/15 and 6/4/15. The resident was listed to have had a fall on 3/3/15, 3/10/15 and 4/14/15. Approaches to the care plan included self-releasing alarming seat belt in w/c (wheelchair), removes self on command. Review of the Resident Care Specialist Assignment Sheet for 9/3/15 revealed for Resident #2, Soft alarming self releasing seatbelt to w/c, remove for meals, ADLs (Activities of Daily Living), Activities. Review of the Physician Order's from 1/1/15 through 9/2015 revealed there were no orders for an alarming belt or orders to discontinue an alarming belt. The Nurse's Notes were reviewed from 5/29/15 through 8/17/15. On 7/11/15 SBAR (Situation, Background, Assessment and Review) stated observed on floor. While trying to go from the wheelchair to the bed, res observed in room on the floor, states s/he hit his/her head on roommates bed, 0 injuries noted, no c/o (complaints of) pain @ this time . An SBAR dated 7/22/15 was reviewed. SBAR 2:45 PM, .Res (resident) observed sitting on bathroom floor, left arm lodged between grab bar and wall. Res c/o of pain of upper left arm, red area noted to upper left arm. Denied hitting his head . Dr. notified, orders for x-ray, family notified . On 9/2/15 at approximately 1:10 PM, Resident #2 was interviewed by the surveyor. The resident stated that s/he had never worn a safety belt. On 9/2/15 at approximately 1:15 PM Certified Nursing Assistant (CNA) #1 was interviewed by the surveyor. When the CNA was asked about the care for Resident #2, s/he stated that s/he helped with Resident #2's care. S/he has a bed alarm, fall mats. S/he used to have a self release seat belt. It's been a while since I have seen it, been over 6 months. I don't know if it got lost or what happened. A lot of stuff missing since the move. On 9/3/15 at approximately 12:57 PM Registered Nurse (RN) #1 was interviewed by the surveyor. The RN reviewed the medical record of Resident #2 for the order for the self release alarming belt. No order was on the chart. The Cumulative Monthly orders did not contain an order. The RN stated the order was on the care guide that the Certified Nursing Assistants (CNA) used. S/he would not be wearing belt in the dining room. On 9/3/15 at 1:15 PM the Minimum Data Set (MDS) Nurse was interviewed by the surveyor. The RN stated the self release belt was a nursing intervention. Falls of 7/11 and 7/22/15 were not on care plan because we didn't know about a fall. If we did we would have signed the post fall. I don't know when the last time s/he had it (self release belt) on. I don't work directly with her/him.",2018-09-01
5785,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-09-03,282,E,1,0,FYM811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to follow the resident's care plan for 1 of 2 residents reviewed for falls. Resident # 1's care plan included resident was to have a chair alarm. On all days of the survey the resident was observed with no chair alarm. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident had a care plan for falls. Review of the care plan revealed the resident had a fall on 4/13/15, 4/20/15, 4/23/15, 5/1/15, 5/18/15, 7/29/15 with no injuries. The resident had fall interventions in place related to falling from the bed. On 8/1/15 the resident had a fall with injury from wheelchair. Review of the Physician Telephone Order's revealed on 8/4/15 a Bed/Chair alarm, place and check every shift, was ordered and added to the care plan. The resident was observed on 9/2/15 at 8:36 AM up in a wheelchair in the dining room. The resident appeared clean and well groomed, wearing glasses, positioned in a wheelchair with pillows. No chair alarm was noted on the wheelchair. At 11:00 AM the resident was observed seated in a wheelchair at the nurse's station, yelling out, no chair alarm was visible. On 9/3/15 at 8:30 AM the resident was observed sitting in the hallway in his/her wheelchair, no chair alarm was observed. The Assistant Director of Nurses (ADON) was asked if the resident had on a chair alarm. S/he confirmed that s/he did not. The surveyor informed the ADON that the resident had not had a chair alarm on all day yesterday (9/2/15). The ADON called for the nurse to put on the alarm. No chair alarm was noted in her/his room. The Resident was left at the nurses' station under supervision while the nurse went to find an alarm for the chair.",2018-09-01
5786,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-09-03,323,E,1,0,FYM811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to provide supervision for 2 of 2 residents with falls. Resident #1 and #2 did not have safety equipment in place. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the falls care plan revealed the resident had a fall on 4/13/15, 4/20/15, 4/23/15, 5/1/15, 5/18/15, 7/29/15 with no injuries. The resident had fall interventions in place related to falling from the bed. On 8/1/15 the resident had a fall with injury from the wheelchair. Review of the Physician Telephone Orders revealed on 8/4/15 a Bed/Chair alarm, place and check every shift, was ordered and added on the care plan. The resident was observed on 9/2/15 at 8:36 AM up in a wheelchair in the dining room. The resident appeared clean and well groomed, wearing glasses. S/he was positioned in the wheelchair with pillows with no chair alarm on the wheelchair. At 11:00 AM the resident was observed up in a wheelchair at the nurse's station, yelling out; no chair alarm was visible. On 9/3/15 at 8:30 AM the resident was observed sitting in the hallway in his/her wheelchair with no alarm. The Assistant Director of Nurses (ADON) was asked if the resident had on a chair alarm. S/he confirmed that s/he did not. The surveyor informed the ADON that the resident had not had a chair alarm on all day yesterday (9/2/15). The ADON called for the nurse to put on the alarm. No chair alarm was noted in her/his room. Resident #1 was left at the nurse's station with supervision while the nurse went to find an alarm. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. On 9/3/15 at 12:00 PM the resident was observed in the dining room in a wheelchair with anti-tipsters on the wheel chair. No self release belt or alarm was observed on the resident, this was confirmed by the nurse in dining room. Review of the medical record revealed the resident was care planned for falls on 12/17/14, with updates on 3/11/15 and 6/4/15. The resident was listed to have had a fall on 3/3/15, 3/10/15 and 4/14/15. Approaches to the care plan included self-releasing alarming seat belt in w/c (wheelchair), removes self on command. Review of the Resident Care Specialist Assignment Sheet for 9/3/15 revealed for Resident #2, Soft alarming self releasing seatbelt to w/c, remove for meals, ADLs (Activities of Daily Living), Activities. Review of the Physician order [REDACTED]. On 9/2/15 at approximately 1:10 PM, Resident #2 was interviewed by the surveyor. The resident stated that s/he had never worn a safety belt. On 9/3/15 at approximately 12:57 PM Registered Nurse (RN) #1 was interviewed by the surveyor. The RN reviewed Resident #2 medical record for the order for the self release alarming belt. No order was on the chart. The Cumulative Monthly orders did not contain an order. The RN stated the order was on the care guide that the Certified Nursing Assistants (CNA) used. He would not be wearing belt in the dining room. On 9/3/15 at 1:15 PM RN #2 was interviewed by the surveyor. The RN stated, I don't know when the last time I saw the release belt. I started (working here) in April.",2018-09-01
6274,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-04-15,502,D,1,0,LKLX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain a laboratory test, which was ordered, for 1 of 3 residents whose physicians orders were reviewed. Resident #1 had an [MEDICATION NAME]/[MEDICATION NAME] ordered on [DATE] related to four wounds, which was not performed until 4/15/15. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) conducted on 3/18/15 coded Resident #1 with a Brief Interview of Mental Status (BIMS) of 3. S/he was also coded as requiring extensive assistance with his/her Activity of Daily Living (ADLs) and was incontinent of bowel, with occasional incontinent bladder episodes. A review of the medical record on 4/14/15 at 1:45 PM, revealed an order written [REDACTED].#1 to have an [MEDICATION NAME]/[MEDICATION NAME] related to (r/t) four wounds. Review of the medical record revealed no results found, a request was made to the nurse for the lab results. No results regarding the 4/9/15 lab order could be produced on 4/14/15 by the facility. On 4/15/15 at 10:30 AM a second request was made to the Director of Nursing (DON) for the [MEDICATION NAME]/[MEDICATION NAME] result from 4/9/15. The DON stated, It was not drawn, but they had identified missing labs as a problem on 4/10/15 during a pharmacy audit. The DON stated they had a plan of correction in place. A review of the laboratory sheet for Resident #1 on 4/15/15 revealed that the [MEDICATION NAME] had been collected on 4/15/15 at 0300 and that there was a laboratory request form for resident #1 for a pre-[MEDICATION NAME] dated 4/15/15. A review on 4/15/15 at approximately 2:30 PM, of the Laboratory Management policy and procedure for the facility, provided by the DON, revealed that The facility is responsible for the quality and timeliness of laboratory services.",2018-04-01
6275,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-04-15,514,D,1,0,LKLX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain complete and accurate medical records for 1 of 3 residents reviewed. Resident #1 had documentation that was missing or that was inaccurate in his/her medical record or reports. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) was conducted on 3/18/15 coding Resident #1 with a Brief Interview of Mental Status (BIMS) of 3. S/he was coded as requiring extensive assistance with his/her Activity of Daily Living (ADLs) and was incontinent of bowel, with occasional incontinent bladder episodes. During the medical record review for Resident #1 on 4/14/15 at approximately 1:45 PM, it was noted that on 3/14/15 Resident #1 experienced a fall which was not witnessed according to the incident report, however the information faxed to the state licensure division stated the resident fell in the hallway. An interview was conducted with the Director of Nursing (DON) at 12:55 PM on 4/15/15 regarding the discrepancy and s/he stated, It was my fault, I was thinking s/he was in the hallway when s/he did it. The medical record indicated Resident #1 having an x-ray on 3/18/15 to the right femur (2 views), right tibia (2 views). A review of the nurse's notes and Medication Administration Record [REDACTED]. The DON was interviewed on 4/15/15 at approximately 2:45 PM, regarding the reasoning for the x-ray. After the DON reviewed the nurse's notes, she spoke with the Unit Manager from the West back hall, who informed the DON that Resident #1 had a change in his/her weight bearing status, which is why they did the x-ray. However, this was not documented in the nurse's notes per the DON. A continued review of the medical record for Resident #1 revealed that on 3/17/15 Resident #1 was experiencing weakness. According to the medical record, Resident #1 was having blood glucose checks performed every morning at 8 AM. The recording for 3/17/15 was written in the box, but it had been written over in the column, and also a value was written outside of the column and was circled with no initials. It was unclear what the original value was, but the value written outside of the column was 198 and the physician was not notified. A review of the Situation Background Assessment Request (SBAR) form completed on 3/17/15 was not timed, but did provide vital signs/oxygen saturation, but no blood glucose level was performed. The physician was notified, but this was not timed and a nurse's note was written, but not timed as well. An interview conducted with the DON on 4/15/15 at approximately 1:00 PM, revealed that Resident #1 was having weakness and s/he would have checked a blood sugar. The DON reviewed the SBAR, nurse's notes and blood glucose flow sheet regarding the missing time and the blood glucose level which had been written over and stated that this was not the way to make a correction.",2018-04-01
6276,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2015-04-15,520,D,1,0,LKLX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow their Quality Assurance (QA) plan identified 4/10/15 related missing laboratory test. A plan of correction was initiated on 4/10/15 after discovering during a pharmacy audit that residents were missing laboratory results. Resident #1 was identified as not having labs done and the labs were not drawn until 4/15/15 (1 of 3 residents reviewed for labs). The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) conducted on 3/18/15 coded Resident #1 with a Brief Interview of Mental Status (BIMS) of 3. S/he was coded as requiring extensive assistance with his/her Activity of Daily Living (ADLs) and was incontinent of bowel, with occasional incontinent bladder episodes. An interview conducted with the Director of Nursing on 4/15/15 related to the missing results for a lab order from 4/9/15 for Resident #1 s/he stated that s/he was made aware during a pharmacy audit that there was a problem with the completion of labs and a plan of correction had been initiated on 4/10/15. The DON was informed that a request had been made yesterday to the staff for the results of the 4/9/15 [MEDICATION NAME]/[MEDICATION NAME] order for Resident #1, but no results had been found. The DON searched for the results and informed the surveyor that the lab order for 4/9/15 [MEDICATION NAME]/[MEDICATION NAME] had not been drawn. However, the DON provided at approximately 2:45 PM on 4/15/15, the results of the [MEDICATION NAME] which had been drawn on 4/15/15 with a result of (2.6), which was lower than the last [MEDICATION NAME] check from 4/1/15 from a recent hospital stay. The DON stated that the [MEDICATION NAME] was drawn, but still pending. A review of the QA for the Completion of Labs revealed there was no intervention listed for the missed laboratory results, no indication that the physician was notified or that orders were given to draw the missed labs.",2018-04-01
6950,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2017-05-06,309,D,0,1,,Deficiency Text Not Available,2017-07-01
7040,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2013-07-31,441,E,0,1,6JS011,"On the days of the survey based on observation and interview the facility failed to prevent the spread of contamination as evidenced by a random observation of multiple staff touching residents food with bare hands and not appropriately sanitizing their hands . The findings included: On 7/31/13 at approximately 12:35 PM, during the lunch meal on the West unit, residents were served grilled chicken sandwiches. Certified Nursing Assistants (CNA) were observed repeatedly touching the sandwiches with their bare hands to apply condiments and or cut the sandwich. CNA #1 was observed feeding a resident. The CNA left the resident to clean a spill and then resumed feeding the resident without sanitizing or washing his/her hands. During an interview with Licensed Practical Nurse (LPN) #2 at approximately 12:55 PM, the LPN confirmed the surveyor findings and did not dispute the CNA's touched the resident's food with their bare hands.",2017-06-01
7041,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2013-07-31,456,E,0,1,6JS011,"On the days of the survey based on observation, interview and review of the facility's Temperature Monitoring Schedule the facility failed to maintain mechanical equipment in a safe and functioning operating condition. Two of 2 dryers in the laundry had an excessive amount of lint build up 2-3 inches away from the pilot. Two of 2 resident refrigerators in the west unit were not operating at the correct temperature. The findings included: Observation of the facility laundry room on 7/29/13 at approximately 3:30 PM revealed 2 of 2 dryers with an excessive amount of lint behind the dryer. The surveyor observed the lint build up to be about 2-3 inches away from the pilot. On 7/31/13 while touring the laundry room with the Administrator, he/she verified the surveyors finding. There was no documentation and/or schedule provided related to the cleaning of the dryers. While conducting the environmental tour in the west unit on 7/31/13 at 12:05 PM, the surveyor observed the resident's refrigerator located in the 300 dietary kitchenette with a temperature of 45 degrees Fahrenheit. Further observation of the west unit revealed another dietary kitchenette on the 400 hall which had a resident refrigerator with a temperature of 43 degrees Fahrenheit. On 7/31/13 at approximately 3:10 PM the surveyor rechecked the temperature of the refrigerator in the 300 hall dietary kitchenette. At this time the temperature revealed 45 degrees. Licensed Practical Nurse (LPN) #1 verified the surveyors finding. On 7/31/13 at approximately 3:15 PM, the surveyor rechecked the temperature of the refrigerator located in the 400 dietary kitchenette. At this time the temperature increased from 45 degrees to 50 degrees Fahrenheit. LPN #2 verified the surveyors finding. When asked what was the correct temperature both LPN's stated it should be between 36-46 degrees. Review of the facility's Temperature Monitoring Schedule revealed resident refrigerator temperatures should be 36-46 degrees Fahrenheit.",2017-06-01
7042,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2013-07-31,514,D,0,1,6JS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review and interview, the facility failed to ensure that the information contained in the record accurately reflected the resident's treatment regimen or to communicate with the physician regarding erroneous information contained in the resident's record for Resident #13, 1 of 14 records reviewed for accuracy of clinical records. Resident #13's record contained an appointment report dated 6/25/13 with orders to continue medications that the resident had not previously received while a resident and the facility failed to obtain clarification from the physician regarding the orders. The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. On 7/31/13 at approximately 9:31 AM, record review of the section in the record labeled Progress Notes revealed a report of a physician appointment dated 6/25/13. The report listed the resident's current medications as [MEDICATION NAME] (HCTZ)-25 mg (milligrams) 25 MG tablet 1 tablet Once a day for high blood pressure, [MEDICATION NAME] 10 MG Tablet Extended Release 24 Hour 1 tablet Once a day for high blood pressure, and [MEDICATION NAME] Oral 40 MG/ML (Milliliter) Suspension 20 ml Once a day for appetite. The report further stated to continue the HCTZ, [MEDICATION NAME] and [MEDICATION NAME] at the same doses. Review of the Medication Administration Records (MAR) for June and July, 2013 at approximately 9:37 AM revealed [MEDICATION NAME] or [MEDICATION NAME] were not listed or signed off as administered. Review of the monthly physician's orders [REDACTED]. Review of the Telephone Orders revealed no orders for the 3 medications. Further review of the Doctor's Progress Notes revealed no documentation after a 5/25/13 note that stated Continue (with) current therapy. Meds (medications) reconciled. At 12:33 PM on 7/31/13, review of the Nurse's Notes revealed no documentation for 6/25/13. During an interview on 7/31/13 at 12:50 PM, the Unit Manager, Licensed Practical Nurse (LPN) # 3 confirmed the findings above. LPN # 3 further stated that when new orders are received, the responsible party is notified and any new medications are transcribed to the MAR. LPN # 3 also confirmed that, since the resident had not previously been receiving any of the medications listed, when the receiving nurse received the report with orders to continue the medications, that nurse should have called the physician for clarification. LPN # 3 verified there was no documentation that anyone had called the physician for clarification. At approximately 2:30 PM, the Director of Nursing (DON) stated that the physician had been contacted regarding the report. The DON stated that the physician had stated the report in the medical record was a mistake. The DON also stated that because the physician listed on the report was also the resident's attending physician at the facility, the resident would not have seen the physician at his office. S/he also stated that the physician hand wrote progress notes at the facility. The DON also stated that s/he thought the report was supposed to be June 25, 2012 not 2013 and would have been prior to the resident's admission to the facility.",2017-06-01
7996,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,156,C,0,1,W3VQ11,"Based on record review and interview, the facility failed to provide the amount of time required for notification on Liability and Appeals Notice to 1 of 3 sampled residents who had been discharged from Medicare Part A Services with days of eligibility remaining for Resident #51. Additionally, the facility failed to post contacts and phone numbers to contact outside of the facility in 2 of the 2 buildings and Resident #70 was unaware of the Ombudsman position. The findings included: A review of Liability and Appeals Notice with the Business Office Coordinator (BOC) on 6/19/16, revealed Resident #51 was discharged from Medicare Part A Services on 4/15/16 without the forty eight hour notification with Medicare eligibility days remaining. During the review of these notices, the BOC verified that the Notice of Medicare Non-Coverage -CMS form had The Effective Date Coverage of Your Current Services Will End: 4/14/16. The BOC indicated if the resident is in the facility and able to sign he/she would have the resident sign the Notice of Medicare Non-Coverage -CMS . The BOC was unaware of the forty eight hour notification requirement. A review of the minutes from the Resident Council meetings in the past year, revealed no written discussion about Facility rules, available Ombudsman support or DHEC Survey results. When asked about the state surveys, the Resident Council President stated that s/he was not aware of available survey results, because no one had explained it to her/him. When asked if s/he knew what an Ombudsman does, s/he was not familiar with the position of the Ombudsman. On 06/08/16 at approximately 2:30 pm, during an interview with the Activity Director (AD), the AD stated that s/he had been with the facility for over four years. The AD was asked about the last time s/he went over the facility rules and the results from the last DHEC survey. The AD stated that it had been way over a year. Also, s/he could not remember the last time an Ombudsman came to a Resident Council meeting, and s/he did not know who the current Ombudsman was for the facility.",2016-09-01
7997,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,157,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the residents' physician and/or responsible party were notified for a change in condition for 1 of 3 residents reviewed for notification. There was no evidence of notification to Resident #199 's physician for the resident's refusal of [MEDICATION NAME]. The findings included: The facility admitted Resident #199 with [DIAGNOSES REDACTED]. Record review on 6/8/15 at 8:55 PM revealed a care plan dated 6/2/16 Problem Exhibition of Behavioral Symptoms as evidenced by Resists Care. Approach: Notify Medical Doctor (MD) as needed. Record review of the Physician 's Order on 06/09/2016 at 7:35 AM revealed that the resident was receiving [MEDICATION NAME] solution 40mg/0.4ml ([MEDICATION NAME] Sodium) inject 0.4ml subcutaneously one time a day for preventative treatment. Record review of the May 2016 Medication Administration Record [REDACTED]. Record review on 06/09/2016 at approximately 8:00 AM of the Progress Notes revealed Resident #199 refused 0.4ml subcutaneously on 6/1/16, 6/3/16, 6/4/16, 6/5/16 and 6/6/16. During an interview with Director of Nursing (DON) on 06/09/2016 at approximately 6:45 PM, after reviewing the chart, he/she confirmed there was no documentation the physician was notified and the physician should have been notified of the refusal.",2016-09-01
7998,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,159,C,0,1,W3VQ11,"Based on interview, record review, and review of the facility 's policy Resident Trust Accounts , the facility failed to ensure that 3 of 4 sampled residents received quarterly statements. Resident #57, Resident #70's Responsible Party and Resident #92 stated they were not given quarterly statements. The Findings included: During a family interview on 6/7/16 at approximately 12:44 PM with Resident #70's Responsible party, individual interview with Resident #57 on 6/7/16 at 1:42 PM, and individual interview with Resident #92 on 6/7/16 revealed they had not received quarterly statements. Review of the facility policy on Resident Trust Accounts: Quarterly Procedures: 3. Trust statements for residents who have been properly declared incompetent to make health care/financial decisions are sent to the resident 's legal representative. During an interview with Accounts Receivable Coordinator (ARC) on 6/9/15 at 5:15 PM, he/she stated the statements are usually mailed out by Corporate. He/she stated there is no documentation when the statement is mailed to responsible party. He/she also stated the resident can request their account statement through the nurse or social worker. ARC confirmed he/she did not give out quarterly statements to the residents that stay in the facility.",2016-09-01
7999,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,170,C,0,1,W3VQ11,"Based on interview, the facility failed to ensure mail would be sent out or delivered promptly to residents whenever there was regularly scheduled postal delivery and pick-up service. Findings included: On 06/08/2016 at approximately 5:15 pm, a phone interview was conducted with the weekend office manager. The office manager stated that she had been with the facility for three years and s/he did not check the Saturday mail on a regular basis. However, if a resident did tell that he or she was expecting mail, s/he would get the mail for that resident. The rest of the mail sits on the AR Coordinator 's desk until Monday morning when s/he comes in. The weekend office manager further stated that if there were no requests for mail, s/he would not get the mail. On 06/08/2016 at approximately 5:25pm, interview with the AR Coordinator revealed that there are some Monday mornings when the mail box was full or there would be a stack of mail on the desk. The AR Coordinator also stated that part of the Monday morning routine was to give the mail to the Activity Director. The Activity Director would then deliver the mail to the residents.",2016-09-01
8000,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,241,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his/her individuality for Resident #59 for 1 of 5 residents reviewed for dignity. Staff failed to answer call lights in a timely manner resulting in Resident #59 having incontinent episodes. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. During an interview on 6/6/2016 at approximately 5:00 PM, Resident #59 reported that staff do not answer call lights in a timely manner resulting in incontinent episodes. He/she stated, Right after breakfast I have to go to the bathroom and no one comes when I call. He/she went on to say that it is frequently during the night, that staff does not answer the call lights. Review on 6/6/2016 at approximately 5:20 PM of the Minimum Data Set ((MDS) dated [DATE] for Resident #59 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Further review of the MDS for Resident #15 revealed in Section G - Functional Status - I. Toilet Use is coded as 3 under self performance as resident needs extensive assistance. And 2. under support is coded as a 2 for one person to physically assist. During an interview on 6/8/2016 at approximately 3:20 PM with Licensed Practical Nurse (LPN) #5 stated, we know we have some problems with the call lights but it is at night usually that the call lights are not getting answered.",2016-09-01
8001,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,242,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility policy titled, Resident Rights, the facility failed to ensure Resident #59 and Resident #203 were afforded the right to choose activities, schedules and health care consistent with his or her interests and to make choices about aspects of his/her life in the facility that are significant to the resident for 2 of 4 residents reviewed for choices. Resident #59 and Resident #203 were not afforded his/her choice to choose the type of bath nor how often he/she would like to bathe. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. During an interview on 6/6/2016 at approximately 8:36 AM with Resident #59, he/she stated,I do not get to choose what kind of bath I want, they just put me on a schedule and I don't know how I got on that schedule. I only get to shower on Tuesday, Thursday and Saturday. Review on 6/8/2016 at approximately 5:20 PM of the Minimum Data Set ((MDS) dated [DATE] for Resident #59 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15. Further review of the MDS for Resident #15 revealed in Section G - Functional Status - under bathing is coded as 4 totally dependent on staff for bathing and support provided is coded as a 2 which indicates Resident #59 requires the assistance of one person. Further review of the MDS dated [DATE], Section F, Preferences for Customary Routine and Activities, C. asks, While you are in this facility how important is it to you to choose between a tub bath, shower, bed bath or a sponge bath? This question is coded with a 1 as, Very Important. No documentation could be found to indicate his/her preference as to the frequency of bathing. During an interview on 6/8/2016 at approximately 2:08 PM with the Director of Nursing, he/she stated, they ask the preference of what type of bath the resident would like to have, but not the preference for the frequency of baths. During interviews on 6/8/2016 at approximately 2:20 PM with Certified Nursing Assistant (CNA) #2 and CNA #3, both revealed that the facility had a shower schedule and it depended on the room number. That's how it is determined what days they get a shower. Review on 6/8/2016 at approximately 3:45 PM of the facility policy titled, Resident Rights, states, The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. The section under,Fundamental Information, states, Residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations affecting resident conduct and those regulations governing protection of resident health and safety. During an interview on 6/8/16 at 10:43 AM with Resident #203 stated, Depends on the weather, prefer to take one in the morning and one in the evening. During an interview on 6/8/16 at 11:26 AM, The Director of Social Services was asked, How do you determine when a newly admitted resident gets a bath? He/she stated, The nurse on the unit will complete an assessment. During an interview on 6/8/16 at 11:40 AM with LPN #5 was asked, How do you determine when a newly admitted resident gets a bath? He/she stated The particular room the resident is in receive showers on the days that are listed. He/she showed the Shower Schedule that lists the rooms and days showers are permitted. Review of the facility 's policy Resident ' s Rights under Federal Law: 29. The Resident has a right to choice activities, schedules, and health care consistent with his or her own interest, assessments, and plan of care.",2016-09-01
8002,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,248,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interview and review of the activity participation record, the facility failed to provide an ongoing program of activities designed to meet the interests, and the physical, mental and psychosocial well being for Resident #57 for 1 of 1 resident reviewed for activities. The findings included: The facility admitted resident # 59 with [DIAGNOSES REDACTED]. Random observations made on 6/6/2016 and 6/7/2016, the first 2 days of the survey, Resident #57 was not provided any type of activities in or outside of his/her room. An observation on 6/7/2016 at approximately 5:15 PM revealed Resident #57 lying in bed, fully dressed in street clothes, sleeping at intervals. Review on 6/7/2016 at approximately 5:28 PM of the activity attendance sheets dated from 3/29/2016 through 5/30/2016 revealed no specific activities for Resident #57 according to his/her preferences. Review on 6/8/2016 at approximately 7:06 AM of the Plan of Care for Resident #57 revealed a need which reads Resident needs continued interaction/socialization and or help adjusting to facility placement with weekly 1 to 1 visits. The goal for Resident #57 included, Resident will continue to have opportunities for socialization, interaction and participate in daily activities as able. The interventions included, Activities of choice as tolerated. Movies and or TV and Music. Other interventions included, resident prefers to have meals in her room, he/she enjoys having his/her mail read to him/her, he/she enjoys visits from friends, family and staff. He/she enjoys touch and or music therapy. He/she also enjoys having books, the Bible, The Daily Bread Devotion and the newspaper read to him/her. No documentation could be found where the above mentioned activities were provided for Resident #57. Review on 6/8/2016 at approximately 8:00 AM of the activity participation record for Resident #57 revealed no specific activities that were being offered to include his/her preferences. During an interview on 6/9/2016 at approximately 10:28 AM with the Activity Director, he/she provided a progress note dated 5/16/2016 which states, continues to be out of bed as tolerated at times, sitting in a large chair in room or at the nurse's station. He/she has family visits almost daily. The family will wheel him/her in the hallway and sometimes outside the facility. Activity staff will continue to invite and encourage him/her to sit in on social group activities . No documentation could be found where activities were being provided for Resident #57.",2016-09-01
8003,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,274,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, the facility failed to complete a SCSA (Significant Change in Status Assessment) within 14 days as required for Resident #160, 1 of 1 resident reviewed receiving Hospice services. The findings included: The facility admitted Resident #160 with [DIAGNOSES REDACTED]. On 06/08/2016 at 2:24 PM, record review revealed the resident was admitted to Hospice on 5/18/16. At 11:37 AM on 06/10/2016, review of the record revealed a SCSA (Significant Change in Status Assessment (Minimum Data Set) with an Assessment Reference Date (ARD) of 6/6/16, which was the 20th day after Resident #160 was admitted to Hospice. Review of the CMS RAI Manual, Chapter 2, page 2-21 revealed A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election . During an interview 2:59 PM 06/10/2016, Registered Nurse (RN) #1 confirmed the Hospice conversion date of 5/18/16. The RN further confirmed that the SCSA was done with an ARD of 6/6/16. When asked when it should have been done, the RN stated we did it within 14 days after we found out. At 3:33 PM, upon review of the RAI Manual, the RN stated that the ARD had been set based on when the MDS office was notified the resident had been admitted to Hospice, not when the resident was admitted to Hospice.",2016-09-01
8004,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,279,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, and review of the facility policy titled, Referral to Outside Agencies, the facility failed to ensure a Plan of Care was developed with measurable goals and interventions to address the care and treatment related to dental/oral health for Resident #102 for 1 of 1 resident reviewed for Dental Status and Services. The findings included: The facility admitted Resident #102 with [DIAGNOSES REDACTED]. An observation on 6/6/2016 at approximately 4:29 PM revealed Resident #102 with his/her top teeth missing. During an interview with Resident #102 on 6/7/2016 at approximately 9:11 AM, he/she stated the he/she did have problems with his/her teeth. Resident #102 went on to say that, X-rays had been taken and the Dentist had visited a time or two, but that was last year and nothing has been done since. Review on 6/9/2016 at approximately 7:01 PM of the Plan of Care for Resident #102 revealed no mention of his/her problems with his/her teeth. The care plan did mention a concern which read, Potential for weight loss/Nutritional Risk. Review on 6/10/2016 at approximately 12:54 PM of the medical record for Resident #102 revealed an oral examination on 8/4/2015 by Senior Dental Care. The notes and recommendations included ,Patient is a candidate for max. partial. He/she would need root tip #9 removed first, then the impression taken. Refer out for extraction of #9 root tip. Further review on 6/10/2016 at approximately 12:54 revealed another dental visit by Senior Dental Care on 9/26/2015 which states, #9 root tip needs extracting, starting to be symptomatic at times . Needs consent form signed by his/her medical doctor and personal representative before the extraction can be done. The consent form was sent to the Social Services Director. No documentation could be found in the medical record where the consent was signed by the doctor nor the personal representative for Resident #102. Resident #102 was seen again on 12/2/2015, and still no one had addressed the #9 root tip extraction. The next appointment was scheduled for February 2016, and Resident #102 stated that he/she had not been to the dentist this year. No documentation could be found to ensure Resident #102 had been seen for the February 2016 appointment, and no documentation to ensure Resident #102's dental work had been completed. During an interview on 6/10/2016 at approximately 2:19 PM with the Social Services Director stated, I think this resident went to the dentist for the extraction. I am not sure if he/she has upper teeth or not. The social service director could not ensure Resident #102 attended the follow up appointments as ordered nor could he/she ensure the extraction was done. The social services director could not provide documentation or paper work to ensure the matter was taken care of for Resident #102. During a second interview on 6/10/2016 at approximately 2:30 PM with Resident #102 he/she stated, I have not been to the Dentist this year. I was told once they removed one of my teeth, they could do the impression and get me some top teeth, but they have not removed the tooth yet. Review on 6/10/2016 at approximately 3:45 PM of the facility policy titled, Referral to Outside Agencies, Under Procedure, #3 states, The Social Service Director makes an appointment for the resident with the appropriate outside agency. Number 7 reads, Service providers' recommendations are to be integrated into the resident's plan of care.",2016-09-01
8005,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,280,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the care plan to include a left elbow extension splint for Resident #41, 1 of 3 residents reviewed for care plans. The facility also failed to revise the care plan to reflect the change of a Foley catheter to a suprabubic catcher for Resident #117, 1 of 2 residents reviewed for catheters. The care plans were not revised related to weight loss for Residents #6 and #33, 2 of 4 reviewed for nutrition and the care plans did not include wound doctor visits for Residents #139, #145 and #182, 3 of 5 residents reviewed for pressure ulcers. The findings included: Resident #41 was admitted to the facility with [DIAGNOSES REDACTED]. At 1:34 PM on 06/09/2016, review of the Physician Order Summary Report for May, 2016 revealed an order that stated Restorative Nursing Splint Order: L (left) elbow Extension Splint to be worn Mon (Monday)-Sat (Saturday), as tolerated by the resident. Further review revealed an order dated 3/23/16 for Occupational Therapy 5 times a week from 3/23/16 through 4/23/16. Therapeutic interventions included Therapeutic Exercises and Activities, Diathermy and splinting. No order was noted to discontinue the left elbow extension splint. At 3:03 PM on 06/09/2016 review of the Care Plan revealed Risk for decline in Range of Motion was identified as a problem area. Interventions included Restorative PROM (Passive Range of Motion) 3-5 times per week for 8 weeks. The PROM was not reordered upon return from the hospital as the resident was receiving Occupational Therapy. The care plan was not updated to include the left elbow extension splint ordered on [DATE]. During an interview on 06/09/2016 6:00:29 PM, the Director of Nursing (DON) confirmed the left elbow extension splint was not listed on the care plan. The DON further stated that the therapist had reported that no referral had been made to Restorative and no education provided for splint application. The DON did also confirm the resident had an order for [REDACTED]. The facility admitted Resident #117 with a Foley catheter due to [MEDICAL CONDITION] status [REDACTED]. Review of the Discharge summary revealed the hospitalist stated Resident #117 would need a chronic Foley due to being unresponsive to [MEDICATION NAME] and Advodart therapy, Recurrent UTI (Urinary Tract Infection) and Recurrent Acute [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]. Record review revealed the resident was sent to the hospital for evaluation and to have the Foley replaced with a suprapubic due to penile erosion on 3/21/16. At 4:45 PM on 06/10/2016, review of the care plan revealed a problem dated 12/17/15 for a #16 French Indwelling Foley catheter. Interventions included but were not limited to, catheter care and changes per physician orders. The care plan was not updated to reflect the change from a Foley catheter to a suprapubic catheter. During an interview on 06/10/2016 at 5:09 PM, the Director of Nursing confirmed confirmed the resident had a suprapubic catheter and that the care plan had not been updated. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. During the Stage I Census Record Review, Resident #6 weights were noted as 117 pounds on 05/11/201; Weight 30 days prior to current weight (04/08/2016): 128 (which is 11 lbs. less than on the first date or a 9.4% loss); Weight 90 days ago (02/01/2016): 137 (which is 20 lbs. less than on the first date or a 17.1% loss; and Weight 180 days ago (11/15/2015): 140 (which is 23 lbs. less than on the first date or a 19.7% loss) At 5:51 PM on 06/10/2016, review of the Care Plan revealed Potential for weight loss related to Chronic Disease: [MEDICAL CONDITION] Reflux, [MEDICAL CONDITION], Hypertension, Chronic Obstructive Heart Failure, [MEDICAL CONDITIONS] Embolism, and Acute [MEDICAL CONDITION] was identified as a problem area. The goal was that the resident's weight would be stabilized through the next review period. The care plan was reviewed on 6/1/16 and continued but was not updated to reflect actual weight loss. During an interview 06/10/2016 6:51:47 PM, Licensed Practical Nurse (LPN) #5 confirmed the weight loss as documented. The LPN also confirmed the care plan was not updated to reflect the actual weight loss. The facility admitted Resident # 182 with [DIAGNOSES REDACTED]. Review on 6/8/2016 at approximately 1:40 PM of the medical record for Resident #182 revealed visits by a wound care specialists contracted by the facility to care for pressure ulcers. The wound care specialists visits were from 4/12/2016 to present date. No physicians order could be found in Resident #182's medical record for the Wound Specialist to evaluate and treat Resident #182. Review on 6/9/2016 at approximately 7:10 AM of Resident #182's Plan of care revealed no mention of the wound care specialist. The facility admitted Resident # 139 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 1:53 PM of Resident #139's medical record revealed visits made the by the wound care specialists with no physician's order found in the the medical record for the wound care specialists to evaluate and treat Resident #139. Review on 6/9/2016 at approximately 2:00 PM of the Plan of Care for Resident #139, revealed no mention of the wound care specialists visits or treatment. The facility admitted Resident #145 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 6:54 PM of Resident #145's medical record revealed visits from the wound care specialists dated from 5/10/2016 through 5/31/2016. No physician's order could be found in the medical record for the would care specialists to evaluate and treat the wounds for Resident #145. Review on 6/9/2016 at approximately 6:54 PM of the Care Plan for Resident #145 revealed no mention of visits or treatment from the wound care specialists. Further review of the Plan of Care for Resident #145 revealed the ordered trunk wedge, knee spreader/flexion block cushion and the bilateral heel/ankle protectors were in place for resident use, but the Plan of Care did not include the devices. An interview on 6/9/2016 at approximately 3:00 PM with the Director of Nursing confirmed that there was not a Physician's order for the wound care specialists and also confirmed that there was not mention on the Plan of Care for Residents #182, #139 and #145. The physician's order for the wound care specialists was obtained during the survey on 6/9/2016. During an interview on 6/10/2016 at approximately 2:33 PM with the Care Plan Coordinator, Registered Nurse #1 he/she confirmed that the wound care specialists was not on the Plan of Care for the above mentioned residents. The facility admitted Resident #33 which included but not limited to [MEDICAL CONDITION] Vascular Disease ([MEDICAL CONDITION]), Type 2 Diabetes Mellitus with [MEDICAL CONDITION] (DM-II), and [MEDICAL CONDITION]. During dining observation on 6/8/16 at 12:36 PM revealed the resident's meal consisted of smothered steak, bread, greens, sweet potatoes, water and ginger ale. He/she only consumed a small portion of sweet potatoes, collards and drank the water and ginger ale. During an interview with Resident #33 on 6/8/16 at 12:49 PM was asked, Why they did not eat their lunch? He/she stated I asked for a piece of chicken and the Certified Nurse Aide (CNA) stated I had to eat what was on the paper. During an interview with CNA #4 on 6/8/16 at 1:12 PM, he/she stated Past her tray and made sure she had what she needed. Resident #33 saw another resident had chicken and asked for some. I was only allowed to give the resident what was on the paper. I asked if he/she wanted a sandwich. Review of the Care Plan on 6/8/16 at 9:54 PM revealed the care plan dated 3/28/16 Weight Loss/Nutritional risk related to Chronic Disease, [MEDICAL CONDITION] Reflux Disease (GERD), Diabetes Mellitus (DM), [MEDICAL CONDITION] Disease [MEDICAL CONDITION], and Hypertension (HTN). The Approach for the care plan included offer preferred food and determine individual likes and dislikes. During an interview with Dietary Manager on 6/9/16 at 12:09 PM, he/she stated the Resident is on a cardiac diet that consist of no fried food. The foods are baked and not fried except for the chicken. He/she also stated the resident is offered a diet free holiday or may have menu of the month. Record review on 6/9/16 at 2:57 PM revealed Resident#33 weight for 4/28/16 was 183 and 5/11/16 was 173. During an interview with the Director of Nursing (DON) on 6/9/16 at 6:31 PM, he/she confirmed the care plan was not revised for the significant weight loss that occurred in the month May 2016.",2016-09-01
8006,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,281,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the facility policy and Potter, P.A., & Perry Fundamentals of Nursing , the facility failed to meet professional standard of quality for 1 of 5 residents reviewed for subcutaneous administration. Staff used a gauge needle inconsistent with a subcutaneous injection. The findings included: The facility admitted Resident #205 with [DIAGNOSES REDACTED]. On 6/8/16 at 8:51 AM, during Resident #205's medication administration LPN #3 withdrew units of [MEDICATION NAME] Solution (Epoetin) into a 21 gauge, 1 inch needle. Prior to administration LPN #3 was asked to review Resident #205 Physicians Orders that stated [MEDICATION NAME] Solution UNIT/ML (Epoetin Alfa) inject 1 dose subcutaneously Weekly every Wed. Following the observation LPN#3 verified s/he was going to administer Epoetin units subcutaneously with a 21 gauge, 1 inch needle. Review of the facility policy Administration of Medications, subtitle: Subcutaneous Injections under Equipment, states Safety Needle 25 or 27 gauge, 1/2 - 7/8 inch length. Review of Potter, P.A., & Perry Fundamentals of Nursing (6th edition), states under Subcutaneous injections, Do not administer more than 1 ml with a single SubQ (subcutaneous) injection. Use a 25-to-30 gauge, 3/8-to 5/8- inch needle.",2016-09-01
8007,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,282,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure the Comprehensive Plan of Care was followed for Resident # 57, #199 and Resident #59. Resident #57's Plan of care not followed related to activities and activity preferences for 1 of 1 resident reviewed for activities. Resident #59's care plan not followed related to a physician ordered fluid restriction, monitoring the Thrill and Bruit and for ensuring [MEDICAL TREATMENT] communication is sent to [MEDICAL TREATMENT] with Resident #59 and returned after the appointment is complete for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The facility further failed to follow a Plan of Care for Resident #199 related to notification for 1 of 1 resident reviewed for Notification. The findings included: The facility admitted resident # 57 with [DIAGNOSES REDACTED]. Review on 6/7/2016 at approximately 5:28 PM of the activity attendance sheets dated from 3/29/2016 through 5/30/2016 revealed no specific activities for Resident #57 according to his/her preferences. Review on 6/8/2016 at approximately 7:06 AM of the Plan of Care for Resident #57 revealed a need which reads Resident needs continued interaction/socialization and or help adjusting to facility placement with weekly 1 to 1 visits. The goal for Resident #57 included, Resident will continue to have opportunities for socialization, interaction and participate in daily activities as able. The interventions included, Activities of choice as tolerated. Movies and or TV and Music. Other interventions included, resident prefers to have meals in her room, he/she enjoys having his/her mail read to him/her, he/she enjoys visits from friends, family and staff. He/she enjoys touch and or music therapy. He/she also enjoys having books, the Bible, The Daily Bread Devotion and the newspaper read to him/her. No documentation could be found where the above mentioned activities were provided for Resident #57. Review on 6/8/2016 at approximately 8:00 AM of the activity participation record for Resident #57 revealed no specific activities that were being offered to include is/her preferences. During an interview on 6/9/2016 at approximately 10:28 AM with the Activity Director, he/she provided a progress note dated 5/16/2016 which states, continues to be out of bed as tolerated at times, sitting in a large chair in room or at the nurse's station. He/she has family visits almost daily. The family will wheel him/her in the hallway and sometimes outside the facility. Activity staff will continue to invite and encourage him/her to sit in on social group activities . No documentation could be found where the mentions activities were being provided for Resident #57. The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Review on 6/8/2016 at approximately 11:43 AM of the medical record for Resident #59 revealed a physician's orders [REDACTED]. Notify the physician if not present. Review on 6/8/2016 at approximately 1:25 PM of the Plan of Care for Resident #59 revealed a Problem/strength which states, Receives [MEDICAL TREATMENT] 3 times weekly. The interventions included, fluid restriction as ordered, 1500 milliliters daily. A second intervention/approach was listed and read, After return from [MEDICAL TREATMENT], check for thrill and bruit two times per shift on days returned from [MEDICAL TREATMENT], and then daily. The plan of care also included in approaches/interventions which reads, [MEDICAL TREATMENT] Communication Record is sent to the [MEDICAL TREATMENT] center with each appointment, and return of the form is ensured after each appointment is completed. No documentation could be found in Resident #59's medical record to ensure the care plan was followed. Review on 6/8/2016 at approximately 4:31 PM of he Treatment Record for Resident #59 revealed that the thrill and bruit had not been monitored per the physician's orders [REDACTED].>During interviews on 6/8/2016 at approximately 4:31 PM with the Director of Nursing and the Unit Manager, Licensed Practical Nurse #5 confirmed that the Care Plan was not followed related to a physician ordered fluid restriction, for checking the thrill and bruit daily and before and after [MEDICAL TREATMENT] nor was it followed to ensure the [MEDICAL TREATMENT] communication records were sent to [MEDICAL TREATMENT] with Resident #59 and were returned after the appointment was completed to coordinate care between the [MEDICAL TREATMENT] center and the facility. The facility admitted Resident #199 with [DIAGNOSES REDACTED]. Record review on 6/8/15 at 8:55 PM revealed care plan dated 6/2/16 Problem Exhibition of Behavioral Symptoms as evidenced by Resists Care. Approach: Notify Medical Doctor (MD) as needed. Record review on the physician's order [REDACTED]. Record review of the May 2016 Medication Administration Record [REDACTED]. Record review on 06/09/2016 at approximately 8:00 AM of the Progress Notes revealed Resident #199 refused 0.4ml subcutaneously on 6/1/16, 6/3/16, 6/4/16, 6/5/16, and 6/6/16. During an interview with Director of Nursing (DON) on 06/09/2016 at approximately 6:45 PM, after reviewing the chart, he/she confirmed there was no documentation the physician was notified and the care plan was not followed to notify the physician when the resident refused the [MEDICATION NAME].",2016-09-01
8008,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,309,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and the facility policy titled, Documentation, the facility failed to ensure a physician ordered fluid restriction was consistently documented to reflect the total intake for resident #59. The facility further failed to ensure the thrill and bruit were monitored and verified for Resident #59. The facility additionally failed to ensure coordination of care via a communication sheet was provided to the [MEDICAL TREATMENT] clinic and returned to the facility with each [MEDICAL TREATMENT] visit for Resident #59 for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The facility failed to ensure medications were administered as ordered by the physician as evidenced by blanks on the Medication Administration Record [REDACTED]. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Review on 6/8/2016 at approximately 11:43 AM of the medical record for Resident #59 revealed a physician's orders [REDACTED]. Notify the physician if not present. A second physician's orders [REDACTED]. No documentation could be found in Resident #59 medical record to ensure the physician's orders [REDACTED]. During interviews on 6/8/2016 at approximately 4:31 PM with the Director of Nursing and the Unit Manager, Licensed Practical Nurse #5 confirmed that the physician's orders [REDACTED]. Review on 6/8/2016 at approximately 2:10 PM of the Medication Administration Record [REDACTED]. The [MEDICATION NAME] 0.5 mg tablet to be given by mouth daily at 8:00 AM and [MEDICATION NAME] Sodium 100 mg tablet to be given by mouth at bedtime had not been documented as given on 6/3/2016. The daily fingerstick blood sugar checks to be done daily at 6:00 AM was not documented as done on 6/1/2016, 6/3/2016 nor on 6/4/2016. The [MEDICATION NAME] 5 units to be administered subcutaneously at bedtime and the [MEDICATION NAME] 75 microgram tablet to be given by mouth daily at 6:00 AM was not documented as given on 6/1/2016, 6/3/2016 and 6/4/2016. The [MEDICATION NAME] 10 mg tablet to be given by mouth at bedtime was not documented as given on 6/3/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 20 mg tablet to be given by mouth daily at 8:00 AM was not documented as given. The Prostat 30 milliliters to be given by mouth daily, and Senispar 60 mg tablet to be given daily by mouth was not documented as given on 6/2/2016. The Tab-A-Vite tablet 1 tablet to be given by mouth daily and Vitamin B 6 100 mg to be given by mouth one time daily was not documented as given on 6/2/2016. The [MEDICATION NAME] 50 mg 1 tablet to be given by mouth daily was not documented as given on 6/3/2016. The [MEDICATION NAME] MultiHealth Fiber Powder 58.6 % [MEDICATION NAME] ordered to give 2 teaspoons by mouth two time daily was not documented as given at 8:00 AM on 6/2/2016 and the 8:00 PM dose was not documented as given on 6/3/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 17 grams to be given by mouth 2 times daily and the Sildenafil [MEDICATION NAME] 20 mg tablet to be given 2 times daily was not documented as given on 6/2/2016 at 8:00 AM as ordered. The Vitamin B 1 100 mg tablet to be given two times a day was not documented as given at 8:00 AM on 6/2/2016. The [MEDICATION NAME] 800 mg tablet to be given by mouth three times daily on Sunday, Tuesday, Thursday and Saturday was not documented as given on 6/2/2016 at 8:00 AM and 12 noon. During an interview on 6/8/2016 at approximately 2:15 PM with the Director of Nurses concerning the blanks on the MARs, he/she stated, Me and all my managers came in Sunday to check orders to make sure they were correct and new orders had been entered correctly. The DON verified multiple blanks on the MARs We had training but not everyone attended. During an interview on 6/8/2016 at approximately 2:45 PM with the Nurse Manager, Licensed Practical Nurse (LPN) #5, he/she confirmed the blanks on the MARs and stated, I think it is because the staff did not know how to chart in the computer once the medication was given. The LPN could not verify that the resident's received the medications as ordered. The facility admitted Resident #102 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 9:00 AM of the MAR for Resident #102 revealed the medication Atorvastatin 10 mg tablet to be given by mouth at bedtime was not documented as given on 6//1/2016. The [MEDICATION NAME] 25 mg tablet to be given by mouth one time daily was not documented as given on 6/2/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 100 mg tablet to be given by mouth was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 5 mg tablet to be given by mouth one time daily was not documented as given on 6/1/2016, 6/4/2016 and 6/4/2016. The [MEDICATION NAME] 0.4 mg tablet to be given by mouth daily was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 400 mg tablet to be given by mouth at bedtime was not documented as given on 6/1/2016. The [MEDICATION NAME] 40 units to be given subcutaneously in the evening was not documented as given on 6/1/2016. The Multi Vitamin with Minerals to be given one time daily was not documented as given on 6/4/2016 and 6/5/2016. The Multivital-M tablet to be given by mouth daily was not documented as given on 6/1/2016. The [MEDICATION NAME] 10 mg tablet to be given one time daily by mouth was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] Insulin on 6/2/2016 with 12 units to be administered daily at 12 noon and 5:00 PM was not given on 6/4/2016 and 6/5/2016. The time preprinted on the MAR indicated [REDACTED]. No 5:00 PM doses were given on 6/2/2016, 6/3/2016, 6/4/2016, 6/5/2016, 6/6/2016, 6/7/2016 or 6/8/2016, then the order was discontinued on 6/8/2016 at 7:18 PM. The [MEDICATION NAME] Insulin 15 units to be given at 8:00 AM was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] 17 grams to be be given daily was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The Senna Lax 17.2 mg tablet to be given at bedtime was not documented as given on 6/1/2016. The Xarelto 20 mg tablets ordered to be given daily at 5:00 PM was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. Blood pressure checks ordered to done every shift were not documented as done on 6/1/2016 AM nor PM, 6/4/2016 AM, 6/5/2016 AM or 6/10/2016 AM. The Carvedilol 25 mg tablet to be given by mouth 2 times daily was not documented as given on 6/1/2016, 6/4/2016 and 6/5/2016. The [MEDICATION NAME] Capsule 300 mg to be given 2 times daily was not documented as given on 6/1/2016 at 2:00 PM, 6/2/1016 at 6:00 AM, 6/4/2016 at 2:00 PM and 6/5/2016 at 2:00 PM. The [MEDICATION NAME] 1000 mg to be given 2 times daily by mouth was not documented as given on 6/1/2016, 6/4/2016, or 6/5/2016 at 8:00 AM. The Fingerstick Blood Sugars ordered 3 times daily were not documented as checked on 6/1/2016 at 12 noon and 5:00 PM, 6/2/2016 at 6:00 AM, 6/4/2016 at 12 noon and 5:00 PM, and 6/5/2016 at 12 noon and 5:00 PM. The facility admitted Resident # 139 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 1:19 PM of the MAR for Resident #139 revealed the medication [MEDICATION NAME] 100 mg to be given daily by mouth was not documented as given on 6/2/2016. The [MEDICATION NAME] 20 mg tablet to given by mouth daily was not documented as given on 6/2/2016. The Multivitamin with Minerals 1 tablet to be given by mouth daily was not documented as given on 6/2/2016. The [MEDICATION NAME] 650 mg to be given by mouth 2 times daily was not documented as given on 6/2/2016 at 8:00 AM. The [MEDICATION NAME] 100 mg to be given two times daily by mouth was not documented as given on 6/2/2016 at 8:00 AM. The House Supplement to be given 2 times daily was not documented as given on 6/2/2016 at 8:00 AM. The [MEDICATION NAME] 50 mg to be given 2 times daily by mouth was not documented as given on 6/2/2016 at 8:00 AM. The [MEDICATION NAME]-[MEDICATION NAME] 25-100 mg to be given 3 times daily by mouth was not documented as given on 6/2/2016 at 8:00 AM nor 12 noon. The [MEDICATION NAME] 250 mg capsule to be be given by mouth 3 times daily for 10 days and ordered on [DATE] at 4:50 PM was not documented as given on 6/4/2016, 6/5/2016 and the 9:00 AM dose on 6/6/2016. The House Supplement for Medpass 90 milliliters to be administered by mouth 4 times daily was documented as given on 6/2/2016 at 9:00 AM and 1:00 PM. The facility admitted Resident #145 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 6:54 PM of Resident #145's MAR indicated [REDACTED]. The House Supplement to be given daily at 10:00 AM was not documented as given on 6/2/2016. The Tylenol 650 mg tablets to be given by mouth every 6 hours was not documented as given on 6/4/2016 at 12:00 AM and 6:00 AM. Review on 6/10/2016 at approximately 9:22 AM of the facility policy titled, Documentation, revealed under, Fundamental Information, Aspects of resident care such as observations and assessments, administration of medications, and services and treatments performed must be documented in the medical record according to policy. Under the topic, Procedure, General, number 6 states, Medication and Treatment Records: When a medication or treatment is administered the nurse initials the appropriate box on the Medication Administration Record [REDACTED].",2016-09-01
8009,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,314,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facilty's policies, the facility failed to provide treatments as ordered for Resident #160, stage the ulcer for Resident #182, or obtain an order for [REDACTED]. The findings included: The facility admitted Resident #160 with [DIAGNOSES REDACTED]. On 06/07/2016 at 10:26 AM, review of the nutrition assessment dated [DATE] revealed the resident had a Stage IV to sacrum. At 1:04 PM on 06/10/2016, review of the Treatment Administration Record (TAR) revealed treatment orders to cleanse the wound with wound cleaner, apply calcium alginate, cover with dry gauze and secure with a dry dressing. Further review revealed the treatments were not signed off 5/28/16 and to the 5/29/16 sacrum, coccyx, left heel, and left ankle. Review of the TAR revealed a treatment for [REDACTED]. A treatment ordered for a skin prep to the left ankle and a wet to dry dressing was not done on 6 days in April prior to the Left Above Knee Amputation (AKA). A treatment for [REDACTED]. Upon return from the hospital status [REDACTED]. Review of the TAR revealed the dressing change was not done on 5/14, 5/15/16. In addition, review of the medical record revealed no body audits in the medical record. Review of the Body Audit notebook revealed 1 body audit dated 5/28/16. During an interview at 1:58 PM on 06/10/2016, Licensed Practical Nurse (LPN) #6 confirmed the missing treatment documentation in April and May and that the sacral dressing was done once daily not BID as ordered. The LPN also confirmed there were no body audits in the resident's medical record and only one body audit dated 5/28/16 in the Body Audit notebook. The facility admitted Resident # 182 with [DIAGNOSES REDACTED]. Review on 6/8/2016 at approximately 1:40 PM of the medical record for Resident #182 revealed visits by a wound care specialists contracted by the facility to care for pressure ulcers. The wound care specialists visits were from 4/12/2016 to present date. No physicians order could be found in Resident #182's medical record for the Wound Specialist to evaluate and treat Resident #182. The facility admitted Resident # 139 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 1:53 PM of Resident #139's medical record revealed visits made the by the wound care specialists with no physician's order found in the the medical record for the wound care specialists to evaluate and treat Resident #139. The facility admitted Resident #145 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 6:54 PM of Resident #145's medical record revealed visits from the wound care specialists dated from 5/10/2016 through 5/31/2016. No physician's order could be found in the medical record for the wound care specialists to evaluate and treat the wounds for Resident #145. A physician's order for the wound care specialists was obtained during the survey on 6/9/2016 for Resident #145. An interview on 6/9/2016 at approximately 3:00 PM with the Director of Nursing confirmed that there was not a Physician's order for the wound care specialists even though Resident # 145, #139 and Resident #182 are receiving care and services from the wound care specialists. Review on 6/9/2016 at approximately 4:20 PM of the agreement with the wound care specialists titled, National Wound Care Services Agreement, states under section II, General Duties and Obligations of Provider, A. Services. states, Provider shall ensure that its personnel provides skin and wound care, upon receipt of: the written order of an attending physician and specific authorization to treat the resident.",2016-09-01
8010,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,318,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide a left elbow extension splint for Resident #41 and failed to follow up on Passive Range of Motion exercises for Resident #145 to increase strength and prevent further decrease in range of motion for 2 of 3 residents reviewed for Range of Motion. The findings included: Resident #41 was admitted to the facility with [DIAGNOSES REDACTED]. At 1:56 PM on 06/08/2016, observation of Resident #41 revealed the resident supine in bed with contractures noted of bilateral hands and wrists. Resident was unable to extend wrist upon request and had on no splints. At 11:35 AM and at 2:39 PM on 06/09/2016, observation revealed Resident #41 supine in bed, arms bent at the elbows, hands on chest with noted contractures and no splints in place. At 1:34 PM on 06/09/2016, review of the Physician order [REDACTED]. Further review revealed an order dated 3/23/16 for Occupational Therapy 5 times a week from 3/23/16 through 4/23/16. Therapeutic interventions included Therapeutic Exercises and Activities, Diathermy and splinting. No order was noted to discontinue the left elbow extension splint. Record review revealed no documentation of application of the splint. At 3:03 PM on 06/09/2016 review of the Care Plan revealed Risk for decline in Range of Motion was identified as a problem area. Interventions included Restorative PROM (Passive Range of Motion) 3-5 times per week for 8 weeks. The PROM was not re-ordered upon return from the hospital as the resident was receiving Occupational Therapy. The care plan was not updated to discontinue the PROM or to include the left elbow extension splint ordered on [DATE]. During an interview at 2:48 PM on 06/09/2016, CNA (Certified Nursing Assistant) #1 confirmed the resident did not have on splints and stated s/he uses a pillow for positioning to help extend the resident's elbow. The CNA confirmed the splint was in the resident's room and stated that lately the resident had been refusing the splint. During an interview at 3:29 PM on 06/09/2016, the Director of Nursing confirmed the order for the left elbow splint and stated the referral had never been made to Restorative. The DON further confirmed that Restorative was not applying the splint. The DON also stated that the therapist had informed her/him that the resident had not tolerated the splint but confirmed the documentation provided by the therapist indicated the resident was tolerating the splint well for 3 hours. The DON also confirmed the left elbow extension splint was not listed on the care plan. During an interview at 3:38 PM on 06/09/2016, LPN (Licensed Practical Nurse) #5 stated s/he had been told maybe once or twice that the resident refused to wear the splint but in the last week, no. The facility admitted Resident #145 with [DIAGNOSES REDACTED]. Review on 6/9/2016 at approximately 8:45 AM of the medical record for Resident #145 revealed that resident #145 had contractures on admission and was seen by therapy with a decrease in mobility, decreased participation with functional tasks, increased dependency upon caregivers and increased pain due to a motor vehicle accident with multiple back surgeries, weakness and difficulty walking. Review on 6/10/2016 at approximately 8:45 AM of a form titled, Rehabilitation/Restorative Service Delivery Record, dated November 2014 included, Passive Range of Motion (PROM) exercises to lower extremities and to do 2 sets of 15 repetitions. Also included were ankle pumps, leg sliders, and leg raises 3 x weekly for strengthening. Random attempts were made 6 times during the month of November 2014. No other attempts have been made to ensure Resident #145 did not develop further contractures. No pain medications were documented as given prior to the exercises. No attempts were made to decrease the repetitions of the exercises to determine if Resident #145 could tolerate some portions of the PROM and gradually increase the ROM and prevent Resident #145 from developing further contractures. During an interview on 6/10/2016 at approximately 11:00 AM with the Nurse Manager, Licensed Practical Nurse (LPN) #7, stated the PROM was never attempted for very long with Resident #145. LPN #7 stated PROM is being done with AM care. No documentation could be found in the medical record for Resident #145 to ensure PROM was being done during AM care. Review on 6/10/2016 at approximately 6:54 PM of the Plan of Care for Resident #145 revealed that he/she is at risk for a decline in range of motion. The goals included, Resident to maintain current ROM status by tolerating range of motion. The approaches included Restorative PROM 5 times weekly. No documentation could be found in Resident #145's medical record to ensure any ROM was being done for this resident.",2016-09-01
8011,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,327,E,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility policy on Fluid Restriction, the facility failed to ensure a physician ordered fluid restriction was followed and documented for Resident #59 for 1 of 1 resident reviewed for [MEDICAL TREATMENT] and any limited fluid intake. The findings included: The facility admitted Resident #59 with [DIAGNOSES REDACTED]. Review on 6/8/2016 at approximately 11:43 AM of the medical record for Resident #59 revealed a physician's order dated 3/8/16 at 3:00 PM which read, Check for bruit and thrill every shift. Notify the physician if not present. A second physician's order was found in Resident's medical record to maintain and monitor a 1500 milliliter fluid restriction. No documentation could be found in Resident #59 medical record to ensure the physician's orders were followed. During interviews on 6/8/2016 at approximately 4:31 PM with the Director of Nursing and the Unit Manager, Licensed Practical Nurse #5 confirmed that the physician's orders for the 1500 milliliter fluid restriction was not followed as evidenced by no documentation to support the monitoring of the fluid restriction Review on 6/9/2016 at approximately 8:45 AM of the facility policy titled, Fluid Restriction, states , To provide residents who have a written physician's order for fluid restriction an appropriate amount of fluid each day while allowing nursing adequate fluid to supply medications, etc. each shift.",2016-09-01
8012,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,329,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy on documentation, the facility failed to ensure a physician's order was followed. Resident #70 (1 of 1 resident sampled for insulin administration) did not receive insulin as originally ordered and did not have an order to decrease the frequency of insulin administration as stated on the Medication Administration Record [REDACTED] Findings include: On 06/10/2016, review of Resident #70's Medication Administration Record [REDACTED]. There was a standing doctor 's order for Novo LOG Flex Pen Solution Pen injector 10 unit subcutaneous with meals. Review of the June MAR indicated [REDACTED]. There was also a standing doctor 's order for [MEDICATION NAME] 50 mg tablet given three times a day. Review of the MAR for June 1 and June 2, 2016, revealed that there were blanks for the afternoon and evening time. There was no nurse notation or circles in the boxes and no entry of why it was not given. The June MAR further revealed the order for Novo LOG Flex Pen Solution Pen injector 10 unit subcutaneous with meals was changed from 3 x per day to 1 x per day. On 06/10/2016 at 1:37 pm, during interview, the South unit manager stated there were standing doctor 's orders for Novo LOG Flex Pen Solution Pen injector 10 unit subcutaneous with meals. The manager does not know why the June MAR for Resident #70 shows an order for [REDACTED]. On 06/10/2016 at approximately 2:01 pm, interview with the Director of Nursing (DON), revealed that if there were blanks on the MAR indicated [REDACTED]. The DON could not locate the physician 's order changing the frequency of the medication.",2016-09-01
8013,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,332,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the manufactures recommendations, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 29 opportunities for error, resulting in a medication error rate of 6.8%. The findings included: Error#1 On 6/7/16 at approximately 4:45 PM, during observation of Resident #71 ' s medication administration, Licensed Practical Nurse (LPN) #2 was observed to administer [MEDICATION NAME] 50 microgram (mcg.) nasal spray to the resident without shaking the bottle prior to administration. Review of the [MEDICATION NAME] manufactures Prescribing Information, state, SHAKE GENTLY BEFORE USE. Error #2 On 6/8/16 at 8:51 AM, during Resident #205's medication administration Licensed Practical Nurse #3 attempted to administer units of [MEDICATION NAME] Solution (Epoetin). Prior to administration LPN #3 was asked to review Resident #205 physicians orders that stated [MEDICATION NAME] Solution UNIT/ML (Epoetin Alfa) inject 1 dose subcutaneously Weekly every Wed. LPN #3 verified s/he was going to administer Epoetin units instead of the physician ordered units.",2016-09-01
8014,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,333,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policy, the facility failed to administer the correct amount of medication resulting in significant medication errors for 2 of 30 residents reviewed for medication administration. Resident #65 did not receive the correct amount of insulin and Resident #205 did not receive the correct amount Epoetin during medication administration. The findings included: The facility admitted Resident #65 with [DIAGNOSES REDACTED]. On 6/7/16 at 4:40 PM, an observation of the East building, North unit (500-600) medication cart with Licensed Practical Nurse (LPN) #1 revealed (1) vial of Resident #65's [MEDICATION NAME] (Lot #5F452A) with a puncture date of 5/3/16, containing 1/10 of insulin. On 6/7/16 at 5:45 PM, review of Resident #65's Medication Administration Record [REDACTED]. On 6/7/16 at 6:00 PM, an interview with the Director of Nursing verified Resident #65's [MEDICATION NAME] vial (Lot # 5F452A) puncture date was 5/3/16 and used past the manufactures recommended discard date of 28 days after opening. Review of the [MEDICATION NAME] 100 Units/ML vial manufactures recommendations states under the section Storage: Discard all containers in use after 28 days, even if there is insulin left. The facility admitted Resident #205 with [DIAGNOSES REDACTED]. On 6/8/16 at 8:51 AM, during Resident #205's medication administration Licensed Practical Nurse (LPN) #3 withdrew 1 milliliter (ml.) from a unit/ml. vial of [MEDICATION NAME] solution (Epoetin) and attempted to administer the medication to Resident #205. Prior to administration LPN #3 was asked to review Resident #205 Physicians orders that stated [MEDICATION NAME] Solution UNIT/ML (Epoetin Alfa) inject 1 dose subcutaneously Weekly every Wed. LPN #3 verified s/he was going to administer Epoetin units instead of the Physician ordered units.",2016-09-01
8015,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,371,F,0,1,W3VQ11,"Based on observation, interviews, and review of facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 2 of 2 kitchens and has the potential to effect 145 of 145 residents with ordered diets as evidenced by failing to do the following: Remove rotted foods, wear hair restraint, reheat food to proper temperature, and have sanitizing buckets containing an adequate chemical solution for sanitization. The findings included: On 6/6/16 at 10:25 AM, during the initial tour of the East kitchen walk-in refrigerator revealed one box cucumbers containing cucumbers with dark green soft areas and areas with a white fuzzy substance. Also, one box of 8 green peppers had areas containing a white fuzzy and black substances. On 6/7/16 at 11:58 AM, an observation of the West kitchen lunch line temping with the Registered Dietician (RD) revealed the mechanically altered/pureed bread on the steam table read 110 degrees. Cook #1 reheated the bread to 131 degrees of Fahrenheit and attempted to serve. Following the observation Cook #1 indicated s/he did not know the correct reheating temperature. Also, a dietary aide in the kitchen food area was observed without a facial hair restraint. Furthermore, no sanitization buckets were observed with a chemical solution for sanitization. On 6/8/16 at 11:49 AM, an observation of the East kitchen walk-in refrigerator with the DM revealed one box cucumbers containing 56 cucumbers with dark green soft areas and a fuzzy white substance. Following the observation the DM verified the cucumbers were in various stages of rotting. On 6/8/16 at 11:58 AM, an observation of the East kitchen lunch line temping with the DM revealed the mechanically altered/pureed chicken on the steam table read 125 degrees. Cook #2 reheated the chicken to 140 degrees of Fahrenheit. Following the observation Cook #2 indicated s/he did not know the correct reheating temperature. Review of the facility policy entitled Food Preparation, states under Action Step (8) Time /Temperature Control for Safety (TCS) hot food items will be heated according to the following guidelines: bullet (5) Mechanically altered foods Reheated to 165 degrees Fahrenheit for 15 seconds. Also, policy Staff Attire, states under Action Step (1) The Food Service Director insures that all staff members have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.",2016-09-01
8016,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,372,E,0,1,W3VQ11,"Based on observations, interviews, and review of the facility policy the facility failed to dispose of garbage and refuse properly for 2 of 4 dumpsters reviewed for garbage disposal. Two dumpster lids were broken and unable to close exposing garbage. The findings included: On 6/7/16 at 1:49 PM, an observation of the East and West building garbage disposal areas with the Dietary Manager (DM) revealed (1) dumpster at the East building and (1) dumpster at the West building had broken lids containing exposed garbage. Following the observation the DM verified the dumpster lids were broken exposing garbage and indicated the dumpster's needed to be replaced. Review of the facility policy Environment, states under Action Step (7) The Food service Director will insure that all trash is properly disposed in external receptacles (dumpsters) and that the area is free of debris.",2016-09-01
8017,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,412,D,0,1,W3VQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews and the facility policy titled, Referral to Outside Agencies, the facility failed to provide from an outside resource, routine and emergency dental services including assisting with appointments to meet the needs for Resident #102 for 1 of 1 resident reviewed for Dental Status and Services. The findings included: The facility admitted Resident #102 with [DIAGNOSES REDACTED]. An observation on 6/6/2016 at approximately 4:29 PM revealed Resident #102 with his/her top teeth missing. During an interview with Resident #102 on 6/7/2016 at approximately 9:11 AM, he/she stated the he/she did have problems with his/her teeth. Resident #102 went on to say that, X-rays had been taken and the Dentist had visited a time or two, but that that was last year and nothing has been done since. Review on 6/10/2016 at approximately 12:54 PM of the medical record for Resident #102 revealed an oral examination on 8/4/2015 by Senior Dental Care. The notes and recommendations included ,Patient is a candidate for max. partial. He/she would need root tip #9 removed first, then the impression taken. Refer out for extraction of #9 root tip. Further review on 6/10/2016 at approximately 12:54 revealed another dental visit by Senior Dental Care on 9/26/2015 which states, #9 root tip needs extracting, starting to be symptomatic at times . Needs consent form signed by his/her medical doctor and personal representative before the extraction can be done. The consent form was sent to the Social Services Director. No documentation could be found in the medical record where the consent was signed by the doctor nor the personal representative for Resident #102. Resident #102 was seen again on 12/2/2015, and still no one had addressed the #9 root tip extraction. The next appointment was scheduled for February 2016, and Resident #102 stated that he/she had not been to the dentist this year. No documentation could be found to ensure Resident #102 had been seen for the February 2016 appointment, and no documentation to ensure Resident #102's dental work had been completed. During an interview on 6/10/2016 at approximately 2:19 PM with the Social Services Director stated, I think this resident went to the dentist for the extraction. I am not sure if he/she has upper teeth or not. The social service director could not ensure Resident #102 attended the follow up appointments as ordered nor could he/she ensure the extraction was done. The social services director could not provide documentation or paper work to ensure the matter was taken care of for Resident #102. During a second interview on 6/10/2016 at approximately 2:30 PM with Resident #102 he/she stated, I have not been to the Dentist this year. I was told once they removed one of my teeth, they could do the impression and get me some top teeth but they have not removed the tooth yet. Review on 6/10/2016 at approximately 3:45 PM of the facility policy titled, Referral to Outside Agencies, Under Procedure, #3 states, The Social Service Director makes an appointment for the resident with the appropriate outside agency. Number 7 reads, Service providers' recommendations are to be integrated into the resident's plan of care.",2016-09-01
8018,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,431,E,0,1,W3VQ11,"Based on observation, interview, review of manufacture recommendation and facility policy, the facility failed to follow a procedure to ensure that medications were stored properly in 3 of 8 medication carts reviewed for medication storage. (1) Insulin vial was on the medication cart after the discard date and 1 Insulin Pen and (1) vial unopened were stored on the medication cart. The finding included: On 6/7/16 at 4:40 PM, an observation of the East building, North Unit, (500-600) hall medication cart with Licensed Practical Nurse (LPN) #1 revealed (1) vial of Lantus insulin (Lot #5F452A) with a puncture date of 5/3/16. On 6/7/16 at 4:55 PM, an observation of the East building, North Unit, (400-500) hall medication cart with LPN #2 revealed (1) unopened Lantus Solostar 100/unit (Lot # 6F2765A) injection Pen unopened or dated in a pharmacy package stating, Refrigerate Until Opened. LPN #2 verified the Lantus Solostar on the cart and indicated the Pen should be refrigerated until opened. On 6/7/16 at 5:20 PM, an observation of the West building, Back unit, (300) hall medication cart with LPN #4 Rebecca Nichols revealed (1) vial of Novolog (Lot #FZF0182) unopened or dated in pharmacy packaging stating, Refrigerate Until Opened. LPN #4 verified the Novolog on the cart and indicated the insulin should be refrigerated until opened. Review of the Lantus Solostar 100Units/ML manufacture recommendation under section Storage, states, Store all unopened insulin containers in the refrigerator between 36-46 degrees. Review of the facility policy entitled Storage and Expiration of Medications, Biologicals, Syringes and Needles, revealed under procedure (4) Facility should ensure that medications and biologicals: (4.2) Have not been retained longer than recommended by manufacture or supplier guidelines. Also, procedure (11) states, Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges.",2016-09-01
8019,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2016-06-09,441,F,0,1,W3VQ11,"Based on observation, record review, and interview, the facility failed to perform surveillance of infections to track and/or trend causative organisms to prevent development and transmission of disease. The findings included: On 6/8/16, the Infection Control Surveillance logs since the last survey were requested from the Director of Nursing (DON) when s/he delivered the Infection Control Manual and the Surveillance logs for 2016. During an interview at that time, 5:17 PM, the Director of Nursing stated that s/he only had surveillance logs since January, 2016. The DON stated s/he did not know what the previous DON had done with the 2015 surveillance logs. The DON later provided October, November, and December 2015 surveillance logs and March, April, May, and June, 2015 logs. The DON was unable to locate the February, July, August, or September, 2015 surveillance logs. At 5:34 PM on 6/8/16, review of the Surveillance logs revealed no tracking or trending of organisms in the 13 months of surveillance logs provided. Further review revealed 41 urinary tract infections in 8 months in 2015 with no documentation of whether a culture was done and/or no documentation of the causative organism if the culture was documented. In 2016 there were 41 urinary tract infections listed during the first 5 months of the year with no documentation of cultures and/or results. In addition there were 11 infections listed in 2015 and 14 infections listed in 2016 with the antibiotic listed but not the location of the infection. On 06/10/2016 at 11:15 AM, the Director of Nursing (DON) confirmed there were no organisms listed in the surveillance logs. The DON stated s/he tracked infections as the lab results came in on the fax machine in her/his office but that s/he didn't document them in the surveillance book.",2016-09-01
8108,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2012-06-20,281,D,0,1,S0VN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview, and Manufacturer's information, the facility failed to ensure that professional standards of practice related to proper administration of insulin were followed for one resident. (Resident A) The findings included: On 6/18/12 at approximately 12:25 PM during medication pass, LPN (Licensed Practical Nurse) #1 used a [MEDICATION NAME] to inject 4 units of insulin into the upper right deltoid of Resident A by pressing the [MEDICATION NAME] to the injection site for not more than 3 seconds. The Manufacturer package insert stated that a [MEDICATION NAME] should be held in place at least 6 seconds. LPN #1 verified that she held the [MEDICATION NAME] in place for approximately 3 seconds and stated that she did not know about holding for 6 seconds because that was not taught during in-service. On 6/19/12 at approximately 11:05 AM, RN (Registered Nurse) #1 provided in-service records for insulin pens which showed LPN #1 had attended. RN #1 stated that the 6 second rule for holding a [MEDICATION NAME] to the injection site had been covered during in-services.",2016-07-01
8571,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2013-02-13,157,D,1,0,OH9611,"**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 in a timely manner of a blood sugar above the guidelines ordered for sliding scale insulin for 1 of 1 residents on sliding scale. Resident #2 had a blood sugar of 586, the physician was not notified timely. The findings included: Resident #2 had a fingerstick blood sugar on 1/12/13 at 8:00 AM of 586. The orders for sliding scale covered for blood sugars up to 400. The fingerstick blood sugar orders included notification of the physician if the blood sugar was over 400. At 8:00 AM the resident was given the sliding scale insulin to cover a 400 blood sugar prior to physician notification. The physician was not aware of the elevate blood sugar until 10:00 AM; there was no follow up blood sugar obtained to monitor the elevation. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. On 1/12/13 at 8:00 AM the Blood Glucose Tracking/Sliding Scale Insulin Administration Record indicated the resident had a Blood Sugar of 586. At 9:20 AM a Change of Condition form indicated that the physician was notified of a change in the resident condition. Under the section on the Change of Condition form, Return call/New order from MD .: Date: 1/12/13 Time: 1000 Dr . on for Dr . informed of resident's FSBS of 586 with 20 units of [MEDICATION NAME] and 5 units of [MEDICATION NAME] (from sliding scale insulin). New orders given to give 10 units additional of [MEDICATION NAME] and change SSI units to . Informed Dr . also, of resident complaining . On 1/12/13 Resident #2 received ordered medication at 8 AM, which, included [MEDICATION NAME] 20 units subcutaneous. Review of the Blood Glucose Tracking/Sliding Scale Insulin Administration Record indicated on 1/11/13 at 4 PM a blood sugar of 202 with 2 units given per sliding scale and at 8 PM a blood sugar of 216 with (?) units given. On 1/12/13 at 8 AM Resident #2's FSBS was 586 and 5 units of [MEDICATION NAME]was given per sliding scale instructions of blood sugars up to 400, and the physician was notified with no documentation of the time the physician was notified. Review of the Sliding Scale Insulin order indicated the following: FSBS (finger stick blood sugar) QID (four times a day) [MEDICATION NAME] If FSBS 70 - 150, give 0 units If FSBS 151 - 200, give 1 unit If FSBS 201 - 250, give 2 units If FSBS 251 - 300, give 3 units If FSBS 301 - 350, give 4 units If FSBS 350 - 400, give 5 units Parameters: less than 70 / greater than 400 call the MD (medical doctor). Please Note: If the blood glucose is Above or Below the parameters the physician must be notified immediately and interventions implemented . Document on the reverse, 15 minute follow-ups of blood glucose checks below parameter requiring intervention. There was no evidence that per the Blood Glucose tracking the physician was notified immediately and interventions implemented when the blood glucose was 586 and 15 minute follow-ups of blood glucose checks were not documented. In an interview with the surveyor on 12/11/13 Registered Nurse (RN) #1 stated s/he checked the residents blood sugar. I gave her/him the medications, S/he had coverage for 400 (blood sugar of 400). I gave it to her. I took care of her/his complaints. They are all listed there (Change of Condition Report) in what I talked to the doctor about.",2016-02-01
8572,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2013-02-13,280,G,1,0,OH9611,"**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 revise the care plan related to falls for Resident #4 to include interventions implemented after a fall in November 2012. Resident #4 had a second fall with injury in January 2013, there was no evidence that the interventions put in place following the fall in November 2012 were in place. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes from 4/4/12 through 2/12/13 revealed a Change of Condition form dated 11/8/12 at 10:58 AM that stated, Resident on floor in room, R (right) side of head on closet. Lying on R side. Goose egg bump to R forehead (and) gash (upper) R eye. Resident denies pain. Moderate amount of blood noted from gash. The Interdisciplinary Post Fall Review dated 11/9/12 stated in the section Summary of Interdisciplinary Team: .Place chair alarm to wheelchair . Further review revealed a Nurse's Note dated 1/20/13 at 5:05 (?) .Res(ident) was observed lying on floor on LT (left) side c (with) w/c (wheelchair) behind her. S/he had blood come (sic) from her LT (upper) eye (with) a hematoma 2. cm (centimeters) x 2. cm. Further review revealed a Change of Condition form dated 1/20/13 with no documentation that safety devices were in place prior to the fall. Review of the Interdisciplinary Post Fall Review revealed Shoes was checked in the box for Footwear/Assistive Devices at the Time of Fall. No other safety devices were listed. On 2/12/13 at 10:26 AM, record review revealed a Report from the hospital dated 1/20/13 for a laceration to the scalp. Further review revealed a physician order [REDACTED].#4 to the hospital for evaluation and treatment status [REDACTED].#4 returned to the facility with an order to clean the wound with normal saline and apply a dry bandage and monitor for signs and symptoms of infection. Review of the care plan dated 7/31/12 and updated 1/25/13 revealed a care plan for Risk for Falls. Chair Alarm was not checked. The care plan had been updated to reflect the falls on 11/8/12 and 1/20/13 but had not been revised to reflect the need for a chair alarm. Review of the Resident Care Specialist Assignment Sheet, the Certified Nursing Assistants (CNA) care plan, dated 2/3/13 revealed a chair alarm was not listed for Resident #4. On 2/6/13 at approximately 12:15, the Director of Nursing confirmed that the chair alarm was not listed on the nursing care plan. During an interview on 2/6/13 at approximately 1:30 PM, the Assistant Director of Nursing confirmed that the chair alarm had not been listed on the 2/3/13 CNA care plan.",2016-02-01
8573,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2013-02-13,281,D,1,0,OH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interviews and additional information provided by the facility, the facility failed to meet professional standards related to documentation of administration of medications and treatments and the care plan for a newly admitted resident did not include respiratory status or diabetes for 1 of 3 residents reviewed. Resident #2 did not have documentation of medication administration; the Interim Care Plan failed to address respiratory needs and Diabetes. The findings included: Cross refer to F-309 Quality of Care, Resident #2 did not receive medications as ordered for approximately 18 hours, oxygen settings were not consistent and [MEDICAL CONDITION] settings could not be determined. On 1/12/13 Resident #2's blood sugar was 586 and the physician was not notified timely. Resident #2 admitted with [DIAGNOSES REDACTED]. Review of the Interim Care Plan failed to address the resident's respiratory problems, including the need for Continuous Positive Air Pressure ([MEDICAL CONDITION]), nebulizers, respiratory and cardiac medications. The care plan did not speak to the resident's potential for abnormal blood sugar. The Medication Administration Record [REDACTED]. Medications not given included: [MEDICATION NAME] 0.5 mg (milligrams) Inhalant at 4:00 PM, [MEDICATION NAME] 300 mg at 4:00 PM, [MEDICATION NAME] 50 mg at 4:00 PM. [MEDICATION NAME] Inhalant 2.5/0.5, 3 ml Inhalant at 4:00 PM and 8:00 PM., [MEDICATION NAME] 40 mg at bedtime (8 PM), and [MEDICATION NAME] 0.125 mg at 6 PM. On 2/13/13 the facility provided additional information that nurses who provided care were interviewed by the facility and stated they did administer the medications on 1/11/13 at 1600 nurse . did give the resident meds and a [MEDICATION NAME] nebulizer treatment . 2000 per night nurse . s/he did give the resident a nebulizer treatment alone (sic) with her/his sliding scale insulin.",2016-02-01
8574,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2013-02-13,309,E,1,0,OH9611,"**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 care and services for 1 of 3 residents who required respiratory care. Resident #2 did not receive medications as ordered for approximately 18 hours, oxygen settings were not consistent and [MEDICAL CONDITION] settings could not be determined. On [DATE] Resident #2's blood sugar was 586 and the physician was not notified timely. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the Admission Nursing assessment dated [DATE] at 12:00 PM documented that the resident was alert and oriented to time, place and person with clear speech. The assessment note stated that oxygen was delivered via nasal cannula at 2 liters per minute and the resident's oxygen saturation was 91%. The next documentation was dated on the Nursing Daily Skilled Summary dated [DATE] at 10 PM that stated, Noted some SOB (shortness of breath) [MEDICAL CONDITION] applied. Relief noted . There was no additional documentation until [DATE] at 9:20 AM when a Change of Condition form indicated that the physician was notified of a change in the resident condition. Under the section Return call/New order from MD .: Date: [DATE] Time: 1000 Dr . on for Dr . informed of resident's FSBS of 586 with 20 units of [MEDICATION NAME] and 5 units of [MEDICATION NAME] (from sliding scale insulin). New orders given to give 10 units additional of [MEDICATION NAME] and change SSI units to . Informed Dr . also, of resident complaining 'yelling like going into [MEDICAL CONDITIONS]. Informed of O2 96% on 2L/min NC; .anterior lung lobes clear; posterior right lung diminished with left wheezing; but not complaint of any pain. New order given to send to .emergency room for evaluate and treat if became stressed. Nurse's Note section on Change of Condition: [DATE] at 10:05: Noted resident laying in bed with HOB (head of bed) elevated with neb mask on face with agora breathing, grayish skin tone, mouth opened, and eyes closed. Then noted resident stopped breathing, without chest rising and no pulse. Code called and 911 called. 1005 Noted resident laying in bed with HOB (head of bed) elevated with neb mask on face with aganal breathing, grayish skin tone . Code called and 911 called . 1015 Noted resident's skin tone returned, chest rising on own - CPR stopped . 1016 EMS taking resident to ER . Review of the physician's orders [REDACTED]. The Admission physician's orders [REDACTED]. PM), Dunne Inhalant four times a day (8 AM, 12 PM, 4 PM, 8 PM) and Pumicort Repulse 0.5 mg (milligrams) Inhalant twice a day (8 AM and 4 PM). Review of the Medication Administration Record/Treatment Record (MAR/TAR) revealed on [DATE] the resident did not receive ordered medications at 4:00 PM and/or 8:00 PM as ordered. On [DATE] Resident #2 received ordered medication at midnight and 8 AM, which, included [MEDICATION NAME] 20 units subcutaneous. Review of the Blood Glucose Tracking/Sliding Scale Insulin Administration Record indicated on [DATE] at 4 PM a blood sugar of 202 with 2 units given per sliding scale and at 8 PM a blood sugar of 216 with (?) units given. On [DATE] at 8 AM Resident #2's FSBS was 586 and 5 units of [MEDICATION NAME]was given per sliding scale instructions and the physician was notified with no documentation of the time the physician was notified. Review of the Sliding Scale Insulin order indicated the following: FSBS (finger stick blood sugar) QID (four times a day) [MEDICATION NAME] If FSBS 70 - 150, give 0 units If FSBS 151 - 200, give 1 unit If FSBS 201 - 250, give 2 units If FSBS 251 - 300, give 3 units If FSBS 301 - 350, give 4 units If FSBS 350 - 400, give 5 units Parameters: less than 70 / greater than 400 call the MD (medical doctor). Please Note: If the blood glucose is Above or Below the parameters the physician must be notified immediately and interventions implemented . Document on the reverse, 15 minute follow-ups of blood glucose checks below parameter requiring intervention. There was no evidence that per the Blood Glucose tracking the physician was notified immediately and interventions implemented when the blood glucose was 586 and 15 minute follow-ups of blood glucose checks were not documented. Review of the Physical Therapy Notes of [DATE] revealed, a past medical history of [REDACTED]. The resident was noted to be on 4 O 2/min via NC. (Four liters of Oxygen a minute by nasal cannula). There was no evidence the resident's order had been changed to the higher amount of oxygen. The surveyor interviewed the Physical Therapist on [DATE] at 12:30 PM. The Therapist stated, It was on 4 liters when I walked in the room and 4 AL/AM when I left her. She would have to rest with any movements. Just moving her around she would have to rest and do some purse lipped breathing. The nurses administer the oxygen Review of the Interim Care Plan dated [DATE] revealed no problems listed related to diabetes or that the resident respiratory status was a concern. There was no mention the resident received [MEDICAL CONDITION] at night or what the settings should have been. On [DATE] at approximately 11:00 AM the surveyor interviewed the Director of Nurses (DON). The DON stated, The medications are faxed to pharmacy. They send the medications. The pharmacy delivers throughout the day. They should bring new residents medication. The DON was unable to explain why the resident did not receive her ordered medications/respiratory treatments.",2016-02-01
8575,SUMTER EAST HEALTH & REHABILITATION CENTER,425107,880 CAROLINA AVENUE,SUMTER,SC,29150,2013-02-13,323,G,1,0,OH9611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on observation, record review and interviews, the facility failed to provide safety devices or adequate supervision to prevent fall with injury for Resident #4, 1 of 1 Resident reviewed for falls. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes from 9/18/12 through 2/12/13 revealed two falls with injury. A Change of Condition form dated 11/8/12 at 10:58 AM stated, Resident on floor in room, R (right) side of head on closet. Lying on R side. Goose egg bump to R forehead (and) gash (upper) R eye. Resident denies pain. Moderate amount of blood noted from gash.to send resident to ER (emergency room ) for evaluation . The Interdisciplinary Post Fall Review signed by the team members on 11/9/12 stated in the section Summary of Interdisciplinary Team: Resident c decreased safety awareness. Place chair alarm to wheelchair.monitor resident's whereabouts in room and in facility. 1/20/13 at 5:05 stated, .res(ident) was observed lying on floor on LT (left) side c (with) w/c (wheelchair) behind her. S/he had blood come (sic) from her LT (upper) eye c a hematoma 2. cm (centimeters) x 2. cm . There was no documentation that a chair alarm was in use at the time of the fall. Review of the Change of Condition form revealed no documentation of any safety devices in place at the time of the fall. The Interdisciplinary Post Fall Review signed by the team members on 1/21/13 indicated under the section Footwear/Assistive Devices At Time Of Fall shoes. Stated in the section Summary of Interdisciplinary Team: Encourage resident to ask for assistance as needed. Monitor resident's whereabouts in facility. Incontinent care q (every) 2 hr (hours) and prn (as needed). No other safety devices were listed. Further review of the Nurse's Notes revealed documentation in the Nursing Daily Skilled Summary dated 1/14/13 that indicated Other safety Devices and a Nursing Daily Skilled Summary dated 1/18/13 that stated an alert alarm to w/c (wheelchair). The Director of Nursing was unable to provide any further documentation that the alarm was being used. During an interview with the surveyor on 2/12/13 at approximately 12:15 PM, the Director of Nursing (DON) confirmed there was no documentation that the chair alarm was in use at the time of the fall on 1/20/13. S/he further confirmed that the only documentation that the alarm had been used was on 1/14 and 1/18/13. The DON also verified that the alarm was not listed on the nursing care plan. During an interview at approximately 1:32 PM, the Assistant DON (ADON) confirmed that the Certified Nursing Assistants (CNAs) use the Resident Care Specialists Assignment Sheet (CNA care plan) to know what care to provide to their residents. S/he further confirmed that the chair alarm was not listed on the CNA care plan and that it had been added on the day of the survey. The ADON also stated that s/he had responded to a call when Resident #4 fell on [DATE] but did not recall whether the chair alarm was in use or alarming at the time.",2016-02-01
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
3221,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2020-01-16,609,D,1,1,GVI111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interview and policy review, the facility failed to report an allegation of misappropriation of resident property for Resident #82 to the State Survey Agency within the required timeframe of 24 hours. This failure was found for one (1) of seven (7) facility self-reported incidents reviewed during the survey. Findings include: Review of Resident #82's record indicated the resident's original admitted was [DATE]. The resident's [DIAGNOSES REDACTED]. According to Resident #82's Significant Change Minimum Data Set (MDS) assessment dated [DATE] (most current complete full MDS assessment), Resident #82 was intact in cognition, having scored 13 out of 15 on the Brief Interview for Mental Status (BI[CONDITION]) assessment. Resident #82 required assistance with activities of daily living (ADLs). The Inventory of Personal Effects form completed on [DATE] indicated Resident #82 had a gold ring in his/her possession when s/he was admitted to the facility. Review of the Concern Grievance Form dated [DATE] and completed by the Director of Social Services revealed Resident #82's son reported the concern/grievance on [DATE]. The son indicated Resident #82's wedding ring was missing. The son and family did not know exactly when it went missing. Documentation on the Concern/Grievance Form revealed it most likely fell off Resident #82's finger without him/her realizing it. The Administrator, Director of Nursing and Housekeeping staff were notified of the missing ring on [DATE]. The family was asked for photographs of the ring. A search for the ring was conducted in Resident #82's room and bathroom, in the spa, and in the vacuum cleaner bag (went through its contents). The search did not result in finding the ring. The report indicated the plan also included checking the trap in the vacuum cleaner, checking the resident's robes, laundry washers and dryers, and his/her recliner. The ambulance transport company was contacted to search their vehicles for the ring. The resident had been evacuated from the facility due to a hurricane shortly before the ring was noticed missing. At the son's request, a report was filed with the local sheriff's office. A case number was provided and the Concern Grievance Form indicated the officer would follow up with Resident #82's son regarding the value of the ring and identifying characteristics. The initial Report to the State Survey Agency, dated [DATE] revealed that on [DATE] Resident #82's son reported that his/her mother/father had lost his/her wedding ring. Although the form indicated there was no concern of misappropriation of resident property, staff could not know for certainty that it was lost rather than stolen without having completed the investigation. The allegation was not reported to the State Survey Agency within the 24 hour reporting requirement. A Five (5)-Day Follow-Up Report was dated [DATE]. The date of reportable incident was [DATE]. The Report indicated the resident had experienced weight loss and had a [DIAGNOSES REDACTED]. The resident was documented as being alert and oriented; however, requiring extensive assistance with activities of daily living (ADLs) and transfers and having weakness and debility. Statements from 15 staff members who had worked with the resident during the estimated timeframe the ring went missing were taken. Several staff remembered seeing the ring. A nurse remembered seeing the ring upon return from the facility evacuation on [DATE]. Two (2) staff members (both Certified Nursing Assistants, CNA's) remembered the ring but had not seen it recently. Another CNA indicated that the last time she saw the ring was during the evacuation. The remainder of the witness statements indicated that these staff members had not ever seen the ring or noticed it. The resident was interviewed and stated she did not know when the ring went missing. According to the Five (5)-Day Follow-Up Report interventions in place prior to the reportable incident included the resident being offered to secure valuables such as money, jewelry, credit cards etc. The Report indicated the resident's Physician was notified. The summary report of the investigation indicated there was no suspicion of misappropriation of resident property and the belief was that the ring had fallen off due to the resident's significant weight loss. The investigation was thorough with all relevant persons being interviewed and an extensive search being conducted. On [DATE] at 9:21 AM Resident #82 was sitting in the recliner chair in her room. Her legs were elevated; she was wearing a sleeping gown and socks. She was covered with a blanket. The resident was elderly, emaciated and frail in appearance. A staff member was in the room assisting the resident to drink a thickened beverage of which she took a sip. The resident was not wearing any rings. An attempt was made to interview the resident. The resident was hard of hearing and sleepy; interview with the resident was not successful. On [DATE] at 4:01 AM Resident #82 was sitting in the recliner in her room with her legs elevated. Her eyes were closed. A blanket covered her. The resident was sleeping and an interview could not be conducted. The resident was not wearing any rings. During an interview on [DATE] at 12:14 PM the resident's son stated he filed a grievance related to the resident's missing wedding ring. He stated the ring was still missing and had not been found. He stated he reported the incident to the facility and also talked to the local police. He stated the staff thought his mother had the ring when she came back to the facility after the hurricane. He stated the resident had lost a lot of weight. He stated his mother kept a garbage can by her chair and it may have fallen off and into the garbage can. He stated the ring was not in her chair or in her bed when these areas were searched. He stated the ring was the only possession of his deceased father that his mother had and it was unfortunate it was gone. He stated it was a, very nice large ring. He stated it had a 3/4 inch gold band with lots of diamonds. During an interview on [DATE] at 1:16 PM the Director of Social Services reported one of the CNAs informed her the ring was missing. She stated it was during the time of the evacuation. She stated she talked with the resident and she did not know when it went missing. She stated she called the location of the evacuation and the transportation company and the staff looked everywhere for the ring and could not find it. She stated she called the resident's son and asked what else he would like done and stated he wanted a police report filed. She stated the facility filed the police report and the police then contacted the son. She stated the facility's policy for missing items such as laundry included replacing the items. However, they could not replace a wedding ring. She stated there had been nothing else of value missing over the course of the past year within the facility. During an interview on [DATE] at 4:45 PM the Assistant Administrator/Previous Director of Nursing (DON) and Administrator stated the resident's son reported he thought the resident lost the ring, not that someone took it. They stated they did not adhere to the two (2)/24 hour reporting requirement to the State Survey Agency because they viewed it as a lost item and did not view it as a potential allegation of misappropriation of resident property. Review of the undated Abuse/Grievance /Injury of Unknown Origin policy revealed it was the policy of the facility to protect residents from mistreatment, neglect, abuse, or misappropriation of resident property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of residents' belongings or money without the consent of the resident. Review of the policy indicated allegations needed to be reported to the Charge Nurse on duty, the Director of Nursing (DON), the Administrator and to the State Survey Agency within 24 hours.",2020-09-01
3222,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2020-01-16,638,D,1,1,GVI111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and interview, the facility failed to complete Quarterly Minimum Data Set (MDS) assessments for one (1) of 18 sample residents (Resident #82). Findings include: Review of Resident #82's record indicated the resident's original admitted was 12/22/15. The resident's [DIAGNOSES REDACTED]. According to the resident's Significant Change MDS assessment dated [DATE] (most current complete full MDS assessment), Resident #82 was intact in cognition, having scored 13 out of 15 on the Brief Interview for Mental Status (BI[CONDITION]) assessment. Under the Mood Section, the resident was noted with tiredness/having little energy. She had no behavioral indicators. The resident required assistance with activities of daily living (ADLs). The MDS indicated the resident required extensive assistance from staff for transfers, dressing, and toilet use. Review of the clinical record revealed the last two (2) Quarterly MDS assessments with Assessment Reference Dates (ARD) of 9/12/19 and 12/5/19 were incomplete. The 9/12/19 and 12/5/19 Quarterly MDS sections were blank (no data entered) for the following sections: C - Cognitive Patterns and D - Mood. Section Z - Assessment Administration was not signed off. The 9/28/19 and 12/5/19 Quarterly MDS were incomplete as follows: Section C - The Cognitive Patterns section was blank for the Brief Interview for Mental Status (BIMs), the Staff Interview for Mental Status, and the [MEDICAL CONDITION] Section. There was no determination of the resident's level of cognition. Section D - The Mood section was blank for the Resident Mood Interview, Staff Assessment of Resident Mood, and Total Severity Score. There was no assessment of the resident's mood. The 9/12/19 Quarterly Assessment Section Z, Assessment Administration, revealed all sections of the MDS had been completed by 1/16/2020 (as late as three (3) months after the ARD (annual review date). However, the overall assessment had not been signed off as complete by the Registered Nurse (RN) Coordinator. Although sections C and D were signed off as complete; they were incomplete with a lack of data entered. The 12/5/19 Quarterly Assessment Section Z, Assessment Administration, revealed all sections of the MDS had been completed by 1/15/19. However, the overall assessment had not been signed off as complete by the Registered Nurse (RN) Coordinator. Although sections C and D were signed off as complete; they were incomplete with a lack of data entered. During an interview on 1/16/2020 at 10:05 AM the MDS Coordinator stated the resident interview sections such as sections C and D had not been completed on Resident #82's Quarterly MDS assessments because the MDS was completed after the ARD date. She stated the Resident Assessment Instrument (RAI) manual instructed the use of dashes these sections when it was completed late. The MDS Coordinator stated the most recent complete Quarterly MDS assessment for Resident #82 was dated [DATE]. The MDS Coordinator stated the interviews could be completed a couple days prior to the ARD, but not after the ARD. She stated the facility had a total of seven (7) - 14 days to complete the Quarterly MDS assessment. The MDS Coordinator stated the Assistant Administrator/Previous DON signed the MDS assessments for completion under Section Z because she could not sign them due to being a Licensed Practical Nurse (LPN) instead of Registered Nurse (RN). The MDS Coordinator verified neither the 9/12/19 MDS nor the 12/ 19 MDS had been signed as complete. The MDS Coordinator stated she got behind with the assessments and it snowballed. She stated there was now an RN who was helping her catch up. When asked what the facility policy was regarding completion of MDS assessments, the MDS Coordinator indicated she followed the guidance in the RAI Manual. During an interview on 1/16/2020 at 4:45 PM the Assistant Administrator/Previous Director of Nursing (DON) stated when the MDS assessments were finished, either she or another RN signed them to indicate completion under Section Z. She stated the MDS Coordinator got behind completing the MDS assessments and the facility hired an RN to help them to get caught up. She verified the facility got behind completing and submitting MDS assessments and this had been an ongoing problem. Regarding a lack of documentation of the resident interview sections, she stated dashes had to be entered instead of interview responses if the interview was not conducted by the ARD. The Assistant Administrator/Previous Director of Nursing stated the facility utilized MDS Tracker so they were aware when MDS assessments were due. She stated the facility had a plan to catch up with the assessments and was working on it. Review of the Resident Assessment Instrument (RAI) Manual, Chapter 3, C0100 - Should the Brief Interview for Mental Status Be Conducted? indicated if a resident who was interviewable was not interviewed during the look back period and prior to the ARD, no data should be entered. Dashes should be entered; the staff interview should not be completed if the resident was interviewable.",2020-09-01
3223,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2020-01-16,640,E,1,1,GVI111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure the Minimum Data Set (MDS) assessments were encoded and transmitted to C[CONDITION] (Centers for Medicare and Medicaid Services) according to State and Federal time frames for five (5) of 18 sampled residents (Resident #2, Resident #82, Resident #132, Resident #133, and Resident #182). This deficient practice placed the residents at risk for having incomplete care plans and inadequate care and services resulting in physical and psychosocial decline. Findings include: Record review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected that the facility had not submitted assessment information into the Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System as required for the following residents. 1. Record review of Resident #2's face sheet revealed that Resident #2 was admitted to the facility on [DATE]. Review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected a Last Record Identifiers date of 7/28/19 for Resident #2, meaning that the last assessment received by C[CONDITION] was on that date, and that current data was missing. Resident #2's Admission MDS dated [DATE] and Quarterly MDS dated [DATE] had not been transmitted to C[CONDITION]. 2. Record review of Resident #82's face sheet dated reflected Resident #82 was admitted to the facility on [DATE]. Record review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected a Last Record Identifiers date of [DATE] for Resident #82, meaning that the last assessment received by C[CONDITION] was on that date, and that current data was missing. Resident #82's Quarterly MDS dated [DATE] and Quarterly MDS dated [DATE] had not been transmitted to C[CONDITION]. 3. Record review of Resident #132's face sheet dated reflected the resident was admitted to the facility on [DATE]. Review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected a Last Record Identifiers date of 11/7/19 for Resident #132, meaning that the last assessment received by C[CONDITION] was on that date, and that current data was missing. Resident #132's Admission MDS dated [DATE] and end of Medicare MDS dated [DATE] had not been transmitted to C[CONDITION]. 4. Record review of Resident #133's face sheet dated reflected the resident was admitted to the facility on [DATE]. Review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected a Last Record Identifiers date of 4/25/19 for Resident #133, meaning that the last assessment received by C[CONDITION] was on that date, and that current data was missing. Resident #133's MDS dated [DATE] and MDS dated [DATE] and MDS dated [DATE] MDS had not been transmitted to C[CONDITION]. 5. Record review of Resident #182's face sheet reflected the resident was admitted to the facility on [DATE]. Review of the CASPER report for the facility's MDS 3.0 Missing OBRA Assessment report dated [DATE] reflected a Last Record Identifiers date of 4/25/19 for Resident #182, meaning that the last assessment received by C[CONDITION] was on that date, and that current data was missing. Resident #182's MDS dated [DATE] and Quarterly MDS dated [DATE] had not been transmitted to C[CONDITION]. During an interview on 1/16/2020 at 3:40 PM Interim Administrator/Previous Director of Nursing said that it was her expectation that assessments be transmitted in a timely manner per regulatory standards. She stated that the facility was aware of their failure to meet these requirements, and that the facility had had a Quality Assurance/Process Improvement (QAPI) project in place previously but that they had thought that the problem was resolved. She stated that they had added personnel to assist with the task. She stated that they had recently recognized that the problem had not been resolved and had put another QAPI project in place to address the issue.",2020-09-01
3224,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2020-01-16,657,D,1,1,GVI111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure care plans for two (2) of 18 sampled residents (Resident #2 and Resident #5) were updated when changes in condition occurred. This failure delayed a reduction in antipsychotic medication and possible lack of wound care and bleeding precautions. Findings include: 1. Record review of Resident #2's face sheet dated 1/26/2020 reflected that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 was admitted with medications including Quetiapine (an antipsychotic) and [MEDICATION NAME] (an antidepressant). Record review of the resident's Minimum Data Set ((MDS) dated [DATE] assessed the resident as having minimal cognition impairment as indicated the Brief Interview for Mental Status (BI[CONDITION]) score of 13. The resident was not documented as receiving hospice services or antipsychotic medications. Record review of Resident #2's active Care Plan dated 7/8/19-present reflected that Resident #2 was actively care planned for hospice services and care planned for monitoring of antipsychotic medication side effects. Care plan notes reflected a request for hospice consult on 8/15/19 by the family. Record review of a physician order [REDACTED]. The orders reflected a certification start date of hospice services dated 8/20/2019. The care plan was not updated/revised to reflect the physician orders [REDACTED]. During an interview on 1/15/2020 at 5:45 PM the facility Medical Doctor (MD) stated that he did not know that Resident #2 was no longer on hospice services. He stated that if he had known that he would have attempted a Gradual Dose Reduction (GDR) of Resident #2's antipsychotic if indicated. He stated that when a resident is on hospice care that he treats the resident very differently with respect to diagnostic orders because the resident is being followed by hospice, and if the resident comes off of hospice, then he would order primary care diagnostic procedures and labs to treat the resident appropriately. During an interview on 1/16/2020 at 10:00 AM Registered Nurse (RN) #1 stated that she knew that Resident #2 was no longer on hospice services and had seen that he was still care planned for hospice services. She said that care plan should have been discontinued. She also stated that it was her expectation that the care plans be changed in a reasonable amount of time. When advised that the physician was not aware of the Resident #2's hospice status and that the information had impacted his treatment she said that this was significant. 2. Resident #5 was admitted to the facility on [DATE] following hospitalization for a [MEDICAL CONDITION] Femur. Additional [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] - 11/12/19; she was readmitted to the facility on [DATE]. Review of the Summary of Hospital Stay dated 11/12/19 revealed the resident was hospitalized with a right lower extremity hematoma, was on chronic anticoagulation for stroke prevention with chronic [MEDICAL CONDITION], and status [REDACTED]. Review of the operative report dated 11/10/19 revealed the procedure performed was incision and drainage of right hip hematoma with placement of negative pressure dressing. The hematoma was evacuated manually; the total depth and volume of the wound was six (6) cm (centimeters) in length by six (6) cm in depth by five (5) cm in width. Review of the hospital Order Requisition dated [DATE] revealed the resident's [DIAGNOSES REDACTED]. The resident was discharged with a wound VAC in place and dressing changes every Monday, Wednesday and Friday to the right hip. Review of the Admission Minimum Data Set assessment 11/19/19 revealed the resident was unimpaired in cognition with a Brief Interview for Mental Status (BI[CONDITION]) score of 15. The resident required limited assistance of one (1) staff for most activities of daily living (ADLs). The resident was administered an anticoagulant medication and received this medication all seven (7) days in the assessment period. Review of the physician's orders [REDACTED]. Review of the care plan dated 11/13/19 - 1/16/20 did not address the resident's [DIAGNOSES REDACTED]. During an interview on 1/16/2020 at 4:30 PM the Assistant Administrator/Previous Director of Nursing (DON) stated the resident's [DIAGNOSES REDACTED]. She stated it was her expectation these issues would be care planned and it was important to make sure the important clinical issues were addressed.",2020-09-01
3225,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2017-06-01,246,D,0,1,8Q2911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews, the facility failed to allow Resident #5 the right to receive services in the facility with reasonable accommodations of individual needs and preferences. Resident #5 requested daily showers and only received showers 3 times weekly for 1 of 3 residents reviewed for Choices. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. An interview on 5/31/2017 at approximately 9:00 AM with Resident #5 revealed that he/she does not receive his/her baths/showers according to his/her preferences. Review on 5/31/2017 at approximately 3:45 PM of the Certified Nursing Assistant Care Plan for Resident #5 indicated that Resident #5 received a shower during day shift on Mondays, Wednesdays and Fridays and made no mention of alternate days. Review on 5/31/2017 at approximately 4:47 PM of the shower documentation for Resident #5 revealed that he/she receives showers on Mondays, Wednesdays and Fridays. No documentation could be found in the medical record for Resident #5 to ensure he/she received his/her preference of showers daily. Review on 5/31/2017 at approximately 4:48 PM of a form titled, Centered Around Resident Empowered Services, Resident Service Plan, dated 9/29/2014 reads, Resident requests daily showers. During an interview on 5/31/2017 at approximately 5:00 PM with the Registered Nurse (RN) #1, Minimum Data Set (MDS) assessment, Care Plan Coordinator, stated, there is no documentation in the medical record to ensure Resident #5 receives his/her choice of showers daily as requested by Resident #5 on admission. No assessments were found to indicate that Resident #5 had changed his/her preference of daily showers. RN #5 went on to say that he/she was sure all residents received some type of bath daily even though it is not documented. This surveyor informed RN #1 that Resident #5 was asked during an interview if he;she received his/her bath of choice and he/she stated, No. Resident #5 was asked about alternate days from the scheduled shower days and he/she stated that he/she did not get a bath of any kind on the alternate days from the shower schedule and stated , I just have to stink, I guess.",2020-09-01
3226,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2017-06-01,371,E,0,1,8Q2911,"Based on observation, the facility failed to maintain proper storage and labeling for food items, as well as proper storage of goods 18 inches below the ceiling, in one of one kitchen. The findings included: On 5-30-17 at approximately 11:37 a.m. the dry storage room was reviewed with the Executive Chef. There were 4 boxes stored above the red taped marker indicating the 18-inch threshold from the ceiling. There was a serving table/tray stored on top of filing closet/cabinet. On 5-31-17 at 8:55 a.m. the storage areas were reviewed with the Certified Dietary Manager (CDM). Serving trays remained on top of the filing cabinet, still stored above the 18 inch marker. The walk in freezer contained an opened bag of patties (4 count)on the right shelf; there was a presumed bag of pepperoni that was in saran wrap with no label nor date; there was a Ziploc bag of crab legs, that was not labeled or dated; there was an opened bag of chicken tenders that was not labeled or dated. On the floor of the walk-in freezer an ice cream sandwich was found under the right shelf near the door. Near the rear of the freezer, under the shelf was an oblong-shaped object that could not be identified by the surveyor or CDM, wrapped in plastic on the floor. The CDM was aware of each concern as they were identified. Review of the facility's policy, Food Storage's, on 6-1-17 at ( 10:50 a.m. revealed; 6. All foods stored in walk-in refrigerators and freezers shall be stored a minimum of 6 inches above the floor on shelves, racks, dollies or other surfaces that facilitate thorough cleaning. Further review of the policy indicated 10. Food items are to be clearly labeled. 12. All exposed food should be stored in tightly covered containers and properly labeled and dated.",2020-09-01
3227,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2017-06-01,441,E,0,1,8Q2911,"Based on observations, interviews and review of the facility policy titled, Laundry Services, Soiled Linen Procedures, and, Infection Prevention Assessment of Facility, the facility failed to follow a procedure to ensure proper hand washing during collecting and transporting soiled linen and to follow a procedure during the sorting process to ensure as little agitation as possible. The facility further failed to ensure soiled linen was bagged in resident rooms prior to placing the soiled linen in bins in the soiled utility room. The facility additionally failed to ensure the water temps and the bleach content of the clothes washers were monitored routinely for 1 of 1 laundry processes observed. The findings included: An observation on 6/1/2017 at approximately 9:20 AM revealed the following during soiled linen pick up and transportation: The House Man went into the soiled utility room and then applied gloves, he/she opened a bin with soiled clothes pulled out several that were not in plastic bags and then threw them back in the container and then lifted the entire bag out of the container and placed it into the large covered bin he/she had brought into the soiled utility room. This surveyor asked if it was the facility policy to put soiled linen into bins in the soiled utility room without first bagging the soiled items in the resident room. The House Man stated, it is not, but sometimes it is bagged and sometimes it is not. He/she applied the cover over the soiled cart and pushed it out of the soiled utility room into the hallway. He/she then used the same gloved hands to enter the code on the door access device, after entering the soiled utility room he/she then removed the gloves and came back out into the hallway not washing his/her hands and pushed the soiled linen cart to the laundry room. An observation on 6/1/2017 at approximately 9:20 AM revealed the House Man arriving in the Laundry room with the bin of soiled linen. He/she pushed the bin into the soiled side of the laundry room and then proceeded to leave without washing his/her hands. A large print sign was noted on the side of a clothes washer that read Wash Hands After Dropping Off Any Soiled Linen. The House Man was not observed washing his/her hands after dropping off the soiled linen in the laundry room. During an interview on 6/1/2017 at approximately 9:45 AM with the House Man, he/she stated, I am not sure and can not remember if I went out of the soiled utility room or the laundry room without first washing my hands. An interview on 6/1/2017 at approximately 9:48 AM with the Housekeeping Supervisor confirmed that the House Man had not washed his/her hands during the transporting of the soiled linen. An observation on 6/1/2017 at 10:15 AM during the sorting of soiled linen revealed Laundry Worker #1 holding soiled linen up in front of his/her face and shaking the linen vigorously before putting it into the washers and into bins without goggles or a shield over his/her face. During an interview on 6/1/2017 at approximately 10:25 AM with the Housekeeping Assistant Director confirmed that Laundry Worker #1 was vigorously shaking out the soiled linen in front of his/her face before placing them in the washers and into bins on the soiled side of the laundry room. Review on 6/1/2017 at approximately 10:45 AM of the monthly logs for checking the water temps and the bleach content from the clothes washers revealed inconsistent documentation by a contracted company to ensure the clothes were properly sanitized. The following was reported by the contracted company: On 9/20/2016, 11/18/2016, 12/20/2016, 1/12/2017 and 2/14/17 the hot water temps in machine 1 and machine 2 were not checked and the bleach in parts per million was not checked. On 3/17/2017, 4/27/2017 the hot water temps for washing machine 1 and 2 was not checked. During an interview on 6/1/2017 at approximately 10:49 PM with the Housekeeping Director, he/she confirmed that the monthly logs did not contain the hot water temps for the 2 washers nor the bleach content in parts per million. Review on 6/1/2017 at approximately 11:15 AM of the facility policy titled, Laundry Services, states under Purpose: To assure a clean supply of linens and to protect employees who handle and process the laundry. Under, Policy: number 1. states: Routine Handling of Soiled Linen, [NAME] Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and persons handling the linen. Standard precautions will be used by clinical and laundry staff handling the linen. B. All soiled should be bagged or put into carts at the location where used: it should NOT be sorted or pre-rinsed in patient care areas. Section IV. States,Protecting Personnel Who Sort Laundry. [NAME] In the laundry, and hygiene facilities and protective barriers (e.g., fluid-resistant gowns or aprons, gloves, masks/face protection) shall be made available to personnel who sort laundry. Section V. [NAME] Linens should be washed using the equipment manufacturer's recommendations for appropriate chemical mix and water temperature. Section V11. [NAME] Hot water Washing: 1. The hot water temperature is to be 160 degrees Fahrenheit. 2. Heavily soiled items may be washed at 180 degrees Fahrenheit. Section V111. Contract Laundry Services [NAME] reads Laundry services contracted outside the facility should handle laundry in a manner acceptable to the Infection Prevention Committee after considerations of the above recommendations. Review on 6/1/2017 at approximately 11:30 AM of the facility policy titled, Infection Prevention Assessment of the Facility, states under, Linens (soiled) states, Soiled linen is covered for transport and soiled linen is bagged at bedside. .",2020-09-01
3228,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,574,E,0,1,2VYN11,"Based on record review and interviews, the facility failed to ensure residents were informed of their right to have access to names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations. The facility further failed to ensure residents knew where the above information was located within the facility as revealed by 7 of 7 residents during 1 of 1 resident council meetings. The findings included: Interviews on 10/16/2018 at approximately 11:15 AM, during a resident council meeting, 7 of 7 residents in attendance confirmed they were not aware of their right to have access to a list of names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations and the whereabouts of this information in the facility. Review on 10/16/2018 at approximately 2:40 PM of the Resident Council Minutes for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) made no mention of informing residents or the resident's right to have access to a list of names, addresses and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups and information on filing a complaint and or reporting alleged abuse violations. The Resident Council Minutes did not mention the whereabouts of such information within the facility. During an interview on 10/17/2018 at approximately 3:45 PM with the Admissions Coordinator, he/she stated, the residents are informed of their rights during the move in process, and during the resident council meetings. No documentation could be found to ensure residents were informed of their right to have access to state regulatory and informational agencies and how to file a complaint and or reporting abuse.",2020-09-01
3229,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,577,C,0,1,2VYN11,"Based on record review and interviews, the facility failed to ensure residents were informed of their right to view the most recent survey results of the facility and any plan of correction by the facility, based on those results, and their whereabouts in the facility as revealed by 7 of 7 residents in 1 of 1 resident council meetings. The findings included: Interviews on 10/16/2018 at approximately 11:15 AM, during a resident council meeting, 7 of 7 residents in attendance confirmed they were not aware of their right to view the most recent survey results and the facility's plan of correction based on those results and the whereabouts of the results in the facility. Review on 10/16/2018 at approximately 2:40 PM of the Resident Council Minutes for (MONTH) (YEAR), June, July, (MONTH) and (MONTH) (YEAR) made no mention of the resident's right to view the current survey results and their whereabouts in the facility. During an interview on 10/17/2018 at approximately 3:45 PM with the Admissions Coordinator, he/she stated, the residents are informed of their rights during the move in process, and during the resident council meetings. No documentation could be found to ensure residents were informed of their right to view the survey results or their whereabouts in the facility.",2020-09-01
3230,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,582,D,0,1,2VYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #11 received form CMS- as required to address liability for payment after skilled Medicare Part A services were terminated. Resident #11 remained in the facility with Medicare days remaining for 1 of 3 residents reviewed for Beneficiary Protection Notification Review. The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 1:10 PM of the Beneficiary Protection Notification Review revealed a NOMNC (Notice of Medicare Non-Coverage) CMS that states Medicare Part A services will end on 8/6/2018. Resident #11 has days remaining and is to reside in the facility. Further review on 10/17/2018 at approximately 1:10 PM of the Beneficiary Protection Notification Review indicated that a CMS- form or a denial letter was not issued for Resident #11. During an interview on 10/17/2018 at approximately 2:30 PM with LPN (Licensed Practical Nurse) #1 he/she stated he/she could not locate the CMS- form, but would keep looking for it.",2020-09-01
3231,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,623,D,0,1,2VYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify Resident #27 and the Personal Representative for Resident #27 of the transfer to the hospital in writing and in a language they could understand of the reason for the transfer and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman in a timely manner. The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 12:18 PM of the medical record for Resident #27 revealed no documentation to ensure Resident #27 and the Personal Representative received the reason for the transfer to the hospital in writing and in a language they could understand and send a copy to the Office of the State Long-Term Ombudsman. An interview on 10/17/2018 at approximately 1:38 PM with RN (Registered Nurse) #1 confirmed Resident #27 and his/her personal representative did not receive in writing and in a language they could understand of the reason for transfer to the hospital and confirmed that the Ombudsman did not receive a copy in a timely manner.",2020-09-01
3232,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,625,D,0,1,2VYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Bed Hold Policy, the facility failed to ensure Resident #27 and/or the Personal Representative received a copy of the Bed Hold Policy and the reserve bed payment in a timely manner. The findings included: The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 12:18 PM of the medical record for Resident #27 revealed a transfer to the hospital on [DATE]. Further review on 10/17/2018 at approximately 12:18 PM of the medical record for Resident #27 revealed a Bed Hold Policy given to Resident #27 without the bed hold amount dated 9/6/2018. During an interview on 10/7/2018 at approximately 1:30 PM with RN (Registered Nurse) #1 confirmed the bed hold amount was not on the Bed Hold Policy form and was not conveyed to Resident #27 nor the Responsible Party.",2020-09-01
3233,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,640,B,0,1,2VYN11,"Based on record review and interview, the facility failed to ensure MDS (Minimum Data Set) assessments were transmitted to the state agency in a timely manner for Resident #1, # 2 and #3. The findings included: Review on 10/17/2018 at approximately 8:40 AM of the Resident Assessment Task of the Long Term Care Survey Process revealed Resident #1 and Resident #2 with MDS assessments over 120 days old not transmitted to the state agency. Further review on 10/17/2018 at approximately 8:50 AM of the Missing OBRA Assessment report dated 10/10/2018 revealed an MDS assessment for Resident #3 not transmitted timely to the state agency. During an interview on 10/17/2018 at approximately 2:10 PM with the MDS/Care Plan Coordinator, he/she stated I have been late in transmitting assessments.",2020-09-01
3234,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,657,E,0,1,2VYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure the CNA (Certified Nursing Assistant) most involved with the care for Resident #5, #11, #182, #26, #27, #15, #13 and Resident #332 had input into the care planning process for 8 of 16 residents reviewed for care plan participation. The findings included: The facility admitted Resident #182 with [DIAGNOSES REDACTED]. Review on 10/16/2018 at approximately 2:18 PM of the Plan of Care revealed an Interdisciplinary Care Plan Conference sheet dated (MONTH) 23, (YEAR) and (MONTH) 6, (YEAR) for Resident #182. No documentation could be found to ensure the CNA most involved with the care for Resident #182 had input into the care planning process. The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Review on 10/16/2018 at approximately 2:30 PM of the Plan of Care revealed an Interdisciplinary Care Plan Conference sheet dated (MONTH) 7, (YEAR) and (MONTH) 23, (YEAR) for Resident #26. No documentation could be found to ensure the CNA most involved with the care for Resident #26 had input into the care planning process. The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Review on 10/16/2018 at approximately 5:27 PM of the Plan of Care for Resident #11 revealed an Interdisciplinary Care Plan Conference sheet dated 7/19/2018. No documentation could be found to ensure the CNA most involved with the care for Resident #11 had input into the care planning process. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 12:40 AM of the Plan of Care for Resident #27 revealed an Interdisciplinary Care Plan Conference sheet dated (MONTH) 10, (YEAR) and (MONTH) 16, (YEAR). No documentation could be found to ensure the CNA most involved with the care for Resident #27 had input into the care planning process. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 10:32 AM of the Plan of Care for Resident #13 revealed an Interdisciplinary Care Plan Conference sheet dated 10/4/2018. No documentation could be found to ensure the CNA most involved with the care for Resident #13 had input into the care planning process. The facility admitted Resident #332 with [DIAGNOSES REDACTED]. Review on 10/17/2018 at approximately 12:58 PM of the Plan of Care for Resident #332 revealed an Interdisciplinary Care Plan Conference sheet dated 9/27/2017. No documentation could be found to ensure the CNA most involved with the care for Resident #332 had input into the care planning process. A CNA did not attend the care plan meetings for Resident # 5. This finding was verified on 10/15/18 at approximately 5:38 PM by Licensed Practical Nurse # 1.",2020-09-01
3235,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,730,E,0,1,2VYN11,"Based on record review and interview, the facility failed to ensure each CNA (Certified Nursing Assistant) received the required 12 hours of training annually from hire date based on performance for staffing reviewed. The findings included: Review on 10/17/2018 at approximately 10:30 AM of the staffing revealed the required 12 hours of annual in service training for the CNA's based on performance and the hire date was not completed in a timely manner. The training records of three CNAs did not reflect that they had completed the required 12 hours of continuing education as required based on hire date: (1) CNA with date of hire of 5-7-97 had only one hour from 5-7-17 through 5-6-18; (2) CNA with date of hire of 5-12-10 had 4 hours from 5-12-17 through 5-11-18; (3) CNA with date of hire of 6-28-99 had 4 hours from 6-28-17 through 6-27-18. During an interview on 10/17/2018 at approximately 10:30 AM with the Director of Nursing confirmed that each CNA did not receive the 12 hours of required training based on performance reviews and hire date.",2020-09-01
3236,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,812,F,0,1,2VYN11,"Based on observation, interview and review of the facility policy titled, Perishables Storage, the facility failed to label with a date a food was opened and partially used prior to storing it in the walk up cooler in 1 of 1 walk up coolers observed. The findings included: An observation on 10/15/2018 at approximately 10:00 AM of the foods inside a walk up cooler revealed 2 packages of rolls that has been opened and not dated with opened date. Further observation on 10/15/2018 at approximately 10:00 AM of the foods inside the walk up cooler revealed 1 plastic container used for food storage with cut up fruit and not dated and sweet potato fries partially used with no opened date. An additional observation on 10/15/2018 at approximately 10:05 AM of the same walk up cooler revealed trash and debris on the bottom shelf of the cooler. An interview on 10/15/2018 at approximately 10:02 AM with the Chef confirmed the findings and he/she asked staff to apply an open date to the foods. The Chef went on to say at this time that staff had not cleaned the trash and debris from the bottom shelf of the walk up cooler as they should have. Review on 10/16/2018 at approximately 2:40 PM of the facility policy titled, Perishables Storage, states under Purpose: To ensure compliance with DHEC, maintain nutrient content, maintain aesthetic quality, and ensure food safety of all perishable food items through proper storage and labeling. Number 1 states, All perishables will be labeled with item name and date of preparation and will be used or discarded within 7 days. Date is prep date plus 6 days or less.",2020-09-01
3237,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,814,E,0,1,2VYN11,"Based on observation, interview and review of the facility policy titled, Dumpster Sanitation, the facility failed to ensure paper trash and debris was not accumulated on the ground around the outside of the dumpsters and further failed to ensure bagged trash was put inside the dumpsters and not outside on 1 of 1 observations of the facility's refuse disposal system. The findings included: An observation on 10/15/2018 at approximately 10:30 AM of the outside dumpsters revealed paper trash and debris accumulated on the ground around the outside of the dumpters. Further observation on 10/15/2018 at approximately 10:35 AM of the outside of the dumpster revealed bagged trash next to the dumpster and not placed inside. An interview on 10/15/2018 at approximately 10:35 AM with the CDM (Certified Dietary Manager) confirmed the findings and stated, the trash should be inside the dumpsters and not on the outside. Review on 10/15/2018 at approximately 1:40 PM of the facility policy titled, Dumpster Sanitation, states, The facility will ensure that the dumpster, compactor and surrounding areas remains in sanitary condition. The Guidelines states, 1. Garbage and refuse containers will be kept in good condition with no leaks. 2. Waste will be properly contained in dumpsters or compactors with lids or otherwise covered. 3. Garbage storage areas will be maintained in a sanitary condition to prevent the harborage and feeding of pests.",2020-09-01
3238,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,880,E,0,1,2VYN11,"Based on observations, interview and review of the facility policy titled, Laundry Services, the facility failed to ensure soiled linen was bagged at point of use and then transported to the soiled utility room and placed in bins for laundry service pick up on 3 of 3 Halls. The findings included: An observation on 10/16/2018 at approximately 10:15 AM during the sorting process of soiled linen from the halls revealed a large bin from the soiled utility room with soiled linen unbagged and placed in the bin for pick up by the laundry service workers. During interviews on 10/16/2018 at approximately 10:25 AM with Laundry Worker #1 and the Housekeeping Supervisor confirmed the unbagged soiled linen and stated, The soiled linen should be in bags prior to putting it in the bins in the soiled utility room but sometimes it is not. Review on 10/16/2018 at approximately 10:50 AM of the facility policy titled, Laundry Services, states under Purpose: To ensure a clean supply of linens and to protect employees who handle and process the laundry. Under Policy: 1 B states, All soiled linen should be bagged or put into carts at the location where used; it should NOT be sorted or pre-rinsed in patient care areas. Linen that is saturated with blood or body fluids should be deposited and transported in impervious bags. All staff use standard precautions in handling linen, therefore all linen is handled in the same manner.",2020-09-01
4327,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2016-08-18,242,D,0,1,YTEB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident had the right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for 1 of 25 residents sampled (Resident #66). Findings include: On 8/18/16 at 12:28 PM, the facility policy on Residents Rights was reviewed and indicated (b) Self-determination and participation. The resident has the right to - (1) Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care . On 8/17/16 at 2:03 PM, record review indicated Resident #66 had an admission date of [DATE] with admission [DIAGNOSES REDACTED]. Record review indicated Resident #66 had an admission Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #66 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive dysfunction. Resident #66's MDS indicated she required set up and supervision to complete showering tasks. The MDS indicated Resident #66 was occasionally incontinent of bladder. On 8/16/16 at 1:58 PM during an interview, Resident #66 stated she should get one (shower) a week but indicated since she had been admitted to the facility, she had only had two showers. Resident #66 indicted she had showers daily when residing at home. The resident indicated she was incontinent and viewed showering as a health and hygiene issue. Continued record review on 8/17/16 at 2:03 PM, indicated Resident #66 had a C.[NAME]R.E.S assessment dated [DATE] which indicated the resident was oriented to person, place, and time. (MONTH) have occasional forgetfulness. The assessment indicated Resident #66 preferred showers daily for 7 days weekly. On 8/18/16 at 9:01 AM, record review indicated Resident #66 was scheduled to be offered showers on Mondays, Wednesdays, and Fridays. Record review indicated the following documentation about Resident #66's showers: * Resident #66 had a shower on Wednesday, 8/3/16. * Resident #66 was offered and refused a shower on Monday, 8/8/16. * Resident #66 had a shower on Wednesday, 8/10/16. * Resident was offered and refused a shower on Monday, 8/15/16. *Resident #66 received a shower on Wednesday, 8/17/16. On 8/18/16 at 9:19 AM during an interview, Resident #66 indicated she did not take the shower offered to her on 8/8/16, because she had a dentist appointment in the afternoon. Resident #66 indicated it stated on her calendar that she requested to have her shower as late as possible due to her appointment. On 8/18/16 at 11:35 AM, the Administrator indicated Resident #66 should have been accommodated with showers and offered them daily. The Administrator stated staff should have been considerate of Resident #66's schedule and other appointments.",2020-04-01
4328,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2016-08-18,371,F,0,1,YTEB11,"Based on observation, record review, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in the main dining room kitchen which had the potential to impact all residents. The facility reported a census of 37. Findings include: On 8/15/16 at 11:22 AM, a main kitchen walk-through was completed. The floors in the entrance of the main kitchen, in the main kitchen, in the walk-in refrigerators, freezers, and food storage areas had food particle debris, splatters of brown residue, and collection of dust in corners throughout, predominantly under and surrounding various pieces of equipment, food preparation tables, under and around carts containing and storing dishes and utensil items. The floors had splatters of brown residue and were marred throughout the main kitchen and throughout the walk-ins. Uncovered bins of utensils being stored in the kitchen on carts were observed to have dust and debris in the bottom and corners of the bins. On 8/17/16 between 8:52 AM and 10:55 AM, the main kitchen was observed again. The top lid of the ice machine did not shut tightly leaving a one inch gap into the ice storage unit. There was a small stainless steel table adjacent to the ice cream freezer which had a rack of clean glasses on the bottom shelf near the floor. The floor had food particles, collected dust and brown splatter residue under the cart and in the corners around the surrounding wall. The back of the oven, which faced the food preparation tables for cutting salads and preparing soups, was covered in thick dust residue around the fan, the motor, the ventilation pipe and electrical cords. A half-wall separated the back of the oven from the food preparation area which left the fan which was located on the top half to blow dust and debris into the food preparation area. All the ceiling vents, which included the ones above the food preparation areas, the cooking and frying line, the serving line, and the dish storage areas were uncleaned and had dust residue. The baseboards throughout the main kitchen were marred and discolored. The warming oven, which was located between the main oven and the stove top oven, had grease and old food debris dripped down the side. On 8/17/16 at 10:22 AM during an interview, Dietary Employee (DE) #1 indicated the cleaning schedule consisted of each kitchen aide cleaning their own area after each shift. DE #1 indicated a thorough weekly clean was done on Sundays since the main kitchen only served brunch on Sundays. DE #1 indicated the Sunday cleanings were done by kitchen staff and not the facility housekeeping staff or maintenance staff. DE #1 indicated the staff follow a list of items to do on Sundays but indicated many of the cooks had been here so long, they don't need to go by it. DE #1 indicated the facility has added a kitchen staff to solely work on special projects such as organizing and cleaning as necessary. DE #1 indicated he usually gives her a list of what needs to be done. On 8/18/16 at 10:42 AM during record review, the record show the facility had contracted the main kitchen to be deep cleaned on 6/3/15 and had signed a contract for the kitchen to be deep cleaned on 8/1/16 but was scheduled to be completed prior to 9/1/16. Record review indicated the Sunday Deep Clean List had been initialed as done on 6/5/16, 6/12/15, 6/19/16, 7/3/16, 7/17/16, 7/24/16, 7/31/16, 8/7/16, and 8/14/16. The Sunday Deep Clean List did not list pulling out carts and cleaning the floor underneath or surrounding them in the main kitchen area, food preparation areas, or food storage walk-in areas. On 8/18/16 at 11:55 AM during an interview, the Executive Director (ED) indicated she noticed the Sunday Deep Clean Schedule did not list the walk-ins under and around the tray carts and because the Dietary Manager was a newer employee these items may have been overlooked. The Executive Director indicated the solution would be an easy fix. The ED indicated the Register Dietician fills a kitchen sanitation form during their bi-monthly kitchen walk-through.",2020-04-01
5352,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,756,D,0,1,2VYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the pharmacist failed to assure that 1 of 4 residents were free of unnecessary medications. (Cross refer F758) The findings include: Record review on Resident # 7 on 10/16/18 failed to show that the physician had been notified that a PRN (as needed) psychoactive drug order for [MEDICATION NAME] 5 mg had been in existence since 9/27/17. This finding was verified on 10/17/18 at approximately 09:29 AM by Licensed Practical Nurse #1.",2019-01-01
5353,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2018-10-18,757,D,0,1,2VYN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the Facility failed to assure that 1 of 4 residents were free of unnecessary medications. (Cross refer F756) The findings include: Record review on Resident # 7 on 10/16/18 showed a physicians order for [MEDICATION NAME] 5mg (a [MEDICAL CONDITION] medication) #I 61 as needed at bedtime dated 9/27/17. Record review from 9/27/17 through 10/16/18 showed that [MEDICATION NAME] 5 mg had been administed at bedtime multiple times during this approximately 12 and 1/2 month period Further chart review showed no evidence of being assessed by the MD and recommendation made by RPh during monthly visits. Non-pharmacological interventions frequently noted as Companion Visit, Environmental Temperature, Guided Imagery, Relaxation Techniques, Redirect, Repositioning or None even though the medication had been administered. This finding was verified on 10/17/18 at approximately 09:29 AM by Licensed Practical Nurse #1.",2019-01-01
5434,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2015-11-12,456,D,0,1,BQNJ11,"Based on observations, interviews and review of facility policy titled, Environmental Services, the facility failed to ensure the lint was removed for 2 of 3 clothes dryers. Two of 3 clothes dryers had an excessive large amount of lint build up on the sides, and above the lint baskets. The findings included: An observation on 11/12/2015 at approximately 8:45 AM during initial tour of the laundry room revealed 2 of 3 clothes dryers with an excessive large amount of lint build up. During the observation on 11/12/2015 at approximately 8:45 AM it was brought to the attention of the Director of Environmental Services and he/she verified the large build up of lint and stated, well maybe we should do a better job vacuuming out the dryers. During an interview on 11/12/2015 at approximately 8:48 AM with Laundry Worker #1, this surveyor asked if only one load of 2 bed sheets was all that had been in the dryers this am and he/she stated, yes. The Laundry Worker # then stated, no, three loads have been dried in each dryer. This surveyor brought to the Director of Environmental Services attention that if the laundry workers start washing clothes upon arrival to work at 7:00 AM and the observation was made at 8:45 AM it was unlikely that 3 loads had been dried in 1 dryer at that time. Review of the facility policy on 11/12/2015 at approximately 12:50 PM titled, Environmental Services, Laundry Equipment, Under, Responsibility: states, It is the responsibility of the Director and Assistant Director, Scheduler, Lead(s) and laundry personnel to ensure that laundry equipment is clean and in proper running condition. Under Guidelines: #4. states, Dryer screens and lint areas are vacuumed and documented a minimum of 3 times per day. #5. states, Maintenance will clean the top portion of the dryer around the burner area 1 time a week per the maintenance work order system. #6. states, The Assistant Director and Supervisor will be responsible for inspecting the dryers and documentation on a daily basis (Monday - Friday). The Director will inspect the dryers and documentation 1 time per week.",2018-12-01
5435,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2015-11-12,514,D,0,1,BQNJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility policy titled, Diet/Fluid Restrictions, the facility failed to have a system in place to accurately ensure Resident #15 received the correct amount of fluids daily as ordered by the physician. Resident #15 was to receive a total of 1000 milliliters of fluid daily for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The facility further failed to ensure Resident #70's code status was accurately documented. The findings included: The facility admitted Resident #15 with [DIAGNOSES REDACTED]. Review of the medical record on 11/12/2015 at approximately 1:00 PM for Resident #15 revealed a physician's order dated 3/20/2014 and states, Restrict fluid to 1000 milliliters daily Further review of the medical record for Resident #15 on 11/12/2015 at approximately 1:20 PM revealed a Treatment Administration Record (TAR) dated (MONTH) (YEAR). On 10/5/2015 resident #15 received a total of 2060 milliliters (mls) of fluid. On 10/6/2015 he/she received 280 mls and 240 mls on 10/7/2015. He/she received 220 mls on 10/13/2015 and 195 mls on 10/20/2015. He/she received 60 mls on 10/25/2015 and 160 mls on 10/29/2015 and on 10/30/2015 he/she received 2100 mls. An interview with the Certified Dietary Manager (CDM) on 11/12/2015 at approximately 2:04 PM revealed the he/she receives a breakdown of the fluid restriction from the nurses and we put our amount on the trays for each meal and then the rest is documented by nursing each shift. He/she went on to say that resident #15 is not compliant with the fluid restriction. Review of the Comprehensive Plan of Care on 11/12/2015 at approximately 2:30 PM revealed a problem which states, At risk for weight fluctuations related to [MEDICAL TREATMENT] and fluid restriction and noncompliant with fluid restriction. A problem was also documented as, At risk for dehydration related to fluid restriction. The interventions read, Encourage resident to consume all daily allowance of fluids. Follow fluid restriction as ordered. During an interview on 11/12/2015 at approximately 2:31 PM with the Director of Nurses (DON), he/she stated, the staff will chart all that the resident takes in during the 24 hour period including meals. An interview on 11/12/2015 at approximately 3:07 PM with Licensed Practical Nurse (LPN) #1 verified that he/she adds the meal intake and the fluids given with med pass. During an interview on 11/12/2015 at approximately 3:14 PM with Certified Nursing Assistant (CNA) #1 stated, We calculate the amounts he/she drinks from the size of the glasses and it is documented in the Kiosk. If the resident wants anything extra to drink we have to ask the nurses. This surveyor asked how did he/she know if the resident was going over the amount and he/she stated, it is unlikely. Review on 11/12/2015 at approximately 4:00 PM of the facility policy titled, Diet/Fluid Restrictions. revealed, It is the policy of this facility to provide guidelines for obtaining adequate nutrition and hydration to [MEDICAL TREATMENT] residents. Number 1. states, [MEDICAL TREATMENT] diets/fluid restrictions will be provided as prescribed by a physician order. 2. No change of diet/fluid restriction shall be done without confirmation from specialist (renal physician) and nutritionist at the [MEDICAL TREATMENT] unit. 3. The attending physician will be notified. Under Procedure, #3. states, Notify [MEDICAL TREATMENT] unit physician with resident noncompliance of diet/fluid restriction if indicated. Number 4 states, No change of the diet/fluid restriction shall be done without an order from [MEDICAL TREATMENT] unit physician The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Record review on 11/12/15 revealed the resident had been deemed incapable of making healthcare decisions and the responsible party had requested a Do Not Resuscitate(DNR). Review of the current physician's orders revealed the resident had an order for [REDACTED].>During an interview with Licensed Practical Nurse #1 on 11/12/15 at 4:10 PM, he/she confirmed the discrepancy. During an interview with the Minimum Data Set Coordinator on 11/12/15 at 3:53 PM, he/she stated on admission if the resident is not cognitively intact, the resident's family member is asked or the Power of Attorney is asked if the resident had a Living Will. If the the family requests a DNR, two physician's sign a form the resident is not competent to make healthcare decisions. On 11/12/15, after speaking with facility staff, the facility presented the surveyor with another set of physician orders for Resident #70 which indicated the resident was a Do Not Resuscitate.",2018-12-01
6983,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2014-08-07,309,D,0,1,QTN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to coordinate services related to Hospice Care for 1 of 1 residents reviewed for Hospice Care and Services. There was no updated Plan of Care and no documentation of Nurse Aide visits in Resident #58's medical record. The findings included: The facility admitted Resident #58 with [DIAGNOSES REDACTED]. Review of Resident #58's medical record on 8/6/2014 at approximately 5:08 PM revealed, an admission for Hospice care and services. No updated care plan could be found in Resident #58's medical record or in the facility. Further review of Resident #58's medical record revealed no documentation for the Nurse Aide visits which were ordered for 3 times weekly. An interview on 8/7/2014 at approximately 10:29 AM with the Registered Nurse/Minimum Data Set/Care Plan Coordinator he/she confirmed that no Nurse Aide visits from Hospice were in Resident #58's medical record or in the facility. He/she stated , the plan of care should have been updated every 2 weeks and should be in the medical record. The last one in the medical record was dated May 2, 2014 and no others could be found. The Hospice Company was notified by the facility and the updated Plan of Care was faxed to the facility on [DATE] at 10:35 AM and included updates from 5/13/2014 through 7/22/2014. The Nurse Aide visits were faxed to the facility on [DATE] at 3 :07 PM and included visits from 3/24/2014 through 7/25/2014.",2017-07-01
6984,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2014-08-07,371,F,0,1,QTN111,"Based on observations, interviews, and 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 a well as the serving kitchen in the Health Care Center were inspected and found to have numerous areas of unsanitary conditions. The deficient practice had the potential to affect all residents residing at the Health Care Center. The findings included: During the initial tour of the main kitchen on 8/5/14 at 9:05 AM the following were found with either no open date and/or label: (1) open box of cornstarch; (7) 17 ounce bottles of Designer Dessert Sauce; (1) 12.9 ounce Balsamic Glaze; (1) 4 lb (pound) jar mint flavored apple jelly; (1) 4 lb 13.6 ounce Roland Thai Style Spicy Chili Sweet Sauce. In the reach in freezer/refrigerator the following was observed with no date open and/or label: (1) 40 ounce bag of onion rings; (1) bag of frozen round items; (4) bags of bread; (1) open bag of tortillas. In the walk-in cooler the following was observed with no open date and/or label: (1) 2 lb container of liquid eggs; (4) 16 ounce food bases; (1) bag of biscuits and (1) bag of rolls; Three male kitchen staff members were observed with beards with no beard restraints. The Executive Chef was observed with no hair restraint and was observed with a mustache. One male was observed in the kitchen area with street clothes with no hair restraint. Observation of the satellite kitchen at 4:00 PM on 8/6/14 revealed (4) trays had been placed by the handwashing sink in preparation for the next meal. On 8/7/14 at 9:48 AM observation of the main kitchen with the Executive Chef revealed the following: (1) bag of pasta with no open date; (1) bag of basic cornbread stuffing mix with no open date; (3) Dessert Sauces with no open date; (1) bag of rice wrapped in cellophane with no date. In the walk-in cooler (2) blocks of cheese were observed with no open date. A mop was observed in standing water in the storage area. Two measuring containers were observed stacked with droplets of clear liquid. Observation of the dish machine revealed a rack of items were exiting the machine prior to the rinse cycle reaching 180 degrees. This was pointed out to the Sous Chef and the service contractor was called in at that time. Observation of the Turbo refrigerator revealed (2) Dessert Sauces with no open date and (1) 15 ounce whipping cream with no open date. Observation of the walk-in cooler revealed (1) gallon french dressing with no open date. (1) container of cooked chicken breasts was observed in standing water. The Executive Chef discarded the chicken when it was pointed out on 8/7/14 at 10:57 AM. Two male kitchen staff members with beards were observed without beard restraints. Three males were observed to walk through the kitchen area with no hair restraints. A radio was observed on a shelf above where salads had been prepared. Pots and pans were observed stored above the 3 compartment sink. On 8/7/14 at 3:22 PM the Executive Chef confirmed the radio was on the shelf and the pots and pans were observed over the 3 compartment sink. Review of the Nutritional Consultants findings revealed on 3/13/14-labels must include date and contents; 5/8/14-dating but not labeling some items with the contents; 7/3/14-all items should be dated when opened; and 7/17/14-labeling and dating.An inservice was given to staff on 5/25/14 and 8/5/14 related to labeling and dating food items During an interview with the Certified Dietary Manager Consultant on 8/7/14 at approximately 4:00 PM, he/she stated anyone entering the kitchen should have a hairnet and there was a sign on the door stating such. He/she also stated men with beards should have a beard restraint, mops should not be left in standing water, no items should be stacked wet, and thawing items should not be thawed in standing water. He/she continued stating that he/she was unaware of any information that pots and pans could not be stored above the 3 compartment sink. Review of the facility provided Dress Code Policy states kitchen personnel are required to wear appropriate head coverage.",2017-07-01
6985,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2014-08-07,431,F,0,1,QTN111,"Based on observation, interview, and review of facility policy, the facility failed to follow a procedure to ensure that expired medications were removed from medication storage in 2 of 2 medication carts. The finding included: On 8/6/14 at 2:20 PM, an observation of the Sweet Bay medication cart revealed 2 unit-dosed packaged medication cards, each with 4 individual doses of 15 mg (1 1/2 tablet ' s) of warfarin sodium 10 mg (Lot # MN 6166) with the expiration date of 8/1/14. Following the observation, LPN #1 and the Director of Nursing (DON) verified the medication was expired and stated Pharmacy checked this cart on 7/10/14 and should have removed the packages On 8/6/14 at 3:03 PM, an observation of the Palmetto medication cart with the DON revealed 1 unit-dosed packaged medication card with 3 individual packaged doses of Senna laxative 8.6 mg (Lot #3B ) with an expiration date of 8/1/14. Following the observation the DON verified the finding and stated that s/he checked the cart on 7/24/14. On 8/7/14 at 10:30 AM, a review of the facility policy titled 11-7 Licensed Nurses Duties - Additional Responsibilities. revealed under 8.) Stock the treatment carts. Any expired items should be discarded. Re-order residents medication if necessary. During an interview on 8/7/14 at 10:45 AM, the DON was asked if there was a record or log monitoring if the medication carts were being checked for expired medication. S/he stated, No.",2017-07-01
7930,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2013-02-21,157,E,0,1,BTGG11,"**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 2 of 2 residents' physician was notified of blood sugars outside set parameters.(Resident # 5 & # 7) The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Review of the blood sugars, Medication Administration Records, and nurse's notes for the months of December 2012, January 2013, and February 2013 revealed the physician was not notified of blood sugars outside of the ordered parameters on the following dates: 12/13/2012 - 6:30 AM - 385 12/14/2012 - 9:00 PM - 102 12/15/2012 - 6:30 AM -349 12/16/2012 - 6:30 AM - 308 12/16/2012 - 11:30 AM - 383 12/16/2012 - 9:00 PM - 342 12/17/2012 - 9:00 PM - 195 12/18/2012 - 4:30 PM - 418 12/18/2012 - 9:00 PM - 418 12/19/2012 - 4:30 PM - 147 12/19/2012 - 9:00 PM - 408 12/21/2012 - 9:00 PM - 359 12/22/2012 - 11:30 AM - 319 12/22/2012 - 4:30 PM - 346 12/23/2012 - 4:30 PM - 121 12/24/2012 - 11:30 AM - 146 12/24/2012 - 9:00 PM - 341 12/27/2012 - 6:30 AM - 72 12/27/2012 - 4:30 PM - 87 12/29/2012 - 11:30 AM - 531 12/29/2012 - 4:30 PM - 404 12/30/2012 - 11:30 AM - 532 12/30/2012 - 4:30 PM - 438 12/31/2012 - 4:30 PM - 170 12/31/2012 - 9:00 PM - 359 1/2/2013 - 4:30 PM - 441 1/4/2013 - 4:30 PM - 364 1/4/2013 - 9:00 PM - 311 1/5/2013 - 11:30 AM - 345 1/6/2013 - 9:00 PM - 198 1/8/2013 - 4:30 PM - 137 1/9/2013 - 4:30 PM - 191 1/9/2013 - 9:00 PM - 356 1/11/2013 - 6:30 AM - 80 1/11/2013 - 9:00 PM - 87 1/12/2013 - 11:30 AM - 352 1/12/2013 - 4:30 PM - 357 1/13/2013 - 11:30 AM - 347 1/13/2013 - 4:30 PM - 366 1/14/2013 - 11:30 AM - 347 1/14/2013 - 4:30 PM - 439 1/14/2013 - 9:00 PM - 459 1/15/2013 - 6:30 AM - 154 1/15/2013 - 11:30 AM - 158 1/16/2013 - 9:00 PM - 128 1/18/2013 - 9:00 PM - 188 1/19/2013 - 6:30 AM - 342 1/19/2013 - 11:30 AM - 367 1/19/2013 - 4:30 PM - 301 1/20/2013 - 11:30 AM - 379 1/20/2013 - 9:00 PM - 132 1/21/2013 - 9:00 PM - 373 1/23/2013 - 4:30 PM - 173 1/24/2013 - 6:30 AM - 307 1/24/2013 - 4:30 PM - 94 1/25/2013 - 6:30 AM - 156 1/25/2013 - 9:00 PM - 194 1/26/2013 - 11:30 AM - 337 1/27/2013 - 11:30 AM - 595 1/28/2013 - 4:30 PM - 87 1/28/2013 - 9:00 PM - 158 1/30/2013 - 11:30 AM - 121 2/1/2013 - 9:00 PM - 167 2/2/2013 - 6:30 AM - 337 2/2/2013 - 11:30 AM - 430 2/2/2013 - 4:30 PM - 354 2/3/2013 - 11:30 AM - 556 2/3/2013 - 4:30 PM - 464 2/4/2013 - 6:30 AM - 128 2/3/2013 - 9:00 PM - 96 2/6/2013 - 11:30 AM - 154 2/6/2013 - 4:30 PM - 178 2/6/2013 - 9:00 PM - 311 2/8/2013 - 4:30 PM - 108 2/8/2013 - 9:00 PM - 332 2/9/2013 - 11:30 AM - 421 2/9/2013 - 4:30 AM - 334 2/10/2013 - 6:30 AM - 119 2/10/2013 - 11:30 AM - 347 2/10/2013 - 4:30 PM - 148 2/11/2013 - 4:30 PM - 99 2/11/2013 - 9:00 PM 305 2/12/2013 - 6:30 AM - 60 2/13/2013 - 9:00 PM -110 2/13/2013 - 9:00 PM - 360 2/14/2013 - 6:30 AM - 160 2/15/2013 - 4:30 PM - 314 2/15/2013 - 9:00 PM - 346 2/16/2013 - 11:30 AM - 324 2/16/2013 - 4:30 PM - 318 2/17/2013 - 4:30 PM - 131 2/18/2013 - 11:30 AM - 172 2/18/2013 - 4:30 PM - 123 2/18/2013 - 9:00 PM - 494 2/19/2013 - 9:00 PM - 179 On 2/21/13, during an interview with the Director of Nursing(DON), when asked did she confirm the omission of notifying the physician for blood sugars outside of the ordered parameters, she stated that she had not reviewed all of the months in question. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of Resident #7's medical record on 2/21/13 at approximately 11:50 PM revealed a physician's orders [REDACTED]. (greater than) 400 call MD (Medical Doctor). The Accuchecks were ordered to be done four times a day. The surveyor reviewed Resident #7's medical record for Accucheck documentation which revealed four dates where the resident's blood sugar was lower than 120 and the MD was not notified. 1/06/13 at 4:30 PM the results were 96 1/10/13 at 9:00 PM the results were 89 1/12/13 at 4:30 PM the results were 63 2/08/13 at 6:30 AM the results were 99 Review of the residents Nursing notes did not reveal any documentation the MD had been notified of the low blood sugars. On 2/21/13 at 12:10 PM, Licensed Practical Nurse #2 verified the above findings and confirmed that the MD had not been notified regarding the low blood sugars",2016-10-01
7931,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2013-02-21,309,E,0,1,BTGG11,"**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 follow a physician's order for as needed blood pressure medication for 1 of 1 resident reviewed. Resident #5 had a physician's order for [MEDICATION NAME] to be given when blood pressures were out of the ordered parameters. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review on 2/20/2013 revealed a physician's order which originated on 11/9/2012 to administer [MEDICATION NAME] .1 mg(milligrams) for Systolic Blood Pressure(SBP) greater than 170 or Diastolic Blood Pressure(DBP) over 100 every 6 hours as needed. Further record review of the Medication Administration Records for December 2012, January 2013, and February 2013 revealed the resident received [MEDICATION NAME] twice. Review of the blood pressure records for the months of December 2012, January 2013, and February 2013 revealed the following blood pressures: 12/4/2012 - 9:00 AM - 171/78 12/4/2012 - 2:01 PM - 171/78 12/13/2012 - 11:21 AM - 185/87 12/17/2012 - 8:59 AM - 171/74 12/21/2012 - 6:46 PM - 173/78 12/26/2012 - 9:00 AM - 177/90 12/26/2012 - 10:12 AM - 177/90 12/26/2012 - 11:11 PM - 188/82 12/29/2012 - 9:00 AM - 180/99 12/30/2012 - 9:00 AM - 171/91 12/30/2012 - 11:05 AM - 171/91 1/4/2013 - 6:56 PM - 170/89 1/5/2013 - 4:31 PM - 174/87 1/6/2013 - 9:00 AM - 194/93 1/7/2013 - 11:01 PM - 180/73 1/9/2013 - 8:46 AM - 182/86 1/9/2013 - 9:00 AM - 182/86 1/11/2013 - 4:10 PM - 171/86 1/18/2013 - 9:00 AM - 174/85 1/8/2013 - 10:57 AM - 174/85 1/21/2013 - 6:05 PM - 171/90 1/22/2013 - 6:58 AM - 183/90 1/30/2013 - 9:00 AM - 170/83 1/30/2013 - 10:06 AM - 170/83 1/31/2013 - 10:28 AM - 178/88 2/2/2013 - 9:00 AM - 174/83 2/4/2013 - 11:01 AM - 176/84 2/5/2013 - 11:16 AM - 176/84 2/7/2013 - 9:00 AM - 179/80 2/7/2013 - 3:09 PM - 179/80 2/9/2013 - 9:00 AM - 170/87 2/12/2013 - 9:00 AM - 178/84 2/13/2013 - 9:00 AM - 173/85 2/13/2013 - 10:43 AM - 173/85 2/18/2013 7:01 AM - 171/96 2/18/2013 - 7:37 PM - 172/83 2/19/2013 - 2:41 AM - 177/77 During an interview with the Director of Nursing(DON) on 2/21/2013, he/she confirmed that there was no documentation supporting that [MEDICATION NAME] had been given per the doctor's orders. On 2/21/2013 at 12:25 PM an interview was conducted with the attending physician in which he stated that he/she would like to keep the order in place in case of a spike in the resident's blood pressure and continued by stating he did not know if he wanted it to be given as frequently as ordered due to the resident's multiple falls. He continued by stating that it was a concern that he was not notified of the elevated blood pressures and orders were not followed.",2016-10-01
7932,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2013-02-21,323,E,0,1,BTGG11,"**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 assistive/safety devices were used appropriately for 3 of 3 residents reviewed for quality of care. Resident #1's chair alarm was not on during multiple observations, Resident #3's bed pad alarm not functioning, and Resident #5's bed pad alarm was observed with a missing part. Multiple observations of hand sanitizer on medication carts/isolation cart. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. On 2/20/2013 at 12:40 PM, Licensed Practical Nurse (LPN)#2 was asked to demonstrate that the tab alarm and bed alarm functioned. LPN#2 stated that the bed alarm was missing a part and that Resident #5 would remove alarms and hide them. LPN #2 confirmed that the bed alarm would not work without the missing part. On the following dates and times, 15 oz(ounces) McKesson Instant Hand Sanitizer with 70% Ethanol pump bottle half full was noted left unattended on the medication carts: 2/19/13 at 1:55 PM, 4:05 PM, and 4:30 PM; 2/20/13 at 6:30 AM and 10:30 AM. On 2/19/2013 at 3:30 PM, a bottle was noticed on the isolation cart outside Room 3. On 2/20/13, the above was shared with the staff. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 2/19/13 at approximately 1:55 PM revealed a February 2013 Physician order [REDACTED].#3 was to have a chair alarm which was to be checked for function/placement every shift. The Resident was observed on 2/20/13 at 9:40 AM and at 1 PM sitting in his/her wheelchair with no chair alarm in place. Certified Nursing Assistant #1 (who was responsible for the residents care) verified the alarm was not on as ordered. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review on 2/19/13 at 2:20 PM revealed a Fall Risk Assessment done on 1/27/13 noting the resident to be a high fall risk. Review of the Nurses notes on 2/20/13 at approximately 10:30 AM revealed the resident had recent falls, one of which resulted in a fractured finger. The notes read as follows: 12/10/12 Resident fell on to the floor this morning during an assisted transfer . 01/09/13 Resident was observed sitting on floor in dining room by Certified Nursing Assistant (CNA) 02/18/13 Resident was found on floor during rounds he was laying on floor by bathroom door. Resident # 1's Comprehensive Care Plan (last updated 2/18/13) stated: Resident is at risk for falls r/t (related to) unsteady gait/balance, cognition The interventions to the identified concern of falls did not include the use of alarms despite a physicians order for a bed alarm and to check placement and function every shift. Observation on 2/20/13 at 6 PM revealed a pad alarm on the resident's bed. However, the alarm was not functioning as verified by Licensed Practical Nurse #1.",2016-10-01
7933,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2013-02-21,367,D,0,1,BTGG11,"**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 ensure that 1 of 3 sampled residents on therapeutic diets received a diet as ordered by the physician. Resident #3 did not receive a mechanical soft, chopped solids with ground meat diet as ordered. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. A lunch meal observation on 2/20/13 at approximately 12:35 PM revealed the Resident received meat loaf which was not chopped, mashed potatoes and whole asparagus. Observation of Resident #3's dinner on 2/20/13 at approximately 6:10 PM revealed the Resident received a regular hamburger without a bun and mashed potatoes. The Dietary aide who delivered the tray and Licensed Practical Nurse #1 verified that the hamburger was not chopped as ordered.",2016-10-01
7934,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2013-02-21,371,F,0,1,BTGG11,"**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 store, prepare, distribute and serve food under sanitary conditions as evidenced by sanitizer solution not at the appropriate concentration, lemon juice not refrigerated after opened, cracked plastic ware, ice cream container not completely sealed, a heavy build up of dust behind the oven, cracked containers of seasoning, staff walking in unit kitchen without hairnets and staff failing to reheat food to the proper temperature. The findings included: During initial tour of the kitchen on 2/19/13 at approximately 11:20 AM , the surveyor observed 1 of 1 red sanitizer buckets which did not meet the appropriate concentration. Further observation of the kitchen on 2/19/13 at approximately 3:10 PM revealed a 32 fluid ounce bottle of lemon juice with a open date of 1/10/13 that was not refrigerated after opening per the bottle label. Observation of the main kitchen on 2/19/13 at approximately 3:25 PM revealed three cracked plastic ware containers drying in the dish area. Observation of the main kitchen on 2/20/13 at approximately 9:20 AM revealed the motor behind the oven with a heavy build up of dust; 2 seasoning containers that were cracked and leaking; and a second observation of the three cracked plastic ware. The Food and Beverage Director verified the surveyor findings. Multiple observations were made on 2/20/13 of staff entering the [MEDICATION NAME] kitchen without wearing hair nets. A sign was posted by the kitchen informing staff to use hair nets prior to entering. An observation on 2/20/13 at 11:35 AM revealed 1 of 1 ice cream container in the freezer not completely sealed. During observation of the tray line for lunch in the [MEDICATION NAME] kitchen, the surveyor observed the Certified Dietary Manager (CDM) reheating Salmon. When the surveyor asked the CDM what was the proper reheating temperature, he/she stated between 160 degrees-165 degrees. Observation on 2/20/13 at 12:10 PM revealed the CDM taking the temperature of the Salmon which read 160 degrees. He/she then proceeded to serve the Salmon which was not at the correct reheating temperature. The surveyor stopped the CDM from serving the Salmon and he/she confirmed that it was not at the proper reheating temperature of 165 degrees.",2016-10-01
7935,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2013-02-21,428,D,0,1,BTGG11,"**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 irregularities in physician orders [REDACTED]. Resident #5 with as needed order for Clonidine not administered as ordered and missed on pharmacy review. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Record review on 2/20/13 revealed an order for [REDACTED]. Review of the Medication Administration Records for the months of December 2012, January 2013, and February 2013 revealed Clonidine was only administered on 1/31/2013 at 8:30 AM and 2/11/2013 at 7:35 AM. Further review of the blood pressures for the months revealed multiple times when Resident #5's blood pressure were outside of the ordered parameters with no Clonidine administration. Review of the pharmacy reviews revealed no documentation related to Clonidine not administered as ordered. An interview on 2/21/2013 at 12:35 PM with the consulting pharmacist revealed that he/she was not sure if he/she had noted that Clonidine was not administered as ordered. The pharmacist continued by stating that it was difficult to review the electronic records. No further documentation was provided during the survey related to the omission of Clonidine administration.",2016-10-01
7936,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2013-02-21,441,E,0,1,BTGG11,"On the days of the survey, based on observation and interview, the facility's laundry personnel failed to handle, store , and process linens so as to prevent the spread of infection. The laundry was not designed to eliminate cross-contamination between soiled and clean linen. The findings included: During the tour of the laundry room on 2/20/13 at 9:30 AM, no separation was noted between the soiled side of the laundry room and the clean side. During the sorting of the linen, laundry bags(plastic) were placed on a table after the soiled items were removed from the bags. During the observation, clean items were placed on the same table next to the soiled plastic bags. After sorting, Laundry staff #1 closed two washing machines and started the cleaning cycle on the machines with his/her soiled,gloved hands. Continuing with the soiled gloves, Laundry staff #1 obtained a cloth, wet the cloth and placed soap from the handwashing sink on the wet cloth. He/she continued by wiping the doors of the machines and the table. During the sorting, a staff member from the kitchen entered the soiled side of the laundry, uncovered a soiled cart, placed a soiled item into the cart and exited the soiled side without washing his/her hands. Further observation of the laundry revealed one uncovered bin of soiled linens/cloths beside the dryer. Laundry staff was asked if there were personal protective equipment for the eyes in the laundry area. After searching drawers, laundry staff exited the area and returned with goggles. On 2/21/2013 at 9:15 AM, another observation of the laundry was completed. During the observation, a laundry staff member was observed to enter the soiled side, place a soiled item in a cart, and exit without washing his/her hands. A staff member from the kitchen entered the soiled area and placed an item in the soiled cart and started to exit when Laundry staff #1 asked him/her to wash his-her hands. Measurements in the Laundry area were obtained on 2/21/13 which revealed the following: 1) clean tables to soiled tables equaled 9 feet 2) washer 1 to dryer 1 equaled 75 1/2 inches 3)washer 2 to dryer 1 equaled 52 inches During an interview with Laundry staff #1 he/she confirmed he/she confirmed the observations and that he/she had been spoken to after the laundry observation on 2/20/13.",2016-10-01
8816,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2012-01-24,157,D,0,1,6ERN11,"**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 policy provided by the facility entitled Physician Notification Procedure, the facility failed to notify the Physician of a change in condition which potentially required physician intervention for one of one sampled residents taking [MEDICATION NAME]. Facility staff did not notify the Physician of elevated Blood Pressure (BP) readings for Resident #5. The findings included: The facility admitted Resident #5 on 3/3/10 with [DIAGNOSES REDACTED]. Record review on 1/23/12 at 4:55 PM revealed Vital Signs documentation from October 2011 through 1/17/12 which included Blood Pressure readings that were trending upwards from the 140-150's/70's in October 2011 to the 170-180's systolic in November/December 2011 and January 2012. The following blood pressure readings of concern were noted: 11/13/11- BP 171/85 11/14/11- BP 181/79 11/15/11- BP 173/69 11/22/11- BP 173/76 11/29/11- BP 176/83 12/20/11- BP 178/89 12/27/11- BP 183/86 01/01/12- BP 188/79 01/10/12- BP 170/63 Continued record review on 1/23/12 of Clinical Notes, Physician Orders, and Physician Notes from October 2011 through January 2012 revealed no mention of Physician notification of the above elevated BP readings. Review of Physician order [REDACTED]. Review of the Care Plan revealed no mention of the problem of Hypertension or that the resident was taking medication for BP control. During an interview on 1/24/12 at 8:00 AM, Licensed Practical Nurse (LPN) #1 verified the BP readings above and stated she would notify the Physician if the resident's BP was in the 170's to 180's systolic. She stated there would be documentation in the Physician Notes or Clinical Notes if the Physician had been notified. During a phone interview on 1/24/12 at 8:08 AM, The resident's Physician was told that Resident #5, who was taking [MEDICATION NAME], had BP readings that had been trending upwards in the last 3 months. The surveyor stated that documentation in Physician's Progress Notes in October 2011 showed systolic BP's in the 130's-140's. However, there was no documentation noted of Physician notification of BP's ranging from 170/63 to 188/79. When asked if he was aware of the elevated BP readings, he stated he had not been aware. When asked if he thought he should have been notified, he stated that this was important and he should have been made aware of the elevated BP readings. During an interview on 1/24/12 at approximately 8:20 AM, the Care Plan Coordinator verified there was no Care Plan for the problem of Hypertension for Resident #5. According to the policy provided by the facility on 1/24/12 entitled Physician Notification Procedure, if it was a Non-Emergent Situation, the physician could be notified by phone. For any situation that required hospitalization and/or acute physician treatment; the physician should be called up to three times and if no response, the DON or Administrator should be called. If the situation was critical, the nurse should call the physician, and if no response, send for emergency treatment and then notify the physician through the hospital.",2015-12-01
8817,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2012-01-24,164,D,0,1,6ERN11,"**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 General Care, the facility failed to provide full visual privacy for one of one sampled residents reviewed with catheter care. Nursing staff failed to drape Resident #3 appropriately during catheter care. The findings included: The facility admitted Resident #3 on 7/5/11 with [DIAGNOSES REDACTED]. Observation of Suprapubic Catheter Care on 1/23/12 at 4:20 PM revealed Certified Nursing Assistant (CNA) #1 draping a towel over the resident's abdomen above the Suprapubic catheter. She then unfastened the resident's brief exposing the Suprapubic catheter insertion site along with the resident's genitals. She then performed Suprapubic catheter care while leaving the resident's genitals exposed. The blinds covering the resident's window (facing a courtyard) were noted to be partially open at the bottom due to a plant in the window. However, no one was observed outside the window. During an interview on 1/23/12 immediately after the procedure, CNA #1 and CNA #2 were present. They were told of the concern with the towel draping the abdomen and leaving the resident's private parts exposed during the catheter care. They were also told of the blind being partially open at the bottom of the window. They did not dispute the findings. Review of the policy provided by the facility on 1/23/12 entitled Catheter General Care revealed under Procedure that staff need to .Provide full visual privacy and to the extent possible auditory privacy . and they should .Drape resident. Avoid unnecessary exposure .",2015-12-01
8818,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2012-01-24,280,E,0,1,6ERN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews and the facility's Elopement Policy and Procedure, the facility failed to review and revise the comprehensive care plan as determined by the resident's needs for 1 of 1 sampled residents review with exit seeking behaviors. (Resident #4) The facility failed to invite Resident #3 and #5 to care plan meetings and 8 of 8 group members indicated they were not invited to care plan meetings. The findings included: The facility admitted Resident #4 on 6/10/11 with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. An observation on 1/23/12 at approximately 5:30 PM revealed a wanderguard on residents left ankle. Review of the care plan revealed resident was not care plan for a wanderguard. Further review revealed an assessment that was completed upon admission that indicated the resident was not at risk of elopement. An interview on 1/24/12 at approximately 9:15 AM 1 with LPN (Licensed Practical Nurse) #4 confirmed resident was not care planned for exit seeking behavior and the use of a wanderguard was not included in the care plan. LPN #4 further stated resident was not care planned for exit seeking behavior because it was not felt that resident was an exit seeker. However, LPN # 4 acknowledged the resident had a wanderguard device in place. Review of the facility's Elopement Policy and Procedure revealed on admission each resident will be assessed for potential elopement and be re-assessed quarterly. The Elopement Policy further indicated interventions for elopement will be care planned. The facility admitted Resident #3 on 7/05/11 with [DIAGNOSES REDACTED]. Record review revealed an Admission Minimum Data Set (MDS) completed on 7/18/11 and a Quarterly ((MDS) dated [DATE] that indicated the resident had a BIM (Brief Interview for Mental Status) score of 14 which indicated the resident was alert, orient and interview-able. The facility further provided and interview-able list which identified Resident #3 as an interview-able resident. An interview on 1/23/12 at approximately 2:30 PM revealed the resident was not invited to the care plan meetings. Resident #3 further stated he would like to attend his care plan meetings. Further review of the medical record revealed no documentation to indicate the resident was informed of care plan meetings. During an interview on 1/24/12 at approximately 11 AM LPN#4 confirmed there was no documentation in the medical record to indicate that alert residents are invited to care plan meetings. A group interview held on 1/23/12 at approximately 4 PM with 8 of 8 interview-able residents verbalizing residents are not invited to care plan meetings. The group members further stated they do not ever recall being invited to care plan meeting. The facility admitted Resident #5 on 3/3/10 with [DIAGNOSES REDACTED]. During an individual interview on 1/24/12 at 8:42 AM, Resident #5 stated she could not recall having participated in a meeting where staff planned nursing and medical care for her. When asked again if she had been invited to any Care Plan Meetings, she stated she had not been invited to any, and she had been there for 2 years. When asked if she would go if she were invited, she stated she would if she were interested at the time.",2015-12-01
8819,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2012-01-24,281,E,0,1,6ERN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based interviews, record reviews and review of the facility's policy entitled IV Flush Peripheral/Saline Lock, the facility failed to assure that the services provided or arranged by the facility met professional standards of quality. The facility permitted License Practical Nurses (LPN) to administer medications via a Peripherally Inserted Central Catheter (PICC) without the required certification for Resident #1. (1 of 1 resident reviewed with a PICC Line reviewed for professional standards) The findings included: The facility admitted Resident #1 on 1/16/2012 with [DIAGNOSES REDACTED]. On 1/23/2012 at 12:55 PM, during an interview with LPN #2, she stated that Resident #1 had a Boil on her chest and that the area was dry and they were waiting on the Nurse Practitioner to discontinue the dressing changes. The LPN stated that the resident would be on isolation for 31 days while she received intravenous (IV) antibiotics [MEDICAL CONDITION] through her PICC Line. When the surveyor asked if she (LPN #2) administered the antibiotics and flushed the PICC line, LPN #2 stated that she did. Review of the electronic Medication Administration Record [REDACTED]. During an interview at 3:40 PM on 1/23/12, LPN #2 and LPN #3 both stated that they administered medications along with Saline and [MEDICATION NAME] Flushes through Resident #1's PICC Line. Both LPN #2 and #3 stated they did not have IV or PICC Line training or certification. Both also stated they were not aware that a Registered Nurse had to be in the facility when the medication and flushes were administered by a LPN. On 1/23/2012 at 3:45 PM, during an interview with the DON, the Assistant Director of Nursing (ADON) and the Nursing Home Administrator (NHA), all 3 stated that they were unaware that LPN's had to be certified for IV and PICC Line medication administration or that a RN had to be present in the facility during administration. The DON then stated that an RN was in the facility on most days. A copy of the resident's electronic with initials/signatures of the nurses administering each dose was requested and staffing for each shift was requested from the Director of Nursing (DON) at 4:10 PM on 1/23/2012. The DON stated that their system was not set up to print the MAR indicated [REDACTED]. 18 of 21 doses and flushes were administered by LPN's. Staffing for the facility since 1/16/2012 when the resident was admitted was provided by the DON. The DON Verified that on 1/16/12 from 11:00 PM to 7:00 AM, 1/17/12 from 3:00 PM to 7:00 AM, 1/18/12 from 3:00 PM to 11:00 PM, 1/19/12 from 3:00 PM to 7:00 AM, 1/20/12 from 11:00 PM to 7:00 AM, 1/21/12 from 7:00 PM to 7:00 AM, 1/22/12 from 7:00 PM to 7:00 AM, 1/23/12 from 3:00 PM to 7:00 AM and 1/24/12 from from 3:00 PM to 7:00 AM there were no RN's scheduled in the facility. The DON then stated that she had since made arrangements for an RN to administer Resident #1's IV medication and flushes which began on 1/23/12 at 4:00 PM. Review of the facility's policy entitled IV Flush Peripheral/Saline Lock, indicated .Purpose: To maintain patency of a peripheral cannula and allow for the administration of incompatible medications .3. This procedure shall be done using the SASH (saline antibiotic,saline,[MEDICATION NAME]) a. prior to and after each use .Equipment: Syringe filled with 3-5 cc of normal saline .[MEDICATION NAME] flush 3-5 cc . No policy addressing PICC Lines was provided by the facility prior to the team exiting the facility.",2015-12-01
8820,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2012-01-24,315,D,0,1,6ERN11,"**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 General Care, the facility failed to ensure appropriate care and services for Resident # 3, one of one sampled residents reviewed with a catheter. The findings included: The facility admitted Resident #3 on 7/5/11 with [DIAGNOSES REDACTED]. Observation of Suprapubic Catheter Care on 1/23/12 at 4:20 PM revealed Certified Nursing Assistant (CNA) #1 performing Catheter Care while CNA #2 assisted. After washing her hands and putting on her gloves, CNA #1 draped a towel over the resident's abdomen and unfastened the resident's brief. She then proceeded to take a wipe to clean around the catheter insertion site. She did not sanitize her hands or change her gloves before starting the catheter care after draping the resident and unfastening his brief. She took one wipe and cleaned the area around the right side of the catheter insertion site. She took a second wipe and cleaned around the top and both sides of the Suprapubic catheter insertion site with several [MEDICAL CONDITION] returning over areas previously cleaned using the same part of the wipe. She then took a third wipe and without anchoring the tubing, cleaned down the catheter tubing with several [MEDICAL CONDITION] going over areas previously cleaned using the same area of the wipe. She took another wipe and cleaned down the tubing again with 2 [MEDICAL CONDITION] using the same area of the wipe to go back over an area already cleaned. CNA #1 then fastened the resident's brief using the same gloved hands used to do the catheter care. During an interview immediately after the procedure, CNA #1 and CNA #2 were told of the concerns regarding not changing gloves/sanitizing hands immediately before and after catheter care along with wiping over areas previously cleaned using the same area of the wipe and not anchoring the tubing. When asked if they had any comments, CNA #2 stated that with perineal care, they are taught to use one wipe with one stroke and then to discard the wipe. She indicated she wanted to mention this to CNA #1 during the procedure. CNA #1 did not dispute the above findings and returned later to ask if she could do the procedure over again. Review on 1/24/12 of the policy provided by the facility entitled Catheter General Care, the policy stated under Procedure that staff are to .Put on gloves as recommended under universal precautions for potentially hazardous body waste and fluids . It stated that after the procedure, to remove the drape and place it in a plastic bag, then to Remove gloves and dispose of them in plastic bag. Wash hands thoroughly . For the procedure to clean the catheter, it stated .Gently wipe the insertion site of the catheter. Wipe down length of the catheter. For female resident, wipe front to back .",2015-12-01
8821,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2012-01-24,323,E,0,1,6ERN11,"On the days of the survey, based on observations, interviews and review of the facility's policy entitled Section 7: Laundry, Laundry Services Provided by On-Site Laundry and Weekly Dryer Preventive Maintenance Checklist, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. 3 of 3 clothes dryers in use were noted to have heavy build up of lint. The findings included: On 1/23/12 at 12:45 PM, 3 clothes dryer units were noted to be in use. Observation of the lint filter compartment revealed each unit had thick sheets of lint hanging from the filters and had lint rolled up in piles on the compartment floors. Laundry workers #1 and #2 verified the observation of the lint filters. Laundry worker #3 provided Weekly Dryer Preventive Maintenance Checklist, dated 11/2/11, 11/3/11, 11/4/11, 11/28/11, 11/29/11, 12/1/11. 12/3/11, 12/6/11, 1/20/12 and 1/22/12 which were incomplete. Review of the facility's policy entitled Section 7: Laundry, Laundry Services Provided by On-Site Laundry indicated .Is the lint cleaned from the dryers a minimum of 3 times daily? .",2015-12-01
8822,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2012-01-24,371,F,0,1,6ERN11,"On the days of the survey, based on observations, interviews and review of the facility's policy entitled Thermometer Calibration Policy, the facility failed to store, prepare, distribute and serve food under sanitary conditions. Kitchen equipment was observed with dust and grease built up on fans and electrical cords. Electrical cords were not plugged in properly. Ovens and grills were observed with heavy build up of dried/burnt on debris. A free standing box freezer had spills on the walls and paint peeling from the inside surface. Walk in freezers and refrigerators were noted to have spills and debris on the floors. Items in refrigerators were expired, unlabeled or open to air. Items in freezers had no lids leaving them open to air or items were uncovered. Dented cans were in rack with items to be use for residents. Cleaning supplies were observed sitting on spice shelf with spices. 3 of 3 sanitization buckets tested at 400 ppm (parts per million) concentration. 3 Dietary staff members were unable to calibrate thermometers prior to obtaining food temperatures of food to be served to residents. The findings included: On 1/23/2012 at 10:45 AM, during tour of the facility's kitchen area with the Executive Chef, multiple concerns were observed and confirmed by the Executive Chef. The concerns included: the walk-in refrigerator had a box of chicken with the inner bag torn and lid not on properly leaving the chicken exposed. The floor of the refrigerator had a brownish red liquid under the rack expanding to the open floor area and to the wall. The walk in freezer contained a pie shell wrapped in a clear plastic wrap which was undated/unlabeled, 1 bag of breaded catfish, 1 bag of breaded flounder and 1 bag of chicken (identified by the chef) were unlabeled/not dated and spills were noted on the floor. The vegetable cooler contained 3 bags of spring mix (identified by the chef) with no date or label. (11) - 2% Reduced Fat Milk - 8 ounces each were observed with an expiration date of 1/8/12 and (2) - 8 ounce Vitamin D milk containers with an expiration date of 1/18/12 were observed. A Vulcan oven was noted to have a thick layer of burnt on debris on the oven floors, walls and doors. The grill was noted to have a black substance, built up on the grates, the grease trap had excess drippings with black debris and a paper used for lighting the grill was observed lying at the edge of the drip pan. The kitchen contained 2 double oven units (4 ovens). The upper unit of one had a build up of black burnt debris on the oven floor and food splatters on inside door area. Both ovens of the second unit had build up of black burnt food debris on the floors and doors of the ovens. The double oven units were positioned in the kitchen area with the back of each unit to the back of the other unit with a half wall between them. The fans, vents, backs of the units and electrical cords of each unit were covered in a heavy build up of grease and dust. The prongs to one units electrical plug was partially exposed and had dust built up on it. A small square house type freezer contained 3 large containers of ice cream which were not covered properly exposing the ice cream to air. The walls of this freezer had spills frozen to the walls and the finish had peeled from the floor of the freezer. The canned food rack had 2 large cans of food which were dented in the resident use area. A container of 40 Stainless Steel Cleaner wipes was observed sitting on the rack with the spices. A large bag of pasta was on a shelf out of the original box with no label or date. The floor mixer had liquid splatters. In an interview with the Executive Chef, she stated that they do not have a cleaning schedule for any of the kitchen equipment. On 1/24/2012 at 9:00 AM, during tour with the Executive Chef, an additional 3 containers of ice cream were observed in the walk in freezer with no lids. The same items as listed for 1/23/12 were noted to remain unlabeled and undated in the walk in refrigerator and freezer and the brownish red liquid remained on the floor. Boxes had been placed on the freezer shelves from a delivery on 1/23/12 which had been sitting on the floor. Dirt and debris were noted on the floor where the boxes had been near the back wall of the walk-in freezer. Three (3) red sanitation buckets were tested by the Executive Chef. Each bucket tested 400 ppm. The buckets were refilled twice before the concentration of sanitizer was determined to be correct. On 1/24/12 at 11:55 AM, dietary staff #2 and #3 could not calibrate the thermometer prior to checking the temperatures of the resident food. Neither could state the correct temperature to which the thermometer should be calibrated. Dietary staff #2 did not reply and dietary staff #3 stated 40 degrees. The Executive Chef was call by the staff. She stated that the thermometer should be calibrated to 0 degrees before checking the resident food. Review of the facility's policy entitled Thermometer Calibration Policy revealed .Thermometers should be calibrated whenever they are dropped, before first use and when going from one temperature extreme to another. Temperature is a critical measurement for ensuring the safety and quality of many food products. Whether monitoring temperatures at receiving, throughout production or final produce storage and distribution, thermometer calibration is essential .32 degrees .",2015-12-01
8823,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2012-01-24,372,D,0,1,6ERN11,"On the days of the survey, based on observations and interviews, the facility failed to dispose of garbage and refuse properly. The facility's compactor had a foul liquid leaking and the grease pit had evidence of leakage into the soil where it was sitting. The findings included: On 1/23/2012 at 12:15 PM, a large trash compactor was noted to have a foul smelling liquid leaking onto the concrete and spreading into the surrounding soil. The grease pit was noted to be sitting on the soil and had a build up of grease on the front of the container which led to the soil around it. On 1/24/2102 at 8:50 Am, during a tour with the facility's Maintenance Director, he verified the placement of the grease pit on the soil and the leakage from both the grease pit and the trash compactor which ran into the surrounding soil.",2015-12-01
8824,THE PRESTON HEALTH CENTER,425325,87 BIRD SONG WAY,HILTON HEAD ISLAND,SC,29926,2012-01-24,514,D,0,1,6ERN11,"**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 maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and readily accessible for Resident #8, 1 of 2 residents reviewed for Hospice services. Resident # 8's medical record did not contain the Hospice Contract/Agreement, Care Plan, or current visits in the medical record. The findings included: The facility admitted Resident #8 on 11/17/2011 with [DIAGNOSES REDACTED]. Review of the resident's medical chart on 1/24/12 at 10:10 AM, indicated that she had physician's orders [REDACTED]. Further review of the record revealed that there was no Hospice Contract, Agreement or Care Plan in the record. Hospice notes dated 12/20/11, 12/22/11, 12/27/11 and 12/29/11 were the only Hospice documentation located in the resident's record. At 11:05 AM, during an interview with the Director Of Nursing (DON), she verified no other Hospice documentation was present in the chart or within the facility. The DON stated that she would contact the Hospice agency and have them fax the information to the facility.",2015-12-01
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
3401,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2017-09-27,241,E,0,1,HT9X11,"Based on observations and interviews, the facility failed to ensure that residents seated at the same table were served and fed sequentially while others were served and eating. The facility failed to ensure dignity in dining while leaving residents at a table not served or eating, looking at other residents eat while waiting to be served and fed. Staff was observed engaged in conversation with each other and chewing gum while feeding. Staff was observed pulling a resident in a rocker geri chair from the day area down the hallway to his/her room backwards. (Unit 100 and Special Care Unit dining rooms) 2 of 5 dining areas observed. The findings included: A random lunch observation on 9/25/17 of the Special Care Unit at approximately 12:36 PM revealed staff removing food trays from the food cart. Staff was observed providing meals for residents who were capable of feeding themselves. There were two tables with 4 to 5 residents at each table that reportedly required staff to feed the residents. At the table near the day area side, there were three residents seated at the table not served or eating while two residents had meals and were eating or being fed by staff. Staff were observed feeding residents at a table while residents who required assistance with feeding were seated in the dining room not served and eating or being fed. An interview on 9/25/17 at approximately 12:51 PM with Registered Nurse (RN) #1 confirmed the findings that the residents at a table not served or eating where residents that required assistance of staff during meals. Two of the residents at the table not served or eating were looking around at other residents eating, served and/or being fed by staff. RN #1 further stated that staff will assist the residents at the table closer to Unit 100 window once they have fed the residents at the table near the day area side. Two staff members were heard making comments that I am only one person. At approximately 12:57 PM staff was observed providing food trays for some residents at the table close to the Unit 100 window side of the dining room. A Certified Nursing Aide (CNA) was observed touching a resident with his/her bare hands to re-position the resident in his/her geri chair during the meal. The CNA did not wash his/her hands prior to sitting down to feed the residents. The staff that were feeding residents were engaged in having conversations with each other and not residents during meal observation. Staff was observed chewing gum while feeding residents once residents were served. An observation on 9/25/17 at approximately 3:29 PM revealed CNA #2 pulling a resident in a rocker geri chair backwards from the day area on the Special Care Unit to the hallway to the resident's room. An interview with CNA #2 confirmed the findings. The CNA further stated the resident was seated in a chair that required the resident to be pulled backward. An interview on 9/25/17 at approximately 3:34 PM with CNA #3 who was present when CNA #2 pulled the resident backwards in the rocker geri chair stated the resident should not have been pulled backward in the chair the resident was using. A random breakfast meal observation on 9/26/17 on the Special Care Unit at approximately 9:11 AM revealed three residents at a table with staff feeding two of the residents at the table (near day area side). The third resident was not served or eating while staff fed the two other residents. The long table near the 100 unit window had five resident seated not served or eating while seated in the dining room around other residents who are eating or being fed. Staff was observed taking a meal to a resident seated with a bedside table a meal before serving all the residents seated at the same table. At approximately 9:14 AM a resident at the table not served was observed looking around at residents being feed at a table near him/her. An interview and observation on 9/26/17 at approximately 9:16 AM with RN #1 confirmed the findings. RN #1 stated the residents in the dining room will be fed once staff was available. During meal observation, staff was observed engaged in conversations with each other and not the resident they were feeding. Staff was also observed chewing gum while feeding residents. At approximately 9:20 AM during breakfast, three residents were served at a long table near Unit 100. There were two other residents not served. The one resident that was looking around at other residents eat was still looking around. At 9:25 AM the resident who was looking around had food a tray placed in front of him/her but staff was engaged in conversation with another CNA before feeding the resident. A random lunch meal observation on 9/26/17 at approximately 12:48 PM revealed residents seated at the same table not served or fed sequentially. There were four residents seated at the table that required assistance with feeding with one resident not eating or being fed while others are eating. Staff continued to engage in conversation with each other while feeding the residents. An interview on 9/27/17 at approximately 9:26 AM with the Director of Nursing revealed the facility does not have a policy on etiquette in dining. During observation of lunch on unit 1 on 9/25/2017 at 12:15 PM, lunch trays were not passed to tables sequentially. Three residents were observed seated at a table and 2 of the 3 were served lunch. Staff then served the next table. At 12:18 PM, the 3rd resident at the aforementioned table was served lunch.",2020-09-01
3402,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2017-09-27,371,E,0,1,HT9X11,"Based on observation and interview the facility failed to ensure food was distributed and served with professional standards for safety. A facility employee was observed to enter the kitchen area when food was being plated for distribution not wearing a hair net or washing his/her hands. In addition trays were delivered from the dining room to resident rooms without covering all the food items intended for resident consumption. The findings included: During a second observation of the main kitchen on 9/16/17 at 12:10 PM, an activity assistant entered the kitchen area from the hall . The assistant walked into the kitchen and up to the area behind the serving line where the lunch meal was being plated for the residents. This employee did not wash his/her hands nor put on a hair restraint before entering the serving line area. The Dietary Manager was notified immediately who went to talk to the employee. The employee told the manager he/she knew he/she was not supposed to enter the dietary area but every one was busy and he/she decided to look for silverware on his/her own. At 1:30 PM an interview was held with the Activity Director who showed documents that she had done a Performance Coaching sheet with the employee for failure to follow a better way which resulted in negative customer outcome. Documents were presented showing employee was inserviced on infection control issues during orientation on 2/21/17. There was also a sign posted outside the kitchen door Documenting Only Kitchen Employees Allowed. An interview with the Dietary Manager on 9/26/17 at 11:30 AM confirmed that deserts and salads should be covered on the meal trays if staff carried trays down the hall. No covers were required only if the food cart was parked in front of the resident room to be served. Then the tray could be taken off the cart and taken directly into the resident room. The Dietary Manager further stated that the covers were on the beverage carts on each hall for the staff to use. The manager also stated that nursing did an inservice with the nursing staff on covering food when delivering trays. During a random lunch meal observation on 9/25/17 at approximately 12:36 PM in the Special Care Unit, food trays with uncovered foods such as pudding and/or pies were delivered from the dining room to resident rooms on the hallway. At approximately 12:40 PM a staff member with hair in a pony tail was observed holding a food tray high up close to his/her hair with pie not covered. At approximately 12:43 PM Registered Nurse #3 asked staff if they had enough covers to take desserts down hallway. There were no covers provided with the food cart. During lunch meal observation on 9/26/17 at approximately 12:33 PM in the Special Care Unit, food trays with uncovered foods such as brownies and toss salad were delivered from the dining to resident rooms on the hallway. An interview on 9/26/17 at approximately 12:35 PM with Certified Nursing Aide (CNA) #1 confirmed the findings. Further observation of the food cart revealed there were no food covers available. At approximately 12:45 PM staff located food covers for food to be delivered from the dining room to the hallway.",2020-09-01
3403,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2017-09-27,502,D,0,1,HT9X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that physician's orders for labs were followed for 1 of 5 sampled residents reviewed for unnecessary medications. Resident #60 did not get [MEDICATION NAME] level labs done per physician's orders and as found to be an intervention in the resident's care plan. The findings included: The facility admitted Resident #60 with [DIAGNOSES REDACTED]. A review of the medical record on 9/26/17 at approximately 11:26 AM revealed a physician's order dated 8/23/17 requested a Complete Metabolic Panel, Magnesium, Complete Blood Count and [MEDICATION NAME] level laboratory be performed. The record revealed labs were done on 8/24/17 for Complete Metabolic Panel, Magnesium and Complete Blood Count. There was no documentation to indicate Resident #60 had the [MEDICATION NAME] level laboratory as ordered by the physician. There was a list of physician's visits in the medical record which indicated the physician completed an annual physical for Resident #60 on 8/23/17. A copy of the physician's report on 8/23/17 was unavailable during survey. The medical records staff stated the physician needed to make some changes prior to submitting the report. Further record review revealed a care plan updated on 8/07/17 that indicated in the problem area: resident on 9 plus medications and at risk for adverse side effects and drug interactions. The approach on the care plan indicated obtain lab values as ordered and assess for signs of medication interactions: abnormal vitals and abnormal labs. An interview on 9/26/17 at approximately 12:04 PM with Registered Nurse (RN) #2 confirmed the [MEDICATION NAME] level laboratory was not done as ordered. RN #2 further stated that he/she could not find any documentation that the physician canceled or discontinued the [MEDICATION NAME] level labs but he/she will talk with the physician. During an interview on 9/26/17 at approximately 12:20 PM, RN #2 stated he/she spoke with the nurse practitioner and the [MEDICATION NAME] level labs will be done stat (immediately).",2020-09-01
3404,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2018-11-01,759,D,0,1,JKPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of the facility policies and the Humalog KwikPen manufacture recommendations, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 32 opportunities for error, resulting in a medication error rate of 6.25%. The findings included: Error #1 On 10/30/18 at approximately 4:50 PM, during an observation of Resident #98's medication administration on the 100 hall, Registered Nurse (RN) #1 checked Resident #98's Blood Sugar (BS) which was 304. RN #1 reviewed the Medication Administration Record [REDACTED]. RN #1 prepared the Humalog KwikPen for administration by attaching the needle, and without priming the Humalog KwikPen, selected 2 units on the Humalog KwikPen Dose Knob dial and administered the insulin to Resident #98. Following the administration RN #1 verified s/he did not prime the Humalog KwikPen before administration of the insulin into Resident #98. Review of the Humolog KwikPen manufactures recommendations reveals under, Priming your Pen. Prime before each injection. Bullet (1.) states, Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the pen is working correctly. Also, bullet (2.) states, If you do not prime before each injection, you may get too much or too little. Review of the facility policy titled, Insulin PEN Administration, revealed under Prime the pen before each injection. Priming the pen gets rid of air bubbles that may be in the pen. Air bubbles can affect the flow of insulin from a pen and cause you to inject the wrong amount of insulin. Error #2 On 10/30/18 at approximately 5:50 PM, during an observation of Resident #437's medication administration on the 300 hall, Registered Nurse (RN) #2 crushed a [MEDICATION NAME] ER (Extended Release) 600 milligram (mg.) tablet and placed the medication in applesauce and administered the medication to Resident #437. During an interview immediately following the administration observation RN #2 was asked by the surveyor to review Resident #437's MAR indicated [REDACTED]#2 verified s/he crushed the [MEDICATION NAME] ER 600 mg. tablet and indicated s/he should not have. On 10/30/18 at approximately 7:30 PM, a review of Resident #437's Active Orders: 10/01/2018 - 11/01/2018 revealed physicians order stating, [MEDICATION NAME] 600 MG ER Take one by mouth twice daily -DO NOT CRUSH-. Also, under Nursing /Ancillary Orders revealed physicians order stating, (MONTH) crush meds and open capsules unless contraindicated. Review of the facility policy titled, Medications-Administering, revealed under procedure (15.) For Administering Tablets and Capsules, bullet (2.) states, Only Crush medications when necessary. Be sure to check the DO NOT CRUSH List or with the pharmacy before crushing any coated or time re-lease medication.",2020-09-01
3405,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2018-11-01,760,D,0,1,JKPJ11,"Based on observations, interview, and review of the facility policies and the Humalog KwikPen manufacture recommendations, the facility failed to administer the correct amount of insulin for 1 of 1 resident reviewed for insulin administration. Staff did not follow an established procedure to deliver the correct amount insulin to Resident #98. The findings included: On 10/30/18 at approximately 4:50 PM, during an observation of Resident #98's medication administration on the 100 hall, Registered Nurse (RN) #1 checked Resident #98's Blood Sugar (BS) which was 304. RN #1 reviewed the Medication Administration Record [REDACTED]. RN #1 prepared the Humalog KwikPen for administration by attaching the needle, and without priming the Humalog KwikPen, selected 2 units on the Humalog KwikPen Dose Knob dial and administered the insulin to Resident #98. Following the administration RN #1 verified s/he did not prime the Humalog KwikPen before administration of the insulin into Resident #98. Review of the Humolog KwikPen manufactures recommendations reveals under, Priming your Pen. Prime before each injection. Bullet (1.) states, Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the pen is working correctly. Also, bullet (2.) states, If you do not prime before each injection, you may get too much or too little. Review of the facility policy titled, Insulin PEN Administration, revealed under Prime the pen before each injection. Priming the pen gets rid of air bubbles that may be in the pen. Air bubbles can affect the flow of insulin from a pen and cause you to inject the wrong amount of insulin.",2020-09-01
3406,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2018-11-01,880,D,0,1,JKPJ11,"Based on observations, interview, and review of the Center for Disease Control (CDC) Prevention safety recommendations, the facility failed to follow infection control practices during med pass for 1 of 1 resident reviewed for finger stick blood sugar (FSBS). Infection control precautions were not taken during a FSBS check on the 100 unit. The findings included: On 10/30/18 at approximately 4:45 PM, during an observation of med pass on the 100 unit, Registered Nurse #1 used Resident #436's blood glucose monitor to check Resident #98's blood sugar (BS). Following the BS check RN#1 cleaned the blood glucose monitor with an alcohol prep pad and placed the monitor back into Resident #98's individual case on the medication cart. On 10/30/18 at approximately 4:50 PM, during an interview with RN #1, s/he verified Resident #98's BS was checked with Resident #436's blood glucose monitor and then sanitized the blood glucose monitor with an alcohol prep pad, not a solution of 1:10 concentration of sodium hypochlorite (bleach). RN #1 further indicated that all residents had their own monitor. Review of the facility policy on blood glucose monitoring, the policy did not mention the sanitization of the monitor after use. Review of the CDC prevention safety recommendations revealed under, Blood Glucose Meter, (1) Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. (2) If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.",2020-09-01
5113,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2016-05-04,280,D,1,0,XM7R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to periodically review and revise the resident's comprehensive care plan. Resident #3's care plan was not updated to reflect bilateral [MEDICAL CONDITION] and anticoagulant therapy. 1 of 5 residents reviewed for care plans. The findings included: Review of Resident #3's Medication Order revealed an order for [REDACTED].#3's Ultrasound Report dated 3/4/16 revealed Doppler results that indicated Acute Right and Left lower extremity [MEDICAL CONDITIONS]. Review of the physician's orders [REDACTED]. Review of Resident #3's Complete Patient Care Plan dated 2/18/16 revealed there was no documentation related to the resident having bilateral [MEDICAL CONDITION] and receiving anticoagulant therapy. Review of the facility's [MEDICATION NAME] Responsibilities of the Nursing Department policy revealed the MDS Coordinator and Nurse will assure an anticoagulant therapy problem is included in the resident's Patient Care Plan and that it includes monitoring for signs and symptoms of bleeding, [MEDICAL CONDITION] Embolism and [MEDICAL CONDITION]. In an interview with the surveyor on 5/3/16 at approximately 5:40 PM, the Director of Nursing reviewed Resident #3's care plan and confirmed that it was not updated to reflect anticoagulant therapy. In an interview with the surveyor on 5/3/16 at approximately 5:50 PM, the ADON (Assistant Director of Nursing) reviewed Resident #3's care plan and confirmed it was not updated to reflect the resident had [MEDICAL CONDITION] and was receiving anticoagulant therapy.",2019-05-01
5114,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2016-05-04,309,D,1,0,XM7R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure each resident receive the necessary care and services to maintain the highest practicable physical well-being in accordance with plan of care. Resident #3 was not monitored per the facility's policy related to anticoagulant therapy. 1 of 3 residents reviewed for anticoagulant therapy. The findings included: Review of the resident's Medication Order revealed an order for [REDACTED].#3's Ultrasound Report dated 3/4/16 revealed Doppler results that indicated Acute Right and Left lower extremity [MEDICAL CONDITIONS]. Review of the physician's orders [REDACTED]. Review of the PT/INR lab results revealed on 3/5/16 the INR was 0.93, on 3/6/16 the INR was 1.1, and on 3/7/16 the INR was 1.33. Review of Resident #3's medical record revealed there were only two Nurses' Notes in the month of (MONTH) (YEAR). There was a Nurses' Note on 3/6/16 at 12:26 AM that noted the resident's current condition. The second Nurses' Note dated 3/10/16 indicated Resident #3 was sent to the hospital at 10:45 AM for evaluation and treatment of [REDACTED]. Review of the physician progress notes [REDACTED].#3 was seen for a hematoma of the left breast and bruising down in the left axilla. The resident was noted to have a large mass in the left breast the physician felt represented a big hematoma. The physician's plan was to hold anticoagulants for two days and if the area decreased in size then consider restarting at that time. The physician talked with the resident's family about the resident having an INR of 2 and already bleeding spontaneously. Review of Resident #3's SBAR Comminication From dated 3/10/16 revealed the resident had a hematoma to the left chest that had increased in size over 24 hours. The change in condition started on 3/9/16. Resident #3 was found to have bilateral [MEDICAL CONDITION] to lower extremities on 3/4/16. The physician was notified and ordered the resident be sent to the emergency room for evaluation and treatment. Review of the facility's [MEDICATION NAME] Responsibilities of the Nursing Department policy revealed the objective was to maintain INR levels within an acceptable range for residents receiving [MEDICATION NAME] therapy. The section Monitoring for Critical [MEDICATION NAME] Labs indicated a resident with an INR less than 1.5 should be monitored for signs and symptoms of PE or [MEDICAL CONDITION]. Report any shortness of breath, redness, swelling, pain, warmth, or + Homan sign. Immediately report any signs or symptoms to the physician. The policy indicated nursing should document that monitoring for INR less than 1.5 was done in the nursing notes EVERY SHIFT when a critical lab result was noted. In an interview with the surveyor on 5/3/16 at approximately 2:30 PM the MDS Coordinator stated all nurse's notes are in the chart. When the resident comes in they do daily notes for a few days. Then the nurses complete a monthly summary. The nurses talk about a change in status amongst the interdisciplinary team. In an interview with the surveyor on 5/3/16 at approximately 4:40 PM, the ADON stated they have a [MEDICATION NAME] flow sheet for residents that has the date the INR is due and the results and orders. No [MEDICATION NAME] flow sheet was noted in Resident #3's medical record. In an interview with the surveyor on 5/3/16 at approximately 5:40 PM, the Director of Nursing stated nursing should have documented per [MEDICATION NAME] guidelines for the low INR lab values. Reviewed resident's Nurses' Notes and confirmed that there were not notes for every shift that the resident had an INR less than 1.5. In an interview with the surveyor on 5/3/16 at approximately 5:50 PM, ADON (Assistant Director of Nursing) confirmed the only Nurses' Note was on 3/6/16 after reviewing Resident #3's medical record.",2019-05-01
5360,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2015-06-10,155,D,0,1,X50X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents who were deemed competent signed his/her own Advance Directive for Do Not Resuscitate for 1 of 16 sampled residents reviewed. Resident #338 Advance Directive Do Not Resuscitate form was signed by a family member. The findings included: The facility admitted Resident #338 with [DIAGNOSES REDACTED]. A record review on 6/10/15 at approximately 9:38 AM revealed an ADVANCE DIRECTIVE/DNR D[NAME]UMENTATION NOTES form dated 3/18/15 signed by the resident's daughter. There was no documentation in the chart; signed by two physicians to determine the resident could not make his/her own health care decisions. Further record review revealed a statement form for CERTIFICATION OF PATIENT'S INABILITY TO CONSENT TO HEALTH CARE DECISIONS signed by a physician on 5/11/15 that indicated Pt (patient) able to consent to medical procedures. In an interview on 6/10/15 at approximately 10:09 AM LPN (Licensed Practical Nurse) #1 confirmed the findings that there was no documentation in the chart to indicate the resident could not sign his/her own Advance Directive. LPN #1 then referred the surveyor to the SSD (Social Services Director). An interview on 6/10/15 at approximately 10:17 AM with the SSD revealed there was no documentation of two physician's signatures to indicate the resident could not make health care decisions. The SSD then stated he/she will have the resident sign the Advance Directive form.",2019-01-01
5361,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2015-06-10,328,D,0,1,X50X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide oxygen therapy as ordered for 2 of 4 sampled residents receiving oxygen. Resident #365 and #103 had orders for continuous oxygen per nasal cannula (NC) at 2 liters per minute (LPM). Both residents were observed receiving oxygen at 3 LPM. The findings included: The facility admitted Resident # 365 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Resident # 365 was observed in her/his room on 6/8/15 at 1:52 PM and 6/9/15 at 10:42 AM. During both observations the resident was receiving oxygen at 3 LPM per NC from the oxygen concentrator. The resident was observed for Pressure Ulcer care on 6/10/15 at 10:56 AM. Observation of the resident and the oxygen concentrator at 10:56 AM, revealed that the resident was receiving oxygen at 3 LPM. Registered Nurse (RN) #1 and another RN were providing the Pressure Ulcer care. After the Pressure Ulcer care was completed and during an interview at 11:07 AM, RN #1 was asked to verify the amount of oxygen the resident was receiving from the oxygen concentrator. RN # 1 stated that the concentrator was set just below 3 LPM and stated the resident was receiving oxygen at 2.75 LPM. When asked what the resident's oxygen orders were RN #1 stated she/he thought the orders were for 2 LPM, but would have to check the actual order. During an interview with RN #1 at 11:09 AM, RN #1 confirmed the resident's oxygen was ordered continuous at 2 LPM. The facility admitted Resident #103 with [DIAGNOSES REDACTED]. Resident #103 was observed during a Finger Stick Blood Sugar (FSBS) check, performed by RN #1, on 6/10/2015 at 11:26 AM. Resident #103 was receiving oxygen per NC from her/his oxygen concentrator at the time of the FSBS check. The oxygen concentrator was set at 3 LPM. RN #1 was asked to verify the oxygen setting and confirmed the concentrator was set at 3 LPM. RN #1 stated she would have to check the orders to verify the resident's current oxygen orders. During an interview with RN #1 at 11:28 AM, RN #1 confirmed that the resident was receiving the incorrect amount of oxygen and that the oxygen was ordered continuous at 2 LPM. Record review of the Medication Orders with RN #1 at 11:28 AM, revealed an order for [REDACTED]. During an interview with Resident #103 on 6/10/15 at 11:38 AM, Resident #103 stated she never adjusts the setting on her oxygen concentrator and that only the nurse adjusts the oxygen setting.",2019-01-01
6705,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2014-03-06,282,D,0,1,CMU111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and complaint survey, based on record review, review of the facility policy for transfers and interview, the facility failed to provide services in accordance with each resident's written plan of care. Resident #26's care plan for transfers was not followed by staff. ( One of 3 residents reviewed for care plans related to transfers.) The findings included: Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed the Significant Change Minimum (MDS) data set [DATE] coded Resident # 26 as requiring extensive assistance with transfers. Review of the care plan revealed mobility limited due to inability to ambulate was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included the use of the hoyer lift for transfers and to provide assistance of two staff as needed. Review of the Patient Plan of Care for CNA (Certified Nursing Assistant) for Resident #26 documented transfers required a hoyer lift with two assist to reclining gerichair. The facility reported a fracture of unknown origin for Resident # 26 to the State Survey Agency on 12/31/13. Review of the facility's Summary Report dated 1/3/14 indicated that after interviewing staff they could not determine the cause of the injury to Resident #26. Review of the Radiology Report dated 12/30/13 revealed Resident #26 had acute fractures involving the left proximal tibia and fibula shafts. Review of the facility's Transfer - Bed to Chair policy revealed a section for using a mechanical lift. The policy included to use two partners when using a sling type mechanical lift. In an interview with the surveyor on 3/4/14 at approximately 3:30 PM, the facility Administrator, Director of Nursing and Unit Manager were asked about the incident on 12/30/13. The facility Administrator stated that s/he talked with all staff. CNA #1 admitted s/he did not use two people to transfer Resident #26 and that s/he did not have another staff member in the room with him/her. In a telephone interview with the surveyor on 3/5/14 at approximately 12:25 PM, the facility Administrator stated that it was discovered during staff interviews that two staff members had transferred Resident # 26 using the lift without 2 people. S/he stated that s/he asked everyone who did care for Resident #26 on 12/29/13 and 12/30/13 to show how they transferred her. CNA #1 and CNA #2 both admitted they had transferred Resident # 26 with lift and did not have a second person for assistance during that timeframe.",2017-11-01
9101,NHC HEALTHCARE - MAULDIN,425359,850 E. BUTLER RD.,GREENVILLE,SC,29607,2012-08-28,441,F,1,0,XS0811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review, interview and review of the facility policy, the facility failed to maintain an Infection Control Program to help prevent the transmission of infections. The facility did not maintain a record of incidents related to infections for 3 of 3 residents reviewed for scabies (Residents #2, #3 and #4). The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of Resident #2's medical record revealed an order on 7/2/12 for [MEDICATION NAME] Cream to apply from the neck down at HS (hour of sleep) and wash off the next day. Review of the physician progress notes [REDACTED]. An addendum to the physician progress notes [REDACTED]. They were questioning the shingles, which the area on her breast appears to be resolving and drying up. She is not as contagious as she was. Instruction was given to the family in regards to this"" ""...No therapeutic changes are otherwise indicated except for treating this current rash, but we did explain the difference between the shingles and the other rash. Shingles tend to cause pain."" Review of the resident's Weekly Skin Assessment Record revealed a progress note dated 7/3/12 ""resident has rash to trunk buttock and legs complains of itching [MEDICATION NAME] applied"". A progress note dated 7/11/12 stated, ""resident has small rash to trunk buttock and legs healing "". A progress note dated 7/19/12 stated, ""resident continues to have small rash on arms trunk buttock healing."" Review of Resident #2's medical record also revealed an order on 6/18/12 for [MEDICATION NAME] cream to left lower quadrant of abdomen 4 times a day for 7 days and [MEDICATION NAME] 800 mg 4 times a day for 7 days for shingles. [MEDICATION NAME] 1 gram every day for 5 days was also ordered. Review of the Nurse's Notes revealed an entry on 6/19/12 ""on [MEDICATION NAME] tab(let)s and acylovir cream, as ordered, for shingles."" Review of the facility's Infection Control Surveillance and Quality Improvement Monthly Line-Listing Report for June and July revealed that Resident #2 was not listed for shingles or scabies. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of Resident #3's medical record revealed an order on 6/25/12 for [MEDICATION NAME] Cream applied HS and take off in the morning. Review of the Physician's Progress Note dated 6/25/12 revealed ""The patient is seen today with eczema to his skin. Fine, [MEDICATION NAME], [DIAGNOSES REDACTED]tous rash to chest and back. "" An Infection Control Individual Patient Infection Report was completed on 6/25/12 for Resident #3 with a [DIAGNOSES REDACTED]. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Review of Resident #4's medical record revealed a Consultant physician progress notes [REDACTED]. "" Review of the Physician's orders revealed an order dated 6/28/12 for ""[MEDICATION NAME] lotion from neck to feet (large amount) x 4 applications."" Further review revealed orders dated 7/3/12 for Ivermectin 3mg and [MEDICATION NAME] lotion with a total of 4 applications. A Consultant physician progress notes [REDACTED].#4 ""is being treated for [REDACTED]."" Review of the Physician's orders revealed an order dated 7/11/12 for Ivermectin 3mg and [MEDICATION NAME] lotion with a total of 4 applications. An Individual Patient Infection Report Form was completed on 7/11/12 for Resident #4 with a [DIAGNOSES REDACTED]. Review of the facility's Infection Control Manual revealed under the section Surveillance and Quality Improvement that ""the purpose of the surveillance program is to provide baseline data for detecting outbreak situations requiring control measures and provide a system of early detection of healthcare associated infection epidemics."" Elements of the program include ""data collection on a routine basis and consolidation and evaluation of data on a monthly basis. "" Review of the Infection Control Monthly Reports for June 2012 and July 2012 revealed scabies infections were not documented. A typed document provided by the facility stated that there were four residents with suspected scabies on Unit 3. The dates of infection onset were from 6/20/12 - 6/27/12. Residents #2 and #4 were not listed among the four residents with suspected scabies. The document stated that orders were received by the Physician to treat all staff/ residents and include therapy with [MEDICATION NAME] cream. The document stated that treatment was on 7/6/12. During telephone interview on 8/29/12 at approximately 1:38 pm., the Director of Nursing stated that she is responsible for monitoring infection control for the facility. The Director of Nursing stated that she did not track resident's with scabies.",2015-08-01
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
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
2598,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2019-08-28,656,G,0,1,49F511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and interview, the facility failed to ensure Care Plans were developed and implemented for 2 out of 3 residents reviewed for hospitalization s (Residents 5 and 9). The findings include the following: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 5's medical record on 08/28/19 at 12:45 PM revealed s/he was sent to the hospital on [DATE] following an incident of drooling, fixed eye gaze, and inability to grasp a hand. Resident #5 returned from the hospital on [DATE] with an increase in the medication [MEDICATION NAME] to address [MEDICAL CONDITION] activity. Review of Resident #5's initial Care Plan on 08/28/19 at 12:50 PM revealed the Care Plan listed falls as a risk and included [MEDICAL CONDITION] as a potential risk to increase falls, but the Care Plan did not directly address Resident #5's [MEDICAL CONDITION] history including type of [MEDICAL CONDITION], frequency of [MEDICAL CONDITION], or [MEDICAL CONDITION] medications and no revisions or additions had been made to the Care Plan following Resident #5's 07/18/19 hospitalization related to [MEDICAL CONDITION] activity. During an interview on 08/28/19 at approximately 1:00 PM, the Facility Administrator confirmed that Resident #5 was admitted to the facility with a [DIAGNOSES REDACTED].#5 was receiving [MEDICAL CONDITION] medication and this medication was increased following Resident #5's 07/18/19 hospitalization . The Facility Administrator confirmed Resident #5's Care Plan should have been revised following the hospitalization to address the [MEDICAL CONDITION] disorder and related medication. Resident #9 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's 8/14/19 Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 14. During the initial pool process and initial facility rounds, Resident #9 was observed in her/his wheelchair on 08/25/2019 at approximately 01:45 PM. Resident #9 informed the surveyor that her/his right foot and ankle hurt and that no one had looked at her/his right foot. Resident #9 stated I have told everybody. The Surveyor reported the concern to Licensed Practical Nurse (LPN) #1. LPN #1 verified that Resident #9 had a pressure ulcer to her/his right ankle unidentified by the facility staff and not treated or assessed until the surveyor brought it to the facility LPN's attention based on the concern by Resident #9. Record review on 8/25/19 at 02:30 PM with LPN #1 of Resident #9's medical record revealed that the facility last performed a documented body audit for Resident #9 on 8/2/19. This finding was confirmed by LPN #1. The 8/2/19 body audit revealed that Resident #9's skin was documented as intact with old venipuncture site on the right and left forearm. LPN #1 confirmed that no treatment orders were in place for Resident #9's Stage 2 pressure ulcer of the right outer ankle. Review of Resident #9's medical record revealed a note dated 8/25/19 at 8:45 PM that the Doctor was notified of open area to right outer ankle. Resident #9's Weekly Pressure Ulcer Record dated 08/25/2019 revealed right outer ankle identified as a Stage 2 measuring 0.5 x 0.5 x 01 and treatment order was initiated to clean the area with normal saline, apply a polymem oval dressing every 3 days and as needed. Review of the facility Skin Care Protocol Policy and Procedure #2 under procedures the policy states, Weekly skin assessment to be completed and documented on the Body Audit form for all residents. Review of Resident #9's medical record revealed a care plan which included concerns about the resident's abdominal folds redness. Interventions were to assess the resident's skin weekly.",2020-09-01
2599,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2019-08-28,686,G,0,1,49F511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, medical record review and review of the facility Skin Care Protocol Policy the facility failed to perform weekly skin assessments to identify and treat a pressure ulcer for Resident #9. The findings include the following: Resident #9 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial pool process and initial facility rounds, Resident #9 was observed in her/his wheelchair on 08/25/2019 at approximately 01:45 PM. Resident #9 informed the surveyor that her/his right foot and ankle hurt and that no one had looked at her/his right foot. Resident #9 stated I have told everybody. The Surveyor reported the concern to Licensed Practical Nurse (LPN) #1. LPN #1 verified that Resident #9 had a pressure ulcer to her/his right ankle unidentified by the facility staff and not treated or assessed until the surveyor brought it to the facility LPN's attention based on the concern by Resident #9. Record review on 8/25/19 at 02:30 PM with LPN #1 of Resident #9's medical record revealed that the facility last performed a documented body audit for Resident #9 on 8/2/19. This finding was confirmed by LPN #1. The 8/2/19 body audit revealed that Resident #9's skin was documented as intact with old venipuncture site on the right and left forearm. LPN #1 confirmed that no treatment orders were in place for Resident #9's Stage 2 pressure ulcer of the right outer ankle. Review of Resident #9's medical record revealed a note dated 8/25/19 at 8:45 PM that the Doctor was notified of open area to right outer ankle. Resident #9's Weekly Pressure Ulcer Record dated 08/25/2019 revealed right outer ankle identified as a Stage 2 measuring 0.5 x 0.5 x 01 and treatment order was initiated to clean the area with normal saline, apply a polymem oval dressing every 3 days and as needed. Review of the facility Skin Care Protocol Policy and Procedure #2 under procedures the policy states, Weekly skin assessment to be completed and documented on the Body Audit form for all residents.",2020-09-01
2600,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2019-08-28,689,D,0,1,49F511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and interview, the facility failed to ensure medications were stored in a secure manner for 1 out of 6 residents reviewed for accidents (Resident 19). The findings are: Resident #19 was admitted to the facility on [DATE]. Review of Resident #19's 8/26/19 Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 15. Observation in Resident #19's room on 08/25/19 at 02:09 PM revealed medication bottles which included [MEDICATION NAME] 10,00 mcg (3/4 bottle), Garlique OTC (opened in a box/labeled), Calcium 600 plus D3 OTC (3/4 bottle full), and [MEDICATION NAME] Silver Vitamins (3/4 bottle) in clear sight sitting on the resident's bedside table. Registered Nurse #1 went into the room with the surveyor, s/he confirmed the medications were present and in full view and removed the medications to a secure location. During an interview on 08/26/19 at 1:45 PM, Resident #19 confirmed s/he was administering her/his own [MEDICATION NAME], Garlique, Calcium, and [MEDICATION NAME] before it was removed from his/her room. Review of the facility policy titled Medications, Self-Administration of Drugs revealed residents were allowed to self-administer medications if there was a physician's order to self-administer medications and if the medications were stored in a closed drawer at the bedside. During an interview on 08/28/19 at 11:18 AM, the Facility Administrator confirmed Resident #19 did not have an order to self-administer medications and should not have the medications in his/her room.",2020-09-01
2601,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2017-11-15,155,D,0,1,G4YM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were afforded the opportunity to formulate their own Advance Directives for 1 of 11 residents reviewed for Advance Directives. (Resident #79) In addition, the facility failed to have a signed physician's orders [REDACTED].#41) The findings included: The facility admitted Resident #79 with [DIAGNOSES REDACTED]. On 11/14/17 at 11:00 AM, a review of Resident #79's medical record revealed that on Resident #79's Resuscitation Status Consent Form there was a check on the line that stated, DO NOT Resuscitate Status, and the form was not signed by Resident #79. Review of Resident #79's Minimum Data Set ((MDS) dated [DATE] revealed under section AC-500 a score of 13 indicating Resident #79 was independently able to make decisions. On 11/14/17 at 3:00 PM during an interview with the Director of Social Services, s/he verified Resident #79s Resuscitation Status Consent Form was not signed by the resident, and s/he indicated that Resident #79 was able to make decisions independently. The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Review of the medical record on 11/14/17 revealed a Resuscitation Status Consent Form dated 7/27/17 which indicated Resident #41 wanted to be a DNR. Further review of the medical record revealed there was no valid physician's orders [REDACTED]. During an interview on 11/14/17 at approximately 2:45 PM, the surveyor requested documentation from the Social Services department related to the resident's code status. On 11/14/17 at approximately 3:30 PM, the Social Services Director informed the surveyor that nursing staff reviewed the medical record and determined that there was no order for DNR status. The Social Services Director stated that staff would obtain a clarification order 11/14/17. On 11/14/17 at approximately 4:00 PM, the Director of Nursing (DON) reviewed the Advance Directive paperwork and stated the he/she would obtain the physician's orders [REDACTED].>On 11/15/17 at approximately 10:00 AM, the Social Services Director stated that the facility had recently begun using a Do Not Resuscitate Order form as part of the Advance Directive paperwork. The Social Services Director had no explanation for why Resident #41's record did not have a valid MD order upon review on 11/14/17.",2020-09-01
2602,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2017-11-15,167,C,0,1,G4YM11,"Based on observations during the survey, the facility failed to post the results of the most recent and preceding three years' surveys in a place readily available to residents and family members without having to ask on 1 of 1 unit. The findings included: Observations during the survey from 11/13/17 to 11/15/17 revealed a notebook labeled Survey Results was located sitting on the top of a credenza at the side of the receptionist's window in the main lobby. Observation further revealed that the notebook was located at a height above the head of the surveyor and would be inaccessible to any residents in a wheelchair. Observation of the notebook on 11/15/17 at approximately 9:30 AM revealed the (YEAR) survey was the only survey posted in the notebook. There was no signage located near the notebook nor posted on the bulletin board in the hallway on the unit to indicate that the 3 preceding years' surveys were available for review upon request. On 11/15/17 at approximately 2:30 PM, the Administrator confirmed the surveyor's findings.",2020-09-01
2603,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2017-11-15,280,C,0,1,G4YM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to have a care plan conference for one newly admitted resident ( resident #79) one of one newly admitted resident reviewed and the facility failed to have a care plan conference with all disciplines present for one of one resident reviewed for care plan conferences (Resident #41). The findings included: The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Care Plan Conference Attendance form dated 8/9/17 included space for signatures of staff attending the care plan meeting. Further review of the form revealed no signature to indicate that dietary staff or Certified Nurses Aide (CNA) staff participated in the Interdisciplinary Team that developed the care plan. During an interview on 11/15/17 at approximately 10:30 AM, the Social Services Director reviewed the form and confirmed the findings at that time. The facility admitted Resident #79 with [DIAGNOSES REDACTED]. On 11/15/17 at 10:10 AM, a review of Resident #79's medical record revealed that the resident was admitted to the facility on [DATE]. Further review of Resident #79's care plan revealed the facility had not had an interdisciplinary care plan meeting to assess or reassess the resident's needs since admission (27 Days). On 11/15/17 at 10:30 AM, an interview with the Director of Social Services, s/he verified Resident #79 had not had an interdisciplinary care plan meeting to assess or reassess the resident's needs since admission (27 days).",2020-09-01
2604,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2017-11-15,287,C,0,1,G4YM11,"Based on record review and interview, the facility failed to submit a Minimum Data Set (MDS) OBRA assessment in a timely manner for 10 of 11 discharged residents reviewed for MDS transmission of records. (Residents #89, #54, #50, #7, #90, #91, #92, #55, #93, and #43) In addition, the facility failed to submit a complete and timely MDS assessment for 1 current resident reviewed for MDS transmission of records. (Resident #34). The findings included: Review of the facility's MDS 3.0 Missing OBRA Assessment report revealed 10 discharged residents (Resident's #89, #54, #50, #7, #90, #91, #92, #55, #93, and #43) and 1 current resident (Resident #34) were listed on the report. On 11/14/17 the surveyor asked the Assistant Director of Nursing (ADON) / MDS Coordinator to review the report and to determine why the assessments were reported as missing. During an interview on 11/15/17 at approximately 2:30 PM, the ADON/MDS Coordinator stated that he/she had been the MDS Coordinator for a short period of time. At that time, the ADON/MDS Coordinator stated that he/she was still working on the report. No further information was provided related to the missing MDS assessments prior to exit from the facility.",2020-09-01
2605,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2017-11-15,356,C,0,1,G4YM11,"Based on observations, the facility failed to post complete nurse staffing information on a daily basis as required on 1 of 1 unit observed. The findings included: Observations during the survey on 11/13/17-11/15/17 revealed a Daily Staffing form was posted on the bulletin board located inside the Nurses' Station. Observations also revealed a Daily Staffing form was posted on the bulletin board in the hallway leading to the unit. Further observations revealed the form did not list the total number and actual hours worked for Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides. The form also did not include the resident census for each shift. The staffing information and resident census was not posted at the beginning of each shift. On 11/15/17 at approximately 2:30 PM, the Administrator reviewed the information and confirmed the findings at that time.",2020-09-01
2606,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2018-11-21,552,D,0,1,0OGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Influenza Vaccine, and Pneumococcal Vaccine, the facility failed to ensure Resident #122 was afforded the right to make his/her own decisions to receive or decline the Influenza Vaccine and the Pneumococcal Vaccine for 1 of 5 residents reviewed for the Influenza Vaccine and the Pneumococcal Vaccine. The Findings included: The facility admitted Resident #122 with [DIAGNOSES REDACTED]. Review on 11/20/2018 at approximately 12:30 PM of the medical record for Resident #122 revealed forms titled, Resident Vaccine Acceptance or Declination of the Influenza Vaccine and Resident Vaccine Acceptance or Declination of the Pneumococcal Vaccine. Both forms were signed by the Personal Representative. No documentation could be found in the medical record to ensure Resident #122 was deemed unable to make her own health care decisions by 2 physicians. Review on 11/20/2018 at approximately 1:00 PM of the facility policy titled, Influenza Vaccine, states under Policy: All residents, volunteers, private duty sitters and employees who have direct contact with residents will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Further review on 11/20/2018 at approximately 1:00 PM of the facility policy titled, Pneumococcal Vaccine, states under Policy: All residents will be offered the Pneumovac (Pneumococcal Vaccine) to aid in preventing pneumococcal infections (e.g., Pneumonia) An interview on 11/20/2018 at approximately 1:40 PM with the Administrator confirmed that Resident #122 was not offered the Flu and Pneumonia Vaccine, but the personal representative had declined for Resident #122 to receive them.",2020-09-01
2607,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2018-11-21,578,D,0,1,0OGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Advance Directive Use, the facility failed to ensure Resident #122, #13 and #1 were afforded the right to formulate an advance directive for 3 of 3 residents reviewed for Advance Directives. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review on 11/19/2018 at approximately 2:08 PM of the medical record for Resident #1, revealed a form titled, Resuscitation Status Consent Form, signed by Resident #1's personal representative. Resident #1 has a BIMS (Brief Interview for Mental Status) score of 15 out of 15. Resident #1 was not deemed unable to make his her own health care decisions for 2 physicians and therefore could formulate his/her own Advance Directive and sign for his/her wishes. The facility admitted Resident #122 with [DIAGNOSES REDACTED]. Review on 11/19/2018 at approximately 5:07 PM of the medical record for Resident #122 revealed a form titled, Resuscitation Status Consent Form, singed by Resident #122's personal representative. Resident #122 was not deemed unable to make his/her own health care decisions by 2 physicians and therefore could make the decision to be Full Code Status or a Do Not Resuscitate Status. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 11/20/2018 at approximately 11:08 AM of the medical record for Resident #13 revealed a form titled, Resuscitation Status Consent Form, signed by Resident #13's personal representative. Resident #13 has a BIMS of 15 out of 15, and was not deemed unable to make his her own health care decisions by 2 physicians and therefore could make his/her own decisions related to Code Status. An interview on 11/20/2018 at approximately 11:10 AM with the Administrator confirmed that Resident #1, #122 and #13 were able to make his/her own decision to formulate an Advance Directive and were not deemed unable to make his?her own health care decisions by 2 physicians. Review on 11/20/2018 at approximately 12:35 PM of the facility policy titled, Advanced Directive Use, which states, It is the policy of the facility to comply with state and federal regulations to provide each resident or responsible party, upon admission, a copy of the facility's policy regarding the implementation of the Patient Self-Determination Act which explains resident's rights under the law to make decisions regarding their health care.",2020-09-01
2608,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2018-11-21,623,D,0,1,0OGC11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #13 and the personal representative received in writing and in a language they could understand of the the reason for the transfer to the hospital for 1 of 1 resident reviewed for hospitalization . The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 11/20/2018 at approximately 12:10 PM of the medical record for Resident #13 revealed Resident #13 was transferred to the hospital on [DATE]. A transfer form was found in the medical record but no documentation to ensure the resident and the personal representative had received in writing and in a language they could understand of the reason for transfer to the hospital. During an interview on 11/21/2018 at approximately 9:30 AM with the Administrator confirmed that a copy of the Resident Transfer Form had gone in the packet to the hospital during the transfer but Resident #13 and the Personal Representative had not received a copy.,2020-09-01
2609,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2018-11-21,625,D,0,1,0OGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's, Admission Agreement, the facility failed to ensure Resident #13 and or his/her personal representative received a copy of the Bed Hold Policy with the bed payment upon transfer/discharge to the hospital for 1 of 1 resident reviewed for hospitalization . The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Review on 11/20/2018 at approximately 12/15 PM of the medical record for Resident #13 revealed this resident nor the personal representative have received a copy of the bed hold policy with the bed payment. An interview on 11/21/2018 at approximately 9:40 AM with the Administrator confirmed that Resident #13 nor the personal representative had received a copy of the Bed Hold Policy with the bed payment upon transfer to the hospital. The Administrator stated, The personal representative did not want to hold the bed. Review on 11/21/2018 at approximately 10:00 AM of the facility's, Admission Agreement. states, In the event that a resident is eligible for Medicare Part A benefits and is transferred to or readmitted to a hospital, Medicare Part A eligibility will be determined on the day the resident is admitted to the hospital. Resident's bed will be reserved at the Routine Services Daily Rate unless the resident elects, in writing, not to reserve a bed. During an interview on 11/ 8 at approximately 10:00 AM, the Social Service Worker stated, It is in our Admission Agreement, that the Resident nor the personal representative receives a copy of the Bed Hold Policy unless they are admitted to the hospital. If they go out to the hospital and then return because they are not admitted they do not receive a copy of the Bed Hold Policy with the bed payment.",2020-09-01
2610,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2018-11-21,689,D,0,1,0OGC11,"Based on observation and interview the facility failed to assure that 1 of 20 resident rooms inspected during the initial tour were free of hazards. The findings included: On 11/19/18 at approximately 8:41 AM an unsecured oxygen tank was found sitting upright near the wall, opposite the foot of the bed, of Resident #20. This finding was brought the the attention of CNA (Certified Nursing Assistant) # 1 on 11/19/19 at approximately 8:47 AM who acknowledged that the tank was not secured. CNA # 1 then removed the unsecured oxygen tank to secured storage.",2020-09-01
2611,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2018-11-21,730,D,0,1,0OGC11,"Based on record review and interview, the facility failed to ensure each CNA (Certified Nursing Assistant) received the required 12 hours annually of in service/training based on hire date and performance during the review of the staffing for 1 of 1 facility. The findings included: Review on 11/20/2018 at approximately 12:43 PM of the facility's staffing revealed no tracking and documentation of the required 12 hours annually of in service/training for each CN[NAME] An interview on 11/20/2018 at approximately 12:44 PM with the Director of Nursing confirmed that the tracking and documentation of the required 12 hours of annual in service/training had not been done for each CN[NAME]",2020-09-01
2612,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2018-11-21,761,D,0,1,0OGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, manufacturer labeling and manufacturer package insert the facility failed to assure that medications were properly stored in 1 of 2 medication carts and 1 of 1 medication rooms. The findings included: On 11/19/18 at approximately 12:22 PM inspection of the Medication Cart for Rooms 101-108, top left drawer, revealed one opened, 1/4 full, bottle of Acidophilus [MEDICATION NAME] 1 billion CFU (colony forming units) by Geri-Care Pharmaceuticals labeled Refrigerate after opening. This finding was verified by RN (Registered Nurse) # 1 on 11/19/18 at approximately 12:29 PM. On 11/19/18 at approximately 12:37 PM inspection of the Medication Room Refrigerator revealed a temperature of 41 degrees F (Fahrenheit) and four 1 ml (milliliter) multi-dose vials of [MEDICATION NAME] Injection USP (United States Pharmacopoeia) 1,000 mg (milligram)/ml by APP Pharmaceuticals belonging to Resident 121. The manufacturer package insert states: Store at 20 to 25 degrees Centigrade (68 to 77 degrees F). This finding was verified by RN # 1 on 11/19/18 at approximately 12:43 PM.",2020-09-01
2613,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2018-11-21,812,F,0,1,0OGC11,"Based on observation, interview and review of the facility policy titled, Proper Thawing, the facility failed to follow a procedure to ensure meat was thawed properly during meal preparation in 1 of 1 kitchen with the potential for affect all residents eating food prepared in the kitchen. The findings included: An observation during initial tour of the kitchen on 11/19/2018 at approximately 8:45 AM revealed meat thawing in a sink of water. The water was not running over the meat. An interview on 11/19/2018 at approximately 8:45 AM with the Culinary Production Manager confirmed the findings and stated, the water should have been running over the meat. Review on 11/21/2018 at approximately 9:15 AM of the facility policy titled, Proper Thawing, states under Policy: All frozen foods will be thawed according to proper thawing methods. The Purpose: states, Proper thawing methods help minimize the time food is in the temperature danger zone and prevent cross-contamination. The Procedure under #1 states, There are four safe ways to thaw frozen foods. The second bullet states, Cold running, potable water may be used if the the product can be thawed in 2 hours or less. The water should be 70 degrees or below. In order to prevent cross contamination do not mix different products in the sink to thaw at the same time. The sink should be cleaned and sanitized before and after thawing each item.",2020-09-01
2614,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2018-11-21,880,D,0,1,0OGC11,"Based on observation, interview and review of the facility policy titled, Laundry And Bedding, Soiled, the facility failed to follow a procedure to prevent the spread of infection during the transportation of soiled linen in 1 of 1 soiled utility rooms. The findings included: An observation on 11/19/2018 at approximately 11:05 AM during the pick up of soiled linen by the laundry department from soiled utility room on the unit revealed soiled linen in a large bin in a large plastic bag. Not all soiled linen was bagged prior to placing the soiled linen in the bin in the soiled utility room. During an interview on 11/19/2018 at approximately 11:15 AM with Laundry Worker #1 confirmed the soiled linen was not bagged at the point of use prior to putting it in the bin in the soiled utility room. Review on 11/19/2018 at approximately 11:45 AM of the facility policy titled, Laundry And Bedding, Soiled, states under Policy: Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. Number 2 under Policy Interpretation and Implementation states,Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use.",2020-09-01
2615,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2018-11-21,908,E,0,1,0OGC11,"Based on observation, interviews and review of the facility policy titled, Dryer Lint Policy, and Policies and Procedures for Handling Soiled Linen, the facility failed to ensure an excessive amount of lint was removed from 2 of 2 clothes dryers. The findings included: An observation on 11/19/2018 at approximately 8:45 AM of the laundry room revealed 2 of 2 clothes dryers with an excessive amount of lint build-up on the upper 3 inside walls and hanging on the wiring. An interview on 11/19/2018 at approximately 8:50 AM with the laundry worker confirmed the excessive build up of lint in the clothes dryers. A second interview on 11.19/2018 at approximately 9:30 AM with the Housekeeping Supervisor confirmed the excessive lint build up and provided the facility policy on lint removal. Review on 11/19/2018 at approximately 9:45 AM of the facility policy titled, Dryer Lint Policy, states, Remove lint from the dryer lint screen every time you use the dryer. This helps prevent a fire, but it also helps laundry to dry faster. Review on 11/19/2018 at approximately 9:45 AM of the facility policy titled, Policy And Procedure For Handling Soiled Linen, number 5 states, All lint in dryer vents needs to be cleaned after every load dried. It is important that is is done to prevent fires in the dryer. No documentation could be found to ensure the area behind the lint baskets were cleaned on a regular basis.",2020-09-01
4570,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2016-11-16,371,D,0,1,ITYB11,Based on observations and interviews the facility failed to ensure foods in walk-in freezer were frozen and staff did not handle foods with their bare hands. ( 1 of 2 kitchens and main dining room) The findings included: Initial tour of the main kitchen on 11/14/16 at 9:45 AM revealed 3 boxes of individual ice cream cups and 3 boxes of popsicles soft and not frozen. The Dining Services Director confirmed these were soft and not completely frozen. On 11/14/16 at 12 Noon in the Main Dining Room a CNA ( Certified Nursing Assistant) was observed to serve a resident his/her lunch. The CNA lifted the slice of bread on the sandwich with his/her bare hands to place mustard on the sandwich. The staff member then used his/her hands to hold and cut the sandwich in half.,2019-11-01
4571,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2016-11-16,441,D,0,1,ITYB11,"Based on observation and interview a staff member did not wash hands between helping 2 different residents in the main dining room during lunch meal. The findings included: On 11/15/16 at 12 Noon during the lunch meal in the main dining room, staff member#2 went to a resident and was touching him/her on the head and shoulder. The staff member then went to another resident to place a clothing protector on that resident. The Staff member also went to kitchen /serving window to pick up plate and serve resident. The staff member did not wash or sanitize hands between touching both residents. The Administrator stated all staff are inserviced about washing hands between residents.",2019-11-01
5346,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2016-01-21,155,D,0,1,ZBI211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that 1 of 10 sampled residents reviewed for Advance Directives were given the opportunity complete/sign their own Advance Directive. Resident #29 Advance Directive for Do Not Resuscitate (DNR) was signed by a family member without two physician's signatures to determine competency. The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. A review of the medical record on 1/20/16 at approximately 10:44 AM revealed a physician's orders [REDACTED].#29 was on a 72 hour Do Not Resuscitate (DNR) order. Further record review revealed there was a RESUSCITATION STATUS CONSENT FORM in the chart that indicated the resident's DNR was signed by a family member with one physician's signature that indicated the resident could not make health care decisions. An interview on 1/20/16 at approximately 11:47 AM with the Social Services/Admission Staff confirmed the findings that only one physician signature was noted on the form and two physician signatures were required. An interview on 1/20/16 at approximately 11:55 AM with the Assistant Director of Nursing (ADON) revealed another 72 hours DNR physician's orders [REDACTED].",2019-01-01
5347,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2016-01-21,334,C,0,1,ZBI211,"Based on record reviews, interview and the facility's VACCINATION OF RESIDENTS policy, the facility failed to ensure that 5 of 5 sampled residents reviewed for documentation of immunization education was provided for 5 of 5 census sampled residents reviewed. (Residents #29, #57, #114, #117 and #120) The findings included: Review of 5 of 5 census charts on 1/19/16 that included Residents #29, #57, #114, #117 and #120 revealed there was no documentation in the medical record to indicate immunization education was provided. Review of the facility's VACCINATION OF RESIDENTS policy revealed under #1: Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. #2: Provision of such education shall be documented in the resident's medical record. #5: If vaccinations are refused, the refusal shall be documented in the resident's medical record. An interview on 1/19/16 at approximately 3:50 PM with the Director of Nursing (DON) confirmed the findings that there was no documentation in the medical record to determine that immunization education was provided related vaccines.",2019-01-01
5348,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2016-01-21,371,F,0,1,ZBI211,"Based on observations and interviews the facility failed to maintain the range top backsplash and the top free standing oven in a clean sanitary condition. ( 1 of 1 main kitchen observed) The findings included: During the initial tour of the main kitchen on 1/19/16 at 10 AM with the Dietary Manager, several items were pointed out to the Manager. The range top back splash had a heavy build up of dark brown caked on splatters over a large area of the black splash. The top free standing oven had a large build up inside the oven of dark brown splatters and food debris on all inside walls of the oven and the inside glass doors. When the Manager was asked about the cleaning schedule for these two items, he/she responded. I don't know what the schedule is. The range and ovens were observed the same x 3 days of the survey. Another interview on 1/21/16 at 9:30 AM with Cook/Dietary Aide #1 verified with the schedule posted on the board that the schedule had not been kept up. The Cook/Aide stated that the items were not cleaned last week, nor this week, and possibly not the week before that. The Dietary Manager presented a cleaning schedule, but not the posted schedule, which had range initialed as having been cleaned but no date for the cleaning. The Cook/Aide confirmed the back splash and oven had a heavy build up and had not been cleaned recently.",2019-01-01
6523,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2014-10-09,241,E,0,1,FP7B11,"Based on observations and interviews the facility failed to enhance the resident's dining experience with respect and dignity. During lunch observations on 10/7/14 staff was observed placing clothing protectors on 10 of 10 residents in the dining room without asking resident preference. On 10/08/14 staff was observed placing clothing protectors on 5 of 5 residents in the dining room without determining the residents preference. ( 1 of 1 dining rooms observed for dignity related to dining) The findings include: Observations made during the lunch dining service on 10/7/14 and 10/8/14 revealed Certified Nursing Assistant # 1 and Certified Nursing Assistant # 2 placing clothing protectors on residents without first determining the residents preference. On 10/7/14 at approximately 11:54 AM CNA #1 was observed placing the clothing protector on Resident #90 who made the statement: Oh, so you are going to put the lovely bib on me. During an interview with CNA #1 and CNA #2 on 10/8/14 at approximately 12:20 PM, they both confirmed residents were not given a choice or preference of wearing clothing protectors. Review of the meal observation procedure provided by the facility on 10/9/14 at approximately 10:45 AM, revealed the direction that Staff needs to ensure clothing protectors are available and worn. There was no facility policy in place/provided related to determining residents choice for wearing clothing protectors.",2018-01-01
6524,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2014-10-09,441,F,0,1,FP7B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews and review of the facility's Infection Control Policies and Procedures for Clostridium Difficile and Isolation-Categories of Transmission-Based Precautions policy, the facility failed to maintain an Infection Control Program to prevent the transmittal of disease for 1 of 1 residents identified with Clostridium Difficile (C-Diff). Resident #93, diagnosed with [REDACTED]. There was no evidence staff was fully informed to monitor, prevent or appropriately treat reoccurrence of the behavior. A staff member was observed in the resident's room without use of the appropriate personal protective equipment contrary to facility policy. The findings included: The facility admitted Resident #93 on 10/02/14 with [DIAGNOSES REDACTED]. A chart review on 10/08/14 at approximately 10:30 AM revealed a Social Services note dated 10/05/14 that indicated nursing staff reported Res (resident) has increased confusion at night. Res (resident) has gone into other rooms to use the bathroom. Res (resident) also in halls, walking unassisted. Staff reminded Res (resident) he/she needs to be walking with staff. Further record review revealed a Nurse's note dated 10/05/14 at 7 PM that indicated Resident #93 went to someone else's room to go to the bathroom. The Nurse's note further indicated Resident #93 tried to flush a pull-up in the commode. There was no documentation to indicate which room/rooms Resident #93 was in or what precautions/ procedures were used once it was discovered that Resident #93 was using other residents bathrooms. An interview on 10/08/14 at approximately 10:59 AM with the DON (Director of Nursing) revealed the DON did not know which room/rooms the resident went in after reviewing the nurse's note. The DON further stated he/she was not sure if the resident actually used the bathroom of another resident's room. The DON stated he/she could not locate an incident /24 hour report related the Resident #93 using another resident's bathroom. An interview on 10/08/14 at approximately 12:20 PM with OT (Occupational Therapist) revealed resident's with[DIAGNOSES REDACTED] are able to participate in therapy in the therapy room and that everything the resident touches is wiped down . OT further stated a resident with[DIAGNOSES REDACTED] was taken back to use his/her own bathroom if it was needed. An interview on 10/08/14 at 12:22 with PT (Physical Therapist) revealed equipment use by resident's with[DIAGNOSES REDACTED] was wiped down after use and that the resident was taken back to his/her own bathroom if needed. An interview on 10/08/14 at approximately 12:25 PM with LPN (Licensed Practical Nurse) #2 revealed a resident on Contact Precautions should use their own bathroom. An interview on 10/08/14 at approximately 2:20 PM with the MD (Medical Director) revealed residents on contact precautions should be in a private room and if the resident participates in therapy the equipment should be wiped down after use. When asked if he/she was aware the resident was eating in the dining room with other residents, the MD stated he/she was not aware the resident was eating in the dining room with other residents. An interview on 10/08/14 at approximately 2:29 PM with SW (Social Worker) revealed he/she was informed by a nurse that resident was in another resident's bathroom. The SW further stated he/she had seen Resident #93 walking in the hall unassisted by staff. A telephone interview on 10/08/14 at approximately 2:39 PM with LPN (Licensed Practical Nurse) #1 revealed a CNA (Certified Nursing Aide) informed him/her that Resident #93 was observed using another resident's bathroom. LPN #1 further stated the resident was in the dining room on 10/05/14 and went to the wrong hall and ended up in the wrong bathroom. Review of the facility's policy Clostridium Difficile revealed under policy interpretation #1. The facility has adopted Standard Precautions, and all residents' blood, body fluids, excretions, and secretions are considered potentially infectious. Review of the facility's Isolation-Categories of Transmission-Based Precautions policy revealed under Contact Precautions b. Resident Placement (1) Place the individual in a private room if it is not feasible to contain drainage, excretions, blood or body fluids (e.g., the individual is incontinent on the floor, or wanders and touches others). (2) If a private room is not available, the Infection Control Coordinator will assess various risks associated with other resident placement options (e.g, cohorting). In addition to wearing gloves as outlined under Standard Precautions, wear gloves, (clean, non sterile) when entering the room .After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces or items in the resident's room. During an observation of the Resident #93 room on 10/8/14 at approximately 2:18 PM, there was an orange sign on the door that stated: Contact Precautions .before care wash hands,wear gown if soiling likely, wear gloves when entering room and change after contact with infective material. On 10/8/14 at approximately 10/8/14 at approximately 2:24 PM Certified Nursing Assistant (CNA) #1 was observed entering the resident's room who was under contact precaution for Clostridium Difficile Colitis (C Diff). CNA #1 asked if the resident needed anything. CNA #1 was observed disposing a used Styrofoam cup in the resident's trash and then leaving the resident's room. During an interview with CNA #1 on 10/8/14 at approximately 2:48 PM, s/he confirmed that gloves were not worn while entering the resident's room. CNA #1 stated We are to go in the room with gloves. If providing care we are to wear gown and gloves. Further review of the residents Bowel and Bladder Detail Report, provided by the facility, revealed the resident was usually continent with an occasional episode of incontinence. Of 47 toileting details recorded, the resident was incontinent 8 times. It was unclear if the incontinency was bowel or bladder related.",2018-01-01
7545,WESTMINSTER HEALTH & REHAB CENTER,425291,831 MCDOW DRIVE,ROCK HILL,SC,29732,2013-05-08,502,D,0,1,5DEG11,"**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 laboratory testing supplies were removed from storage with other laboratory supplies, available for resident testing, in the facility's medication room. The findings included: On [DATE] at 9:17 AM, observation of the facility's medication room revealed two 40 milliliter Versa Trek Redox 2, EZ Draw Diagnostic Systems with an expiration date of ,[DATE]. During an interview on [DATE] at 9:29 AM, the facility's Assistant Director of Nursing revealed that the Charge Nurses and the Nurse Supervisors are responsible for checking the medication room for expired products. S/he stated the checks are done randomly but are done approximately monthly.",2017-01-01
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
1841,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2017-05-25,157,D,0,1,K3UF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician of multiple incidents of pulling on a Permacath used for [MEDICAL TREATMENT] and a Percutaneous Endoscopic Gastrostomy feeding tube in order to timely initiate treatment for [REDACTED].#193, 1 of 1 resident reviewed with a Permacath. The findings included: The facility admitted Resident #193 with [DIAGNOSES REDACTED]. On 04/19/2017, review of the nurses notes revealed the following entries: 3/26/17 Resident observed digging in wound, removing dressing and putting BM in the wound. 3/25/17 Removed dressing from [MEDICAL TREATMENT] port, pulling at GT (Gastrostomy Tube). 3/20/17 Unhooked GT, feeding on floor. 3/15/17 Removed dressing from [MEDICAL TREATMENT] port, stitches observed to be dislocated. GT disconnected, feeding on floor. 3/12/17 Cont(inues)) to pull at [MEDICAL TREATMENT] port, removed dressings, pulling on GT 3/11/17 Pulling at [MEDICAL TREATMENT] port, removing dressing, pulling at GT, feeding observed on floor, resident removed GT from port 2/18/17 observed pulling on portcath (sic) to upper chest wall times two. Informed resident not to pull on it. Observed dressing to portacath half way off and bright red drainage noted from the insertion site. Nurse cleaned area and put new and bigger dressing to site to prevent resident from pulling on portacath. Record review revealed no documentation the physician was notified of any of the above incidents At 4:51 PM, review of the Physicians Orders revealed orders dated 4/6/17 for mitts to bilateral hands daily for safety and 4/11/17 for chest xrays AP (anterior/posterior), lateral and left oblique to check port (permacath) placement. During an interview at 4:24 PM on 04/20/2017, the Director of Nursing (DON) confirmed the documentation of the resident pulling at the [MEDICAL TREATMENT] access line and the PEG tube on 2/18/17, 3/11, 3/12, 3/15 and 3/20/17. The DON also confirmed the resident had a Permacath, not a portacath and that the staff were using the incorrect terminology. When asked if s/he would have expected the nurse to notify the physician of the incidents, especially when Stitches to [MEDICAL TREATMENT] port observed to be dislocated on 3/15/17 and bright red drainage noted from the insertion site o 2/18/17, the DON stated that would have been the appropriate thing to do.",2020-09-01
1842,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2017-05-25,201,D,1,1,K3UF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that each resident remained at the facility and was not discharged inappropriately. There was a resident to resident incident on 3/23/17 between Resident #68 and Resident #237. The facility failed to adequately document the circumstances of the incident and discharged Resident #237 because of the incident. The incident happened at approximately 4:50 PM on 3/23/17. Resident #237 was discharged from the facility to the hospital at 2:00 AM on 3/24/17. There was no documentation related to why there was a lapse in time between the incident and the resident's discharge. There was no documentation of Resident #237 having additional behaviors between the time of the incident and the time of the resident's discharge. One of one resident reviewed for inappropriate discharge. The findings included: Resident #237 was admitted to the facility on [DATE]. The resident was seen by the psychiatrist on 1/22/17 who indicated the resident was hospitalized with withdrawal and possible [MEDICAL CONDITION] activity prior to nursing home admission. The resident had a history of [REDACTED]. Review of the hospital Discharge Summary dated 12/16-12/28/16 revealed the resident's past medical history was positive for chronic [MEDICAL CONDITION] and it appears that he has dementia associated with it. Review of the Physician's Telephone Orders dated 3/23/17 revealed, may send to hospital for evaluation, may have 1:1 until leaves for hospital. Review of the Behavior Management Documentation Form revealed the program was initiated 1/3/17 and the resident entered into the program. The resident was removed from the program 2/27/17 related to no behaviors noted. Review of the Nurses' Notes dated 1/6/17 revealed behavior reviewed. Admit to behavior management program for aggression with staff during redirection, attempt transfer with no assist, wanders with exit seeking and refusal of care. The Nurse's Note dated 2/2/17 indicated resident behaviors reviewed with no new behavior noted. The Nurse's Note dated 2/27/17 revealed behaviors reviewed, no new new behaviors noted since last review. Remove from behavior management program. There were no additional Nurses' Notes until 3/23/17 at 4:02 AM, the note indicated the resident was attempting to touch and rub the chest of female residents when in the [CONDITION]U common area. Staff present and redirected him with a snack. He accepted the snack and went into the dining room and sat and ate his snack. No further behaviors noted. On 3/24/17 at 2:15 AM the nursing note indicated the resident was transferred to the hospital for psych evaluation. The resident left the facility at 2:00 AM. Review of Resident #68's medical record revealed a SBAR Communication Form dated 3/23/17 that indicated the resident was noted sitting on a male peer's lap (Resident #237). The SBAR noted Resident #68 was fully clothed sitting on the male peer's lap while the male peer had his penis exposed. Review of the medical record revealed Resident #68's [DIAGNOSES REDACTED]. The residents resided on the facility's memory support unit ([CONDITION]U), Review of the Resident Incident Report for Resident #68 dated 3/23/17 at 4:50 PM revealed Resident #68 was unable to be interviewed. Resident confused and disoriented x 3 at baseline. The Resident Incident Report indicated the location of the incident was resident room, but did not indicate the room number where the incident occurred. The follow-up section indicated the resident's physician was notified, deferred to ER physician for examination. ER physician did not perform a rape kit, but did screen for a urinary tract infection via urinalysis. The surveyor requested a complete copy of the facility's investigation into the incident involving Resident #68 and Resident #237 on 3/23/17. The facility provided the surveyor with a copy of the police report and a copy of the hospital discharge summary. There was also a handwritten statement from the Memory Support Unit Manager, RN #1, that indicated s/he had interviewed 3 residents on the unit that were noted to have dementia and confusion. There was no additional information provided related to investigating the incident. In an interview with the surveyor on 4/19/17 at approximately 12:50 PM, LPN #3 stated that s/he was assigned to Resident #68 today, but usually works the other side. LPN #3 stated Resident #237 was on the same hall as Resident #68. Resident #237 was friendly and pleasant, he talked to everyone, staff and residents. The resident could converse with staff. LPN #3 stated there were no complaints from CNAs and s/he never witnessed the resident be combative with staff. LPN #4 on that side came and asked him/her to help do an assessment after the incident on 3/23/17. They completed a body assessment on Resident #68. The checked for any changes and any bruising. LPN #4 told him/her the female resident was found sitting in the male resident's lap. LPN #4 brought Resident #68 to the front of the unit and they completed the assessment in the bathroom near the nurses' station. They told them the next morning that the resident was sent out to the hospital for an evaluation. In an interview with the surveyor on 4/19/17 at approximately 1:05 PM, CNA #6 stated s/he has been at the facility for [AGE] years. She is usually assigned to Resident #68. Resident #68 has never gone up to other residents, she walks around in her own world. The resident walks around the unit a lot. They will find her in other residents' rooms. Resident #68 will go up and pat other residents. CNA #6 stated s/he has not witnessed her try to sit on other resident's laps. CNA #6 stated s/he would see Resident #237 around the unit, he liked to talk a lot. He liked to talk with staff and some of the residents. In an interview with the surveyor on 4/19/17 at approximately 3:05 PM, CNA #7 stated s/he works on [CONDITION]U. S/he is usually assigned to Resident #68. Resident #68 wanders but has no other behaviors. Resident #68 does not interact with the other residents very much. CNA #7 stated s/he has never noticed Resident #68 trying to approach other residents or sit in their laps. CNA #68 stated s/he was at the facility on the day of the incident, but did not see the residents. CNA #7 stated the nurses did not tell them very much about the incident. CNA #7 stated s/he did get Resident #68 ready for the hospital, s/he changed the resident's clothes and brief and got her ready. CNA #7 stated Resident #237 liked to talk a lot. Resident #237 was more with it than some of the other residents on the unit. Resident #237 was very nosy, he would listen to your conversation and try to get in on it. The resident would repeat whatever he heard. CNA #7 stated Resident #237 was not combative with care. When he first came back to the unit, he had behaviors. They would find him under the bed trying to fix things. He wouldn't let the nurses give him care. As time went on he became very pleasant. He did a lot for himself. In an interview with the surveyor on 4/19/17 at approximately 3:30 PM, the social worker stated when Resident #237 first came to the facility he didn't want anyone to bother him, he would get aggressive with staff. After he went through withdrawals he was fine. Resident #237 was on the behavior management program. Resident #237 would stay in his room, he would want to be nude most of the time. After the withdrawals, he would come out his room and socialize more. The social worker stated s/he thinks he may have disrobed out in the hall toward the end of his withdrawal, staff would redirect him. Resident #237 came off the behavior management program. Resident #237 was very social. In an interview with the surveyor on 4/19/17 at approximately 3:45 PM, [CONDITION]U Unit Manager stated s/he was at the facility the day of the incident. S/he was on another unit when LPN #4 notified him/her about the incident. Resident #68 was found sitting on Resident #237's lap. Resident #237 was removed from the room. They were in room [ROOM NUMBER], the room of another resident. That resident was in the room at the time and was in his/her bed. When the [CONDITION]U unit manager got to the unit, LPN #3 and LPN #4 had completed the body audit on Resident #68 and s/he was wandering around the unit. Resident #237 was in his room and was on 1:1. Resident #237 was sent out to the hospital for a psych evaluation on 3/23/17 after the incident. He was sent out for inappropriate, abnormal behaviors, sexual. Resident #237 was admitted to the rehab unit of the facility, he was sent to [CONDITION]U because he was exit seeking. Resident #237 had some combative behaviors and resisted care when he first came onto the [CONDITION]U unit. The resident's behaviors improved, he was on the behavior management program. Resident #237 was very friendly and talkative. He liked to talk with other staff and residents. The [CONDITION]U unit manager stated the other residents on the unit could not talk appropriately. Resident #237 was alert and oriented. In an interview with the surveyor on 4/19/17 at approximately 4:30 PM, the facility administrator stated s/he found out about the incident right after it happened. The [CONDITION]U unit manager told him/her that one of the resident's on the unit told LPN #4 s/he needed to check on a room. LPN #4 went into the room to check and found Resident #237's exposed penis and Resident #68 sitting in his lap still fully clothed. The facility administrator stated there was no one else in the room with them. The facility administrator stated s/he does not recall which resident told LPN #4 s/he needed to look in the room where the 2 residents were. The administrator stated the physician said Resident #68 did not need to go out to the hospital. They secured transport for Resident #237 to go out as well to get him out of the patient population. Resident #237 was sent out because he could not remain on the [CONDITION]U unit with that type of behavior. The facility administrator stated they cannot provide continuous 1:1. They notified the police about the incident because of the nature of the situation, Resident #237's attempt and exposure. The facility administrator stated s/he did not talk with Resident #237. In an interview with the surveyor on 4/19/17 at approximately 6:45 PM, the facility administrator stated the facility investigation consisted of the police report and the hospital report. The facility administrator stated there was no need to investigate because it was not an allegation, it was witnessed by staff. When asked what was witnessed, s/he stated the male resident was exposed. The administrator stated that a resident told LPN #4 s/he should go look at what was happening in the room. The facility administrator could not provide the name of the resident when asked by the surveyor who the resident was. The facility administrator stated they did not interview CNAs on the unit because they didn't want to start anything and have it spread around. The facility administrator stated that no one interviewed Resident #237, he was sent out because he was the perpetrator. When asked how they knew he was the perpetrator, the facility administrator stated because he was exposed. The surveyor asked how they knew Resident #68 was not the instigator, and they stated they didn't know. There were no staff interviews conducted to see if other staff witnessed any behavior between the 2 residents involved in the incident. The administrator stated there was no one else in the room at the time of the incident, while the unit manager stated in an earlier interview that there was another resident in the room at the time of the incident. There was no statement that indicated if there was any other interaction between the residents other than sitting. In a telephone interview with the surveyor on 4/26/17 at approximately 2:20 PM, the residents' physician stated s/he did not remember Resident #237, too many residents come and go for him/her to remember. The physician stated s/he did know about the incident and that Resident #68 was found sitting on Resident #237's lap. The physician stated both residents were dressed and there was no harm, no foul.",2020-09-01
1843,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2017-05-25,225,G,1,1,K3UF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse are reported to the State Survey Agency and failed to provide evidence that an allegation of sexual abuse was thoroughly investigated. Resident #68 was found sitting in Resident #237's lap in a resident room. Resident #237 was noted to have his penis exposed. One of one allegation reviewed for abuse. The findings included: Review of Resident #68's medical record revealed a SBAR Communication Form dated 3/23/17 that indicated the resident was noted sitting on a male peer's lap (Resident #237). The SBAR noted Resident #68 was fully clothed sitting on the male peer's lap while the male peer had his penis exposed. Review of the medical record revealed Resident #68's [DIAGNOSES REDACTED]. The residents resided on the facility's memory support unit ([CONDITION]U). Review of the Resident Incident Report for Resident #68 dated 3/23/17 at 4:50 PM revealed Resident #68 was unable to be interviewed. Resident confused and disoriented x 3 at baseline. The Resident Incident Report indicated the location of the incident was resident room, but did not indicate the room number where the incident occurred. The follow-up section indicated the resident's physician was notified, deferred to ER physician for examination. ER physician did not perform a rape kit, but did screen for a urinary tract infection via urinalysis. Review of the Nurse's Note dated 3/23/17 at 10:15 PM revealed Resident #68 was transferred to the hospital ER via ambulance to be evaluated. The Nurse's Note dated 3/24/17 at 2:30 AM indicated Resident #68 returned to the facility from the hospital. Review of the Nursing Home to Hospital Transfer Form for Resident #68 dated 3/23/17 revealed the reason for transfer section was not completed by the facility. Review of the Physician Telephone Order dated 3/23/17 indicated to send Resident #68 to the hospital for evaluation and treatment as needed. Resident #237 was admitted to the facility on [DATE]. The resident was seen by the psychiatrist on 1/22/17 who indicated the resident was hospitalized with withdrawal and possible [MEDICAL CONDITION] activity prior to nursing home admission. The resident had a history of [REDACTED]. Review of Resident #237's Physician's Telephone Orders dated 3/23/17 revealed, may send to hospital for evaluation, may have 1:1 until leaves for hospital. The surveyor requested a complete copy of the facility's investigation into the incident involving Resident #68 and Resident #237 on 3/23/17. The facility provided the surveyor with a copy of the police report and a copy of the hospital discharge summary. There was also a handwritten statement from the Memory Support Unit Manager, RN #1, that indicated s/he had interviewed 3 residents on the unit that were noted to have dementia and confusion. There was no additional information provided related to investigating the incident. In an interview with the surveyor on 4/19/17 at approximately 3:05 PM, CNA #7 stated s/he works on [CONDITION]U. S/he is usually assigned to Resident #68. Resident #68 wanders but has no other behaviors. Resident #68 does not interact with the other residents very much. CNA #7 stated s/he has never noticed Resident #68 trying to approach other residents or sit in their laps. CNA #68 stated s/he was at the facility on the day of the incident, but did not see the residents. CNA #7 stated the nurses did not tell them very much about the incident. In an interview with the surveyor on 4/19/17 at approximately 3:45 PM, [CONDITION]U Unit Manager stated s/he was at the facility the day of the incident. S/he was on another unit when LPN #4 notified him/her about the incident. Resident #68 was found sitting on Resident #237's lap. Resident #237 was removed from the room. They were in room [ROOM NUMBER], the room of another resident. That resident was in the room at the time and was in his/her bed. When the [CONDITION]U unit manager got to the unit, LPN #3 and LPN #4 had completed the body audit on Resident #68 and s/he was wandering around the unit. Resident #237 was in his room and was on 1:1. Resident #237 was sent out to the hospital for a psych evaluation on 3/23/17 after the incident. He was sent out for inappropriate, abnormal behaviors, sexual. In an interview with the surveyor on 4/19/17 at approximately 4:30 PM, the facility administrator stated s/he found out about the incident right after it happened. The [CONDITION]U unit manager told him that one of the resident's on the unit told LPN #4 s/he needed to check on a room. LPN #4 went into the room to check and found Resident #237's exposed penis and Resident #68 sitting in his lap still fully clothed. The facility administrator stated there was no one else in the room with them. The facility administrator stated s/he does not recall what resident told LPN #4 s/he needed to look in the room where the 2 residents were. The administrator stated the physician said Resident #68 did not need to go out to the hospital. Resident #68's husband wanted the resident to go to the hospital to have the rape kit performed. They secured transport for Resident #237 to go out as well to get him out of the patient population. Resident #237 was sent out because he could not remain on the [CONDITION]U unit with that type of behavior. They cannot provide continuous 1:1. They notified the police about the incident because of the nature of the situation, Resident #237's attempt and exposure. The facility administrator stated s/he did not talk with Resident #237. The facility administrator stated they did not report the incident to certification because it was resident to resident and did not involve a staff member. In an interview with the surveyor on 4/19/17 at approximately 6:45 PM, the facility administrator stated the facility investigation consisted of the police report and the hospital report. The facility administrator stated there was no need to investigate because it was not an allegation, it was witnessed by staff. When asked what was witnessed, s/he stated the male resident was exposed. The administrator stated that a resident told LPN #4 s/he should go look at what was happening in the room. The facility administrator could not provide the name of the resident when asked by the surveyor who the resident was. The facility administrator stated they did not interview CNAs on the unit because they didn't want to start anything and have it spread around. The facility administrator stated that no one interviewed Resident #237, he was sent out because he was the perpetrator. When asked how they knew he was the perpetrator, the facility administrator stated because he was exposed. The surveyor asked how they knew Resident #68 was not the instigator, and they stated they didn't know. There were no staff interviews conducted to see if other staff witnessed any behavior between the 2 residents involved in the incident. The administrator stated there was no one else in the room at the time of the incident, while the unit manager stated in an earlier interview that there was another resident in the room at the time of the incident. There was no statement that indicated if there was any other interaction between the residents other than sitting. In a telephone interview with the surveyor on 4/26/17 at approximately 2:20 PM, the residents' physician stated s/he did not remember Resident #237, too many residents come and go for him/her to remember. The physician stated s/he did know about the incident and that Resident #68 was found sitting on Resident #237's lap. The physician stated both residents were dressed and there was no harm, no foul. Review of the facility's Abuse Policy revealed it is the policy of [ENTITY] to investigate allegations and occurrences of patient abuse. The Administrator is responsible for assuring that an accurate and timely investigation is completed. If there is an occurrence of or allegation involving patient abuse, the following investigation and reporting procedures will be followed: documentation of the investigation, information gathering, interviews, all investigative information should be kept on file in a secured location. Documentation of the investigation should include date and time of the alleged occurrence, names of accused and any witnesses, names of staff who investigated the allegation, any physical evidence and description of emotional state of resident, details of the alleged incident, and information gathered from the investigation. Information gathering included who did it, what happened (be specific about the event that occurred), and where did it happen. Further review of the facility's Abuse Policy revealed it is the policy to comply with all applicable federal and state requirements regarding the reporting of patient abuse. Any allegation, suspicion, or identified occurrence is identified involving patient abuse should be immediately reported to the Administrator. The Administrator should notify the appropriate state agency. The state survey agency should be notified through established procedures of any allegations of abuse within 2 hours after the allegation is made if the events upon which the allegation is based involve abuse. The Administrator should direct an investigation into the allegation or incident.",2020-09-01
1844,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2017-05-25,319,G,1,1,K3UF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that a resident who displays a psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Resident #237 was noted to develop behaviors after being admitted to the facility. Resident #237 was seen once by a psychiatrist and the recommendation was not followed up on. The resident's facility physician did not document anything related to the resident's behaviors or improvement. One of two residents reviewed for behaviors. The findings included: Resident #237 was admitted to the facility on [DATE]. Review of Resident #237's SC Limited Power of Attorney Form revealed the resident signed the form 12/29/16 and the witness attestation indicated the resident was of sound mind. Review of the resident's Admission Interim Care Plan revealed the resident required admission to the [CONDITION]U and was admitted [DATE] for [DIAGNOSES REDACTED]. Admit to [CONDITION]U. Review of the hospital Discharge Summary dated 12/16-12/28/16 revealed the resident's past medical history was positive for chronic [MEDICAL CONDITION] and it appears that he has dementia associated with it. Review of Resident #237's Physician's Progress Notes revealed the resident was seen 1/17/17, 2/14/17 and 3/14/17. The Physician's Progress Notes did not indicate anything related to the resident's mental status or overall cognitive status. There was no documentation related to the resident residing on the [CONDITION]U or evaluating the resident being appropriate for the unit. The resident was seen by the psychiatrist on 1/22/17 who indicated the resident was hospitalized with withdrawal and possible [MEDICAL CONDITION] activity. The resident had a history of [REDACTED]. In addition, if his [MEDICAL CONDITION] are just related to withdrawal it is possible that the [MEDICATION NAME] is playing a role in his behavioral problems and I would consider tapering and discontinuing it. I would ask neurology their opinion. There was no documentation in the resident's medical record that there was follow up on the [MEDICATION NAME] or consulting the neurologist. Review of the resident's Care Plan revealed resident exhibits behaviors of rejecting care, disruptive to environment, disrobes. Interventions included to review patient drug regime, evaluate for dosage reduction and document findings. Assess resident for comfort level when disrobing. Review of the Physician's Telephone Orders dated 3/23/17 revealed may send to hospital for evaluation, may have 1:1 until leaves for hospital. Review of the Admissions to the Memory Support Unit ([CONDITION]U) policy indicated the memory support unit is designed to provide person-centered care that meets the unique needs of adults who have been diagnosed with [REDACTED]. Review of the Behavior Management Documentation Form revealed the program was initiated 1/3/17 and Resident #237 entered into the program. Resident #237 was removed from the program 2/27/17 related to improved behaviors. Review of the Nurses' Notes dated 1/6/17 revealed behavior reviewed. Admit to behavior management program for aggression with staff during redirection, attempt transfer with no assist, wanders with exit seeking and refusal of care. The Nurse's Note dated 2/2/17 indicated resident behaviors reviewed with no new behavior noted. The Nurse's Note dated 2/27/17 revealed behaviors reviewed, no new behaviors noted since last review. Remove from behavior management program. There were no additional Nurses' Notes until 3/23/17 at 4:02 AM, the note indicated the resident was attempting to touch and rub the chest of female residents when in the [CONDITION]U common area. Staff present and redirected him with a snack. He accepted the snack and went into the dining room and sat and ate his snack. No further behaviors noted. On 3/24/17 at 2:15 AM the nursing note indicated the resident was transferred to the hospital for psych evaluation. The resident left the facility at 2:00 AM. Review of the Social Services Progress Notes Form revealed the resident care plan meeting was held 1/13/17. The next Social Services Progress Note was dated 3/24/17 and indicated the social worker received report of resident to resident incident on 3/23/17. Review of Resident #68's medical record revealed a SBAR Communication Form dated 3/23/17 that indicated the resident was noted sitting on a male peer's lap (Resident #237). The SBAR noted Resident #68 was fully clothed sitting on the male peer's lap while the male peer had his penis exposed. Review of the medical record revealed Resident #68's [DIAGNOSES REDACTED]. The resident's resided on the facility's memory support unit ([CONDITION]U), Review of the Resident Incident Report for Resident #68 dated 3/23/17 at 4:50 PM revealed Resident #68 was unable to be interviewed. Resident confused and disoriented x 3 at baseline. The Resident Incident Report indicated the location of the incident was resident room, but did not indicate the room number where the incident occurred. The follow-up section indicated the resident's physician was notified, deferred to ER physician for examination. ER physician did not perform a rape kit, but did screen for a urinary tract infection via urinalysis. Review of the Nurse's Note dated 3/23/17 at 10:15 PM revealed Resident #68 was transferred to the hospital ER via ambulance to be evaluated. The Nurse's Note dated 3/24/17 at 2:30 AM indicated Resident #68 returned to the facility from the hospital. In an interview with the surveyor on 4/19/17 at approximately 3:30 PM, the social worker stated when Resident #237 first came to the facility he didn't want anyone to bother him, he would get aggressive with staff. After he went through withdrawals he was fine. Resident #237 was on the behavior management program. Resident #237 would stay in his room, he would want to be nude most of the time. After the withdrawals, he would come out his room and socialize more. The social worker stated s/he thinks he may have disrobed out in the hall toward the end of his withdrawal, staff would redirect him. Resident #237 came off the behavior management program. Resident #237 was very social. In an interview with the surveyor on 4/19/17 at approximately 3:45 PM, [CONDITION]U Unit Manager stated s/he was at the facility the day of the incident. S/he was on another unit when LPN #4 notified him/her about the incident. Resident #68 was found sitting on Resident #237's lap. Resident #237 was removed from the room. They were in room [ROOM NUMBER], the room of another resident. That resident was in the room at the time and was in his/her bed. When the [CONDITION]U unit manager got to the unit, LPN #3 and LPN #4 had completed the body audit on Resident #68 and s/he was wandering around the unit. Resident #237 was in his room and was on 1:1. Resident #237 was sent out to the hospital for a psych evaluation on 3/23/17 after the incident. He was sent out for inappropriate, abnormal behaviors, sexual. Resident #237 was admitted to the rehab unit of the facility, he was sent to [CONDITION]U because he was exit seeking. Resident #237 had some combative behaviors and resisted care when he first came onto the [CONDITION]U unit. The resident's behaviors improved, he was on the behavior management program. Resident #237 was very friendly and talkative. He liked to talk with other staff and residents. The other residents on the unit could not talk appropriately. Resident #237 was alert and oriented. The [CONDITION]U unit manager stated they have a FAST score that measures the progression of a disease. If the residents are at certain level, they don't meet criteria. They do FAST scores on admission and readmission, and if there have been any changes. Resident #237 did not have another FAST score done. It was being discussed to have him reevaluated during the behavior management program. They would have to discuss with the Administrator, social worker, director of nursing and the resident's family. At that point, they had been evaluating the resident . In an interview with the surveyor on 4/19/17 at approximately 2:15 PM, the facility administrator stated there were no additional physician or psychiatric progress notes for Resident #68. In an interview with the surveyor on 4/19/17 at approximately 4:30 PM, the facility administrator stated s/he found out about the incident right after it happened. The [CONDITION]U unit manager told him that one of the resident's on the unit told LPN #4 s/he needed to check on a room. LPN #4 went into the room to check and found Resident #237's exposed penis and Resident #68 sitting in his lap still fully clothed. The facility administrator stated there was no one else in the room with them. The facility administrator stated s/he does not recall what resident told LPN #4 s/he needed to look in the room where the 2 residents were. The administrator stated the physician said Resident #68 did not need to go out to the hospital. Resident #68's husband wanted the resident to go to the hospital to have the rape kit performed. They secured transport for Resident #237 to go out as well to get him out of the patient population. Resident #237 was sent out because he could not remain on the [CONDITION]U unit with that type of behavior. They cannot provide continuous 1:1. They notified the police about the incident because of the nature of the situation, Resident #237's attempt and exposure. The facility administrator stated s/he did not talk with Resident #237. The facility administrator stated they did not report the incident to certification because it was resident to resident and did not involve a staff member. The facility administrator stated they don't have a policy that says you do a reassessment within any time frame for residents on the memory support unit. In an interview with the surveyor on 4/19/17 at approximately 5:30 PM, the [CONDITION]U Unit Manager stated there is no policy related to monitoring or discharging residents from the memory support unit. If the resident has a change, they monitor them through the behavior management program. Once they come off the behavior management program, they have a nurses note to document normal charting. Once they are off the behavior management program, then they are off. The resident goes back to regular charting. Any documentation about discussion related to the resident improving would be in the medical record. The [CONDITION]U unit manager stated the physicians are involved in the [CONDITION]U program. They will discuss residents with the physicians and get feedback. Resident #237 was seen by the psychiatrist on 1/22/17. The [CONDITION]U unit manager reviewed the resident's medical record and stated the physician saw the resident in January, February and March. The [CONDITION]U unit manager stated that is all the documentation completed by the physician. There were no additional notes from the psychiatrist. The behavior management program is started for a resident if they are admitted to the [CONDITION]U with an antipsychotic on admission or if the resident has shown behavioral issues. The [CONDITION]U unit manager stated there is no documentation from him/her related to talking about moving Resident #237 off the unit related to his improvement. If the pharmacist gives them a recommendation, they give it to the physician , s/he reviews and agrees or disagrees. The [CONDITION]U unit manager reviewed Resident #237's medical record and stated the recommendation was not addressed by the physician. The [CONDITION]U unit manager provided no additional information related to a pharmacy recommendation. In an interview with the surveyor on 4/19/17 at approximately 6:45 PM, the facility administrator stated the facility investigation consisted of the police report and the hospital report. The facility administrator stated there was no need to investigate because it was not an allegation, it was witnessed by staff. When asked what was witnessed, s/he stated the male resident was exposed. The administrator stated that a resident told LPN #4 s/he should go look at what was happening in the room. The facility administrator could not provide the name of the resident when asked by the surveyor who the resident was. The facility administrator stated they did not interview CNAs on the unit because they didn't want to start anything and have it spread around. The facility administrator stated that no one interviewed Resident #237, he was sent out because he was the perpetrator. When asked how they knew he was the perpetrator, the facility administrator stated because he was exposed. The surveyor asked how they knew Resident #68 was not the instigator, and they stated they didn't know. There were no staff interviews conducted to see if other staff witnessed any behavior between the 2 residents involved in the incident. In a telephone interview with the surveyor on 4/26/17 at approximately 2:20 PM, the residents' physician stated s/he did not remember Resident #237, too many residents come and go for him/her to remember. The physician stated s/he did know about the incident and that Resident #68 was found sitting on Resident #237's lap.",2020-09-01
1845,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,559,E,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notification of room/ roommate changes to 3 of 3 sampled residents reviewed for these changes. Residents #18, #41, #115 and/or their Resident Representatives were not notified in advance of room/roommate changes or reasons for room changes as required. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of Progress Notes on 8/30/18 at 7:54 AM revealed that Resident #18 had new roommates on 7-12-18, 8-7-18, and 8-24-18. Further review of the medical record revealed no evidence of advance written notification. During an interview on 8/30/18 at 12:43 PM, Social Worker #2 stated the resident had not been provided advance written notification of new roommates. The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Review of Progress Notes on 8/30/18 at 9:19 AM and physician's orders [REDACTED].#41 was transferred to another room in the facility on 8-24-18. Further review of the medical record revealed no evidence of prior written notification to the Resident/Resident Representative, including the reason for the move. During an interview on 8/30/18 at 12:33 PM, Social Worker #2 stated the resident had not been provided advance written notification of the room change. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. Review of Progress Notes on 8/29/18 at 9:38 PM revealed that Resident #115 was transferred to another room in the facility on 8-24-18. Further review of the medical record revealed no evidence of prior written notification, including the reason for the move, to the Resident/Resident Representative. During an interview on 8/30/18 at 12:37 PM, Social Worker #2 stated the Resident Representative had not been provided advance written notification of the room change.",2020-09-01
1846,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,585,D,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to issue a written grievance decision to 1 of 1 sampled resident reviewed for abuse. Resident #72 did not receive a written response to a grievance when s/he made an allegation of verbal abuse. The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. During an interview on 8/28/18 at 9:45 AM, when asked if s/he had ever been abused, Resident #72 stated, About 1 month ago. The CNA (Certified Nursing Assistant) would not shut up. S/he knew better than I did what I should and could do. The resident stated s/he had reported it to Social Services. When asked how the complaint had been resolved, the resident stated, I think they moved the CN[NAME] S/he hasn't worked with me since. Review of the Grievance Log on 8/28/18 at 6:44 PM revealed that the resident's report had not been entered. During an interview on 8/28/18 at 6:52 PM, Social Worker (SW) #2 stated s/he had been the Manager on Duty the day of the incident, had notified the Director of Nursing and Administrator, and had initiated the investigation. When asked about the lack of information in the Grievance Log, the SW said s/he had processed the information to the Administrator. S/he stated, It would not be in the log if it never came back to me. During an interview on 8/29/18 at 4:39 PM, when asked if s/he had received the results of the investigation in writing, Resident #72 stated s/he had never received anything in writing from the facility. During an interview on 8/30/18 at 12:49 PM, SW #2 verified that there was no evidence of written notification of the resident of the results of the grievance in the medical record. The SW stated s/he knew that the form used to record the grievance had a place for documentation of resident/family notification, but I don't think a written response is given. During an interview on 8/30/18 2:40 PM, the Admissions Coordinator verified that a written grievance decision had not been issued to the resident.",2020-09-01
1847,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,606,D,0,1,H9EX11,"Based on review of personnel files and facility abuse policies, and interview, the facility failed to ensure that 2 of 5 newly employed nursing staff had license and/or certification verification completed prior to date of hire. The findings included: Review of newly hired nursing staff on 8/29/18 at 9:55 AM revealed the following: (1) Registered Nurse #3 was hired on 7-12-18. The license verification was not completed until 7-16-18. (2) Certified Nursing Assistant (CNA) #2 was hired on 5-22-18. The CNA verification of certification was not completed until 6-6-18. During an interview on 8/29/18 at 10:13 AM, this information was reviewed and confirmed by the Administrator. The facility policy titled Partner Background Screening to Prevent Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property states: 2. The background screening of all applicants for employment should involve the following . Licensure/certification verification .",2020-09-01
1848,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,607,D,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of abuse policies and procedures, the facility failed to follow established policies/procedures for pre-employment licensure/certification verifications and for reporting allegations of abuse for one of one sampled resident reviewed for abuse. The facility failed to notify the State Agency within 2 hours for Resident #72. The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Review of the 7-3-18 Quarterly Minimum Data Set Assessment revealed that the resident was cognitively intact with a Brief Interview for Mental Status score of 15. During an interview on 8/28/18 at 9:45 AM, when asked if s/he had ever been abused, Resident #72 stated, About 1 month ago. The CNA (Certified Nursing Assistant) would not shut up. S/he knew better than I did what I should and could do. The resident stated s/he had reported it to Social Services. When asked how the complaint had been resolved, the resident stated, I think they moved the CN[NAME] S/he hasn't worked with me since. Review of the Grievance Log on 8/28/18 at 6:44 PM revealed that the resident's report had not been entered. During an interview on 8/28/18 at 6:52 PM, Social Worker (SW) #2 stated s/he had been the Manager on Duty the day of the incident, had notified the Director of Nursing and Administrator, and had initiated the investigation. When asked about the lack of information in the Grievance Log, the SW said s/he had processed the information to the Administrator. S/he stated, It would not be in the log if it never came back to me. Review of the investigation file on 8/28/18 at 7:32 PM revealed that the incident of alleged verbal abuse/altercation occurred on 6-23-18 at approximately 12 PM. There was no evidence in the file that Certification was notified until a 5-day report was sent on 6-26-18, though both Licensure and the Ombudsman were notified on 6-24-18 at 11:56 and 11:59 respectively. During an interview on 8/28/18 at 7:41 PM, the Consultant Administrator produced an email notification to Certification/Complaints dated 6-24-18. S/he verified that the incident occurred on 6-23-18 at lunchtime and that the State Agency had not been notified within 2 hours. The facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property (Revised 4-26-17) states: 2 . The state survey agency . should be notified . of any allegations of abuse . within 2 hours after the allegation is made . Review of newly hired nursing staff on 8/29/18 at 9:55 AM revealed the following: (1) Registered Nurse #3 was hired on 7-12-18. The license verification was not completed until 7-16-18. (2) Certified Nursing Assistant (CNA) #2 was hired on 5-22-18. The CNA verification of certification was not completed until 6-6-18. During an interview on 8/29/18 at 10:13 AM, this information was reviewed and confirmed by the Administrator. The facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property (Revised 11-21-16) states: Providers should assure that they do not employ or otherwise engage individuals who . Have a finding entered into the state nurse aide registry . Have a disciplinary action in effect against his or her professional license . The facility policy titled Partner Background Screening to Prevent Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property states: 2. The background screening of all applicants for employment should involve the following . Licensure/certification verification .",2020-09-01
1849,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,609,D,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's abuse policies, the facility failed to ensure that the State Agency was notified of an allegation of verbal abuse within the required time frame for one of one sampled resident reviewed for abuse. The facility failed to notify the State Agency within 2 hours for Resident #72. The findings included: The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Review of the 7-3-18 Quarterly Minimum Data Set Assessment revealed that the resident was cognitively intact with a Brief Interirew for Mental Status score of 15. During an interview on 8/28/18 at 9:45 AM, when asked if s/he had ever been abused, Resident #72 stated, About 1 month ago. The CNA (Certified Nursing Assistant) would not shut up. S/he knew better than I did what I should and could do. The resident stated s/he had reported it to Social Services. When asked how the complaint had been resolved, the resident stated, I think they moved the CN[NAME] S/he hasn't worked with me since. Review of the Grievance Log on 8/28/18 at 6:44 PM revealed that the resident's report had not been entered. During an interview on 8/28/18 at 6:52 PM, Social Worker (SW) #2 stated s/he had been the Manager on Duty the day of the incident, had notified the Director of Nursing and Administrator, and had initiated the investigation. When asked about the lack of information in the Grievance Log, the SW said s/he had processed the information to the Administrator. S/he stated, It would not be in the log if it never came back to me. Review of the investigation file on 8/28/18 at 7:32 PM revealed that the incident of alleged verbal abuse/altercation occurred on 6-23-18 at approximately 12 PM. There was no evidence in the file that Certification was notified until a 5-day report was sent on 6-26-18, though both Licensure and the Ombudsman were notified on 6-24-18 at 11:56 and 11:59 respectively. During an interview on 8/28/18 at 7:41 PM, the Consultant Administrator produced an email notification to Certification/Complaints dated 6-24-18. S/he verified that the incident occurred on 6-23-18 at lunchtime and that the State Agency had not been notified within 2 hours. The facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property (Revised 4-26-17) states: 2 . The state survey agency . should be notified . of any allegations of abuse . within 2 hours after the allegation is made .",2020-09-01
1850,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,637,D,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a Significant Change in Status Assessment (SCSA) MDS (Minimall Data Set) timely for 1 of 3 residents reviewed with a significant change in condition. The findings included: The Facility admitted Resident #116 on 12/17/12 with current [DIAGNOSES REDACTED]. On 08/28/18 at 10:52 AM, review of a 5-day PPS (Perspective Payment System) MDS dated [DATE] revealed Resident #116 had a significant decline in ADLs upon return from a hospitalization on [DATE]. Review of the state MDS data-base revealed no SCSA assessment had been transmitted. Decline was noted in bed mobility, transfers, ambulation, locomotion, toileting, and hygiene. At 04:01 PM, further review revealed the resident also had a significant decline in cognition, behaviors and continence. During an interview at 5:17 PM, MDS Nurse #1 stated the resident had started to decline towards the end of the look-back period for the 5-day PPS Medicare assessment. S/he stated that the facility started assessing the resident at that time for a SCSA and set an ARD of 08/14/18. The nurse stated that the computer then generated a completion due date of 08/28/18 and that s/he guessed they had become too dependent on the computer for that information. The nurse further confirmed the 08/07/18 MDS was the date that the facility identified the change in condition and that according to the RAI (Resident Assessment Instrument) manual, the assessment should have been completed by 08/21/18.",2020-09-01
1851,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,638,D,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a Quarterly MDS (Minimal Data Set) Assessment within 92 days of the prior assessment for Resident #116, 1 of 2 residents reviewed for missing MDS assessments. The findings included: The Facility admitted Resident #116 on 12/17/12 with current [DIAGNOSES REDACTED]. On 08/28/18 at 10:52 AM, review of the State Agency MDS data-base revealed an Annual MDS with an ARD (Assessment Reference Date) of 04/26/18. Review of the data-base revealed no Quarterly MDS assessment had been done within 92 days of the Annual MDS assessment. During an interview at 5:17 PM, MDS Nurse #1 confirmed that a quarterly MDS assessment had not been conducted because the resident was sent out to the hospital on the due date and had not been done on return because they were assessing the resident for a SCS[NAME]",2020-09-01
1852,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,656,E,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to develop and/or implement the care plans for 2 of 3 sampled residents reviewed for activities, 2 of 5 sampled residents reviewed for pressure ulcers, and 4 of 4 sampled residents reviewed for range of motion (R0M). For Resident #18, a Care Plan was not developed to address contractures, the activity Care Plan goal was not measurable, and the Care Plan was not followed related to activities and positioning. For Resident #115, Care Plan goals and interventions did not reflect the staff assessment for activities on the Minimum Data Set assessment and Care Plan interventions were not followed for contractures. The Care Plan was not followed for Resident #120 related to provision of ROM and turning and positioning every 2 hours. Resident #19's Care Plan related to splint application and provision of ROM was not followed. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Initial observation on 8/27/18 at 11:34 AM and throughout the survey revealed left upper extremity contractures with a soft elbow splint but no device or handroll in place for the hand/wrist. Review of the 6-12-18 Quarterly Minimum Data Set (MDS) Assessment on 8/29/18 at 10:57 PM revealed that the resident had functional impairment of one upper and both lower extremities. No ROM or Restorative services were noted as provided. No behaviors were noted. Review of the Care Plan on 8/30/18 at 8:02 AM revealed no reference to contractures or planned interventions to maintain or improve ROM. During an interview on 8-30-18, Registered Nurse #1 verified that the Care Plan did not address the resident's contractures. Continued review of the 10-19-17 Annual and 6-12-18 Quarterly Minimum Data Set Assessments on 8/29/18 at 10:57 PM revealed that the resident required extensive assistance with bed mobility and was at risk for pressure ulcer development. Review of the Care Plan on 8/30/18 at 8:02 AM revealed that interventions to prevent pressure ulcers included to Reposition patient every 2 hours as tolerated. Observations during the first 2 days of the survey revealed the resident was never out of the bed or the room. Multiple observations (on 8/27/18 at 11:34 AM, 1:32 PM, 3:03 PM, 3:58 PM, and 5:05 PM; on 08/28/18 at 8:20 AM, 10 AM, 11:17 AM, and 12:31 PM; on 8/29/18 at 7:55 AM, 9:07 AM, 10:43 AM, 12:35 PM, 2:14 PM, 3:50 PM, and 4:54 PM) revealed that Resident #18 was on his/her back and was not turned and positioned at least every 2 hours per the Care Plan. No turning and positioning pillows or wedges were present in the resident's bed to indicate attempts made. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator reviewed SMART charting and verified that there was no documentation relating to turning and positioning for Resident #18. Further review of the 10-19-17 Annual Minimum Data Set (MDS) Assessment on 8/29/18 at 10:57 PM revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. Section F of the MDS noted that listening to music and being around animals were activities the resident classified as somewhat important. S/he considered keeping up with the news, going outside, and participation in religious practices to be very important. Review of the Care Plan on 8/30/18 at 8:02 AM revealed that the resident wanted to maintain interests as when s/he was at home. Interests included watching TV, listening to music (gospel, easy listening, rhythm and blues), attending church, going outside, hunting, fishing, gardening, and sports. The care plan goal of Will have his (her) interests met daily through next review was not specific and measurable. Interventions included: Assist with TV and music as needed and going outside as weather permits; Inform/invite to activities of interest; Assist to and from and in activities; Visit as needed; Provide magazines about hunting, fishing, sports and gardening. During an interview at 4:08 PM on 8/29/18, when questioned about activity attendance, Resident #18 stated,I don't get out of bed. When asked if it was his/her choice to not get up and out of the room, s/he stated,No, that is not by my choice. On 8-28-18 at 3:03 PM, the resident stated s/he would like to get up some more, but they leave me up too long and I have pain. S/he stated s/he had not gone to church or outside for a long time. The resident could not remember when s/he had last attended. S/he stated s/he just stays in bed because I don't want to be no trouble. During an interview on 8/28/18 at 3:21 PM, the Activity Director and Assistant stated, The resident does not get up. They stated that nursing used to get more people up. It all depends on the CNA (Certified Nursing Assistant). He (She) used to get up more. Staff does not get him (her) up. The Activity Director copied, reviewed and verified the Care Plan as written. Review of 6/18, 7/18, and 8/18 participation records with the Activity Director revealed that 1:1 activities were provided in the room. There was no participation in group or out of room activities. The documented records did not reflect his/her individual interests as stated on the Care Plan. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. Review of the 7-24-18 Quarterly MDS Assessment on 8/29/18 at 11:46 AM revealed that the resident had functional impairment of bilateral upper and lower extremities. No ROM or Restorative services were noted as provided. During an interview on 8/30/18 at 3:41 PM, the Occupational Therapist (OT) and Rehab Director stated they treated Resident #115 in 1/18. S/he was discharged with orders to wear soft elbow splints and palmar supports or rolled washcloths in the hands. They stated they saw the resident today and (s)he did not have elbow splints on but had washcloths in his (her) hands. They stated the resident needed splints to maintain current ROM so (s)he doesn't get worse. They noted that Physical Therapy also saw the resident in (MONTH) and that soft splints were to be used for the knees. These were also not observed to be in place and were still recommended. Review of the Care Plan on 8/29/18 at 12:08 PM revealed that interventions to address contractures included provision of ROM and devices as ordered. Initial observation on 08/27/18 at 11:30 AM through 8/29/18 during the survey revealed contractures of all extremities with only a left handroll in place. There were no other positioning devices or pillows to prevent further decline in contractures. Positioning was observed and confirmed with Licensed Practical Nurse #7 on 8/27/18 at 4:53 PM. Review of the medical record revealed no evidence of provision of ROM or splint application as per the Care Plan to prevent further decline in ROM. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator stated that Resident #18 was not on a restorative program. S/he reviewed the SMART charting and confirmed that it did not reflect provision of ROM. Continued review of the 5-8-18 Annual MDS Assessment on 8/29/18 at 11:46 AM revealed the resident was totally dependent for all activities of daily living. The staff assessment for activities noted the following as important to the resident: books, newspapers, and magazines, listening to music, keeping up with the news, spending time outdoors and participating in religious activities. Further review of the Care Plan on 8/29/18 at 12:08 PM revealed that it did not reflect the staff assessment on the MDS. The resident was noted at risk for social isolation related to medical condition. He (she) is passive. The goal was for Activity staff to visit 1:1 2x weekly through next review. Interventions included: Reinforce attendance at activities events with verbal praise; Activity staff/Social Services to visit as needed; Post activity schedule in patient's room; Provide 1:1 visits, in room activities and supplies for patient for sensory stimulation. Observations throughout the survey revealed the resident never out of the bed or the room and no activities were observed other than a radio playing. The resident was unresponsive to verbal stimuli. During an interview on 8/28/18 at 3:32 PM, the Activity Director and Assistant stated, The resident does not get up. They stated that nursing used to get more people up. It all depends on the CN[NAME] When he (she) was on Unit 3 and 4, he (she) used to get up. Staff does not get him (her) up now. The activity staff noted that the resident had no family visits and that they had never seen anyone. They stated they really knew nothing about the resident except that s/he had worked for the railroad and at a nuclear plant. The Activity Director copied, reviewed and verified the Care Plan as written. Review of 6/18, 7/18, and 8/18 participation records with the Activity Director revealed that 1:1 activities were only provided in the room [ROOM NUMBER]-6 times per month. There were only 2 times during the 3 month period that the resident was noted to be out of the room, sitting in the TV room which did not reflect participation in any type of activity. The 1:1 documentation only noted reading to the resident (not the subject), current events x 2, and listening to music (not the type). There was no other sensory stimulation noted. During an interview on 8/29/18 at 5:07 PM, when asked if Residents #18 and #115 got out of bed, Licensed Practical Nurse #7 stated, Depends on the CNA and nurse that has them. The facility admitted Resident #120 with [DIAGNOSES REDACTED]. Review of the 12-12-17 Annual and 7-31-18 Quarterly Minimum Data Set Assessments on 8/29/18 at 3:09 PM revealed that the resident was totally dependent for bed mobility and was at risk for pressure ulcer development. Review of the Care Plan on 8/29/18 at 3:48 PM revealed that interventions to prevent skin breakdown included to Reposition patient every 2 hours as tolerated. Multiple observations (on 8/27/18 at 11:30 AM, 1:22 PM, 3:03 PM, 3:55 PM, and 4:50 PM; on 08/28/18 at 8:20 AM, 10 AM, 11:17 AM, and 12:31 PM; on 8/29/18 at 7:58 AM, 9:10 AM, 10:47 AM, 12:41 PM, 2:17 PM, 3:57 PM, and 4:58 PM) revealed that Resident #18 was on his/her back and not turned and positioned at least every 2 hours. No turning and positioning pillows or wedges were present in the resident's bed to indicate attempts made. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator reviewed SMART charting and verified that there was no documentation relating to turning and positioning for Resident #18. Continued review of the MDS Assessments on 8/29/18 at 3:09 PM revealed that the 12-12-17 Annual assessment noted ROM impaired in one upper and 2 lower extremities and the 7-31-18 Quarterly assessment noted impairment in both upper and lower extremities. No ROM, restorative services, or therapy was coded. During an interview on 8/30/18 at 4:01 PM, the OT and Rehab Director stated that Resident #120 had been discharged from therapy with a left palmar splint to maintain ROM. The therapists stated they had looked at the resident that day and s/he had not had a decline on the left side. OT stated that the resident needed to keep it elevated for [MEDICAL CONDITION] and that the resident does want the splint. During an interview on 8/29/18 at 5:13 PM with the 3 MDS Coordinators, Licensed Practical Nurse #4 verified the coding for the MDS assessments. When asked what had been implemented to prevent any further decline, they researched and found that OT completed an evaluation only on 4/12/18 with no new recommendations made. Review of the Care Plan on 8/29/18 at 3:48 PM revealed that interventions to address contractures included provision of ROM with ADL (activities of daily living) care and devices as ordered. Initial observation on 08/27/18 at 11:30 AM and throughout the survey revealed contractures of both upper extremities with no splints or handrolls in place. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator stated that Resident #18 was not on a restorative program. S/he reviewed the SMART charting and confirmed that it did not reflect provision of ROM. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Review of the 6-12-18 Quarterly MDS Assessment on 8/30/18 at 2:27 PM revealed that the resident had functional impairment of one upper and one lower extremity. No ROM or Restorative services were noted as provided. Review of Occupational Therapy (OT) notes on 8/30/18 at 2:53 PM revealed that the resident was discharged with a hand splint on 1/18/18. Review of the Care Plan on 8/30/18 at 2:57 PM revealed that interventions to address contractures included provision of ROM and devices as ordered. Initial observation on 8/27/18 at 11:34 AM and throughout the survey revealed contractures of the right upper extremity with no splint or handroll in place. Continued review of the medical record revealed no evidence of splint application or provision of ROM. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator stated that Resident #18 was not on a restorative program. S/he reviewed the SMART charting and confirmed that it did not reflect provision of ROM.",2020-09-01
1853,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,657,E,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to have all disciplines participate in the multidisciplinary care conference for Residents #13, #62, #19, #115 and # 120. Five of 5 residents sampled for care conference participation. The findings included: The facility admitted Resident #13 on 02/02/15 with [DIAGNOSES REDACTED]. On 08/28/18 at 09:16 AM, review of the Multidisciplinary Care Conference Meeting form dated 04/12/18 revealed no indication of attendees. The form indicated information was entered by Activities and reviewed by an LPN (Licensed Practical Nurse). Further review revealed a 02/02/18 care plan conference form that indicated the information was entered by an LPN and there was no documentation of the attendees. No evidence a Registered Nurse (RN) attended or reviewed either care plan. Additional review revealed a care plan signature sheet dated 8/8/18 signed by activities, social services and the Certified Dietary Manager (CDM). There was no evidence the care plan meeting was attended by a RN. On 08/30/18 at 11:28 AM, review of the EHR (electronic health record) IDT (interdisciplinary team) care plan documentation revealed the 08/08/18 care plan information was completed by an LPN. There was no documentation of input from Dietary, Social Services, Registered Nurse or Certified Nursing Assistant. On 06/19/18 the completion of information was conducted by an LPN. There was no documentation of input from a Registered Nurse. The 04/03/18 care plan completion of information was conducted by an LPN. There was no documentation of input from a Registered Nurse. On 01/16/18, the completion of information was conducted by an LPN. There was no documentation of input from Dietary, Social Services, Registered Nurse or Certified Nursing Assistant. During an interview on 08/30/18 at 02:00 PM, RN #1 confirmed there was no documentation that a Registered Nurse (RN) participated in the IDT or was involved in the review of the care plan dated 04/03 or 06/19/18. The RN further confirmed there was no documentation that Dietary, Social Services, a Registered Nurse or Certified Nursing Assistant participated in the IDT or was involved in the review of the care plan on 01/16/18. The facility admitted Resident #62 on 10/25/17 with [DIAGNOSES REDACTED]. On 08/27/18 03:20 PM, record review revealed no CNA (Certified Nursing Assistant) signature on the Interdisciplinary Care Conference Meeting attendance sheet. There was no documentation that a CNA attended the meeting. On 08/30/18 at 11:44 AM, review of the EHR IDT care plan meeting documentation revealed on 07/10/18 the completion of information was conducted by a LPN. There was no documentation of input from or care plan meeting attendance by Registered Nurse. Further review revealed a 04/25/18 a Multidisciplinary Care Conference Meeting form that indicated completion by a LPN. There was no documentation of input from or care plan meeting attendance by Registered Nurse. During an interview at 2:35 LPN #4, stated very seldom did a RN attend the care plan meetings unless a unit manager attended. The nurse stated that the facility now had all RN unit managers and that they were starting to attend the care plan meetings. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Review of 6-26-18 and 4-10-18 Multidisciplinary Care Conference Meeting forms on 8/30/18 at 2:57 PM revealed no participation in the development of the plans or review by a Registered Nurse. During an interview on 8/30/18 at 4:08 PM, Licensed Practical Nurse #4 confirmed this. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. Review of 5-22-18 and 8-9-18 Multidisciplinary Care Conference Meeting forms on 08/29/18 12:08 PM revealed no participation in the development of the plans by a Certified Nursing Assistant or Registered Nurse. During an interview on 8/30/18 at 4:08 PM , Licensed Practical Nurse #4 confirmed this. The facility admitted Resident #120 with [DIAGNOSES REDACTED]. Review of the 8-16-18 Multidisciplinary Care Conference Meeting forms on 8/29/18 at 3:48 PM revealed no participation in the development of the plans by a Certified Nursing Assistant. During an interview on 8/29/18 at 5:13 PM, Licensed Practical Nurse #4 confirmed this. The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Review of the 7-3-18 Quarterly Minimum Data Set Assessment revealed that the resident was cognitively intact with a Brief Interview for Mental Status score of 15. During an interview on 8/28/18 at 9:45 AM, when asked if s/he had ever been abused, Resident #72 stated, About 1 month ago. The CNA (Certified Nursing Assistant) would not shut up. S/he knew better than I did what I should and could do. The resident stated s/he had reported it to Social Services. When asked how the complaint had been resolved, the resident stated, I think they moved the CN[NAME] S/he hasn't worked with me since. During an interview on 8/28/18 at 6:52 PM, Social Worker (SW) #2 stated s/he had been the Manager on Duty the day of the incident, had notified the Director of Nursing and Administrator, and had initiated the investigation. Review of the Care Plan on 8/29/18 at 9:22 AM revealed that it had not been updated with the abuse allegation/altercation. During an interview on 8/29/18 at 10:22 AM, the incident was reviewed with Licensed Practical Nurse (LPN) #7 who stated s/he was aware of the incident. S/he reviewed the Care Plan and confirmed it had not been updated with the abuse allegation. When asked, LPN #7 stated that the Care Plan should have been updated by nursing or Social Services. The facility policy titled Care Plans states : 4. Care Plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient's/resident's needs at any given moment.",2020-09-01
1854,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,677,E,0,1,H9EX11,"Based on observations and interview, the facility failed to provide grooming supplies and assistance to 4 of 4 sampled residents reviewed for activities of daily living. Residents #19, #41, #115, and #120 were not shaved for 4 days of the survey. The findings included: Multiple observations throughout the survey revealed that Residents #19, #41, #115, and #120 had not been shaved. Minimum Data Set Assessments and Care Plans for these residents did not address refusal of care. During an interview on 8/29/18 at 1:50 PM, when asked about the male residents not being shaved, Certified Nursing Assistant #3 stated,We ran out of razors the weekend. During an interview on 8/29/18 at 9:06 PM, Licensed Practical Nurse #6 stated, They were looking for razors on Saturday and we only found one. During an interview on 8/30/18 at 12:18 PM, Resident #41 stated, See this (rubbing clean shaven face)? I finally got a shave. I haven't had one since I was in the other building (referring to Unit 3).",2020-09-01
1855,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,679,D,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff and resident interviews, the facility failed to provide out of room group activities and on-going activities based on individualized prior interests for 2 of 3 sampled residents reviewed for activities (Residents #18 and #115). The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Observations during the first 2 days of the survey revealed the resident was never out of the bed or the room. Review of the 10-19-17 Annual Minimum Data Set (MDS) Assessment on 8/29/18 at 10:57 PM revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating s/he was cognitively intact. Section F of the MDS noted that listening to music and being around animals were activities the resident classified as somewhat important. S/he considered keeping up with the news, going outside, and participation in religious practices to be very important. During an interview at 4:08 PM on 8/29/18, when questioned about activity attendance, Resident #18 stated,I don't get out of bed. When asked if it was his/her choice to not get up and out of the room, s/he stated,No, that is not by my choice. On 8-28-18 at 3:03 PM, the resident stated s/he would like to get up some more, but they leave me up too long and I have pain. S/he stated s/he had not gone to church or outside for a long time. The resident could not remember when s/he had last attended. S/he stated s/he just stays in bed because I don't want to be no trouble. Review of the Care Plan on 8/30/18 at 8:02 AM revealed that the resident wanted to maintain interests as when s/he was at home. Interests included watching TV, listening to music (gospel, easy listening, rhythm and blues), attending church, going outside, hunting, fishing, gardening, and sports. The care plan goal of Will have his (her) interests met daily through next review was not specific and measurable. Interventions included: Assist with TV and music as needed and going outside as weather permits; Inform/invite to activities of interest; Assist to and from and in activities; Visit as needed; Provide magazines about hunting, fishing, sports and gardening. During an interview on 8/28/18 at 3:21 PM, the Activity Director and Assistant stated, The resident does not get up. They stated that nursing used to get more people up. It all depends on the CNA (Certified Nursing Assistant). He (She) used to get up more. Staff does not get him (her) up. The Activity Director copied, reviewed and verified the Care Plan as written. Review of 6/18, 7/18, and 8/18 participation records with the Activity Director revealed that 1:1 activities were provided in the room. There was no participation in group or out of room activities. The documented records did not reflect his/her individual interests as stated during the Activities interview section of the MDS or as stated on the Care Plan. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. Observations throughout the survey revealed the resident never out of the bed or the room. The resident was unresponsive to verbal stimuli. Review of the 5-8-18 Annual MDS Assessment on 8/29/18 at 11:46 AM revealed the resident was totally dependent for all activities of daily living. The staff assessment for activities noted the following as important to the resident: books, newspapers, and magazines, listening to music, keeping up with the news, spending time outdoors and participating in religious activities. Review of the Care Plan on 8/29/18 at 12:08 PM revealed that it did not reflect the staff assessment on the MDS. The resident was noted at risk for social isolation related to medical condition. He (she) is passive. The goal was for Activity staff to visit 1:1 2x weekly through next review. Interventions included: Reinforce attendance at activities events with verbal praise; Activity staff/Social Services to visit as needed; Post activity schedule in patient's room; Provide 1:1 visits, in room activities and supplies for patient for sensory stimulation. During an interview on 8/28/18 at 3:32 PM, the Activity Director and Assistant stated, The resident does not get up. They stated that nursing used to get more people up. It all depends on the CN[NAME] When he (she) was on Unit 3 and 4, he (she) used to get up. Staff does not get him (her) up now. The activity staff noted that the resident had no family visits and that they had never seen anyone. They stated they really knew nothing about the resident except that s/he had worked for the railroad and at a nuclear plant. The Activity Director copied, reviewed and verified the Care Plan as written. Review of 6/18, 7/18, and 8/18 participation records with the Activity Director revealed that 1:1 activities were only provided in the room [ROOM NUMBER]-6 times per month. There were only 2 times during the 3 month period that the resident was noted to be out of the room, sitting in the TV room which did not reflect participation in any type of activity. The 1:1 documentation only noted reading to the resident (not the subject), current events x 2, and listening to music (not the type). There was no other sensory stimulation noted. During an interview on 8/29/18 at 5:07 PM, when asked if Residents #18 and #115 got out of bed, Licensed Practical Nurse #7 stated,Depends on the CNA and nurse that has them.",2020-09-01
1856,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,684,E,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure ongoing assessment of peripheral vascular ulcers located on bony prominences for 1 of 4 sampled residents reviewed for non-pressure skin conditions. The facility failed to initially assess the presence of an ulcer on the left outer ankle for Resident #115 and conduct on-going assessments to determine progress or decline in the resident's skin condition. The findings included: The facility admitted Resident #115 with [DIAGNOSES REDACTED]. Review of Body Audits on 8/29/18 at 11:07 AM revealed that the open area on the left foot was not documented. During an interview at that time, the Unit Manager stated that the body audits should be done weekly and include all areas of compromised skin. Review of the most recent Quarterly Minimum Data Set Assessment (7-24-18) on 8/29/18 at 11:46 AM revealed no pressure or vascular ulcers coded. During a skin observation with Licensed Practical Nurse #7 on 8/27/18 at 4:53 PM, the resident was noted with an open area to the left outer ankle. Review of the skin documentation in the medical record revealed no on-going assessment of this area. During observation of wound treatments on 8/30/18 at 10:54 AM, the Registered Nurse (RN) Wound Nurse verified the condition of the left ankle and stated s/he had started measuring the area weekly.",2020-09-01
1857,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,686,E,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review , and interview, the facility failed to promote prevention of pressure ulcer development as evidenced by 2 of 5 sampled residents reviewed for pressure ulcers not being turned and positioned at least every 2 hours (Residents #18 and #120). The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of the 10-19-17 Annual and 6-12-18 Quarterly Minimum Data Set Assessments on 8/29/18 at 10:57 PM revealed that the resident required extensive assistance with bed mobility and was at risk for pressure ulcer development. Review of the Care Plan on 8/30/18 at 8:02 AM revealed that interventions to prevent pressure ulcers included to Reposition patient every 2 hours as tolerated. Multiple observations (on 8/27/18 at 11:34 AM, 1:32 PM, 3:03 PM, 3:58 PM, and 5:05 PM; on 08/28/18 at 8:20 AM, 10 AM, 11:17 AM, and 12:31 PM; on 8/29/18 at 7:55 AM, 9:07 AM, 10:43 AM, 12:35 PM, 2:14 PM, 3:50 PM, and 4:54 PM) revealed that Resident #18 was was on his/her back and not turned and positioned at least every 2 hours. No turning and positioning pillows or wedges were present in the resident's bed to indicate attempts made. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator reviewed SMART charting and verified that there was no documentation relating to turning and positioning for Resident #18. The facility admitted Resident #120 with [DIAGNOSES REDACTED]. Review of the 12-12-17 Annual and 7-31-18 Quarterly Minimum Data Set Assessments on 8/29/18 at 3:09 PM revealed that the resident was totally dependent for bed mobility and was at risk for pressure ulcer development. Review of the Care Plan on 8/29/18 at 3:48 PM revealed that interventions to prevent skin breakdown included to Reposition patient every 2 hours as tolerated. Multiple observations (on 8/27/18 at 11:30 AM, 1:22 PM, 3:03 PM, 3:55 PM, and 4:50 PM; on 08/28/18 at 8:20 AM, 10 AM, 11:17 AM, and 12:31 PM; on 8/29/18 at 7:58 AM, 9:10 AM, 10:47 AM, 12:41 PM, 2:17 PM, 3:57 PM, and 4:58 PM) revealed that Resident #18 was not turned and positioned at least every 2 hours. No turning and positioning pillows or wedges were present in the resident's bed to indicate attempts made. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator reviewed SMART charting and verified that there was no documentation relating to turning and positioning for Resident #18.",2020-09-01
1858,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,688,E,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide on-going care and services to prevent further decline in existing contractures for 4 of 4 sampled residents reviewed with limited range of motion (ROM). Residents #18, #19, #115, and #120 had no evidence of provision of ROM, restorative services, and/or splinting to prevent further decline. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of the 6-12-18 Quarterly Minimum Data Set (MDS) Assessment on 8/29/18 at 10:57 PM revealed that the resident had functional impairment of one upper and both lower extremities. No ROM or Restorative services were noted as provided. No behaviors were noted. Initial observation on 8/27/18 at 11:34 AM and throughout the survey revealed left upper extremity contractures with a soft elbow splint but no device or handroll in place for the hand/wrist. Review of the Care Plan on 8/30/18 at 8:02 AM revealed no reference to contractures or planned interventions to maintain or improve ROM. Nor did the plan address any concern related to refusal of care. During an interview on 8-30-18, Registered Nurse #1 verified that the Care Plan did not address the resident's contractures. Continued review of the medical record revealed no evidence of services provided to prevent further decline in ROM. During an interview at 4:08 PM on 8/29/18, when asked about ROM, Resident #18 stated,I don't get any exercises. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator stated that Resident #18 was not on a restorative program. S/he reviewed the SMART charting and confirmed that it did not reflect provision of ROM. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. Review of the 6-12-18 Quarterly MDS Assessment on 8/30/18 at 2:27 PM revealed that the resident had functional impairment of one upper and one lower extremity. No ROM or Restorative services were noted as provided. No behaviors were noted. Initial observation on 8/27/18 at 11:34 AM and throughout the survey revealed contractures of the right upper extremity with no splint or handroll in place. Review of the Care Plan on 8/30/18 at 2:57 PM revealed that interventions to address contractures included provision of ROM and devices as ordered. The plan did not address any concern related to refusal of care. Continued review of the medical record revealed no evidence of splint application or provision of ROM. Review of Occupational Therapy (OT) notes on 8/30/18 at 2:53 PM revealed that the resident was discharged with a splint on 1/18/18. During an interview on 8/30/18 at 3:17 PM, OT stated the resident had been discharged from therapy with a hand splint which s/he could not put on per self. When OT asked Resident #19 about the splint, the resident indicated the location and s/he found it in the top drawer of the bedside stand. The resident denied pain with use and OT stated the resident did not appear to have declined. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator stated that Resident #18 was not on a restorative program. S/he reviewed the SMART charting and confirmed that it did not reflect provision of ROM. The facility admitted Resident #115 with [DIAGNOSES REDACTED]. Review of the 7-24-18 Quarterly MDS Assessment on 8/29/18 at 11:46 AM revealed that the resident had functional impairment of bilateral upper and lower extremities. No ROM or Restorative services were noted as provided. No behaviors were noted. Initial observation on 08/27/18 at 11:30 AM through 8/29/18 during the survey revealed contractures of all extremities with only a left handroll in place. There were no other positioning devices or pillows to prevent further decline in contractures. Positioning was observed and confirmed with Licensed Practical Nurse #7 on 8/27/18 at 4:53 PM. Continued review of the medical record revealed no evidence of services provided to prevent further decline in ROM. Review of the Care Plan on 8/29/18 at 12:08 PM revealed that interventions to address contractures included provision of ROM and devices as ordered. The plan did not address any concern related to refusal of care. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator stated that Resident #18 was not on a restorative program. S/he reviewed the SMART charting and confirmed that it did not reflect provision of ROM. During an interview on 8/30/18 at 3:41 PM, the OT and Rehab Director stated they treated Resident #115 in 1/18. S/he was discharged with orders to wear soft elbow splints and palmar supports or rolled washcloths in the hands. They stated they saw the resident today and (s)he did not have elbow splints on but had washcloths in his (her) hands. They stated the resident needed splints to maintain current ROM so (s)he doesn't get worse. They noted that Physical Therapy also saw the resident in (MONTH) and that soft splints were to be used for the knees. These were also not observed to be in place and were still recommended. The facility admitted Resident #120 with [DIAGNOSES REDACTED]. Initial observation on 08/27/18 at 11:30 AM and throughout the survey revealed contractures of both upper extremities with no splints or handrolls in place. Review of the MDS Assessments on 8/29/18 at 3:09 PM revealed that the 12-12-17 Annual assessment noted ROM impaired in one upper and 2 lower extremities and the 7-31-18 Quarterly assessment noted impairment in both upper and lower extremities. No ROM, restorative services, or therapy was coded. No behaviors were noted. During an interview on 8/29/18 at 5:13 PM with the 3 MDS coordinators, Licensed Practical Nurse #4 verified the coding for the 12/17 and 2/18 assessments indicated ROM was impaired in one upper extremity. The assessments completed in 5/18 and 7/18 indicated ROM was impaired in both upper extremities. When asked what had been implemented to prevent any further decline, they researched and found that OT completed an evaluation only on 4/12/18 with no new recommendations made. Review of the Care Plan on 8/29/18 at 3:48 PM revealed that interventions to address contractures included provision of ROM with ADL (activities of daily living) care and devices as ordered. The plan did not address any concern related to refusal of care. During an interview on 8/29/18 at 4:50 PM, when asked about the location of ROM documentation, RN #2 s/he would need to find the CNA (Certified Nursing Assistant) Book or get the SMART charting. During an interview on 8/29/18 at 6:01 PM, the Consultant Administrator stated that Resident #18 was not on a restorative program. S/he reviewed the SMART charting and confirmed that it did not reflect provision of ROM. During an interview on 8/30/18 at 4:01 PM, the OT and Rehab Director stated that Resident #120 had last had therapy in (YEAR) and had been discharged with a left palmar splint to maintain ROM. The resident had refused a right upper extremity because s/he uses the TV remote, call bell, and bed control with that hand. The therapists stated they had looked at the resident that day and s/he had not had a decline on the left side. OT stated that the resident needed to keep it elevated for [MEDICAL CONDITION] and that the resident does want the splint.",2020-09-01
1859,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2018-08-30,758,E,0,1,H9EX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents had [DIAGNOSES REDACTED]. Residents #71 and #102 received antipsychotics without an appropriate diagnosis (2 of 5 reviewed for unnecessary medication). The findings included: Resident #71 had [DIAGNOSES REDACTED]. Record review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Record review of a 4/12/18 Consultant Pharmacist Communication to Physician regarding a gradual dose reduction review for [MEDICATION NAME] for aggression revealed the following: It appears from nursing notes that (Resident #71) is having significant behaviors despite being on an antipsychotic for aggression. [MEDICATION NAME] may not be helping with (Resident #71's) behaviors. Consider discontinuing [MEDICATION NAME] and starting (Resident #71) on [MEDICATION NAME] 250 mg QAM (every morning). The physician indicated: No change. An attempted GDR (gradual dose reduction) is likely to result in impairment of function or increased distressed behavior. Interview with Licensed Practical Nurse (LPN) #2 on 08/29/18 at 03:56 PM confirmed the medication was ordered for aggression. S/he provided the original physician's orders [REDACTED]. Resident #102 had [DIAGNOSES REDACTED]. Record review of the (MONTH) (YEAR) Physician order [REDACTED]. Record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of a 6/28/18 pharmacy note revealed [MEDICATION NAME] .25 mg BID (twice daily) was added for aggression. Record review of a 7/17/18 Consultant Pharmacist Communication to Physician revealed a recommendation to reduce [MEDICATION NAME] to 0.25 mg qd (every day) was denied by the physician due to behaviors. Interview with LPN #3 on 08/30/18 at 10:38 AM revealed aggression was on the original 6/26/18 Physician's Interim Orders and Behavioral Disorders associated with Dementia was on the current (MONTH) (YEAR) physician's orders [REDACTED].",2020-09-01
1860,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-14,550,D,1,0,T11M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to promote dignity and provide privacy related to an uncovered urinary catheter bag for three (3) residents observed during a tour of unit. (Residents #22, #23 and #24) The findings included: On [DATE] at approximately 10:15 AM during a tour of the 200 hall a urinary drainage bag was observed hanging from the side of Resident #24's bed. The drainage bag was uncovered and visible from the hallway. No urine was visible in the bag. On [DATE] at approximately 10:17 AM during a tour of the 200 hall a urinary drainage bag was observed hanging from the side of Resident #23's bed. The drainage bag was uncovered, visible from the hallway and contained approximately 100 cubic centimeters (cc) of urine. On [DATE] at approximately 11:11 AM during a tour of the 300 hall, a urinary drainage bag was observed hanging from the side of Resident #22's bed. The drainage bag was uncovered, visible from the hallway and contained a copious amount of urine. Review of Resident #22's record revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. Review of Resident #23's record revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]., Hypertensive Heart and [MEDICAL CONDITION] with Heart Failure and with Stage 5 [MEDICAL CONDITION]. Review of Resident #24's record revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. An interview and walk through were conducted with the Director of Nursing (DON) on [DATE] at 11:35 AM. The DON confirmed that Resident #22's bag was uncovered and contained approximately 700cc of urine. The DON confirmed that the bag should have been covered. It was discovered that Resident #23's bag had been folded incorrectly exposing the urine contents of the bag. The bag had to be readjusted to provide the correct privacy. Resident #24's drainage bag had no cover initially. A request was made for policies regarding dignity was made and the facility provided Lippincott procedures for indwelling and suprapubic catheter care. Review of the facility's policies for both indwelling and suprapubic catheters revealed instructions to provide privacy when working with resident's catheters.",2020-09-01
1861,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-14,609,D,1,0,T11M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and facility policy review, it was determined the facility failed to report to the State Agency within two (2) hours an incident of potential neglect and failed to follow-up with the State Agency within five (5) workings days with final report and with evidence appropriate actions/interventions were in place to prevent further incidents for one (1) of 26 sampled residents, Resident #16. Resident #16 resided on the Memory Support Unit ([CONDITION]U) and had a history of [REDACTED]. On 10/4/19 the resident was unsupervised and obtained a peanut butter sandwich. The resident choked on the sandwich, staff worked on the resident for approximately one (1) hour, stabilizing the resident's oxygen (02) saturation levels. Later that evening the resident experienced respiratory distress, was transferred to the hospital and was admitted with [MEDICAL CONDITION]. The facility failed to report to the state and investigate this incident of potential neglect and did not produce a written report to the state agency of potential neglect within five (5) days of the incident as mandated. The findings included: Resident #16 was admitted to the Memory Support Unit ([CONDITION]U) of the facility on 6/6/18. The resident's [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) review dated [DATE] the resident was assessed and required supervision of one (1) person, physical assistance walking in room and corridor, required extensive one (1) person physical assistance with eating a mechanically altered diet. The resident's Care Review of the Care Plan with revision date 9/23/19 noted Resident receives a therapeutic mechanically altered diet. Review of Order History Dietary Order with start date 3/6/19 end date 10/13/19: Regular, Pureed with Special Instructions: Food in bowls Review of the facility policy, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property with revision date 11/21/16 revealed it is facility policy to investigate allegations and occurrences of abuse, neglect, exploitation, mistreatment and misappropriation of patient property. The administrator is responsible for assuring an accurate and timely investigation is completed. If there is an occurrence of abuse, neglect, exploitation, mistreatment or misappropriation of property, an investigation will be initiated, and reporting will be followed. In accordance with applicable laws and regulation, the Administrator or his or her designee should notify the appropriate state agency of any allegation of abuse, neglect, exploitation, mistreatment, and misappropriation of property. The state agency should be notified within two (2) hours after the allegation if the events upon which the allegation is based involve abuse or result in serious bodily injury. The administrator or designee should direct an investigation into the allegation or incident. The facility should follow specific state reporting requirements for a reportable event. A written investigation report should be submitted to the state agency within five (5) days of the incident. Review of the Resident Progress Notes revealed: 10/4/19 11:15 AM (Recorded as late entry on 10/6/19 at 1:32 PM) documented by Director of Health Services (DHS): Approached the unit to find the resident in respiratory distress. The Nurse Practitioner (NP) and other nursing staff present provided care which included oxygen (02), suctioning and nebulizer treatments. The resident seemed more relaxed when standing and leaning onto staff. Ambulated with staff to bed where resident was able to rest without attempts to get up. Staff sat at the bedside while the resident slept. 10/4/19 7:22 PM Documentation entry by NP: Was asked to come and look at the resident who was coughing. The resident is in a chair appearing pale and coughing. There is food pocketed in cheeks that looks like bread. A CNA got the food out of the resident's cheek. The resident had just eaten a peanut butter sandwich. More food was extracted from the residents left cheek. The resident's received O2, nebulizer treatment, antibiotic injection. Resident was transferred to room and remained stable and rested well. 10/6/19 5:38 PM Documentation entry by RN (Registered Nurse) #1: (Recorded as a late entry): On 10/4/19 around 10:46 PM Resident #16 was sitting in a chair in common area of [CONDITION]U. Resident was pale and attempting to cough. The resident's skin was cool and clammy with 02 saturation of [AGE]%. Resident given scheduled [MEDICATION NAME] nebulizer treatment with 02 saturation increase to 78% but decreased to [AGE]-[AGE]% when resident began moving around. Bilateral rales in lungs. NP on call notified and received orders to send to hospital for evaluation. E[CONDITION] (Emergency Medical Services) arrived and resident left facility via stretcher. An interview was conducted with the Administrator on [DATE] at 3:25 PM. The Administrator stated nobody knows how Resident #16 got the peanut butter sandwich she choked on. The nurse on the unit said she didn't know how the resident got the sandwich. She further said no investigation was conducted on Resident #16's choking incident but concluded the Director of Health Services (DHS) or a nurse could have done the investigation. A further interview with the Administrator on 12/12//19 at 1:15 PM revealed he/she would not do an investigation just because a resident got the wrong tray or ate a food item which they choked on, that was not part of the resident's physician ordered diet. An interview with the DHS (Director of Health Services) on [DATE] at 2:00 PM revealed staff on the Memory Support Unit ([CONDITION]U) are constantly watching the residents and there was not a whole lot more staff could do, all staff could do was intervene as needed. The DHS stated she did not know how the resident got the sandwich, I did not address it at the time. He/she said I just asked nurses and CNA's (certified nursing assistants) and they said they didn't give the sandwich to the residents. The DHS concluded he/she did not need to initiate an occurrence report regarding Resident #16's choking incident. The facility failed to report to the State Agency, conduct an investigation and submit a report to the state agency within five (5) days of an incident in which an unsupervised resident on a physician ordered pureed diet obtained a peanut butter sandwich, choked, was later sent to the hospital with [MEDICAL CONDITION].",2020-09-01
1862,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-14,610,J,1,0,T11M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of facility policy, it was determined the facility failed to investigate an incident of potential neglect for one (1) of twenty-six (26) sampled residents, Resident #16. Resident #16 was assessed to have severe cognitive impairment and resided on the secured Memory Support Unit ([CONDITION]U). The resident was evaluated by Speech Therapy and it was determined the resident was at moderate risk for aspiration and needed a pureed diet which had initially been ordered by the physician on 3/ 6 /19. The resident's behaviors included wandering and taking resident's food from other residents in the [CONDITION]U. On 10/4/19, the resident was observed to be pale and to have difficulty breathing. When the Nurse Practitioner assessed the resident, a peanut butter sandwich was pocketed in the resident's mouth. After the sandwich was removed, the resident was suctioned, and oxygen was applied. Staff worked approximately one (1) hour to stabilize the resident. Later that evening the resident experienced respiratory distress and was transferred to the emergency room and was admitted to the hospital with [REDACTED]. The resident returned to the facility on Hospice with a [DIAGNOSES REDACTED]. The facility failed to investigate an incident potential of neglect, failed to obtain witness statements in an attempt to identify how the resident got the sandwich, thus no corrective action was taken to protect other residents from potential neglect. The facility's failure to conduct a thorough investigation of the choking incident placed residents at risk for serious injury, harm, impairment or death. The facility Administrator was notified of the Immediate Jeopardy on 12/12/19 at 1:30 PM. The Immediate Jeopardy was removed on 12/12/19 at 8:30 PM. The scope and severity was lowered to a D. The findings included: Resident #16 was admitted to the facility on [DATE] to the Memory Support Unit ([CONDITION]U). The resident's [DIAGNOSES REDACTED]. According to a quarterly Minimum Data Set (MDS) review dated [DATE] the resident's cognitive status was severely impaired, and the resident required supervision of one (1) person, physical assistance walking in room/ corridor, and required extensive one (1) person physical assistance with eating a mechanically altered diet. Review of the Care Plan with revision date 9/23/19 revealed the resident received a mechanically altered diet and would wander and eat off other resident's trays. Review of Order History Dietary Order with start date 3/6/19 end date 10/13/19: Regular, Pureed with Special Instructions: Food in bowls A Speech Therapy Plan of Care (Evaluation Only) dated [DATE]: The resident has a [DIAGNOSES REDACTED]. The evaluation determined the resident was at the moderate range for dysphagia and aspiration. The resident is on the least restrictive diet for safe po intake. Review of the facility policy, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property with revision date of 11/21/16 revealed it is facility policy to investigate allegations and occurrences of abuse, neglect, exploitation, mistreatment and misappropriation of patient property. The administrator is responsible for assuring an accurate and timely investigation is completed. If there is an occurrence of abuse, neglect, exploitation, mistreatment or misappropriation of property an investigation will be conducted. A review of the facility policy, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, with revision date of 11/21/16 documented it is the policy of the facility to actively preserve each patient's right to be free from abuse and neglect. Neglect is the failure of the facility to provide goods and services to a patient that are necessary to avoid physical harm, mental anguish or emotional distress. Facilities are to identify and correct and intervene it situations in which abuse, neglect, mistreatment or exploitation may occur. This should include an analysis of the following: Features of the physical environment that could make abuse, neglect, mistreatment, or exploitation more likely to occur, such as secluded areas of the facility. The deployment of staff on each shift in sufficient numbers number to meet the individual needs of patients. Monitoring of patients with needs and behaviors such entering other resident's rooms and self-injurious behaviors. Review of the Resident Progress Notes: 10/4/19 11:15 AM (Recorded as late entry on 10/6/19 at 1:32 PM) documented by Director of Health Services (DHS: Approached the unit to find the resident in respiratory distress. Nurse Practitioner (NP) and nursing staff present and providing care. The resident was suctioned, given O2 (oxygen), nebulizer treatments and antibiotics. The resident was difficult to manage, was constantly attempting to get up from chair. The resident was eventually more relaxed when standing and leaning onto staff and ambulated with staff to bed where resident was able to rest without attempts to get up. 10/4/19 7:22 PM Documentation entry by NP: Received request to come to assess the resident who was coughing. Upon arriving to the unit, the resident sitting in chair, pale and coughing. There was food pocketed in the resident's cheeks that looks like bread. A CNA (certified nursing assistant) got the food out of the resident's cheek. The resident had just eaten a peanut butter sandwich. O2 saturation checked and was [AGE]%. 02 was started at two (2) liters and was increased to four (4) liters via nasal cannula to bring 02 saturation to [AGE]%. More food was then extracted from the residents left cheek. Resident was restless taking off the 02 saturation monitor constantly wanting to sit up and stand up. [MEDICATION NAME] nebulizer was given via mask with 02 level increased to [AGE]%. Suction was started. Resident appeared to be breathing better but rales (abnormal lung sounds characterized by discontinuous clicking or rattling sounds) still heard in bilateral lungs, A stat chest x-ray was ordered and [MEDICATION NAME] (antibiotic) one (1) gram was given IM (intramuscular) by the nurse. Resident then ambulated to room with 02 saturation still low at 82%. 02 at two (2) liters with concentrator was increased to three (3) liters per minute with 02 saturation at [AGE]-94%. Resident remained stable and rested well. 10/6/19 5:38 PM Documentation entry by RN (Registered Nurse) #1: (Recorded as a late entry): On 10/4/19 around 10:46 PM Resident #16 was noted to be pale with cool clammy skin and was attempting to cough. The resident's 02 saturation of [AGE]% and was given scheduled [MEDICATION NAME] nebulizer treatment with 02 saturation increased to 78% but decreased to [AGE]-[AGE]% when resident began moving around. The NP on call notified and received orders to send to hospital. An interview was conducted with the Administrator on [DATE] at 3:25 PM. The Administrator stated nobody knows how Resident #16 got the peanut butter sandwich he/she choked on. The nurse on the unit said she didn't know how the resident got the sandwich. She further said no investigation was conducted on Resident #16's choking incident but concluded the Director of Health Services (DHS) or a nurse could have done the investigation. An interview with the DHS on [DATE] at 2:00 PM revealed Resident #16 would not sit down for staff and the resident would remove food from other resident's meal trays. He/she said staff on the Memory Support Unit ([CONDITION]U) are constantly watching the residents and there was not a whole lot more staff could do, all staff could do was intervene as needed. The DHS stated she did not know how the resident got the sandwich, I did not address it at the time. He/she said I just asked nurses and CNA's (certified nursing assistants) and they said they didn't give the sandwich to the residents. The DHS concluded he/she did not initiate an investigation into Resident #16's choking incident. A further interview with the Administrator on 12/12//19 at 1:15 PM revealed he/she would not do an investigation just because a resident got the wrong tray or ate a food item that was not part of the resident's diet. The facility's failure to conduct a timely through investigation to the choking incident of Resident #16 in an attempt to identify causative factors of the incidents placed residents of the facility at risk for serious injury, harm, impairment or death. REMOVAL PLAN: Facility failed to remove finger food intervention for a resident on a puree-only diet. [AGE] year-old resident on the secured dementia unit who staff identified as constant wanderer, required feeding by staff, and had a behavior of taking food from other residents' trays. This occurred on or around 10/4/2019. Resident no longer resides in the facility. All residents on the [CONDITION]U with a mechanically altered diet have the potential to be affected by the alleged deficient practice. All [CONDITION]U resident diets were reviewed to identify those with mechanically altered diet by the Case Mix Directors. These care plans have been reviewed and updated to ensure that interventions are appropriate for all [CONDITION]U residents with mechanically altered diets. The team reviewed 15 residents with mechanically altered diets and did not need to make any revisions. The care plan policy was last reviewed on 12/12/19 by the interdisciplinary team and signatures were secured. No nursing staff shall work until they have completed in services on updating care plans starting 12/12/19. Newly hired staff will be in serviced on updating care plans during orientation and annually thereafter by the CCC. Staff will not be permitted to work until education has been completed. The Director of Health Services (DHS), and/or nursing unit managers will review [CONDITION]U residents care plans weekly to ensure that they have been updated with acute changes, for four weeks starting 12/12/19 and quarterly there after for three months. The Director of Health Services (DHS) and or Unit Manager will report any adverse findings to the Administrator immediately and to QAPI. The Director of Health Services (DHS) and/or Unit Manages will review the Facility Activity Report five times a week to monitor for any acute changes of condition including diet changes and updated care plan for four weeks. The Director of Health Services (DHS) and/or Unit Managers will review care plans to ensure care plan interventions are updated. Any adverse findings will be reported by the Director of Health Services (DHS), Assistant Director of Health. An Ad Hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Health Services (DHS), Licensed Practical Nurse, Restorative Nurse and Certified Nursing Assistant on 1212/2019 to discuss the immediate jeopardy finding and the removal plan. All corrective actions were completed by 12/12/2019. The immediacy of the IJ was removed on 12/12/2019.",2020-09-01
1863,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-14,657,J,1,0,T11M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of facility policy, the facility failed to revised a care plan for one 1 of 26 sampled residents, Resident #16. Resident #16's initial care plan dated 6/5/18, for wandering behavior listed interventions which included giving the resident finger foods. The resident's diet order was changed on 3/3/19 to pureed diet due to swallowing difficulty. Staff failed to revise the resident's care plan which placed the resident at risk for harm and on 10/4/19 the resident choked on a peanut butter sandwich and was transferred to the emergency room later in the day and diagnosed with [REDACTED]. The facility's failure to update Resident #16's Care plan placed the resident at risk for serious injury, harm, impairment or death. The facility Administrator was notified of the Immediate Jeopardy on 12/12/19 at 1:30 PM. The Immediate Jeopardy was removed at 8:30 PM. The scope and severity was lowered to a D. The findings included: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility policy, Care Plans, with revision date 10/5/17 revealed it is the policy of the facility to have a comprehensive care plan with the focus of the resident at the center of control. The care plan must include at a minimum information necessary to address the resident's health and safety concerns to prevent decline or injury. Care plans will be updated by nurses, Case Mix Director (CMD), or any member of the interdisciplinary team so that the care will reflect the resident's needs at any given time. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] noted the resident was assessed with [REDACTED]. According to the assessment, the resident required extensive one (1) person physical assistance for transfers, dressing, eating, toilet use, personal hygiene and was totally dependent on one (1) staff for bathing. The resident had no impairment for functional limitation in range of motion for upper and lower extremity. The resident received a mechanically altered diet and speech therapy services were provided on [DATE]. Review of the Care Plan with revision date 9/23/19: Problem [ENTITY]t Date 6/5/18: 1.Category: Nutritional Status: Resident receives a therapeutic mechanically altered diet and is edentulous. History of significant weight loss with poor appetite Long Term Goal: Maintain weight without significant weight loss (Target date [DATE]) Approach [ENTITY]t Date:1/31/19: Pudding added to all meals, Observe and record all po (by mouth) intake. Provide diet as ordered. Provide alternative meals when resident is uninterested in meal served. Provide supplements as ordered. Weekly weight. 2. Problem [ENTITY]t Date 6/5/18: Category: Behavioral Symptoms: Resident wanders daily. Refuses to rest. Leans to one (1) side when tired. Will go in other's rooms. Will eat off other resident's trays. Refuses care, can be verbally and physically aggressive. Long Term Goal: Will wander safely within specified boundaries. Will have decreased episodes of refusing care and aggression. (Target date [DATE]) Approach [ENTITY]t Date: 8/26/19: Maintain a calm environment. Offer finger foods (initiated 6/5/18). Provide diversional activities. Remove resident from unsafe situations-other resident rooms, Staff to intervene to protect the right and safety of others. Review of Order History Dietary Order with start date 3/6/19 end date 10/13/19: Regular, Pureed with Special Instructions: Food in bowls A Speech Therapy Plan of Care (Evaluation Only) dated [DATE]: The resident is total care for ADL's (Activities of Daily Living), wanders the halls constantly. The resident has a [DIAGNOSES REDACTED]. The resident was administered the MASA ([MEDICATION NAME] of Swallowing Ability) to assess swallow functions with resident scoring 143, placing the resident in the moderate range for dysphagia and aspiration. The resident is on the least restrictive diet for safe po intake. Review of the Resident Progress Notes between [DATE] through 10/3/19 revealed the resident had 13 incidents of the resident wandering the halls incessantly, in other's room and not wanting to take rest breaks. An entry on 9/15/19 at 6:59 PM Resident continues to wander on [CONDITION]U and the only activities he/she is truly interested in is meals and snacks and on 10/2/19 at 6:37 PM resident was seen by staff to pick up food with his/her hands and threw it at another resident in dining room. Resident was removed from the dining room and redirected. Further review of the Resident Progress Notes: 10/4/19 at 11:15 AM (Recorded as late entry on 10/6/19 at 1:32 PM) documented by Director of Health Services (DHS) Approached the unit to find the resident in respiratory distress. Nurse Practitioner (NP) and nursing staff were present and providing care. Staff suctioned the resident applied O2 and a nebulizer treatment (medication used to open airway passages) was administered. The resident was difficult to manage as was making constant attempts to get up from chair. When the resident oxygen saturation levels improved to 90-[AGE]% the resident was transferred to room with staff assistance. 10/4/19 7:22 PM Documentation entry by NP (Nurse Practitioner): Was asked to come and look at the resident who was coughing. The resident is in a chair appearing pale and coughing. There is food pocketed in cheeks that looks like bread. A CNA (Certified Nursing Assistant) got the food out of the resident's cheek. The resident had just eaten a peanut butter sandwich. O2 saturation checked and was [AGE]%. 02 was started. More food was extracted from the residents left cheek. O2, nebulizer treatments and antibiotics were administered to the resident. Resident ambulated to room with staff assistance and remained stable and rested well. 10/6/19 5:38 PM Documentation entry by RN (Registered Nurse) #1: (Recorded as a late entry): On 10/4/19 around 10:46 PM Resident #16 was sitting in a chair in common area of [CONDITION]U. Resident was pale and attempting to cough. The resident's skin was cool and clammy with 02 saturation of [AGE]%. Resident given scheduled [MEDICATION NAME] nebulizer treatment with 02 saturation increase to 78% but decreased to [AGE]-[AGE]% when resident began moving around. Bilateral rales in lungs. Resident took off 02 and began hitting nurse. NP on call notified and received orders to send to hospital for evaluation. E[CONDITION] arrived and resident left facility via stretcher. An interview with LPN #1 on 12/13/19 at 1:10 PM revealed all nurses are responsible for updating care plans when physician orders change or if there is a change in the resident's condition. LPN#1 said if an order is received to change the resident's diet the nurse should take the order off, send a copy to dietary and update the care plan immediately. Unit Manager (UM) #1 said during an interview on 12/13/19 at 1:20 PM care plans should be updated for every new physician order or whenever there is a change in resident condition. The UM stated all nurses are educated on updating care plans and should be ensuring care plans are updated prior to leaving their shift and she could not say why Resident #16's care plan had not been revised to remove finger foods from the care plan. An interview with the Director of Nursing (DON) was conducted on 12/13/19 at 1:30 PM The DON stated nurses should update care plans at the time of change of condition with new interventions as needed and when new orders are received. The facility's failure to update Resident #16's Care Plan placed the resident at risk for serious injury, harm, impairment or death. REMOVAL PLAN: Facility failed to remove finger food intervention for a resident on a puree-only diet. [AGE] year-old resident on the secured dementia unit who staff identified as constant wanderer, required feeding by staff, and had a behavior of taking food from other residents' trays. This occurred on or around 10/4/2019. Resident no longer resides in the facility. All residents on the [CONDITION]U with a mechanically altered diet have the potential to be affected by the alleged deficient practice. All [CONDITION]U resident diets were reviewed to identify those with mechanically altered diet by the Case Mix Directors. These care plans have been reviewed and updated to ensure that interventions are appropriate for all [CONDITION]U residents with mechanically altered diets. The team reviewed 15 residents with mechanically altered diets and did not need to make any revisions. The care plan policy was last reviewed on 12/12/19 by the interdisciplinary team and signatures were secured. No nursing staff shall work until they have completed in services on updating care plans starting 12/12/19. Newly hired staff will be in serviced on updating care plans during orientation and annually thereafter by the CCC. Staff will not be permitted to work until education has been completed. The Director of Health Services (DHS), and/or nursing unit managers will review [CONDITION]U residents care plans weekly to ensure that they have been updated with acute changes, for four weeks starting 12/12/19 and quarterly there after for three months. The Director of Health Services (DHS) and or Unit Manager will report any adverse findings to the Administrator immediately and to QAPI. The Director of Health Services (DHS) and/or Unit Manages will review the Facility Activity Report five times a week to monitor for any acute changes of condition including diet changes and updated care plan for four weeks. The Director of Health Services (DHS) and/or Unit Managers will review care plans to ensure care plan interventions are updated. Any adverse findings will be reported by the Director of Health Services (DHS), Assistant Director of Health. An Ad Hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Health Services (DHS), Licensed Practical Nurse, Restorative Nurse and Certified Nursing Assistant on 1212/2019 to discuss the immediate jeopardy finding and the removal plan. All corrective actions were completed by 12/12/2019. The immediacy of the IJ was removed on 12/12/2019.",2020-09-01
1864,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-14,684,D,1,0,T11M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview and record review, the facility failed to ensure that physician orders [REDACTED].#22) observed during a complaint survey. The findings included: Review of Resident #22's record revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. On 12/11/19 at approximately 9:43 AM, Resident #22 was observed in his room in bed. The room smelled heavily of urine. The resident's urine drainage bag was covered but appeared to be sagging slightly. A staff member entered the room and noted that the bag was leaking onto the floor near the resident's bed. The resident stated that the issue had been going on for a couple of days. An observation of the drainage bag revealed that the bag contained approximately 1100 cc of urine with an undetermined amount of urine on the floor near the bed. Record review and review of physician orders [REDACTED].#20 French scale (Fr) 10 cubic centimeter (cc) bulb; Change Foley catheter monthly, Once A Day on the 9th of the Month and Flush suprapubic catheter with sterile water for leakage as needed. Review of the care plan dated [DATE], revealed that the resident was care planned for Urinary Incontinence: Resident has history of renal [MEDICATION NAME], [DIAGNOSES REDACTED], recurrent urinary tract infection and [MEDICAL CONDITION] bladder with suprapubic catheter patent. The plan notes that the resident went out to have a bladder stone procedure. Review of the resident record and progress notes revealed that the resident's catheter was changed on [DATE]. The note indicated that on 12/10/2019 a New 20Fr 30cc bulb suprapubic catheter was placed using sterile technique. An interview was conducted with LPN #1 on 12/11/19 at approximately 9:53 AM An inquiry was made regarding the catheter and why a different size bulb was utilized. The LPN stated that she would find out the reason. An interview was conducted with LPN #1 on 12/11/19 at approximately 12:33 PM The LPN confirmed that the 20Fr 30cc was used and that the physician's orders [REDACTED].",2020-09-01
1865,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-14,689,J,1,0,T11M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility failed to provide adequate supervision to maintain a safe environment for the resident and on [DATE], the resident was on a physician ordered pureed diet when the resident choked on a peanut butter sandwich. The resident was sent to hospital later that day, returned to the facility on [DATE] on Hospice and expired at the facility on [DATE]. The facility's failure to implement policy and ensure care plan interventions were revised and implemented resulted in a failure to provide adequate supervision to Resident #16 to ensure safety. The resident had a physician ordered pureed diet and on [DATE] the resident was observed having difficulty breathing. When assessed by staff the resident was pale, with low oxygen saturation levels and a peanut butter sandwich was found in the resident's mouth. Staff worked with the resident for approximately one (1) hour attempting to get the resident's oxygen saturation level up. Staff sat with the resident for several hours. Later that evening the resident experienced respiratory distress and was sent to the emergency room . The resident returned to the facility on [DATE] on Hospice care for [MEDICAL CONDITION] related to pneumonia. The resident expired at the facility on [DATE]. The facility Administrator was notified of the Immediate Jeopardy on [DATE] at 1:30 PM. The Immediate Jeopardy was removed on [DATE] at 8:30 PM. The scope and severity was lowered to a D. The findings included: Review of Resident #16's clinical record revealed an admitted to the facility of [DATE]. The resident's [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) review dated [DATE] revealed the resident was assessed to have unclear speech, rarely understood, rarely understands others, vision highly impaired and cognitive status was severely impaired. The resident had difficulty falling asleep two to six days of assessment period and exhibited physical, verbal and other behaviors directed toward others one to three days of the assessment period. According to the assessment, the resident required supervision of one (1) person, physical assistance for bed mobility, walking in room and corridor, required extensive one (1) person physical assistance for transfers and eating. The resident received a mechanically altered diet and speech therapy services were provided on [DATE]. Review of the Care Plan with revision date [DATE]: Problem [ENTITY]t Date [DATE]: 1. Category: Nutritional Status: Resident receives a therapeutic mechanically altered diet and is edentulous. History of significant weight loss with poor appetite Long Term Goal: Maintain weight without significant weight loss (Target date [DATE]) Approach [ENTITY]t Date:[DATE]: Pudding added to all meals, Observe and record all po (by mouth) intake. Provide diet as ordered. Provide alternative meals when resident is uninterested in meal served. Provide supplements as ordered. Weekly weight. 2. Problem [ENTITY]t Date [DATE]: Category: Behavioral Symptoms: Resident wanders daily. Refuses to rest. Leans to one (1) side when tired. Will go in other's rooms. Will eat off other resident's trays. Long Term Goal: Will wander safely within specified boundaries. Will have decreased episodes of refusing care and aggression. (Target date [DATE]) Approach [ENTITY]t Date: [DATE]: Maintain a calm environment. Offer finger foods (initiated [DATE]). Remove resident from unsafe situations-other resident rooms, Staff to intervene to protect the right and safety of others. Review of Order History Dietary Order with start date [DATE] end date [DATE]: Regular, Pureed with Special Instructions: Food in bowls. Surveyor received conflicting information both in the record and interviews with staff and the facility's [DATE] investigation of when the resident's choking incident occurred. From statements of staff and record review the incident occurred sometime between 11:15 AM and 7:22 PM. A Speech Therapy Plan of Care (Evaluation Only) dated [DATE]: The resident is total care for ADL's (Activities of Daily Living), wanders the halls constantly. The resident has a [DIAGNOSES REDACTED]. The resident was administered the MASA ([MEDICATION NAME] of Swallowing Ability) to assess swallow functions with resident scoring 143, placing the resident in the moderate range for dysphagia and aspiration. The resident is on the least restrictive diet for safe po intake. Review of the Resident Progress Notes documented on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE], [DATE], [DATE], [DATE] and [DATE], staff documented the resident wandering the halls incessantly, in others room and not wanting to take rest breaks. An entry on [DATE] at 6:59 p.m. Resident continues to wander on [CONDITION]U and the only activities he/she is truly interested in is meals and snack. On [DATE] at 6:37 p.m., resident was seen by staff to pick up food with his/her hands and threw it at another resident in the dining room. Resident was removed from the dining room and redirected. Further review of the Resident Progress Notes: [DATE] at 11:15 AM (Recorded as late entry on [DATE] at 1:32 PM) documented by Director of Health Services (DHS): Approached the unit to find the resident in respiratory distress. Nurse Practitioner (NP) and nursing staff present and providing care. Oxygen (02) at 2 liters with no effects. Titrated 02 up to four (4) liters also without effect. Audible crackles (clicking, rattling noises) in upper airway. Moderate amount of mucus obtained with suctioning. NP ordered [MEDICATION NAME] nebulizer treatment (medication used to open airway passages) which brought O2 saturation to low 90s. (normal 02 saturation levels ,[DATE]%). When 02 reapplied 02 saturation dropped back down to ,[DATE]'s. Resident continued with difficulty breathing second [MEDICATION NAME] nebulizer treatment was given with a decrease in rhonchi (low pitch wheezes in lung fields). Resident was difficult to manage as was making constant attempts to get up from chair. The resident seemed more relaxed when standing and leaning onto staff. Ambulated with staff to bed where resident was able to rest without attempts to get up. O2 was decreased to three (3) liters per minute on concentrator with 02 levels improved to ,[DATE]%. Staff sat at the bedside while the resident slept. [DATE] at 7:22 PM Documentation entry by NP: Was asked to come and look at the resident who was coughing. The resident is in a chair appearing pale and coughing. There is food pocketed in cheeks that looks like bread. A CNA got the food out of the resident's cheek. The resident had just eaten a peanut butter sandwich. O2 saturation checked and was [AGE]%. 02 was started at 2 liters and was increased to 4 liters via nasal cannula to bring 02 saturation to [AGE]%. More food was extracted from the residents left cheek. Resident was restless taking off the 02 saturation monitor constantly wanting to sit up and stand up. The nasal cannula was changed to a mask with still low 02 saturation levels. The DHS arrived to help support the resident. [MEDICATION NAME] nebulizer was given via mask with 02 level increased to [AGE]%. When 02 reapplied, 02 saturation level down to 81% and resident coughing. Suction started with regular suction and [MEDICATION NAME] suction which extracted some mucus. Resident appeared more ruddy (healthy reddish color) and breathing better but rales (abnormal lung sounds characterized by discontinuous clicking or rattling sounds) still heard in bilateral lungs, Stat chest x-ray ordered and [MEDICATION NAME] (antibiotic) one (1) gram IM (intramuscular) via nurse. Resident walked to room, toileted and assisted to bed. 02 saturation still low at 82%. 02 at two (2) liters with concentrator and increased to three (3) liters per minute with 02 saturation at ,[DATE]%. Resident remained stable and rested well. [DATE] at 5:38 PM Documentation entry by RN (Registered Nurse) #1: (Recorded as a late entry): On [DATE] around 10:46 PM Resident #16 was sitting in a chair in common area of [CONDITION]U. Resident was pale and attempting to cough. The resident's skin was cool and clammy with 02 saturation of [AGE]%. Resident given scheduled [MEDICATION NAME] nebulizer treatment with 02 saturation increase to 78%, but decreased to ,[DATE]% when resident began moving around. Bilateral rales in lungs. Resident takes off 02 and began hitting nurse. NP on call notified and received orders to send to hospital for evaluation. E[CONDITION] (Emergency Medical Services) arrived and resident left facility via stretcher. [DATE] at 6:34 PM Resident arrived back to facility from hospital via ambulance per stretcher. The resident was a manual lift from stretcher to bed. Resident returned on Hospice care. [DATE] at 12:53 PM Pharmacy review: Resident is on no routine meds. Resident was hospitalized for [REDACTED]. [DATE] at 12:19 PM Resident noted without respirations and heart rate. The Hospice nurse notified and confirmed death assessment. Review of the Nursing Home to Hospital Transfer Form dated [DATE] at 11:15 PM revealed Resident #16 was transferred to the hospital at 10:45 p.m. with oxygen saturation [AGE]% and heart rate of 134. Review of a hospital ER (emergency room ) Physician Record dated [DATE] at 4:50 PM, the patient presented with difficulty breathing, has severe dementia, noted to be very short of breath with loud respirations just before arrival per E[CONDITION] and was hypoxic in route. The course/duration is constant. Degree of onset severe. Degree at present severe. The resident was admitted to hospital for eight (8) day stay. A hospital Speech Therapy form dated [DATE] documented resident was seen for swallow study. The resident was admitted to the hospital in respiratory distress with bilateral lower lobe pneumonia and multifocal pneumonia. Spoke with ST at the facility the resident resides, the resident is ambulatory at baseline and is very active, constantly walking around the nursing home. The resident is on a pureed diet and apparently got a hold of a sandwich from another resident's tray. The ST assessment determined the resident's level of alertness combined with dementia affects ability to safely swallow, oropharyngeal dysphagia with signs and symptoms of aspiration with minimal intake. Recommend nothing by mouth with no exception. Family input is needed to determine wishes for alternate nutrition. Review of the Hospital Discharge Summary dated [DATE] revealed Resident #16 presented to the emergency room in respiratory distress. A CTA (computed tomography [MEDICATION NAME]) of the chest shows bilateral multifocal pneumonia. The resident was admitted to the hospital for acute hypoxic [MEDICAL CONDITION] secondary to bilateral multifocal pneumonia and was started on broad-spectrum IV (intravenous) antibiotics for healthcare associated pneumonia. Initially needed two (2) to three (3) liters of oxygen therapy and resident has severe dementia and would not follow verbal commands. Consulted with speech therapy and a PEG (percutaneous endoscopic [MEDEQUIP]) tube placement was recommended. Discussed with family about PEG tube placement and medical illness and family refused PEG tube placement and wanted comfort care. The resident is discharging to nursing home on Hospice Care. Review of the National Center for Biotechnology Information data base (a part of the United States Library of Medicine a branch of the National Institutes of Health) from an article in the British Journal of Radiology dated [DATE] documentation review revealed: Aspiration pneumonia can give rise to multifocal pneumonia consolidation affecting primarily the dependent portions of the lungs, in particular the posterior segments of the upper lobes and apical segments of the lower lobes. An interview with the Nurse Practitioner (NP) on [DATE] at 8:45 AM revealed she was called to the Memory Support Unit ([CONDITION]U) on [DATE] at approximately 2:00 PM He/she said upon arriving on the unit Resident #16 was noted to have labored breathing, and he/she did not immediately know why until he/she noted the resident had pocketed food in her mouth. The NP said he/she removed what appeared to be a peanut butter sandwich from the resident's mouth. He/she stated the resident was suctioned and that staff had a difficult time keeping the oxygen on the resident, that the resident was very restless she would get up and take the oxygen off. The NP stated he/she spent approximately one (1) hour providing treatment to the resident until his/her oxygen saturation levels improved and the resident was able to rest in bed with staff at bedside to monitor the resident closely. The NP said he/she felt upon leaving unit the resident was stable and was resting in bed. Later that evening at 9:45 PM the nurse on duty call the NP on duty due to the resident being in respiratory distress and the resident was transferred to the emergency room for evaluation. An interview was conducted with LPN (Licensed Practical Nurse) #3 on [DATE] at 10:05 AM The LPN stated on [DATE] upon entering the [CONDITION]U there were a lot of people surrounding Resident #16 in the common area of unit. The NP and the DHS were working with the resident and that he/she assisted them by suctioning the resident, removing mucus and encouraging the resident to cough. He/he stated the resident had a hard time coughing and it was difficult to get the resident to calm down. The LPN said when the resident's O2 saturation levels had improved the resident was transferred to room to bed with 02. The LPN said he/she sat by the resident's bedside for a couple of hours. He/she stated during the time he/she sat with the resident, the resident did not attempt to get up or walk and did not have anything to eat or drink because he/she was not responsive enough. The LPN concluded staff on the [CONDITION]U were focused and know how to approach the residents, but staff were unable to watch everybody because they (the residents) wander. A telephone interview was conducted with RN #1 on [DATE] at 10:00 AM The RN stated she received in report when coming on duty on [DATE] at 7:00 PM that Resident #16 had aspirated on a sandwich earlier in the day, the resident had choked, and oxygen saturations levels dropped significantly. The RN was told that staff had to work on the resident for a couple of hours to get oxygen saturation levels up. The RN said he/she questioned the nurse going off duty why the resident had not been sent out to the hospital to be evaluated, because the nurse would not be able to closely monitor the resident that evening because the RN was responsible for approximately 40 residents when coming on duty. RN #1 stated the resident was up walking the halls at 7:00 PM and when it was time to administer the resident's scheduled breathing treatment at approximately 9:30 p.m., the resident could barely stand up and was very pale, the resident's breathing was very loud, it sounded like a death rattle. The RN said she took the resident's oxygen saturation levels and they were down in the 70's with heart rate around 130, and the RN could actually hear the resident's breathing from down the hallway. RN #1 contacted the Nurse Practitioner on call and resident was sent out to emergency room for an evaluation. The nurse concluded, I could not understand why the resident was not sent out earlier. During an interview with the Medical Director (MD) on [DATE] at 9:45 AM, the MD said after reviewing Resident #16's hospital records, the resident was not diagnosed with [REDACTED]. The MD stated everybody aspirates all the time and that aspiration cannot be prevented. The MD stated he/she had no idea how the resident could have gotten the sandwich, but if you leave food out residents on the [CONDITION]U will get it. The MD said staff on the [CONDITION]U do the best they can do, and they can't monitor everyone every minute, that would be unrealistic expectations. He/she stated staff cannot watch all the residents all the time and that a pureed diet can also be aspirated. During an interview with the Speech Therapist (ST) on [DATE] at 11:00 AM he/she said a speech evaluation was conducted on Resident #16 in [DATE]. The ST said it was determined the resident could not be upgraded from a pureed diet. The ST said the assessment determined the resident remained at moderate risk for aspiration. The ST stated the resident had previously been able eat sandwiches, but since it was documented on the [DATE] speech therapy evaluation the resident could not safely eat sandwiches. An interview with CNA (certified Nursing Assistant) #3 was conducted on [DATE] at 4:35 PM The CNA said Resident #16 was on a pureed diet and was not supposed to have sandwiches, but the resident would grab out and get other resident's food if staff didn't have their eye on him/ her. The aide stated he/she witnessed the resident grabbing other resident's food, and if the resident saw staff coming the resident would cram the food in his/her mouth. LPN #1 stated during an interview on [DATE] at 10:30 AM Resident #16 was a wanderer who wandered almost non-stop. He/she said staff would attempt to get the resident to sit down and the resident would get right back up. She said the resident would wander to the point of exhaustion and that she would just pick up food and eat it. An interview with LPN #4 on [DATE] at 10:40 AM revealed Resident #16 had started out on a Regular diet, but she was downgraded to a pureed diet after a speech therapy evaluation. The LPN said the resident wandered all time and took very short rest breaks and was not easy to redirect. He/she said snacks are offered to all residents on the [CONDITION]U, the snacks are brought to the unit from the dietary department to include peanut butter and jelly sandwiches, which the residents love. She stated Resident #16 was on a purred diet with thickened liquids and could not have peanut butter and jelly sandwiches, but at times the resident would grab food and cram it in his/her mouth before staff could intervene. The LPN said once the resident got the food staff was not usually successful in getting the food back from the resident. Observation on [DATE] at 10:45 AM revealed 11 peanut butter and jelly sandwiches were in the unit snack refrigerator with dated ,[DATE] which the LPN stated was the expiration of the sandwiches. Observation on [DATE] at 1:08 PM in the [CONDITION]U dining room revealed 28 residents were sitting in the chairs/wheelchairs at four (4) person tables awaiting the lunch meal. Six (6) staff began serving the meals trays at 1:12 PM one table at a time. Resident # 25 and Resident #26 were observed sitting at a table with two (2) other residents. On [DATE] at 1:20 PM Resident #26 moved Resident #25's plate toward himself/herself, and Resident #26 immediately began eating the food from Resident #25's plate. After approximately one (1) minute CNA #2 walked by the table and pushed Resident #25's plate from Resident #26's reach and placed the plate back in front of Resident #25 which the resident began to eat. Surveyor immediately informed CNA #2 that Resident #26 had been eating from Resident #25's plate. CNA #2 stated he/she had only noted the plate had been moved and had not seen Resident #26 eating from Resident #25's plate. CNA #2 immediately removed Resident#25's meal and contacted the dietary department for a meal replacement. Observation on [DATE] at 1:30 PM of the tray cards sitting on the table by the residents, Resident #25's diet was listed as NCS (no concentrated sweets diet), Resident #26's diet was listed as Mechanical Soft Diet. Review of physician orders [REDACTED].#26 confirmed the residents had received the correct diets during the meal on [DATE]. Resident #26 ate from Resident #25's plate that did not contain mechanical soft food items. An interview with the Dietary Manager on [DATE] at 11:30 AM revealed a resident on a NCS diet would have regular textured diet with no concentrated and a Mechanical Soft Diet would have ground meat. Staff had no knowledge Resident #26 had eaten an undetermined amount of food off the tray of Resident #25 until surveyor intervention, thus the resident was at risk for potential choking due to consuming an incorrect diet. A review of facility policy revised [DATE] and titled, Occurrences, noted the facility recognizes that due to the frailty of residents served, there is an increased risk of occurrences that may result in injury to the resident. In an effort to prevent occurrences, each resident will be observed and assessed for risks, and appropriate interventions will be implemented in accordance to their plan of care. Occurrence hazards are physical features in the healthcare environment which may pose a risk to the resident's safety to include any event, accident or incident, which results in an injury or has the potential for injury. Review of a facility policy issued 2012 and titled, Support Unit Safety and Security revealed Memory Support Unit ([CONDITION]U) residents shall not be allowed to have any item or materials that could cause harm if used inappropriately. Staff on every shift shall periodically monitor common and private areas of the [CONDITION]U for safety hazards. The facility failed to implement their policy, failed to provide adequate supervision, update the resident's plan of care to address R#16's behavior wandering and eating food the resident had been assessed as unsafe to consume. These failures resulted in immediate jeopardy when Resident #16 ate a peanut butter sandwich, choked, was sent out to the hospital hours later, returned from hospital on Hospice care and expired at the facility 10 days later. An observation on [DATE] of the lunch meal on [CONDITION]U determined staff failed to supervise meal service again, when a resident was able to eat from another resident's plate. REMOVAL PLAN: Facility failed to remove finger food intervention for a resident on a puree-only diet. [AGE] year-old resident on the secured dementia unit who staff identified as constant wanderer, required feeding by staff, and had a behavior of taking food from other residents' trays. This occurred on or around [DATE]. Resident no longer resides in the facility. All residents on the [CONDITION]U with a mechanically altered diet have the potential to be affected by the alleged deficient practice. All [CONDITION]U resident diets were reviewed to identify those with mechanically altered diet by the Case Mix Directors. These care plans have been reviewed and updated to ensure that interventions are appropriate for all [CONDITION]U residents with mechanically altered diets. The team reviewed 15 residents with mechanically altered diets and did not need to make any revisions. The care plan policy was last reviewed on [DATE] by the interdisciplinary team and signatures were secured. No nursing staff shall work until they have completed in services on updating care plans starting [DATE]. Newly hired staff will be in serviced on updating care plans during orientation and annually thereafter by the CCC. Staff will not be permitted to work until education has been completed. The Director of Health Services (DHS), and/or nursing unit managers will review [CONDITION]U residents care plans weekly to ensure that they have been updated with acute changes, for four weeks starting [DATE] and quarterly there after for three months. The Director of Health Services (DHS) and or Unit Manager will report any adverse findings to the Administrator immediately and to QAPI. The Director of Health Services (DHS) and/or Unit Manages will review the Facility Activity Report five times a week to monitor for any acute changes of condition including diet changes and updated care plan for four weeks. The Director of Health Services (DHS) and/or Unit Managers will review care plans to ensure care plan interventions are updated. Any adverse findings will be reported by the Director of Health Services (DHS), Assistant Director of Health. An Ad Hoc QAPI meeting was held with the Medical Director, the Administrator, Director of Health Services (DHS), Licensed Practical Nurse, Restorative Nurse and Certified Nursing Assistant on ,[DATE] to discuss the immediate jeopardy finding and the removal plan. All corrective actions were completed by [DATE]. The immediacy of the IJ was removed on [DATE].",2020-09-01
1866,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-19,584,E,0,1,HRL411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility's cleaning schedule it was determined the facility failed to maintain a clean and sanitary environment on three (3) of four (4) units. The findings include: On [DATE] at 8:40 AM upon entrance to facility the odor of urine was detected around the area of the front desk. During initial tour on [DATE] at 9:30 AM a strong urine odor was detected in rooms [ROOM NUMBERS]. On [DATE] at 1:30 PM a strong odor of urine was detected around the nurses' station on the 200 Unit. On 1[DATE] at 11:21 AM a strong odor of urine was detected in room [ROOM NUMBER] Bed A, there were several missing tiles under the bed, black residue around the base of the commode and even stronger odor of urine and feces in the resident's bathroom room. Observation of the resident's bedroom detected even stronger odor and feces. On 1[DATE] at 12:10 PM a strong odor of urine was detected in the hallway leading to the Ritz dining room. There were several residents in wheelchairs lined up against the wall waiting for the dining room to open Interview with Family member of Resident #19 on 1[DATE] at 12:05 PM revealed she had identified problems with the cleanliness in the assisted dining room. The chairs in the dining room needed upholstering and requested the dining room to be repainted. On [DATE] 8:42 AM a strong odor of urine and feces was noted in the hallway from Rooms 212 to 223. Interview with R#45's daughter on [DATE] at 8:45 AM revealed the facility has an odor. I believe the facility has a ventilation problem. On [DATE] at 9:05 AM an environmental tour conducted on the 200 Unit with the Maintenance Director and the Interim Housekeeping Supervisor revealed the following: - room [ROOM NUMBER] entrance door with splintered wood edges - room [ROOM NUMBER] resident's bathroom door with splintered edges - room [ROOM NUMBER] resident's closet door has small holes, splintered wood edges on the door and a gauged hole at the bottom. - room [ROOM NUMBER] entrance door with splintered wood edges. Commode missing a toilet seat and the bathroom door with jagged wood edges. - room [ROOM NUMBER] Bed A top drawer in night stand missing edge covering exposing sharp wood edges; entrance door with splintered edges. Dried tube feeding formula on base of the pole and on the floor. Black scuff marks around the head of Bed A. Bed B had the missing protective edging at the foot of the bed. The first (1st) and second (2nd) drawers of the night stand at Bed B missing the edging covering. There was dried tube feeing formula on the floor and the base of the pole. In the bathroom the grout around the commode with dark residue; strong urine odor present. The ceiling ventilation was tested by holding a toilet paper to vent by the surveyor and Maintenance Director to see if the air vent sucked the toilet paper towards it. The toilet paper did not move. - room [ROOM NUMBER] entrance door with splintered edges. Wall paint peeling around Bed A. Closet door with missing wood at the bottom of the door. The night stand by Bed B has the bottom drawer missing the edge covering and does not close completely. Also, there was dried beige color stain at the head of Bed B. - room [ROOM NUMBER] entrance and bathroom doors with splintered gouged areas. Closet doors not on track causing the doors to swing with the slightest pressure. The night stands at both beds missing edge covering. - room [ROOM NUMBER] urine odor still present in the room. Tile under bed has now been replaced. Night stand at Bed A has top drawer missing edge covering. Hole in the wall at the foot of Bed A. Dirt buildup at entrance to bathroom and discolored grout around the commode. Strong urine odor present in bathroom. Ceiling vent sounding but failed toilet paper test. Peeling paint on the wall under the sink. Bed B night stand first (1st) and third (3rd) drawers missing edge covering. - Rooms 212 - 223 - all rooms had chipped and scrapped paint on the walls. Both rooms have patchwork in need of painting. - Chipped paint on door jam in rooms [ROOM NUMBER] - room [ROOM NUMBER]-bathroom ventilation system not working and a heavy buildup dirt and grime residue on the floor and damaged sheetrock on wall behind 216 Bed B - 217 - loose baseboard near bathroom door - Broken drawer and missing drawer on nightstand in closet of room [ROOM NUMBER] - Community Shower (Spa) stall walls with black substance buildup. Dim lighting in the shower room and dead roaches in ceiling lighting. Interviews with the Maintenance Director and the Interim Housekeeping Supervisor (IHS) during the environmental tour on [DATE] at 9:05 AM revealed as the staff identify areas that need repair, they should report it through facility's maintenance computerize system. The Maintenance Director stated that he had not received any notifications from the staff on the areas identified during the tour. The Maintenance Director was not sure how to test to see if the system was working properly. After showing the Maintenance Director how to test the ventilation in the bathroom he agreed that it appeared there was a problem with the ventilation system in the identified bathrooms. The IHS stated the housekeeping staff have assigned rooms daily that are to be deep cleaned. The deep cleaning included cleaning the room from top to bottom. The IHS also stated there were housekeeping staff assigned to mopping the bathroom floors and shower room floor but after this environmental tour it was evident the staff were not performing their assigned duties. The Maintenance Director and the Interim Housekeeping Supervisor stated the facility does not conduct any type of environmental rounds. Both agreed the continual problem with odors and the inadequate cleaning could be contributing factors to the continuing roach infestation. Environmental tour of the 300 unit on [DATE] at 10:00 AM revealed the following: - rooms [ROOM NUMBERS]- Paint chipped on the bathroom door frames - room [ROOM NUMBER]- corners of the wall on the entrance marked with scraping from the floor to ceiling, baseboard along the floor on left wall pulled loose from the wall - room [ROOM NUMBER] - on the left side and back wall torn wallpaper from the wall - rooms [ROOM NUMBERS]- paint scraped along length of wall the side where bed's A and B reside - room [ROOM NUMBER]- paint scraped along the bottom of the left wall - room [ROOM NUMBER]- Linoleum chipped away of eight (8) inches long by three (3) inches on the floor in the back of the room in front of the resident's bed - room [ROOM NUMBER]- paint chipped and scraped on both sides of the walls - rooms [ROOM NUMBERS]- closest doors are off the track - room [ROOM NUMBER] - peeling wallpaper on the top at the ceiling of the right wall - room [ROOM NUMBER] - scraping of paint on right side of the wall - Shower room on the 300 Hall, the interior of the wood door entering the shower room had scrapings across one side to the next from the bottom of the door to the door handle An environmental tour of the 100-Unit on [DATE] 10:29 AM revealed the following: - room [ROOM NUMBER] closet door scratched up - room [ROOM NUMBER] hole and scratches in closet door - Nurses station unit one the bottom of door into the nurses station is marred and at the bottom of the door frame along the floor there is dirt and old wax build up - room [ROOM NUMBER] corridor door chipped on edges. - room [ROOM NUMBER] bathroom door frame rust at the bottom of the frame, - room [ROOM NUMBER] mold around toilet, - room [ROOM NUMBER]-bathroom door frame rust and dirt at the bottom of the frame, - room [ROOM NUMBER]-bathroom door frame has rust at bottom, - room [ROOM NUMBER] corridor door chipped, - room [ROOM NUMBER] dirt and mold around base of toilet, - room [ROOM NUMBER]-bathroom door frame scratched, dirt and mold build up on base of toilet. A walk-through Environmental tour on [DATE] at 12:20 PM of the 300 Unit was done with the Environmental Services Consultant to show him the concerns that were found. Interview [DATE] at 12:20 PM with the Environmental Services Consultant, he stated, we are hiring a Maintenance Assistant to help the Maintenance to help with the daily maintenance of this building. Our last Assistant Maintenance person just retired, and we are looking to replace him. A review of the facility's computerized system for deep cleaning revealed the housekeeping staff were to clean the following: clean sprinkler heads; ceiling lights; check cubicle curtain and change if needed; clean windows and window sills with Green works glass cleaner; clean bedframes, head and foot boards; clean mattresses and wipe down with Pro Quaternary cleaner; clean walls; clean air conditioner grills and frames; fill soap and paper towel dispensers; clean bathroom sink, light, mirror and commode; clean and dust picture frames; high dust and wipe down door and trim; clean all furniture and polish; wet clean trash cans, wipe down and replace liner use Pro Quaternary cleaner; sweep and dust mop bathrooms and floor barring; clean plank, VCT and carpet floor and mop floor. A review of the facility's December Deep Cleaning Room Schedule revealed that eight (8) rooms were scheduled for deep cleaning each day starting 12/2/19 thru [DATE] for a total of [AGE] rooms. The IHS confirmed only eight (8) rooms out of the [AGE] rooms scheduled had received the deep cleaning treatment. An observation and interview with the Environmental Services Consultant (ESC) on [DATE] at 3:45 PM regarding the ventilation system in room [ROOM NUMBER]. The ESC was asked to check to see if the ventilation system was functioning properly in room [ROOM NUMBER]. The ESC held toilet paper to the vent and determined the ventilation system was not functioning properly. The ESC stated there were plans to start renovations in the facility in the near future but was unable state when the renovations would start.",2020-09-01
1867,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-19,625,D,0,1,HRL411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide evidence that the Bed-hold notice upon transfer for hospitalization was shared with the residents and responsible parties for two (2) of 31 sampled residents. Findings Include: 1. Review of the facility's Bed Hold Policy with the revision date of 5/07 indicated Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during this admission, which is well in advance of any transfer. The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer. Review of Resident #53's record indicated the resident was admitted [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the resident's Discharge Assessment Minimum Data Set ((MDS) dated [DATE] indicated the resident had a severe cognitive impairment. The resident's performance level with activities of daily living indicated the resident performed bed mobility with extensive assist of two persons; transferred with total assistance of two persons; the resident required total assistance of two persons to move about the facility; was in need of total assistance of two persons with dressing and was in need of total assistance with one person with eating and toilet use. Review of Resident #53's Progress notes dated [DATE] at 1:38 a.m. indicated the resident was sent out to the hospital for further evaluation due to abnormal vital signs. In an interview on 1[DATE] at 6:17 p.m. the Responsible Party for Resident #53 indicated the resident had gone to hospital 11/15/19 due to low oxygen saturation and not being responsive. The responsible party reported the facility did not let the responsible party know about the bed hold policy for this November hospitalization . The responsible party also said the resident had been hospitalized in August but it was the insurance's fault that the resident could not be readmitted immediately. Interview with the DON (Director of Nursing) on [DATE] at 12:10 p.m., indicated it was not August but September when Resident #53 went to the hospital. They did have evidence of the Responsible Party for Resident #53) was given documentation of the bed hold policy for the September transfer to the hospital but not the November hospitalization . 2. Review Resident #3's record indicated the resident was admitted on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the 11/19/19 quarterly MDS indicated the resident's performance with activities of daily living involved bed mobility with supervision; transfer with limited staff assistance; walk with limited assistance; locomotion on unit with limited staff assistance; dressing with limited staff assistance of one; eating required staff supervision; toilet use was with limited staff assistance and the resident was not steady but only able to stabilize with staff assistance. The resident was severely cognitively impaired. Review of the [DATE] Discharge Summary indicated Resident #3 had been admitted to the geriatric psychiatry unit on 11/19/19. An attempt was made on 1[DATE] at 5:13 p.m. to call the responsible party but he did not have time to talk. In an interview on [DATE] at 10:00 a.m. the DON indicated they had the Bed Hold policy that was given to the resident's responsible party on 8/23/18 at the time of admission but confirmed the documentation for the hospitalization for 11/19/19 was not in the medical record.",2020-09-01
1868,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-19,698,D,0,1,HRL411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure ongoing communication between the facility and the [MEDICAL TREATMENT] center for three of four sampled residents (R#10, R#34, and R#114). Findings included: 1. Review of R#10's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Care Plan revised 12/03/19 revealed R#10 is at risk for complications related to [MEDICAL TREATMENT] for [DIAGNOSES REDACTED]. The long-term goal with a target date of 03/01/2020 is R#10 will not develop complications related to [MEDICAL TREATMENT] through next review. Approaches included BP (blood pressure) and pulse before and after [MEDICAL TREATMENT]; check shunt site for signs and symptoms of infection, pain or bleeding daily and PRN (as needed); communicate with [MEDICAL TREATMENT] center regarding medication, diet, and lab results; coordinate care with [MEDICAL TREATMENT] center utilizing communication sheets; consult with dietitian for nutritional support related to [MEDICAL CONDITION] as needed; make transportation arrangements for [MEDICAL TREATMENT]; meds as ordered; No BP or venipuncture in shunted arm every shift; observe for signs and symptoms of fluid volume overload; observe for signs and symptoms of volume deficit; and refer to MD (medical director) or RP (responsible party) as needed. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R#10 was assessed as having a Brief Interview for Mental Status (BI[CONDITION]) score of 7 indicating the resident is moderately impaired in skills for daily decision-making. R#10 was assessed as needing extensive physical assistance of one person for bed mobility, dressing and personal hygiene; total physical assistance of two or more people for transfers; total physical assistance of one person for locomotion on the unit, toilet use and bathing; and supervision of one person for eating. R#10 was assessed as always incontinent of bladder and bowel. R#10 was assessed as receiving [MEDICAL TREATMENT] while a resident. Review of R#10's [MEDICAL TREATMENT] Center Communication Forms for the period of 9/18/19 through 12/9/19 revealed eight (8) out of 18 forms were not completed by the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] center failed to complete their section. No documentation was found in resident's chart indicating nursing attempted to obtain the information from the [MEDICAL TREATMENT] center. 2. Review of R#34's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Care Plan initiated on 9/18/18 revealed R#34 requires [MEDICAL TREATMENT] three times weekly related to DX. (diagnosis) of [MEDICAL CONDITION]. The long-term goal with a target date of 1/1/2020 is R#34 will be free from complications related to [MEDICAL TREATMENT] through next review. Approaches included BP and pulse before and after [MEDICAL TREATMENT]; check shunt for signs and symptoms of infection, pain or bleeding daily and PRN; check thrill and bruit as ordered; communicate with [MEDICAL TREATMENT] center regarding medication, diet, and lab results; coordinate care with [MEDICAL TREATMENT] center; coordinate transportation to the [MEDICAL TREATMENT] center as scheduled; diet as ordered; may take inhaler to [MEDICAL TREATMENT] and self-administer meds as ordered; no BP or venipuncture in shunted arm every shift; and observe for signs/symptoms of fluid volume overload. Review of the Quarterly MDS assessment dated [DATE] revealed R#34 was assessed as having a BI[CONDITION] score of 14 indicating the resident is cognitive in skills for daily decision-making. R#34 was assessed as needing extensive physical assistance of two or more people for transfers and personal hygiene; total physical assistance of two or more people for transfers and bathing; total physical assistance of one person for dressing and toilet use; and supervision of one person for eating. R#34 was assessed as always incontinent of bladder and bowel. R#34 was assessed as receiving [MEDICAL TREATMENT] while a resident. Review of R#34's [MEDICAL TREATMENT] Center Communication Forms for the period of 8/13/19 through 12/7/19 revealed 10 out of 14 forms were not completed by the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] center failed to complete their section. No documentation was found in resident's chart indicating nursing attempted to obtain the information from the [MEDICAL TREATMENT] center. 3. Review of #114's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Care Plan initiated on 9/3/19 revealed R#114 has [MEDICAL CONDITION] and requires [MEDICAL TREATMENT] three times weekly. The long-term goal with a target date of [DATE] is R#114 will be free from complications related to [MEDICAL CONDITION] or [MEDICAL TREATMENT] through next review. Approaches included all labs via [MEDICAL TREATMENT] as able; coordinate care with [MEDICAL TREATMENT] via communication sheet; coordinate transportation to/from [MEDICAL TREATMENT]; document VS (vital signs) before and after [MEDICAL TREATMENT]; no BP/Vein sticks in shunted arm; observe access for signs/symptoms infection; observe for fluid overload; observe for fluid restriction - encourage compliance; observe for volume deficit; observe thrill/bruit/patency of graft/shunt as ordered; and refer to MD/RP/[MEDICAL TREATMENT] center as needed. Review of the Quarterly MDS assessment dated [DATE] revealed R#114 was assessed as having a BI[CONDITION] score of 11 indicating the resident is moderately impaired in skills for daily decision-making. R#114 was assessed as needing supervision of one person for bed mobility, dressing, toilet use and personal hygiene; independent with set-up help only for transfers and eating; and physical assistance with part of bathing from one person. R#114 was assessed as always continent of bladder and bowel. R#114 was assessed as receiving [MEDICAL TREATMENT] while a resident. Review of R#114's [MEDICAL TREATMENT] Center Communication Forms for the period of 9/3/19 through [DATE] revealed 10 out of 16 forms were not completed by the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] center failed to complete their section. No documentation was found in resident's chart indicating nursing attempted to obtain the information from the [MEDICAL TREATMENT] center. Interview with Unit Nurse #2 on 1[DATE] at 11:30 a.m. revealed the [MEDICAL TREATMENT] communications sheets are filled out by the nurse on duty and sent with the resident to [MEDICAL TREATMENT]. Unit Nurse #2 said sometimes the form is filled out when it come backs and sometimes it is not. Unit Nurse #2 said she usually calls the [MEDICAL TREATMENT] center when the form returns incomplete. Unit Nurse #2 said the form is used as a communication tool between the facility and the [MEDICAL TREATMENT] center. During an interview with the Director of Health Services on [DATE] at 10:16 a.m. regarding [MEDICAL TREATMENT] Communication Sheets, she stated the sheets are used for communication between the [MEDICAL TREATMENT] center and the facility. She stated it is a form used to inform the facility of the treatments, issues or new physician's orders [REDACTED]. The DHS stated she understood efforts should be made by the nursing staff to ensure the communication sheets are completed. The DHS stated there is not a policy regarding the use of the communication sheet.",2020-09-01
1869,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-19,812,F,0,1,HRL411,"Based on observation, interview and record review the facility failed to prepare food in accordance with professional standards for food service safety. Specifically, kitchen staff did not change gloves between cleaning the steamer and then checking the temperature of the food on the steam table. This issue has the potential to effect residents in the facility who ate lunch from the kitchen. Findings include: Review of the facility policy Bare Hand Contact with Food and Use of Plastic gloves received from the facility on [DATE] at 10:10 a.m., was dated Effective: 12/1/17, Reviewed 10/18/17 and Revised 10/18/17 indicated that gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task such as working with ready to eat food or with raw animal food, used for no other purpose and discarded when damaged or soiled or when interruptions occur in the operation. Hands are to be washed when entering the kitchen and before putting on the plastic gloves. During the observation on [DATE] at 10:31 a.m., Cook #1 cleaned spill from steamer with the green bucket of soap and water. Cook #1 did not change gloves before going over to the steam table with a thermometer. Cook #1 took the temperature of the pureed carrots with the same gloves on that she used to clean out the oven. Cook #1's gloved finger of her left hand touched the pureed carrots. In an interview on [DATE] at 10:45 a.m., Cook #1 confirmed she used the same gloves to check food temperatures as the ones she used to wipe the spill from the bottom of the steamer. In an interview on [DATE] at 11:00 a.m., the Assistant Kitchen Manager said they do training quarterly with staff on hand washing. In an interview on [DATE] at 12:00 p.m., the Kitchen Manager said that Cook #1 should have changed her gloves in between task. Review of the training documentation dated 5/30/19 showed Cook #1 had been trained on handwashing but not glove usage. The competencies list for Dining Services did not show that glove usage was part of the competencies to be trained on.",2020-09-01
1870,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-19,920,D,0,1,HRL411,"Based on observation and interview, the facility failed to ensure the dining tables in two (2) of five (5) dining rooms were adequately furnished with steady tables that did not shake or move. The findings included: During the Environmental tour on [DATE] at 9:05 AM with the Maintenance Director the following was identified: - In the assisted dining room on the 200 Unit there were three (3) of five (5) tables with loose (unsteady) table tops. And an overbed table with splintered edges - In the Ritz dining room three (3) of six (6) tables with unsteady table tables An interview with the Maintenance Director during the tour revealed if the nursing staff had completed a maintenance request, he could have repaired the tables without any problems. The Maintenance Director acknowledged having tables that were unsteady posed a hazard and contribute to resident falls.",2020-09-01
1871,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2019-12-19,925,E,0,1,HRL411,"Based on observation, interview, review of facility policy it was determine the facility failed to maintain an effective pest control program. The findings include: Review of the facility document titled Pest Control - [STATE] with a revision date 6/1/17 documented It is our policy to have program for insect, rodent, and pest control. Pest control will be maintained and conducted in a manner that continually protects the health of the residents . Interview with Family member of Resident #129 on 1[DATE] at 12:05 PM revealed the facility has a bad problem with roaches I have seen them in my mother's room and even took one (1) home with me in my mother's laundry. You can see them scurrying down the hallway in the early morning. If you look in the assisted dining room, you will see them on the walls and in the ceiling lights. Interview with Unit Nurse #2 on 1[DATE] at 11:30 AM revealed the facility has problems with roaches, it seemed like it was getting better, but now they are back. The Unit Nurse stated they're supposed to report the sightings to the Maintenance department through a computerized system, but she had not reported any sightings. The Unit Nurse could not recall the last time the exterminator had been at the facility. During the Resident Council meeting on 1[DATE] at 2:30 PM the residents voiced concerns that included pest control. The residents stated there are roaches throughout the facility. They are everywhere voiced one resident, climbing on the wall, in your clothing and in your bed. They reported this concern in the Council meeting with no results. According to the AT Director, the facility has hired an exterminator to come and spray the facility. Residents stated that was some time ago, but the roaches are still here, and they have increased. Maybe they like the chemical he provides because they are not dying. Interview with Family member of Resident #19 on [DATE] at 3:25 PM revealed she has seen roaches especially during the summer. The family member also stated it would be better if the exterminator focused on spraying outside the facility also. Observation on 1[DATE] at 3:10 PM in the Ritz dining room revealed a dead roach in the top drawer of the credenza. Observation on [DATE] at 9:45 AM during the environmental tour revealed in the community shower room (SPA) several dead roaches in the ceiling lighting. Observations in the surveyors' conference room on [DATE] at 11:34 AM and 1:13 PM revealed a roach climbing up and down the wall. Review of the facility's pest control records revealed extermination services from Ecolab on the following dates: - 3/18/19 (monthly) - 4/18/19 (monthly) - 6/24/19 (monthly - 7/18/19 (monthly) - 8/2/19 - 8/4/19 (monthly) - 8/15/19 (monthly) - 8/30/19 - [DATE] (monthly) - 9/27/19 (monthly) - 10/10/19 - 10/14/19 (monthly) - 10/22/19 (monthly) - [DATE] (monthly) - 11/26/19 (monthly) - 1[DATE] (monthly) However, the records did not reflect whether the effectiveness of the chemicals used eliminated the roaches or identified the contributing factors of the roach infestation. An interview on [DATE] at 3:05 PM with the Nurse Navigator revealed there was a problem with a number of homeless residents admitted to the facility. Their clothing contained roaches and this was a contributing factor to the current roach infestation. The Nurse Navigator further stated if roaches are sighted the nurse should report it through the building computerized system or directly to the Maintenance Director. Interview on [DATE] at 3:33 PM with the Administrator revealed the facility has a contract with Ecolab for monthly visits. If pest sightings occur between the monthly visits, then Ecolab can come out to perform extra spraying and it should be documented in the pest control records.",2020-09-01
4276,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,157,D,0,1,443S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to notify the physician with a change in the resident's condition. Resident # 115 had a change in condition and there was no evidence or documentation that the physician was notified. The findings included: The facility admitted resident # 115 with a [DIAGNOSES REDACTED]. A review of resident #115's medical record on 06/28/2016 at 09:45 AM, revealed that there was no documentation throughout the nurses notes on 03/16/2016 at 04:20 AM through 03/16/2016 at 07:50 AM regarding decreased pulse, periods of apnea, not responding to chest rub, no blood pressure, no pulse and no respirations. There is no documentation that the physician was notified at the time of these changes. An interview with Licensed Practical Nurse (LPN) # 3 on 06/30/2016 at 09:45 AM , revealed that the physician was notified when there was a change in the residents condition. We are suppose to call when there is a change in condition. I thought I charted it but , I must have not. I did leave a message for the family but when I left that morning they still had not called back. Interview with the physician on 07/01/2016 at 10:48 AM, revealed that he could not remember that far back about Resident # 115. He stated, It depends on the situation, if the patient is a Do Not Resuscitate (DNR) and the decline was expected , then no I do not want to be called. My phone is in the kitchen every night, they can leave a message. I am in this building every day.",2020-04-01
4277,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,253,E,0,1,443S11,"Based on observations, interviews and the facility's policy, the facility failed to provide housekeeping and maintenance services for 3 of 4 units with observed environmental concerns noted during initial tour and all days of the survey. The findings included: During an environmental tour with the Director of Maintenance and the Administrator on 07/01/16 at 11:43 AM, all of the following issues were confirmed: Unit 100: Room 107- Wallpaper peeling on near the ceiling by the resident ' s shelf on the wall. Room 109- Wallpaper peeling near the window. Room 120B- Strip missing on the bedside table. Room 123 -Wall paper near the Heating, Ventilating, and Air Condition (HVAC) Room 122- Privacy curtain with brown stains. Room 147-Dried spills and stain on the floor in the back left corner of the room. Unit 200: Room 205- Resident ' s bathroom stain on the ceiling and the wall has a hole. Room 209A - Resident ' s side rail on the bed has a reddish stain. Room 212- Resident ' s wheelchair arms on both side are torn with foam exposed. Room 215-Resident ' s bathroom stool riser frame contains rust. Room 217A-Resident ' s room a hole in the wall near the bed. Room 217B- Resident ' s room outlet near the bed is cracked. Room 219- Resident ' s bathroom ceiling has a stain, base of the toilet stool riser frame is rusty, and the left bathroom wall is damaged. Unit 300: [RM #]1-Dried spills on the wall near the bathroom. [RM #]5A- Resident ' s room wallpaper torn and dried spills on the wall. [RM #]6A- Resident ' s closet door are off the rollers. [RM #]9A- Resident ' s walls are scuffed near the bed. Room 313- Resident ' s room hole in the wall near the bathroom. Room 319-Resident ' s room wall is scuffed near the bed. Room 322B- Resident ' s room paint is peeling off the wall behind the bed. Review of the facility ' s policy entitled Safety Guidelines revealed #13. Report defective flooring, loose hand railings, bad stair treads, and dangerous projections from walls to your supervisor so he or she can arrange the repair.",2020-04-01
4278,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,279,D,0,1,443S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop a care plan to address the risk factors related to contracture development and implement interventions to prevent contractures and/or prevent continued decline for 1 of 3 sampled residents reviewed for range of motion (ROM). The facility did not develop a Care Plan for impaired ROM/contractures for Resident #168 with measurable goals and interventions to prevent contracture development and/or worsening of existing contractures. The findings included: The facility admitted Resident #168 with [DIAGNOSES REDACTED]. Review of the 6-7-16 Quarterly Minimum Data Set Assessment on 6-29-16 at 8:49 PM revealed the resident was cognitively intact with a Brief Interview for Mental Status score of 15 and had functional impairment in one upper and both lower extremities. No therapy or restorative services were coded as having been provided. On 6-27-16 at 1:40 PM and 2:59 PM and on 6-28-16 at 9:29 AM and 10:20 AM, Resident #168 was observed seated in an upright gerichair. Her/his right elbow was bent and her/his right hand was contracted in the form of a fist. No splint or handroll was observed in place. During an interview on 6-28-16 at 9:29 AM, when asked if ROM exercises were provided for her/his arms and legs, Resident #168 stated s/he received no type of exercises. During an interview on 6/27/2016 at 2:40 PM, when asked if the resident had a contracture, Licensed Practical Nurse (LPN) #2 stated, Yes, the right hand and possibly the elbow. When asked if Resident #168 received range of motion services or had a splint device in place, the nurse replied,No, but all Certified Nursing Assistants (CNAs) are supposed to do ROM during care. The resident in not on a restorative program and s/he has no splints. During an interview on 6-30-16 at 10:57 AM, the Rehab Manager stated the resident had last been seen by Occupational Therapy (OT) and had been discharged on [DATE] with right hand and elbow splints to be continued by nursing daily. When the splint was not on, a rolled ace wrap was to be placed in the hand. No referral was made for restorative services. Review of an Inservice Report provided by the Rehab Manager revealed that OT had issued hand and elbow splints to Resident #168 and trained staff on ROM and application and care of splints on 2-20-15. The OT-Therapist Progress & Discharge Summary noted that upon start of therapy on 10-12-15, The patient presents with full fist formation and unable to wear prefabricated splint with her (his) R(ight) hand. Upon discharge, Caregivers will appropriately don and doff R. hand splint and R. soft elbow splint consistently to prevent further joint changes and contractures while they monitor skin condition as she (he) tolerated wearing 3 hours without any difficulty. An (MONTH) (YEAR) Inservice Report Sign-In Sheet provided by the Rehab Manager noted that an inservice had been conducted regarding Orthotic Management-(Resident #168) and included the following: (1) Application of R(ight) resting hand splint and soft elbow splint per patient tolerance daily (during the daytime). (2) Once R. resting hand splint is removed, cone roll to be placed in the hand to maintain joint mobility and ROM. (3) Inspect patient hand for skin integrity. (4) Complete hand hygiene daily before application of R. resting hand splint. (5) Notify Occupational Therapy Department of concerns + issues. (6) Clean orthotic device and cone roll as needed for hygiene. Record review at 2:18 PM on 6-29-16 revealed no Care Plan had been developed to address the contracture with specific interventions to prevent further decline. Therapy goals and interventions were not included. There was no plan in place to evaluate the resident's condition on an ongoing basis in an effort to maintain or improve ROM or prevent further decline. During an interview on 6-29-16 at 4:34 PM, the Director of Healthcare Services confirmed that the resident had a contracture of the right upper extremity. S/he reviewed the Care Plan and verified that the contracture had not been addressed on the Care Plan. S/he pointed out that the resident had a [DIAGNOSES REDACTED]. During an interview on 7-1-16 at 12:15 PM, when asked if the resident was admitted with the right upper extremity contractures, the MDS Coordinators reviewed the medical record and stated that the resident was found by therapy with contractures in 10-15 and that s/he had only exhibited stiffness on admission. After review of the Care Plan, they verified there had been no Care Plan developed for contractures until 6-29-16, though the most recent Quarterly MDS had been appropriately coded with functional limitations in one upper and two lower extremities. MDS Coordinator #1 stated that changes in the restorative program may have resulted in the omission. After providing a copy of the CNA Care Record Form, MDS Coordinator #2 verified that there were no instructions for CNAs to provide ROM or apply splints. A copy of the updated Care Plan provided on 6-30-16 still did not reflect therapy orders/recommendations.",2020-04-01
4279,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,282,E,0,1,443S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to follow the care plan related to implementation of fall prevention measures for 2 of 4 sampled residents reviewed for accidents. Residents #48 and #213, both assessed at risk for falls, did not have the bed alarm applied as ordered by the physician and/or care planned. In addition, based on record reviews and interviews, the facility failed to follow care planned interventions prior to administration of as needed (PRN) antianxiety medication for one of seven sampled residents reviewed for unnecessary medication. Although there were care planned interventions for designated behaviors, facility staff administered [MEDICATION NAME] to Resident #184 without evidence that interventions were attempted prior to administration. The findings included: The facility admitted Resident #213 with [DIAGNOSES REDACTED]. Review of the 4-28-16 Fall Risk Assessment at 1:18 PM on 6-30-16 revealed the resident was at high risk for falls. Review of the Care Plan on 6-30-16 at 11:55 AM revealed that the resident was documented at risk for falls related to requiring extensive assistance with bed mobility and transfers as well as use of psychoactive medication. She (he) has a hx. (history) of falls. Approaches included use of a bed alarm. Record review at 12:58 PM on 6-30-16 revealed physician's orders [REDACTED]. Observations on 6-29-16 at 2:43 PM and 6-30-16 at 5:30 AM revealed the resident laying in bed with no alarm in place. During an interview at 7:30 AM on 6-30-16, when asked how s/he knew what care items were required for her/his assigned residents, Certified Nursing Assistant (CNA) #2 referred to the CNA Care Record. Review of the document with the CNA revealed instructions for use of a bed alarm. At that time, the CNA accompanied the surveyor to the resident's room and verified that the resident was in bed, but the alarm was not in place as ordered/care planned. The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review of Resident Incident Reports and Nurses Notes on 6-30-16 at 5:43 PM revealed the resident sustained [REDACTED].>On 2-8-16, the resident was noted to be on the floor on his (her) buttocks in his/her room. On 5-1-16, Res(ident) noted to be on floor sitting on bottom in hallway. Ambulating down hall holding onto railing, lost balance and fell down. On 5-22-16, (Resident #48) fell in bathroom, getting off toilet and sustained 3 small skin tears to right elbow area. On 6-22-16, Resident lost balance while leaving his (her) room and fell on the floor in the hallway. S/he sustained abrasions-one of left knee and one of left elbow. Review of the Care Plan on 6-30-16 at 4:25 PM revealed that Resident #48 had been assessed at risk for falls r/t (related to) hx and the use of antianxiety, antidepressant, and antipsychotic meds. The Care Plan had been updated with the falls and bed alarm added was hand-written under approaches following the 6-22-16 fall. A falls alarm to bed/wc (wheelchair) to alert staff of attempts to transfer unassisted had already been listed as an approach on the plan with an onset date of 1-27-16. Multiple observations (on 6-27-16 at 12:24 PM, 2:48 PM, and 4:23 PM; on 6-29-16 at 8:27 AM and 10:40 AM; on 6-30-16 at 7:02 AM and 9:26 AM) revealed the resident sleeping on the bed with no alarm in place. During an interview and observation on 7-1-16 at 10:05 AM CNA #1 verified the resident was in bed with no alarm in place. The CNA stated,I don't know why he (she) should have one because he (she) gets up and around on his (her) own. When asked how s/he knew what care items were required for her/his assigned residents, CNA #1 referred to the instructions for care on the kiosk. S/he reviewed the items and stated there was no information regarding use of alarms. Review of the CNA Care Record provided by Minimum Data Set (MDS) Coordinator #1 on 7-1-16 revealed no instructions for an alarm to be placed. The facility admitted Resident #184 with [DIAGNOSES REDACTED]. Review of Nurses Notes and behavior monitoring at 11:45 AM on 6-29-16 revealed the resident was disoriented to place and time with documented behaviors over the previous 3 month period of rejection of care, picking up items laying about, wandering, exit-seeking, inappropriate touching of staff, pacing, head banging, and hitting. Review of the Medication Administration Records (MARs) on 6-28-16 at 12:13 PM revealed that [MEDICATION NAME] was administered on an as needed (PRN) basis on 4-20-16, 4-23-16, and 4-24-16 for exit seeking and/or unspecified inappropriate behaviors. On 6-14-16, [MEDICATION NAME] was administered for increased agitation. No behaviors were noted. There was no evidence of attempts at non-pharmacological interventions prior to administration of the medication found in the record. Record review at 2:30 PM on 6-29-16 revealed that the Care Plan included interventions for assessed problems of exit seeking behavior, going into others' rooms, care refusal, and inappropriate touching of staff, but there was no evidence in the record that any interventions had been attempted prior to administration of the [MEDICATION NAME]. During an interview at 4:26 PM on 6-29-16, the Director of Healthcare Services (DHS) reviewed the record and confirmed that anxiety and agitation were the reasons noted for administration of [MEDICATION NAME]. S/he confirmed that behaviors were not documented and there was no evidence of attempts at non-pharmacological interventions prior to administration of the [MEDICATION NAME].",2020-04-01
4280,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,318,E,0,1,443S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide services to prevent decline in range of motion (ROM) for one of three sampled residents reviewed for ROM. The facility failed to provide ROM exercises and/or splinting as ordered by therapy post contracture development. The findings included: The facility admitted Resident #168 with [DIAGNOSES REDACTED]. Review of the 6-7-16 Quarterly Minimum Data Set (MDS) Assessment on 6-29-16 revealed the resident was cognitively intact with a Brief Interview for Mental Status score of 15 and had functional impairment in one upper and both lower extremities. No therapy or restorative services were coded as having been provided. On 6-27-16 at 1:40 PM and 2:59 PM and on 6-28-16 at 9:29 AM and 10:20 AM, Resident #168 was observed seated in an upright gerichair. Her/his right elbow was bent and her/his right hand was contracted in the form of a fist. No splint or handroll was observed in place. During an interview on 6-28-16 at 9:29 AM, when asked if ROM exercises were provided for her/his arms and legs, Resident #168 stated s/he received no type of exercises. During an interview on 6/27/2016 at 2:40 PM, when asked if the resident had a contracture, Licensed Practical Nurse (LPN) #2 stated, Yes, the right hand and possibly the elbow. When asked if Resident #168 received range of motion services or had a splint device in place, the nurse replied,No, but all Certified Nursing Assistants (CNAs) are supposed to do ROM during care. The resident in not on a restorative program and s/he has no splints. Review of Nurses Notes for April-June, (YEAR) on 6-29-16 at 1:03 PM revealed no reference to ROM, splinting, or refusal of these services. Record review at 1:57 PM revealed no evidence of ongoing provision of restorative services. Review of the Medication and Treatment Administration Records at 1:31 PM on 6-29-16 revealed no evidence that ROM exercises had been provided or splints applied. No behaviors were noted (refusal of care). During an interview on 6-30-16 at 10:57 AM, the Rehab Manager stated the resident had last been seen by Occupational Therapy (OT) and had been discharged on [DATE] with right hand and elbow splints to be continued by nursing daily. When the splint was not on, a rolled ace wrap was to be placed in the hand. No referral was made for restorative services. Review of an Inservice Report provided by the Rehab Manager revealed that OT had issued hand and elbow splints to Resident #168 and trained staff on ROM and application and care of splints on 2-20-15. The OT-Therapist Progress & Discharge Summary noted that upon start of therapy on 10-12-15, The patient presents with full fist formation and unable to wear prefabricated splint with her (his) R(ight) hand. Upon discharge, Caregivers will appropriately don and doff R. hand splint and R. soft elbow splint consistently to prevent further joint changes and contractures while they monitor skin condition as she (he) tolerated wearing 3 hours without any difficulty. An (MONTH) (YEAR) Inservice Report Sign-In Sheet provided by the Rehab Manager noted that an inservice had been conducted regarding Orthotic Management-(Resident #168) and included the following: (1) Application of R(ight) resting hand splint and soft elbow splint per patient tolerance daily (during the daytime). (2) Once R. resting hand splint is removed, cone roll to be placed in the hand to maintain joint mobility and ROM. (3) Inspect patient hand for skin integrity. (4) Complete hand hygiene daily before application of R. resting hand splint. (5) Notify Occupational Therapy Department of concerns + issues. (6) Clean orthotic device and cone roll as needed for hygiene. Record review at 2:18 PM on 6-29-16 revealed no Care Plan had been developed to address the contracture with specific interventions to prevent further decline. Therapy goals and interventions were not included. There was no plan in place to evaluate the resident's condition on an ongoing basis in an effort to maintain or improve ROM or prevent further decline. In addition, there was no Care Plan to indicate any refusal of care. During an interview on 6-29-16 at 10:14 AM, the Director of Healthcare Services (DHS) stated staff did not document splint application if it's as tolerated. When asked who was responsible to ensure that the splints were donned, s/he stated, The nurse or CNA puts it on. When asked about how s/he would know how long the resident was tolerating the splint, the DHS stated that the nurse should document the application, how long tolerated, and any refusal. S/he further stated that the information should be included in the CNA smart charting. During an interview on 6-29-16 at 4:34 PM, the DHS confirmed that the resident had a contracture of the right upper extremity. S/he reviewed the Care Plan and verified that the contracture had not been addressed on the Care Plan and the plan did not address any refusal of care. S/he pointed out that the resident had a [DIAGNOSES REDACTED]. During an interview on 6-30-16 at 1:42 PM, when asked when s/he had last worn the splint, the resident stated, It hasn't been too long. They put a roll in my hand sometimes. At 1:53 PM on 6-30-16, Resident #168 was observed for the 1st time with a hand splint. It was laying next to her/him in the gerichair. Nothing was observed in the right hand. When asked if the resident was supposed to wear an elbow splint, LPN #4 (responsible for the resident's care) stated,I don't know, I'd have to look in her (his) chart to know. I don't see it on the physician's orders [REDACTED].#4 responded,Yes. The nurse searched in the resident's closet and through her/his belongings but was unable to locate the elbow splint. S/he then asked the CNA (#3) assigned to the resident about the elbow splint. CNA #3 stated,It may be in the closet, but It took me awhile to dig that one out (indicating the resting hand splint). At 2:01 PM, CNA #3 stated s/he did not know when Resident #168 had last worn the splint. When asked if it still fit, s/he stated,When I put it on, she (he) screamed. She (he) didn't wear it long. She (he) said it hurt. During an interview on 7-1-16 at 3:25 PM, the Rehab Manager stated s/he had not been advised that the splint possibly did not fit and caused the resident pain when applied. During an interview on 7-1-16 at 12:15 PM, when asked if the resident was admitted with the right upper extremity contractures, the MDS Coordinators reviewed the medical record and stated that the resident was found by therapy with contractures in 10-15 and that s/he had only exhibited stiffness on admission. After review of the Care Plan, they verified there had been no Care Plan developed for contractures until 6-29-16, though the most recent Quarterly MDS had been appropriately coded with functional limitations in one upper and two lower extremities. MDS Coordinator #1 stated that changes in the restorative program may have resulted in the omission. After providing a copy of the CNA Care Record Form, MDS Coordinator #2 verified that there were no instructions for CNAs to provide ROM or apply splints. A copy of the updated Care Plan provided on 6-30-16 still did not reflect therapy orders/recommendations. MDS Coordinator #2 also verified that there was no evidence of splint application in the CNA documentation (smart charting).",2020-04-01
4281,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,323,E,0,1,443S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe environment for residents. Water temperatures were above accepted parameters of 120 degrees Fahrenheit on 3 of 4 units. The Maintenance Director was unaware of how to calibrate a thermometer. Additionally, interventions were not implemented following falls to prevent recurrence for 2 of 4 residents reviewed for accidents (Resident #48 and #213). The findings included: Observation on unit 3 in Room 312 on 6/28/2016 at approximately 12:30 PM revealed the water temperature in the sink was 121.4 degrees Fahrenheit. Random observation of Unit 3 rooms with the Maintenance Director using the surveyors calibrated thermometer revealed the following water temperatures on 6/28/2016 at approximately 12:45 PM: 123.2 degrees Fahrenheit in Room 313, 124.4 degrees Fahrenheit in [RM #]1, 124.2 degrees Fahrenheit in room 302, 123.2 degrees Fahrenheit in room 309, and 124.2 degrees Fahrenheit in room 310. On 6-28-16 beginning at 1:19 PM, water temperatures were taken and recorded on half of Unit 2 with Licensed Practical Nurse (LPN) #4. Results were confirmed and were as follows: -Room 201 = 128.0 degrees Fahrenheit (F.) -Room 202 = 117.0-126.7 F. -Room 203 = 122.5 F. -Room 204 = 123.6 F. -Room 205 = 124.1 F. -Room 206 = 124.0 F. -Room 207 = 124.4 F. -Room 208 = 124.5 F. -Room 209 = 120.7 F. -Room 210 = 123.8 F. -Room 211 = 121.2 F. On 6-28-16 beginning at 1:48 PM, water temperatures were taken and recorded on the other half of Unit 2 with LPN #3. Results were confirmed and were as follows: -Room 213 = 122.9 F. -Room 216 = 120.6 F. -Room 218 = 121.7 F. -Room 219 = 123.0 F. -Room 220 = 122.7 F. -Room 221 = 123.8 F. -Room 223 = 123.9 F. The sink in the shower room was 80.0 degrees F.and the shower temperature was 101.0 F. In an interview with the Maintenance Director on 6/28/2016 at approximately 2:00 PM, when asked how he/she calibrates his/her thermometer he/she stated, that must be a trick question because I have never heard of that. He/she was aware that the water temperature in the resident's rooms should never exceed 120 degrees Fahrenheit. The facility's Maintenance Director and Administrator were not aware the water temperatures exceeded 120 degrees Fahrenheit. Review of Water Temperature Daily Log Forms provided by the Administrator on 6/28/16 revealed temperatures being recorded on a daily basis 2 residents ' rooms on each unit, kitchen and laundry. Eleven residents were identified as cognitively impaired and self mobile, which put them at elevated risk for burns. During an interview at approximately 2:30 PM, the Maintenance Director stated that the facility had 3 hot water heaters, all of which were set at 148 degrees. S/he stated the mixing valve was set for 115 degrees. On 7/1/16 at 4:22 PM during a phone conversation with the licensed Plumber revealed, fluctuations earlier in the week with a new temping valve ordered to be installed as soon as it arrives. Based on observations, record reviews, and interviews, the facility failed to implement fall prevention measures as ordered/care planned for 2 of 4 sampled residents reviewed for accidents. Resident #213, with a history of falls, did not have the bed alarm applied as ordered/care planned. The facility admitted Resident #213 with [DIAGNOSES REDACTED]. Review of the 4-28-16 Fall Risk Assessment at 1:18 PM on 6-30-16 revealed the resident was at high risk for falls. Review of the Care Plan on 6-30-16 at 11:55 AM revealed that the resident was documented at risk for falls related to requiring extensive assistance with bed mobility and transfers as well as use of psychoactive medication. She (he) has a hx. (history) of falls. Approaches included use of a bed alarm. Record review at 12:58 PM on 6-30-16 revealed physician's orders [REDACTED]. Observations on 6-29-16 at 2:43 PM and 6-30-16 at 5:30 AM revealed the resident laying in bed with no alarm in place. During an interview at 7:30 AM on 6-30-16, when asked how s/he knew what care items were required for her/his assigned residents, Certified Nursing Assistant (CNA) #2 referred to the CNA Care Record. Review of the document with the CNA revealed instructions for use of a bed alarm. At that time, the CNA accompanied the surveyor to the resident's room and verified that the resident was in bed, but the alarm was not in place as ordered/care planned. At 7:40 AM on 6-30-16, Registered Nurse #3 also verified that the alarm was not on the bed. S/he searched the resident's room and was unable to locate the alarm. The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Review of Resident Incident Reports and Nurses Notes on 6-30-16 at 5:43 PM revealed the resident sustained [REDACTED].>On 2-8-16, the resident was noted to be on the floor on his (her) buttocks in his/her room. On 5-1-16, Res (ident) noted to be on floor sitting on bottom in hallway. Ambulating drawn hall holding onto railing, lost balance and fell down. On 5-22-16, (Resident #48) fell in bathroom, getting off toilet and sustained 3 small skin tears to right elbow area. On 6-22-16, Resident lost balance while leaving his (her) room and fell on the floor in the hallway. S/he sustained abrasions-one of left knee and one of left elbow. Review of the Care Plan on 6-30-16 at 4:25 PM revealed that Resident #48 had been assessed at risk for falls r/t (related to) hx and the use of antianxiety, antidepressant, and antipsychotic meds. The Care Plan had been updated with the falls and bed alarm added was hand-written under approaches following the 6-22-16 fall. A falls alarm to bed/wc to alert staff of attempts to transfer unassisted had already been listed as an approach on the plan with an onset date of 1-27-16. Multiple observations (on 6-27-16 at 12:24 PM, 2:48 PM, and 4:23 PM; on 6-29-16 at 8:27 AM and 10:40 AM; on 6-30-16 at 7:02 AM and 9:26 AM) revealed the resident sleeping on the bed with no alarm in place, During an interview and observation on 7-1-16 at 10:05 AM CNA #1 verified the resident was in bed with no alarm in place. The CNA stated,I don't know why he (she) should have one because he (she) gets up and around on his (her) own. Review of the CNA Care Record provided by MDS Coordinator #1 and the kiosk information for resident care reviewed with CNA #1 revealed no instructions for an alarm to be placed.",2020-04-01
4282,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,329,E,0,1,443S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to attempt non-pharmacological interventions prior to administration of anti-anxiety medication for 3 of 7 sampled residents reviewed for unnecessary medication. Residents #48, #168, and #184 were given [MEDICATION NAME] on an as needed basis without documented behaviors or evidence of non-pharmacological interventions attempted prior to administration. The findings included: The facility admitted Resident #184 with [DIAGNOSES REDACTED]. Review of Nurses Notes and behavior monitoring at 11:45 AM on 6-29-16 revealed the resident was disoriented to place and time with documented behaviors over the previous 3 month period of rejection of care, picking up items laying about, wandering, exit-seeking, inappropriate touching of staff, pacing, head banging, and hitting. Review of the Medication Administration Records (MARs) on 6-28-16 at 12:13 PM revealed that [MEDICATION NAME] was administered on an as needed (PRN) basis on 4-20-16, 4-23-16, and 4-24-16 for exit seeking and/or unspecified inappropriate behaviors. On 6-14-16, [MEDICATION NAME] was administered for increased agitation. No behaviors were noted. There was no evidence of attempts at non-pharmacological interventions prior to administration of the medication found in the record. Record review at 2:30 PM on 6-29-16 revealed that the Care Plan included interventions for assessed problems of exit seeking behavior, going into others' rooms, care refusal, and inappropriate touching of staff, but there was no evidence in the record that any interventions had been attempted prior to administration of the [MEDICATION NAME]. During an interview at 4:26 PM on 6-29-16, the Director of Healthcare Services (DHS) reviewed the record for 6-16 and confirmed that anxiety and agitation were the reasons noted for administration of [MEDICATION NAME]. S/he confirmed that behaviors were not documented and there was no evidence of attempts at non-pharmacological interventions prior to administration of the [MEDICATION NAME]. The facility admitted Resident #168 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. [MEDICATION NAME] was noted as given on 3-30-16, 4-28-16, 5-8-16, and 5-21-16 for anxiety. No behaviors were documented in the medical record. There was no evidence of attempts at non-pharmacological interventions prior to administration of the medication found in the record. Record review at 2:18 PM on 6-29-16 revealed that the Care Plan included interventions for assessed problems of depression and anxiety, but there was no evidence in the record that any interventions had been attempted prior to administration of the [MEDICATION NAME]. During an interview on 6-30-16 at 10:24 AM, the DHS reviewed the medical record and confirmed there were no behaviors noted and there was nothing in the record regarding non-pharmacological interventions attempted prior to administration of the [MEDICATION NAME]. The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Record review on 6-30-16 at 4:42 PM revealed physician's orders [REDACTED]. Review of the MARs at 8:58 AM on 7-1-16 revealed that [MEDICATION NAME] was given 6 times in 4-16 (4-14, 16, 21 (twice), 26, 27-16). Reason for administration each time the medication was given was increased anxiety. No behaviors were noted. [MEDICATION NAME] was administered 10 times in 5-16 (5-6, 7, 9, 13, 14, 15, 18, 19, 20, 23-16). Reason for administration each time was increased anxiety. No behaviors were noted. [MEDICATION NAME] was administered 8 times in 6-16 (6-4, 5, 11, 16, 21, 25, 29, 30-16). Although not documented on the behavior monitoring section of the MAR, yelling was noted five times as the behavior exhibited for which the medication was given. Increased agitation/anxiety, not behaviors, were noted as reasons for administration of the remainder of the doses. There was no evidence of non-pharmacological interventions attempted prior to administration of the medication. Record review on 6-30-16 at 4:25 PM revealed that the Care Plan did not address pacing and yelling behaviors that were noted on the behavior monitoring section of the MAR. No specific non-pharmacological interventions were included to be attempted prior to administration of the [MEDICAL CONDITION] medication. During an interview on 7-1-16 at 1:17 PM, the DHS reviewed the medical record and verified that behaviors were not documented and there was nothing in the record regarding non-pharmacological interventions attempted prior to administration of the [MEDICATION NAME].",2020-04-01
4283,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,356,B,0,1,443S11,"Based on record review and interviews, the facility failed to post staffing information on a daily basis as required. Postings available for review failed to include resident census and the total number and actual hours worked by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift. Lack of posting information had the potential to affect all residents and visitors who desired to obtain this information. The findings included: During the extended survey on 7-7-16, staff postings (1-1-16 through 6-30-16) were requested for review. The Administrator provided a notebook that s/he stated contained the requested information. The Director of Healthcare Services (DHS) provided a copy of the documents for review at 12:12 PM on 7-7-16. Review of the POS [REDACTED]. Restorative personnel were listed at the bottom of the forms with neither scheduled or actual hours noted. January, (YEAR) Postings were not available for the following dates: 1-1, 1-2, 1-3, 1-4,1-6 through 1-17, 1-19 through 1-24, and 1-26 through 1-31-16. The postings did not include the census on the following dates: 1-5, 1-18, and 1-25-16. Duplicate forms were reviewed that included discrepant staffing information and/or were missing census data for 1-18-16. February, (YEAR) Postings were not available for the following dates: 2-2, 2-3, and 2-4-16. The postings did not include the census on the following dates: 2-10, 2-11, 2-13, 2-18, 2-20, and 2-22-16. Multiple duplicate forms were reviewed that included discrepant staffing information and/or were missing census data: 2-1, 2-12, 2-16, 2-18, 2-19, 2-20, 2-22, 2-25, 2-26, 2-27, 2-28, and 2-28-18. March, (YEAR) Multiple duplicate forms were reviewed that included discrepant staffing information and/or were missing census data: 3-1, 3-9, 3-11, 3-12, 3-14, and 3-28-18. April, (YEAR) A posting was not available for 4-11-16. Multiple duplicate forms were reviewed that included discrepant staffing information and were missing census data: 4-4, 4-16, 4-17, 4-18, 4-20, 4-21, 4-22, 4-23, 4-24, 4-25, 4-26, 4-27, 4-28, and 4-29-16. May, (YEAR) The postings did not include the census on the following dates: The posting for 5-2-16 was missing CNA staffing information for 2 units. Multiple duplicate forms were reviewed that included discrepant staffing information and/or were missing census data:5-2, 5-3, 5-4, 5-5, 5-9, 5-11, 5-17, 5-18, 5-19, 5-20, 5-26, and 5-27-16. June, (YEAR) The 6-24-16 posting included 2 handwritten CNAs' names with question marks instead of hours behind their names. During an interview at 5 PM on 7-7-16, the Administrator reviewed the posting documents and verified multiple dates missing, dates duplicated, and those with census missing and discrepant staffing information. S/he stated s/he was sure the facility had them in the notebook. The DHS verified s/he had copied the documents from the notebook. No further documentation was provided.",2020-04-01
4284,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,441,E,0,1,443S11,"Based on record review and interview, the facility failed to conduct competencies and/or inservices to prevent the spread of infection after identification of an increase in Urinary Tract Infections (UTIs). The findings included: Review of the facility's Epidemiology Report Form dated (MONTH) (YEAR) revealed: #4 states, Most of the UTI's were on (1) particular station . result from improper handwashing. The report indicated the facility would educate the staff on proper handwashing for (MONTH) (YEAR) findings. No inservices could be provided for the month of (MONTH) (YEAR). Review of the facility's Epidemiology Report Form for (MONTH) (YEAR): #4 states, St. (Station) 2 had the most recurrent infections UTI's/ URI's(Upper Respiratory Infections), education to include: continue to educate R/T (related to) proper handwashing. No inservices could be provided for the month of April. Review of the facility's Epidemiology Report Form for (MONTH) (YEAR) revealed that improper pericare and handwashing was a problem but no inservices could be provided. On 7/1/2016 at 7:00 PM Registered Nurse (RN) #4 provided four copies of inservices dated 6/22/2016 for Hand Hygiene, and two copies dated 6/28/16 for Indwelling urinary catheter (Foley) care and management. RN #4 stated s/he just started the inservices in (MONTH) after the trending showed an increase in UTI's for March, (MONTH) and May.",2020-04-01
4285,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,497,E,0,1,443S11,"Based on review of inservice education records and interviews, the facility failed to ensure that 18 of 70 Certified Nursing Assistants (CNAs) reviewed had completed at least 12 hours of continuing education per year, as required, based on date of hire. The findings included: During the Extended Survey on 7-7-16, the Administrator provided a list of currently employed CNAs. Seventy of these had been employed for greater than or equal to one year. Review of the CNAs' individual training records on 7-8-16 revealed that 16 of these CNAs failed to have accumulated at least 12 hours of continuing education in the last full 12 month period based on hire date. During an interview on 7-11-16, the Administrator submitted additional information and was advised of the CNAs who had not completed the required 12 hours. Review of the continuing education records revealed that CNAs with hire dates as designated completed the following number of hours as noted : (1) CNA A - hired 11-21-14 had completed 9.5 hours from 11-21-14 through 11-20-15. (2) CNA B - hired 10-2-10 had completed 0.5 hours from 10-2-14 through 10-1-15. (3) CNA C - hired 7-11-00 had completed 5.0 hours from 7-11-14 through 7-10-15. (4) CNA D - hired 10-10-06 had completed 8.75 hours from 10-10-14 through 10-9-15. (5) CNA [NAME] - hired 11-18-13 had completed 1.0 hour from 11-18-14 through 11-17-15. (6) CNA F - hired 11-6-14 had completed 5.0 hours from 11-6-14 through 11-5-15. (7) CNA G - hired 1-22-14 had completed 1.0 hour from 1-22-15 through 1-21-16. (8) CNA H - hired 7-11-2000 had completed 5.0 hours from 7-11-14 through 7-10-15. (9) CNA I - hired 6-16-15 had completed 4.25 hours from 6-16-15 through 6-15-16. (10) CNA J - hired 8-16-11 had completed 1.5 hours from 8-16-14 through 8-15-15. (11) CNA K - hired 8-16-11 had completed 7.0 hours from 8-16-14 through 8-15-15. (12) CNA L - hired 1-6-86 had completed 0.0 hours from 1-6-15 through 1-5-16. (13) CNA M - hired 7-1-15 had completed 9.75 hours from 7-1-15 through 6-30-16. (14) CNA N - hired 5-18-10 had completed 0.5 hours from 5-18-14 through 5-17-15. (15) CNA O - hired 8-5-08 had completed 6.5 hours from 8-5-14 through 8-4-15. (16) CNA P - hired 1-20-15 had completed 1.5 hours from 1-20-15 through 1-20-16. (17) CNA Q - hired 9-27-12 had completed 6.5 hours from 9-27-14 through 9-26-15. (18) CNA R - hired 6-13-14 had completed 0.0 hours from 6-13-15 through 6-12-16. During a communication on 7-12-16 at 5:30 PM, the Administrator stated that 3 of the CNAs were primarily employed elsewhere.",2020-04-01
4286,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2016-07-12,499,E,0,1,443S11,"Based on review of personnel files and staff interviews, the facility failed to ensure that professional licenses were checked prior to hire for four of eleven nurses reviewed who were hired since the previous annual recertification survey. The findings included: During the extended survey on 7-7-16, personnel files were reviewed for four Licensed Practical Nurses (LPNs) and seven Registered Nurses (RNs) who were hired since the previous annual recertification survey. There was no evidence that 2 of the 4 LPNs' licenses were verified prior to hire. (1) LPN B was hired on 9-29-15. The only license check in the file was for 5-10-16. (2) LPN C was hired on 3-2-16. The only license check in the file was for 5-10-16. There was no evidence that 2 of the 7 RNs' licenses were verified prior to hire. (1) RN (D) was hired on 9-29-15. The only license check in the file was for 5-10-16. (2) RN (E) was hired on 11-9-15. The only license check in the file was for 5-10-16. During an interview at 11:20 AM on 7-7-16, the Director of Healthcare Services stated that the Clinical Competency Coordinator (CCC) was the person in the facility responsible to ensure that nursing licenses were checked/verified prior to date of hire. During an interview at 4:11 PM on 7-7-16, the Administrator reviewed the personnel files and verified the above. S/he was unable to locate any additional information. On 7-7-16 at 4:55 PM, the CCC stated, All I have is copies of current licenses.",2020-04-01
5412,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2015-03-12,253,E,0,1,26JC11,"Based on observation, interview, and review of the facility policy on Compliance Rounds, the facility failed to provide services as necessary to maintain a sanitary, orderly, and comfortable environment on 3 of 4 resident units reviewed for environment. Unit 1 was observed with multiple resident overbed tables in disrepair, call lights in bathrooms not properly installed, lights above resident beds with missing pull strings, and baseboard and wallpaper in disrepair in multiple resident rooms. Unit 2 and Unit 3 were observed with cracked side rails; scuffed, damaged walls; and furniture with damaged edges. The findings included: Observations on Unit 1 on 3/09/15 and 3/10/15 revealed the following environmental concerns: -Room 102 B - The pull string on the bathroom call light was missing. A section of baseboard on the left side of the closet was missing, wallpaper was peeling away from the wall above the baseboard, and the baseboard was pulling away from the wall on the left corner beside the bathroom. -Room 103 A - The faceplate on the bathroom call light was pulling away from the wall. The top of the resident's overbed table was not flat but was leaning to the side. -Room 103 B - The overbed table had missing veneer covering on one edge exposing the board underneath and one edge had missing veneer covering resulting in a sharp edge. -Room 105 B - The top of the overbed table was leaning to one side, and a light bulb was burned out over the bathroom mirror. -Room 106 A - The faceplate on the bathroom call light was pulling away from the wall, and wallpaper was pulling away from the wall on the right side of the window. -Room 106 B - The veneer covering on the bed's footboard was missing along the top edge. -Room 114 A - The pull string on the light above the head of the bed was missing, the top edge of the wall along the ceiling had a gap and missing areas of wallpaper, and there was a large gap between the end of the mattress and the footboard of the bed. -Room 115 A - The pull string on the light above the head of the bed was missing. -Room 115 B - A board on the wall behind the head of the bed had a missing section/ hole. -Room 121 B - The overbed table had missing sections along the table edges. -Room 123 A - The overbed table top was leaning to the side and had missing sections of veneer and sharp areas along the edges. The top edge of the wallpaper along the ceiling had missing areas. Environmental rounds were made with the Housekeeping Director, Maintenance Director, and Administrator on 3/12/15 at approximately 4:15 PM, and the above findings were verified at that time. A copy of a Construction Services Daily Work Log for (MONTH) and (MONTH) (YEAR) was provided with no needed maintenance services documented for Unit 1. A policy entitled Compliance Rounds was provided. The policy stated under the Procedure section that during rounds, Maintenance issues identified should be entered into building engines or work orders submitted per healthcare center policy. During observations of resident rooms on 3/9/15 and 3/10/15, the following were observed: -Room 207 A had a broken tile under the resident's bed and the right siderail on the bed was cracked; -Room 218 B had a badly scuffed wall on the right side of the room and wall damage next to resident's bed; -Room 315 had a damaged wall at the foot of the bed and a hole in the wall beside the air conditioner. During room rounds with the Administrator on 3/12/15 at 4:50 PM, Room 221 was noted with damage to the wall on the right side of the resident's room. During an interview with the Administrator during environmental rounds on 3/12/15 at 4:50 PM, s/he stated room rounds were done daily by the Unit Managers and Department Heads and any concerns were shared in the morning stand-up meetings. No evidence was provided that these concerns had been noted prior to the survey.",2018-12-01
5413,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2015-03-12,279,D,0,1,26JC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a care plan for 1 of 1 sampled resident reviewed for constipation and 1 of 5 sampled residents reviewed for unnecessary medications. Resident #223 with a known history of constipation did not have a care plan to reflect a potential for constipation and Resident #184 did not have a care plan to reflect use of [MEDICAL CONDITION] medications. The findings included: The facility admitted Resident #223 with [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] 325 milligrams (mg) three times daily, Dok Plus 8.6-50 mg twice daily, and [MEDICATION NAME] every 6 hours as needed for pain. Record review on 3/11/15 at 4:11 PM revealed a 1-2-15 Hospital Report upon admission which stated in large printed block letters across the top of the page: Please note: Nurse giving report stated that resident has not had BM (bowel movement) during hospital stay!! Please make note of this in chart!! Review of the Admission Interim Care Plans Form dated 1/2/15 revealed there was no problem area added for constipation. Review of the Comprehensive Care Plan also revealed no Care Plan had been developed for the potential for constipation, though the resident had a history of [REDACTED]. During an interview on 3/12/15 at 6:24 PM, the Care Plan Coordinator stated that the nurses on the stations completed the Admission Interim Care Plan and that the resident should have been care planned as at risk for constipation. The facility admitted Resident #184 with [DIAGNOSES REDACTED]. Record review revealed Resident #184 was currently receiving the following psychoactive medications: [REDACTED] Review of the care plan revealed the care plan did not address the use of psychoactive medications for Resident #184. The care plan did not address the risks, need for monitoring, and behaviors related to the use of psychoactive medications. The care plan did not address interventions to be used, monitoring for effectiveness, or interventions to prevent adverse consequences.",2018-12-01
5414,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2015-03-12,309,E,0,1,26JC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's Standing Protocols, the facility failed to follow the bowel protocol for 1 of 1 sampled resident reviewed for constipation. Resident #223 had multiple instances without a bowel movement for 3 or more days without intervention. Also, based on record review and interview, the facility failed to follow physician's orders [REDACTED]. Staff discontinued a medication without an appropriate physician's orders [REDACTED]. The findings included: The facility admitted Resident #223 with [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] 325 milligrams (mg) three times daily, Dok Plus 8.6-50 mg twice daily, and [MEDICATION NAME] every 6 hours as needed for pain. Record review on 3/11/15 at 4:11 PM revealed a 1-2-15 Hospital Report upon admission which stated in large printed block letters across the top of the page: Please note: Nurse giving report stated that resident has not had BM (bowel movement) during hospital stay!! Please make note of this in chart!! Review of the nursing documentation on the Medication Administration Record [REDACTED]. Further review of the physician's orders [REDACTED]. Review of the MARs revealed an undated MAR indicated [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED] Review of the bowel protocol for the facility revealed the following: E. Constipation: 1. Check for stool in lower vault and remove if present. 2. MOM (Milk of Magnesia) 30 mls (milliliters) daily PRN (as needed) if no BM (bowel movement) in 3 days. 3. If no results from MOM in SIX hrs (hours), give [MEDICATION NAME] Suppository 10 mg 1 PR (per rectum) QD (every day) PRN. If no result in 24 hours call MD (physician). 4. [MEDICATION NAME]-S1 tablet PO (by mouth) BID (twice daily) if resident is on opiate medications to prevent further constipation. Review of the MAR's for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that the resident had not received PRN medication when no bowel movement was recorded for three days or more. Review of the undated CNA (Certified Nursing Assistant) ADL (Activities of Daily Living) Flow Sheet Form listed the resident as incontinent but did not note the number of incontinent episodes the resident had had. During an interview on 3/12/15, the Unit Manager confirmed the resident had gone three or more days without a bowel movement and should have received an intervention. S/he stated the nurses should monitor and be aware of how often the resident has a bowel movement. During an interview on 3/12/15 at 5:00 PM, the Assistant Director of Health Services stated s/he would have expected the nurses to provide an intervention and call the physician when the resident did not have a bowel movement for three days. The facility admitted Resident #184 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #184 was re-admitted to the facility on [DATE] following hospitalization . Re-admission orders [REDACTED]. Review of the (MONTH) 2014 Medication Administration Record [REDACTED]. Further record review indicated Resident #184 was seen in the physician's office on 10/25/14. At that time, the physician ordered [MEDICATION NAME] 25 mg every evening. In addition, review of the report from the physician's office indicated that Resident #184 was receiving [MEDICATION NAME] 300 mg twice daily; however, the resident was receiving 150 mg twice daily. Also, review of the (MONTH) 2014 MAR indicated [REDACTED]. Review of the (MONTH) 2014 MAR indicated [REDACTED]. Review of a report from the physician's office dated 11/22/14 again indicated that Resident #184 was receiving [MEDICATION NAME] 300 mg twice daily; however, the resident was receiving 150 mg twice daily. Review of the Physician's Telephone Orders revealed an order dated 11/26/14 which stated, Clarification order d/c (discontinue) Oxcarbazepin TAB 150. The physician did not sign the telephone order. Review of the MAR indicated [REDACTED]. Review of the (MONTH) 2014 MAR indicated [REDACTED] Record review revealed no documentation related to the telephone order dated 11/26/14 and discontinuation of [MEDICATION NAME]. No documentation related to this medication change was contained in the nursing notes or physician's notes. During an interview on 3/11/15 at approximately 1:00 PM, the Unit Manager reviewed and confirmed the above findings. The Unit Manager was asked for information related to discontinuation of [MEDICATION NAME]. The Unit Manager indicated that the physician's office would be contacted for information related to the medication. During an interview on 3/12/15 at approximately 3:30 PM, the Unit Manager stated that the staff member who wrote the telephone order to discontinue [MEDICATION NAME] did not remember why the order was written. No further explanation was provided at that time. The Unit Manager was asked to contact the physician's office for information related to discontinuation of the medication. No explanation nor information related to discontinuation of [MEDICATION NAME] was provided prior to exit from the facility.",2018-12-01
6874,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2013-07-18,241,D,0,1,SQXR11,"**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 ensure that 1 of 1 residents reviewed, received services that enhanced their dignity in respect wearing clean and appropriate fitting clothing. Resident #112 was observed during survey wearing thermal underwear top as day wear and other stained clothing . One random residents observed wearing wet clothing due to saturated brief. The findings included: The facility admitted Resident #112 with [DIAGNOSES REDACTED]. A chart review on 7/17/13 at 2:17 PM revealed and Annual MDS (Minimum Data Set) dated 1/07/13 and a Quarterly MDS (Minimum Data Set) dated 6/17/13 that indicated the resident was severely cognitively impaired and never/rarely made decision. An observation on 7/16/13 at approximately 9 AM revealed the resident walking on the unit, and in and out of other residents rooms, wearing a gray thermal underwear top with pink pants. The top and the pants were observed to be stained in front and back. The thermal underwear top was observed to be thin and clinging to resident's body. The outline of the resident's bra less breasts could be seen because the thermal underwear top was thin and clinging to the body. An interview with staff revealed the thermal top was considered as day wear. An observation on 7/17/13 at 2:15 PM revealed the resident wearing a burgundy top and light purple pants that were stained in front and back. An observation of the residents clothes in the resident's closet revealed the clothes were stained and placed on a hanger. Registered Nurse # 1confirmed the resident was wearing the thermal underwear as day wear and further stated s/he would not consider wearing thermal underwear as day wear. RN #1 also confirmed the resident clothes worn on 7/17/13 were stained in the front and back. An interview on 7/17/13 at approximately 2:55 PM with the Social Services Worker for Unit 1 confirmed the resident clothing were stained and some may not to appropriate for the season. An interview on 7/17/13 at approximately 4:05 PM with the Social Services Worker revealed the family had been contacted and made aware of the resident's clothing needs. A random observation on 7/17/13 at 4:32 PM revealed a resident walking up and down the hall on the unit wearing a navy top with thin light colored pink pants that were wet due to brief being saturated with urine. RN # 1confirmed the findings and stated sometimes the resident will not let staff change him/her. However, the resident was observed from 2 PM to 4:32 PM and no staff was observed attempting to provide dry clothing for the resident.",2017-08-01
6875,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2013-07-18,253,E,0,1,SQXR11,"On the days of the survey, based on observation and interview, the facility failed to ensure the facility was maintained in a clean and sanitary environment for 2 of 4 units. Cleanliness and maintenance concerns were identified on Unit 2 and Unit 3. The findings included: On 7/15/13 between 12:30 PM and 4:00 PM, the following was observed, Unit #2: 1) In room 218A, a torn area was noted on the wall and scuffed areas were noted on the wall opposite of the bed. 2) Two green striped chairs setting at the nursing station had stains on both chairs. 3) In room 209A, the bathroom wall had a torn area and the bathroom door had a damaged area. The wall at the side of the bed was noted to have scuffed areas. 4) In room 216B, torn areas were noted behind the bed and across from the bed on the opposite wall. Unit #3: 5) In room 308B, the wall paper was peeling, an area at the window ledge was chipped, behind the head of the bed the wall was scraped, and there were holes noted in the wall at the head of the bed under the wall light. The bathroom ceiling fan was noted to have spider webs on the side of the fan. 6) In room 309A, the privacy curtain was noted to have multiple brown stains and the bathroom ceiling fan was noted to have spider webs on the side of the fan. During a walking tour with the Administrator on 7/18/13 at approximately 10:30 AM, s/he verified the above findings.",2017-08-01
6876,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2013-07-18,309,D,0,1,SQXR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On days of survey, based on record review and interviews, the facility failed to provide radiology services for 1 of residents reviewed for falls. Resident #222 had a fall on 4/25/13 and expressed pain on 4/30/13 and 5/01/13. On 5/1/13, the physician ordered radiology services that was not completed or discontinued. There was no documentation to indicate the physician was notified of radiology results. The findings included: The facility admitted Resident #222 with [DIAGNOSES REDACTED]. Record review on 7/17/13 at approximately 8:50 AM revealed a nursing note dated 4/25/13 at 1:45 AM that indicated Resident #222's bed alarm was sounding . The resident was noted kneeling on the floor mat bedside the bed. The physician was notified. A nurses note dated 4/30/13 at 10 PM stated the resident was in bed calling out in pain with complaint of severe lower back pain. A nurse note dated 5/01/13 at 10:30 AM revealed the resident complained of right hip pain and pain medications were given. The nurse note further indicated the physician was contacted and a physician order [REDACTED]. A nurse note dated 5/01/13 at 11:30 AM documented the responsible party was notified and the responsible party did not want the services provided. There was no further documentation in the chart to indicate whether the radiology examine was completed as ordered or that the physician was notified to discontinue the radiology order. An interview on 7/17/13 at 10:15 AM with LPN # confirmed the radiology results were not on the chart and the written physician order [REDACTED]. The DON further stated there was no documentation in the chart to indicate the physician was notified when the family member indicated the radiology examination was not wanted.",2017-08-01
6877,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2013-07-18,323,D,0,1,SQXR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, observations, and interview, the facility failed to ensure that each resident received adequate supervision and appropriate devices to prevent accidents for 2 of 3 residents reviewed for falls. Resident #9 did not have alarms in place per Physician order [REDACTED]. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review of the Minimum Data Set((MDS) dated [DATE] listed the resident with a BIMS(Brief Interview for Mental Status) as 14. Extensive assistance was needed for transfer and locomotion of the unit. Limited assistance was needed for locomotion on the unit. Balance during transitions/walking surface to surface was coded as not steady and needed assistance. Review of the MDS revealed Resident #9 had one previous fall with no injury. An Occurrence Fall Risk Assessment Form dated 1/7/13 listed the resident as high risk and interventions should be put in place. Review of the current care plan and current physician's orders [REDACTED]. Observation of Resident #9 on 7/16/13 at 3:02 PM revealed the resident was in the bed and no alarms were observed. On 7/17/13 at 4:45 PM, during an observation of the resident with the DHS (Director of Health Services), s/he confirmed that the resident did not have alarms. The facility admitted Resident #92 with [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] revealed the resident had a BIMS of 15. Extensive assistance was needed for transfer, locomotion on and of the unit. Resident # 92 was not steady for balance during Transitions and Walking and was coded as having an impairment to the upper and lower extremity on one side. Review of the Occurrence Fall Risk Assessment Form dated 12/24/12 and 6/16/13 revealed the resident was not high risk. Resident #92 had four documented falls without injury as follows: 8/16/12, 12/29/12, 1/4/13, and 5/10/13. Review of the current care revealed the resident was to have a tabs alarm, sensor alarm, Review of the current physician's orders [REDACTED]. Observation of the resident with the DHS on 7/17/13 at 4:46 PM revealed the resident's bed and wheelchair alarm were not functioning. On 7/18/13, observation of Resident #92 with the DHS revealed the wheelchair alarm was turned off.",2017-08-01
6878,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2013-07-18,371,E,0,1,SQXR11,"On the days of the survey, based on observations, interviews and review of the facility's policy entitled Nourishments, the facility failed to ensure that the resident snacks were dated/labeled and not expired in the resident refrigerators in 2 of 4 Nourishment Kitchens. The findings included: On 7/15/13 during observation of the resident's Nourishment Rooms, at approximately 11:00 AM, the Nourishment Room on Unit 4 contained the following items which were noted to be stored in the resident refrigerator either with no label/date or expired: 8- 1/2 sandwiches with no date/label. 1 to go box of food dated 7/9/13. 1 to go box of food dated 7/7/13. 1- 1/2 sandwich dated 7/12/13. 1- 1/2 sandwich dated 7/11/13. A used stick of margarine, partially wrapped with no date/label. The items were verified by Licensed Practical Nurse (LPN) #1 who stated Dietary staff stocked the refrigerator and delivered items daily. The Unit 3 Nourishment Kitchen refrigerator contained the following expired and/or unlabeled/dated items: 2 small cups of dressing- no date/label. 1 partial package of bologna- open with no date/label. The meat was out of the package, lying in the bottom of a plastic shopping bag. 1 partial 20 oz bottle diet Coke. 7- 1/2 sandwiches with no date/label. 1 to go container of food dated 7/8/12. LPN #2 verified that the items were not dated or labeled. She/he stated that dietary staff had restocked the refrigerator that morning. She/he also stated that the items were usually labeled when they were delivered. Review of the facility's policy entitled Nourishments revealed .Procedure: .4. Label and date all items sent from the dietary department to the nourishment refrigerator. Remove after 48 hours .",2017-08-01
6879,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2013-07-18,441,D,0,1,SQXR11,"**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 the storage area available for resident use, was free of expired supplies, in 1 of 4 medication rooms. The findings included: On [DATE] at approximately 1:30 PM, review of the Unit 4 medication storage room revealed 12 Sterile Trach Kits with an expiration date of ,[DATE]. The dates were verified by Licensed Practical Nurse #3. In an interview with the Director of Health Care Services and the Staff Development Coordinator, both stated that the kits were stored in the room for an up coming training on Trach Care. Both agreed that the kits were not labeled for training and should have been boxed/labeled as do not use - expired and for training use only.",2017-08-01
7891,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2012-06-27,285,D,0,1,J9SM11,"**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 Pre-Admission Screening and Resident Review (PASRR) had been completed prior to admission for 2 of 10 residents admitted since the facility's last survey. (Resident # 8 and Resident # 11) The findings included: Resident # 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident's clinical record on 6/25/11 revealed that the pre-admission screening (PASRR) for Resident #8 was completed on 8/19/11 (one day after admission). During an interview on 6/27/12 at 2:53 PM, the Director of Nursing (DON) confirmed that PASRR) was done after admission and stated that the Social Worker who completed the PASRR for Resident #8 no longer worked for the facility. The facility admitted Resident #11 on 5/01/12 with diagnosesnot limited to, [MEDICAL CONDITION] Fibrillation and Chronic Venous Stasis. Review of the record on 6/25/12 revealed the Pre-admission Screening and Resident Review (PASARR Level 1) was undated, section IV Recommendation of Reviewer was blank, and section V Pertinent Information was blank and there was no signature of the person doing the PASARR evaluation. After the incomplete PASARR was reviewed with the Administrator, a completed PASARR was faxed to the facility on [DATE]. This PASARR contained a Date of Review as 1 May 2012, and sections IV and V were completed and signed. During an interview on 6/27/12 at approximately 10:30 AM, Admissions Staff #1 reviewed the incomplete PASARR and completed PASARR faxed to the facility on [DATE]. The staff member confirmed that faciltiy admissions staff were responsible for reviewing and ensuring completion of PASARR forms for all residents prior to admission. The staff member stated that it was an oversight that Resident #11's PASARR was incomplete upon admission.",2016-10-01
7892,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2012-06-27,314,D,0,1,J9SM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, review of Smith & Nephew's Product Overview for Skin Prep, the facility's policy, Dressing Changes Related to Wound Treatments and interview, the facility failed to provide necessary treatment and services to promote healing and prevent infection for Resident # 1. (1 of 4 resident's review for pressure ulcer care.) Facility staff failed to utilize appropriate handwashing, placed clean dressings on an unclear surface, contaminated clean areas of the wound and inappropriately applied a wound care product. The findings included: The facility admitted Resident #1 with the [DIAGNOSES REDACTED]. During observation of multiple pressure ulcer treatments on 6/25/12 at 3:10 PM, Licensed Practical Nurse (LPN) #2 washed his hands, put on gloves and assisted the resident onto his right side. He removed the soiled dressings from the right buttock, left buttock, and left of center buttock. LPN #2 then changed his gloves without washing/sanitizing his hands. He then opened three [MEDICATION NAME] dressings, placed onto the over the bed table, and added his initials and date to each dressing. The LPN did not clean the over the bed table prior to placing the dressings on the table. LPN #2 sprayed wound cleanser repeatedly over the left buttock and left of center buttock wounds. He then opened approximately ten 4 X 4's, wiped across both wounds, from dirty to clean repeatedly with the same 4 X 4's. LPN #2 shook the [MEDICATION NAME] powder on the wound located on the left buttock and applied a [MEDICATION NAME] dressing to the wound. He proceeded to cleanse the wound located to the left of center buttock, wiping from dirty to clean repeatedly using soiled 4 X 4's. The LPN extended the 4 X 4's into the scarred coccyx area and back across the wound bed, stating just got blood that drained. The surveyors viewed the used 4 X 4's at this time and noted a brown substance with sero-sanguinous drainage from the wound. LPN #2 then applied [MEDICATION NAME] powder and covered the wound with a [MEDICATION NAME] dressing. He proceeded to handle the resident's scrotum and changed his gloves without washing his hands. He used clean 4 X 4's, sprayed wound cleanser on the right buttock pressure ulcer and wiped from dirty to clean repeatedly across the wound using the same 4 X 4's with brown stain. LPN #2 removed his gloves and washed his hands. LPN #2 assisted Resident #1 onto his left side. He proceeded to spray the right buttock wound with the cleanser, wiped the wound repeatedly, back and forth several times from dirty to clean with the same 4 X 4's. He removed 4 X 4's previously soaked in Dakins solution from a plastic cup and packed the right buttock wound and then covered with a [MEDICATION NAME] dressing. He removed his gloves and placed another pair of gloves on without washing his hands. Resident #1 had a pressure ulcer located on the left heel. LPN #2 removed the dressing and sprayed the heel wound with wound cleanser. He wiped the wound repeatedly, from dirty to clean areas, back and forth. The surveyors noted bleeding from the left heel wound. The LPN sprayed the bleeding wound again with wound cleanser and used the same 4 X 4's repeatedly over the same area. He applied a foam [MEDICATION NAME] dressing on the wound. On 6/26/12 at approximately 12:30 PM, an interview with LPN #2 confirmed he cross-contaminated the wounds during care and stated, I don't usually do wounds. The LPN failed to wash hands and change gloves between cleansing of multiple pressure ulcers during wound care for Resident #1.",2016-10-01
7893,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2012-06-27,323,D,0,1,J9SM11,"**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 each resident receives assistive devices to prevent accidents for 1 of 9 residents reviewed for safety alarms. During all days of the survey, observations revealed a physician's orders [REDACTED].#9. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the medical record on 6/25/12 revealed a current physician's orders [REDACTED]. Further record review indicated a physician's telephone order dated 2/24/12 for the tab alarm to the wheelchair. Review of the care plan revealed Risk for falls due to hx (history) falls was identified as a problem area with falls alarm in chair listed as an intervention. Review of the Nurse's Notes indicated Resident #9 fell in the bathroom on 2/24/12 and again on 2/25/12. The Nurse's Note dated 2/24/12 indicated, tabs alarm in place on w/c, and the notation dated 2/25/12 indicated, reapplied tab alarm. Observation of Resident #9 on 6/25/12 at approximately 2:45 PM revealed Resident #9 sitting in his wheelchair in his room. The resident's tab alarm was observed sitting on top of his bedside table. On 6/25/12 at approximately 5:15 PM, Resident #9 was observed propelling his wheelchair in the hallway with no tab alarm in place. On 6/25/12 at approximately 5:20 PM, the tab alarm was observed sitting on top of the resident's bedside table. On 6/26/12 at approximately 3:15 PM, Resident #9 was observed sitting in his wheelchair in his room with no tab alarm in place on the wheelchair. The tab alarm was observed sitting on the top of the bedside table at that time. Observation on 6/27/12 at approximately 9:15 AM revealed Resident #9 was not in the room, and the tab alarm was again observed sitting on top of the bedside table. The resident's wheelchair was not in the room at that time. During an interview on 6/27/12 at approximately 10:20 AM, Licensed Practical Nurse (LPN) #3 reviewed the physician's orders [REDACTED]. At that time, LPN #3 accompanied the surveyor to the resident's room and observed/verified that the tab alarm was sitting on top of the bedside table.",2016-10-01
7894,PRUITTHEALTH-AIKEN,425145,830 LAURENS STREET NORTH,AIKEN,SC,29801,2012-06-27,327,D,0,1,J9SM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the failed to record hydration intake for 1 of 1 diaylsis residents reviewed. (Resident #9) The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the medical record on 6/25/12 revealed a current physician's orders [REDACTED]. Further record review indicated there were no Intake and Output Record forms for April, May, or June 2012. The most recent Intake and Output Record forms available in the record were dated March 2012. Review of the dietary tray card indicated an area to record the fluid consumed at each meal. In addition, the tray card indicated the amount and type of liquid to be provided at each meal. During an interview on 6/27/12 at approximately 10:20 AM, Licensed Practical Nurse (LPN) #3 was asked to review the medical record and was asked for documentation related to the ordered fluid restriction. LPN #3 confirmed that there were no Intake/Output forms documenting the amount of fluids consumed since March 2012. LPN #3 stated that the intake forms should be in the record and documentation related to fluid consumption would not be recorded anywhere else. LPN #3 stated that nursing staff was expected to record the amount of fluids consumed at each medication pass and at the end of each meal after the Certified Nurses Aides (CNAs) collected the meal tray.",2016-10-01
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
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
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
488,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2019-01-16,550,E,1,1,8N1U11,"> Based on observations and interviews, the facility failed to ensure that residents were treated with respect and dignity during the dining experience. Three to four residents were served or being assisted with eating by staff at one table while 18 plus residents were seated at tables in the dining room on the 100 Unit with clothing protectors in place for over 45 minutes and not served or eating.1 of 2 Unit dining rooms observed. The findings included: During a random lunch observation on 1/14/19 at approximately 11:50 AM of the dining room on the 100 Unit revealed residents seated in the dining room on the 100 Unit and residents being transported to the 100 Unit dining room. Staff was observed offering and placing clothing protectors on all residents in the dining room. At approximately 12:15 PM, one table with four (4) residents were served with two of the four residents requiring staff assistance with eating. There were two long tables with multiple residents and two smaller tables with three to four residents with clothing protectors on waiting to be served. Some residents were looking at the table were the residents were eating independently or being assisted by staff. At approximately 12:26 PM two food carts were delivered pass the residents seated in the dining room down the hallways while the resident remained in the dining room on the 100 Unit not served or eating. One resident was observed self-ambulating from the dining table in his/her wheelchair. The resident asked staff when the food was coming. Staff informed the resident not to leave the table because lunch was coming. During an interview on 1/14/19 at approximately 12:46 PM with Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN) #1 revealed the residents at the table being served is restorative dining residents. Both confirmed the observations of 4 residents seated at a dining table and eating or being feed while other residents were waiting to be served. RN #2 and LPN#1 stated the facility has been delivering food to the dining room this way for a long time. At approximately 12:53 PM on 1/14/19, a food cart was delivered to the 100 Unit dining room to serve the other residents seated at the four other tables in the dining room. During the agency group interview on 1/15/19 at approximately 10:59 AM, one of five group members expressed concerns about having to wait close to an hour on the 100 Unit dining for lunch while one group of residents were served and eating. The group member that expressed concerns eat meals in the dining room on the 100 Unit. The group member stated he/she has expressed concerns, but he/she does not want to cause any trouble. The group member further stated food delivery for lunch has been going on like that for a long time. A lunch observation on 1/15/19 at approximately 12 PM revealed staff offering multiple residents clothing protectors on the 100 Unit dining room. There were residents seated at 2 long tables and three smaller tables. At approximately 12:11 PM one cart was delivered to the dining room. At 12:14 PM, staff was observed serving three residents at a small table that required assistance with eating while multiple residents were seated at two (2) long table and two (2) other smaller tables. At 12:25 PM, two food carts had passed the residents seated in the dining room not served or eating while wearing clothing protectors waiting to eat. The two food carts were delivered to the hallways on the 100 Unit. At approximately 12:47 PM on 1/15/19 an observation and interview with the facility consultant confirmed the observation of one table with residents being served and eating while multiple residents in the dining room had not been served or eating. The facility consultant stated he/she did not know why the dining experience was set up that way, but he/she would check and find out. At approximately 12:48 PM on 1/15/19, a staff member ambulated a resident who was in a wheelchair to the dining room to be served. The resident was place at a long table where other residents were waiting to be served. The resident was heard stating you got me out here while they are eating. Staff informed the resident that lunch was on the way, but the resident expressed disagreement verbally and with hand moments. The resident continued to express disagreement about the one table with residents being feed and he/she had to wait. LPN #1 and the facility's Pharmacy Consultant was present and heard the resident's disappointment in having to be in the dining room waiting while others are eating. LPN #1 attempted to console the resident and informed him/her that the food was on the way as he/she still expressed concerns. At approximately 12:55 PM another resident seated at the long table near the glass door in back of the dining room stated he/she was ready to eat. During an interview on 1/15/19 at approximately 1 PM with LPN #2 revealed there was no policy as to why one table with residents are served while the others are waiting. LPN #2 further stated the facility has been serving the residents this way for a long time. During the interview, food carts were observed being delivered to the dining room to serve the other residents waiting to be served.",2020-09-01
489,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2019-01-16,580,D,1,1,8N1U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that residents responsible parties were notified of changes that affected the resident's care while in the facility for 1 of 4 sampled residents reviewed for change in condition. Resident #134's responsible party was not notified of a skin tear that required a bandage/dressing. The findings included: The facility admitted Resident #134 on 4/12/18 with [DIAGNOSES REDACTED]. A review of Resident #134's medical record revealed a nurse's note dated 5/07/18 at 4:26 AM revealed the resident removed a brown bandage from his/her LFA (Left Fore Arm) while receiving a bath causing a category 2 skin tear. Further review of the medical record revealed there was no documentation to address the resident receiving an injury to his/her LFA that required him/her needing a bandage/dressing to the LF[NAME] Further review of Resident #134's record revealed the resident's responsible party was notified on 5/07/18 at 6:58 AM and by 9 AM the resident was transported to the emergency room . During an interview on 1/15/19 at approximately 3:05 PM with Registered Nurse #1 revealed he/she did not know when or why a bandage was first placed on Resident #134 LFA before 5/07/18. RN #1 stated after the resident removed the first bandage; a second bandage was placed on the resident by RN #2 and when that bandage was removed by the resident, further injuries occurred, and the resident was sent to the hospital for treatment. During an interview on 1/15/19 at approximately 3:21 PM with RN #1 revealed through the facility's investigation, no staff member admitted to knowing why a bandage/dressing was on the resident's LFA before 5/07/18 though the resident had a history of [REDACTED]. RN #1 stated whoever put the bandage/dressing on the LFA before 5/07/18 did not report it to the nursing heads and did not document the incident. RN #1 stated the facility did not notify the family prior to the first bandage/dressing to the resident's LFA because no one was aware as to why it was on the resident. During an interview on 1/16/19 at 9:18 AM with RN #2 revealed he/she did not know who applied the first bandage/dressing to Resident #134 LFA but he/she placed the second dressing to the resident's LFA at approximately 4:26 AM and he/she went off duty. It was reported to him/her later that the resident pulled off the second bandage/dressing that required a hospital visit and 17 sutures. RN #2 acknowledged there was no documentation of when the second injury occurred that required the hospital visit and he/she thought it was best to call the responsible party at a decent hour so the responsible party was notified by 7 AM.",2020-09-01
490,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2019-01-16,842,D,1,1,8N1U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to ensure that a resident's medical record accurately document the care and services that was received while placed in the facility for 1 of 4 sampled residents reviewed for change in condition. Resident #134 with treatment being given without documentation as to what occurred that required treatment. The findings included: The facility admitted Resident #134 on 4/12/18 with [DIAGNOSES REDACTED]. A review of Resident #134's medical record revealed a nurse's note dated 5/07/18 at 4:26 AM revealed the resident removed a brown bandage from his/her LFA (Left Fore Arm) while receiving a bath causing a category 2 skin tear. Further review of the medical record revealed there was no documentation to address the resident receiving an injury to his/her LFA that required him/her needing a bandage/dressing to the LFA prior to 5/07/18. During an interview on 1/15/19 at approximately 3:05 PM with Registered Nurse #1 revealed he/she did not know when or why a bandage was first placed on Resident #134 LFA before 5/07/18. RN #1 stated after the resident removed the first bandage; a second bandage was placed on the resident by RN #2 and when that bandage was removed by the resident, further injuries occurred and the resident was sent to the hospital for treatment. During an interview on 1/15/19 at approximately 3:21 PM with RN #1 revealed through the facility's investigation, no staff member admitted to knowing why a bandage/dressing was on the resident's LFA before 5/07/18 though the resident had a history of [REDACTED]. RN #1 stated whoever put the bandage/dressing on the LFA before 5/07/18 did not report it to the nursing heads and wrote no documentation. RN #1 stated the facility did not notify the family prior to the first bandage/dressing to the resident's LFA because no one was aware as to why it was on the resident. During an interview on 1/16/19 at 9:18 AM with RN #2 revealed he/she did not know who applied the first bandage/dressing to Resident #134 LFA but he/she placed the second dressing to the resident's LFA at approximately 4:26 AM and he/she went off duty. It was reported to him/her later that the resident pulled off the second bandage/dressing that required a hospital visit and 17 sutures. RN #2 acknowledged there was no documentation of when the second injury occurred that required the hospital visit and he/she thought it was best to call the responsible party at a decent hour so the responsible party was notified by 7 AM. Further record review revealed the resident's responsible party was notified on 5/07/18 at 6:58 AM and by 9 AM the resident was transported to the emergency room . The interview on RN #2 on 1/16/19 revealed he/she applied the second dressing at 4:26 AM and there was no documentation as to when the second bandage was removed by the resident.",2020-09-01
491,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-03-16,241,E,0,1,3CJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, facility failed to maintain the dignity of residents during meal service on 2 of 2 units. Resident room trays were not distributed in a sequential manner on Unit 1. The privacy curtain was not pulled for a resident who was fed by Gastrostomy tube, when other residents were served in the room. Residents were not offered glasses for canned drinks and supplements served in cartons on Units 1 and 2. Resident #85 was served with plastic utensils without documented current need. The findings included: During observation of the noon meal on 03-13-17 at 12:38 PM, Certified Nursing Assistant (CNA) #1 was the only staff member distributing room trays on Unit 1. S/he served the resident nearest the door in room [ROOM NUMBER], but did not provide a tray for the second occupant in the room or pull the privacy curtain before moving on to the next room (room [ROOM NUMBER]). It was approximately 20 minutes before the second resident in room [ROOM NUMBER] was served. room [ROOM NUMBER] was occupied by 3 residents. CNA #1 served 2 of the 3 residents sequentially. The third resident was nourished by use of a gastrostomy (G-) tube. The CNA did not pull the privacy curtain between residents. Therefore, the resident with the [DEVICE] was fully able to see other residents eating their meals. During meal observation on 03-14-17 at 12:35PM, all residents in the dining rooms on Units 1 and 2 who were served Ready Shakes and/or canned sodas were not offered or provided with glasses for these beverages. During an interview on 03-14-17 at 12:50PM, Registered Nurse (RN) #2 indicated that some residents preferred to have their beverages directly from the container. S/he stated that the kitchen usually sent extra cups on the set up cart. No extra cups/glasses were noted during observed meal times. On 03-14-17, Resident #85 was observed eating with plastic utensils in the Wing 2 dining room at 8:40 AM and at 12:40 PM. Review of the resident's diet card revealed that s/he was to have plastic ware sent with each meal. Review of the incomplete 3/7/17 dietary assessment noted plastic utensils only. Quarterly nutrition notes dated 7-12-16, 10-4-16, and 12-20-16 did not mention the use of plastic utensils. After observing the second meal, an interview with the Assistant Director of Nurses at 12:45 PM revealed that Resident #85 had become aggressive a couple of years ago and attempted to stab a nurse with a fork and it was care planned that s/he would use plastic ware from then on. No disruptive behaviors were observed during the survey. On 03-16-17 at 1:07PM, record review revealed no Physician's Order for plastic utensils. Review of Nurses Notes revealed no recent documented behaviors. Review of the 2-6-17 Minimum Data Set assessment revealed no documented behaviors. The care plan did not include a reference to associated/ongoing behavioral concerns for which the use of plastic ware was indicated. Use of plastic ware was not included in planned interventions.",2020-09-01
492,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-03-16,329,D,0,1,3CJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide evidence of non-pharmacological intervention prior to administration of an antipsychotic for 1 of 5 sampled residents reviewed for unnecessary medications. Staff administered [MEDICATION NAME] multiple times to Resident #36 without documented evidence of behaviors and/or evidence of non-pharmacological interventions prior to administration. The findings included: Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. Record review on 3-15-17 at 12:08PM revealed physician's orders [REDACTED]. Review of behavior monitoring for (MONTH) through March, (YEAR) on 3/16/17 revealed no documented behaviors. Review of the Medication Administration Records revealed that [MEDICATION NAME] was administered twice in 1-17 (on 1-1-17 and 1-20-17), six times in 2-17 (on 2-8-17, 2-9-17, 2-19-17, 2-23-17 x 2, and 2-24-17), and five times in 3-17 (on 3-3-17, 3-4-17, 3-5-17, 3-9-17, and 3-10-17) for yelling out, hollering out, agitation, and anxiety. Review of Nurse's Notes revealed there was no evidence of evaluation of the underlying cause of the behavior and no attempts at non-pharmacological interventions prior to administering the medication. There were no behaviors documented when agitation or anxiety was noted as the reason for administration of the medication. Review of the care plan revealed When res(ident) noted to be yelling out, paranoid, agitated after misinterpretation of others actions or conversation, staff to approach calmly, attempt to get res to talk, give time to express self, take res to a more comfortable area, offer snacks and liquids, and if this does not work offer to take back to room. Reassure res r/t (related to) whatever is causing her (him) agitation. Make nurse aware of behaviors and meds as ordered. Call her (his) daughter or other family member when requested. During an interview on 3-16-17 at 9:44AM, Licensed Practical Nurse (LPN) #1 stated that prior to administering a PRN medication, especially antipsychotics, staff should typically try to always check for pain first and check the patient care record for behaviors. Per LPN #1, staff should do less aggressive measures before administering drug and be sure to check the environment for irritants, check their activities of daily living, and check for pain. A preliminary drug policy was provided by the Director of Nurses on 3-16-17 which did not define parameters for interventions prior to administration of PRN psychoactive medication.",2020-09-01
493,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-03-16,428,D,0,1,3CJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure that irregularities identified by licensed pharmacist during drug regimen review were addressed in a timely manner by the attending physician for one of five residents reviewed for unnecessary medications. The findings included: Resident #23 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. Review of the medical record on 3/15/17 at 4:30 PM revealed that the Consulting Pharmacist initiated three Note to Attending Physician/ Prescriber communication forms on 11/22/2016 regarding recommendations related to irregularities identified during monthly medication regimen review for resident #23. Review of one of the three recommendations submitted by the Licensed Pharmacist on 11/22/2016 revealed request submitted for consideration of Gradual Dose Reduction (GDR) for hypnotic medication from scheduled to as needed (PRN) dosing, this request was not addressed by the Family Nurse Practitioner (FNP) until 2/2/2017, when it was approved. Review of a second communication form submitted by the Licensed Pharmacist on 11/22/2016 addressed irregularity regarding fasting blood glucose levels and request for consideration to change dose of Lantus insulin from 10 units every 12 hours to 20 units every morning to address this issue, which was not addressed by the FNP until 2/2/17, where the request was denied with the following reason provided resident has had multiple hyperglycemic episodes- Lantus increased-HgbA1c 7.8 on 11/21/16. Review of the third communication form submitted by the Licensed Pharmacist on 11/22/2016 revealed that resident #23 was identified with weight loss, difficulty swallowing, and abnormal Thyroid Stimulating Hormone (TSH) laboratory test results with request for consideration to change medication dose for Levothyroxine followed by labs in 8 weeks, where the request was not addressed until 2/2/17 when it was approved and medication was changed and laboratory test was ordered to be done in 8 weeks. During an interview with the Director of Nursing (DON) on 3/16/17 at 10:58 am, s/he stated that after review of the medical record and discussion with the nursing staff, s/he was not able to determine a reason for the delay between when the Licensed Pharmacist submitted recommendations on 11/22/2016 and when the FNP acknowledged and initiated orders related to those recommendations 73 days later on 2/2/2017.",2020-09-01
494,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-03-16,431,D,0,1,3CJJ11,"Based on observations, interview, review of the manufactures recommendations and facility policy, the facility failed to follow a procedure to ensure that expired medication were removed from medication storage in 3 of 8 medication carts and 2 of 2 units reviewed. Expired medications were on the medication carts after the expiration date. The findings included: On 3/13/17 at 12:24 PM, an observation with RN#1 of the Hall 1/Unit 1 medication cart revealed a Novolog FlexPen (Lot #FP ) with approximately 225 units of fluid insulin remaining. The Novolog FlexPen had an open date of 2/10 and expiration date 3/10. Following the observation, RN #1 verified the Novolog FlexPen was expired and stated, The insulin pen should have been removed from the cart. On 3/14/17 at 1:20 PM, an observation with RN #2 of the Hall 2/Unit 1 treatment cart revealed 1-2-3-Paste with a pharmacy stamped expiration date of 1/24/17. Following the observation, RN #2 verified the 1-2-3 Paste was expired and indicated the paste should have been removed from the cart. On 3/14/17 at 1:45 PM, an observation with RN #1 of the Hall 1/Unit 2 treatment cart revealed Premarin vaginal cream .625 mg/g with a manufactures stamped expiration date of 9/16. Following the observation, RN #1 verified the Premarin vaginal cream was expired and indicated the cream should have been removed from the cart. On 3/14/17 at 10:45 AM, a review of the facility policy entitled, Medication Storage in the Facility, revealed under Expiration Dating (Beyond-use dating), procedure ([NAME]) All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. On 3/14 at 2:55 PM, review of the manufacture recommendations for Novolog Flex Pen states under section How should I store Novolog FlexPen, Bullet (2) states, Store the FlexPen you are currently using out of the refrigerator below 86 degrees F or 30 degrees C for up to 28 days. Furthermore, bullet (6) states, The Novolog FlexPen should be thrown away after 28 days, even if it still has insulin left in it.",2020-09-01
495,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-03-16,441,D,0,1,3CJJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and review, the facility's laundry contractor failed to follow agreed upon policy and procedure for transfer of soiled linen from the facility on 1 of 2 units reviewed for Infection Control. The findings included; Observation of the facility's contracted Laundry Service delivering and retrieving laundry on 03/16/17 at 10:14 am revealed that the handler used an unlined and unmarked container which was used to bring clean linen to the facility to retrieve soiled linen. The handler also placed unbagged soiled linen in the container. In an interview on 03/16/17 at 10:14 am while loading the container into the vehicle for transport, the handler stated that the carts are cleaned once or twice a week. Subsequent review of the contractor's policy revealed that Soiled linen containers should be lined with an impervious liner. Do not allow soiled linens to simply be dropped into a container. At designated times, laundry workers using a large bin For Soiled Linen Use Only will go to each Soiled Linen Room to pick up the soiled linens. During observations from 3-13-16 through 3-16-17, resident care equipment was stored in an improper/unsanitary manner: (1) An uncovered, unlabeled bedpan was initially noted on the floor behind the toilet in room [ROOM NUMBER] (semi-private) bathroom on 03/13/2017 at 3:04 PM. (2) On 03/14/2017 at 9:35 AM, an uncovered, unlabeled bedpan was found on the grab bar in the bathroom for room [ROOM NUMBER] (semi-private). An environmental tour was conducted with the Housekeeping/Environmental Manager, Plant Maintenance Manager, Area Manager and Assistant Maintenance Manager on 3/16/17 at 2:35 PM. The bedpans had not been moved or properly stored for the duration of the survey. All staff present verified the storage of the items. The Housekeeping Manager stated that this concern was the responsibility of the nursing department. During an interview on 3/16/27 at 2:54 PM, Registered Nurse (RN) #3 verified that the items were present in both residents' bathrooms. When asked about the protocol for storage, RN #3 stated that bedpans should be bagged and labeled.",2020-09-01
496,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-12-07,582,C,0,1,PQLY11,"Based on record review and interviews, the facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN)/Centers for Medicare/Medicaid (CMS) form to 3 of 3 sampled residents reviewed for Medicare Part A Services. Residents #38, #44 and #80 received the Notice of Medicare Non-Coverage (NOMNC), but did not receive the required SNFABN/CMS form. The findings included: Review of the medicare non coverage notices on 12/04/17 at approximately 3 PM revealed Residents #38, #44 and #80 had services ended with additional days left for services. There was no CMS forms provided by the facility. During an interview on 12/04/17 at approximately 3:10 PM with the Administrator, the Administrator confirmed the facility did not provide the Skilled Nursing Facility Advanced Beneficiary Notice (CMS ) form for Residents #38, #44 and #80. The Administrator stated the CMS would only be given if it was requested by the resident/responsible party. An interview with the facility consultant on 12/05/17 at approximately 3:48 PM revealed the facility does not provide the SNFABN/CMS form until the resident/responsible party request they want to appeal the Medicare non coverage decision.",2020-09-01
497,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-12-07,641,D,0,1,PQLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure accuracy of assessments. Resident #23's Minimum Data Set (MDS) was coded inaccurately for insulin administration, diuretics, and Urinary Tract Infection (1 of 1 sampled resident reviewed for hospitalization ). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. During record review of the MDS on 12/5/17 at 2 pm revealed the MDS with assessment review date (ARD) of 9/25/17 had Insulin coded as 0 under medications, and did not have the [DIAGNOSES REDACTED]. Further review of the MDS ARD of 10/24/17 revealed Urinary Tract Infection was not coded under active diagnoses, and had diuretics inaccurately coded as 7 under medications. Review of the Medication Administration Record [REDACTED]. Review of the (MONTH) MAR indicated [REDACTED]. Review of the hospital records on 12/6/17 at 2:30 pm revealed the resident was treated and sent back to the facility on [DATE] and 10/26/17 on antibiotic therapy for a UTI. During an interview on 12/6/17 at 10:20 am, MDS Registered Nurse #1 verified inaccurate coding on the 9/25/17 MDS regarding Insulin, and did not code the presence of a UTI. S/he also verified the inaccurate coding on the 10/24/17 MDS regarding diuretics under medications.",2020-09-01
498,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2017-12-07,657,D,0,1,PQLY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the comprehensive care plan. Resident #23 was hospitalized and treated for [REDACTED].# 13 did not include a problem and interventions regarding Blepharitis of the left eye (1 of 1 sampled resident for infections, and 1 of 2 sampled residents reviewed for UTI). The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Review of the hospital records on 12/6/17 at 2:30 pm revealed the resident was treated and sent back to the facility on [DATE] and 10/26/17 on antibiotic therapy for treatment of [REDACTED]. During an interview on 12/6/17 at 10:20 am, MDS Registered Nurse (RN) #1 verified the comprehensive care plan was not updated to reflect the UTI or antibiotic therapy on 9/7/17 or 10/26/17 after readmission to the facility from the hospital. The facility admitted Resident #13 with [DIAGNOSES REDACTED]. During an observation on 12/4/17 at 1:45 pm, Resident #13 was noted to have a large amount of dried beige drainage to the left eye and eyelash with swelling and redness of the lower lid. Review of the care plan on 12/5/17 at 4 pm revealed no evidence in the care plan to address the chronic Blepharitis condition of left eye drainage, redness and swelling or the ordered interventions including antibiotic eye ointment and cleansing of the eye with baby soap twice a day. During an interview on 12/6/17 at 10:25 am, MDS RN #1 verified there was no comprehensive care plan to address the Blepharitis [DIAGNOSES REDACTED].",2020-09-01
5237,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2016-06-16,157,D,0,1,PY4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the physician/nurse practitioner and/or other qualified professional of significant weight loss for Resident #12, 1 of 3 residents reviewed for nutrition. The findings included: The facility admitted Resident #12 with [DIAGNOSES REDACTED]. During the Stage I Census Record review at 5:14 PM on 6/13/16, Resident #12 was noted to have a significant weight loss. On 6/16/16 at approximately 3:15 PM, record review revealed the resident's weight on 6/15/16 was 96.0, on 6/1/16 96.7 pounds, on 5/04/16 106.1 pounds, on 3/08/16 109.0 pounds and on 11/4/15 110.2 pounds. Review of the Nurse's Notes revealed no documentation that the physician, family or Registered/ Licensed Dietitian was notified of the resident's significant weight loss. There was no documentation of any recent changes in dietary intake or [MEDICAL CONDITION], diarrhea or vomiting. Record review revealed the RD completed an assessment dated [DATE] and noted the resident consumed 50-75% of meals and recommended ReadyCare. The RD had not re-assessed the resident related to the significant weight loss. During an interview at 2:59 PM on 06/16/2016, the Certified Dietary Manager (CDM) reviewed the weight sheets and stated that Resident #12 was not on the list for weight loss and that a weight for (MONTH) had not been recorded. When informed that the resident's weight on (MONTH) 1st was 96.7 pounds, the CDM stated and that's a major loss. The CDM stated for a resident under 100 pounds, a re-weight is done if there is a difference of 3 pounds and the unit manager notified. The CDM stated that s/he would then be notified and in turn notify the RD. In addition, the CDM stated the RD had been at the facility on 6/15/16 and had not been informed. During an interview at 3:27 PM on 06/16/2016, the Director of Nursing (DON) provided documentation of the (MONTH) weights but stated that the Dietary manager informed her that she had not received the weights. The Dietary Manager usually receives the monthly weight sheets, inputs the information into the computer which calculates the percentage of weight loss. The computer generates a report of significant weight losses. The DON confirmed that the RD did not have access to that report when she was at the facility yesterday. The RD usually comes weekly. The DON also confirmed the MD was not notified of the weight loss until today.",2019-02-01
5238,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2016-06-16,274,D,0,1,PY4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct a Significant Change in Status Assessment upon identification of decline in continence, development of a pressure ulcer, and decline in bed mobility for Resident #20, 1 of 2 residents reviewed with a Significant Change in Status. The findings included: The facility admitted Resident #20 with [DIAGNOSES REDACTED]. At 3:31 PM on 06/15/2016, comparison of the 2/3/16 Admission MDS (Minimum Data Set) to the 4/18/16 Quarterly MDS revealed the resident had an improvement in her/his BIMS (Brief Interview for Mental Status) score, mood and behaviors. The resident was also noted to have a decline from limited assistance to extensive assistance with bed mobility, a decline in continence from occasional to frequent incontinence, and the development of a Stage III pressure ulcer. Review of the Care Plan Progress Notes revealed a note dated 4/21/16 that stated the resident was noted to have decline in the following areas; incontinence, pressure ulcer stage 3 to sacrum, pain symptoms, and one area of ADLs (Activities of Daily Living) (bed mobility). Will begin Significant change review. There was no documentation or results of a review for a significant change in the record. On 6/16/16 review of the Bladder Incontinence Evaluation done 4/11/16 revealed the resident had incontinent episodes daily and was updated on 4/20/16 that indicated the resident remained frequently incontinent of bladder. During an interview at 5:31 PM on 06/15/2016, the RN MDS Coordinator stated the IDT (Interdisciplinary Team) had determined the resident did not have a significant change in status. During the interview, the Social Services Director reviewed the chart and confirmed there was no documentation of an IDT review or determination that the resident had returned to baseline. The MDS Coordinator stated the pressure ulcer was healed on 4/26/16. At 12:09 PM on 06/16/2016 the MDS Coordinator confirmed the documentation on the bladder assessment that the resident remained frequently incontinent on 4/20/16 and that a Significant Change in Status Assessment should have been completed.",2019-02-01
5239,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2016-06-16,281,D,0,1,PY4411,"Based on observation, interview and review of the facility's policies, 1 of 5 nurses observed during the Medication Pass failed to meet professional standards of practice during medication administration for Resident #56. LPN #1 dropped a pill during med pass, retrieved it from the floor and administered it to the resident. The findings included: During medication pass observation on 06/16/2016 at 9:40 AM , LPN (Licensed Practical Nurse) #1 dropped a pill from the medicine cup onto the floor. The LPN picked up the pill, placed it back in the medicine cup and administered it. During an interview on 06/16/2016 at 9:43 AM, the LPN confirmed s/he dropped the pill on the floor, picked it up and proceeded to administer the medication. The LPN then asked what would be the right thing to do in that case. Review of the facility policy entitled Medication Storage in the Facility revealed Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from stock, disposed of according to procedures for medication destruction . Review of the policy entitled Oral Medication Administration Procedure 6. a. page 20 revealed Avoid touching medications if at are possible.",2019-02-01
6492,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2015-05-14,281,D,0,1,RC2511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and a review of the policy provided by the facility entitled Administration of Insulin, a facility nurse failed to properly administer Insulin to Resident #77, 1 of 1 resident observed during medpass for the administration of Insulin. The nurse failed to keep the [MEDICATION NAME] needle embedded in the skin for the appropriate time frame to ensure the full amount of Insulin had been administered. The findings included: The facility admitted Resident #77 with [DIAGNOSES REDACTED]. Observation on 5/13/15 at approximately 4:10 PM revealed Licensed Practical Nurse (LPN) #1 administering 4 units of [MEDICATION NAME] Insulin via flex pen to Resident #77 for a fingerstick blood sugar of 250. The nurse injected the Insulin into the resident's left upper arm and held the flex pen in place for less than 2 seconds before removing it. After removing the flex pen, the nurse immediately pulled the resident's sleeve down and the surveyor was unable to determine if there was any leakage of Insulin. During an interview after the medpass observations of the nurse, the surveyor asked LPN #1 if s/he was aware that there was a specified amount of time that the flex pen needle was to stay under the skin while administering the Insulin. The surveyor informed the nurse that s/he had been observed to leave the needle in for less than 2 seconds. LPN #1 thought s/he had kept the needle under the skin for 2-5 seconds; and was unsure of the required time frame. On 5/13/15 at 4:17 PM, the Unit Manager was asked about how long the flex pen needle would need to stay under the skin. The Unit Manager was unsure, and stated s/he would check the policy to make sure of the timeframe. Registered Nurse (RN) #1 spoke with the consultant pharmacist by phone and reported that the consultant pharmacist had stated that to ensure the full dose of Insulin had been given with the [MEDICATION NAME], that s/he recommended the nurse hold the pen needle in place for 10 seconds to ensure all the Insulin had been administered. A review of the policy provided by the facility entitled Administration of Insulin revealed information to .Leave needle embedded within skin for 5 seconds with 10 seconds for insulin [MEDICATION NAME] for pen insulin administration A review of Novo-[MEDICATION NAME] manufacturer information dated April 2015 regarding the use of the [MEDICATION NAME] at the website [MEDICATION NAME].com, revealed that the needle should be left under the skin for at least 6 seconds while administering insulin with the [MEDICATION NAME].",2018-01-01
7228,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2014-02-07,371,E,0,1,MMNO11,"On one day of the survey, based on observations, interviews, and review of the facility policy titled Employee Guidelines-Infection Control Practices and Food Handling Guidelines, the facility failed to serve and distribute food under sanitary conditions. Observations during the lunch meal distribution on the 100 Unit and 200 Unit Halls and 100 Unit Day area revealed facility staff touched food items with their bare hands. The findings included: Observation on 2/4/14 at approximately 12:45 PM revealed staff serving trays and setting-up residents' lunch in the 100 Unit day area. The menu included cornbread delivered in a paper wrapping. Observation revealed RN #1 and CNA's #1, 2, and 3 reached into the package, retrieved the cornbread with their bare hands, and placed the cornbread onto the plate when serving residents. In addition, RN #1 was observed to take the cornbread into his/her bare hands, break the bread into two pieces, and place the pieces into containers beside the plate while serving one of these residents. During an interview with CNA #3 on 02-07-14 at approximately 11:30 AM, he/she confirmed the surveyor's findings. During an interview with CNA #1 on 02-07-14 at approximately 11:45 AM, he/she stated, okay. During an interview with RN #1 on 02-07-14 at approximately 2:45 PM, he/she stated, I don't remember doing this, but it should not be done. CNA #2 was unavailable for interview. Review of the facility policy titled Employee Guidelines-Infection Control Practices revealed in section All Food and Nutrition Services Employees the following: Handle plates by the bottom or the edge; keep hands off the eating surface. Keep thumb and fingers away from food on the plate. Review of the facility policy titled Food Handling Guidelines revealed in section Prevention of Food Infection the following: Minimize hand contact with food by the use of utensils or disposable gloves.",2017-04-01
8094,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2012-11-15,318,D,0,1,ZETP11,"**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 accurately assess one of three residents reviewed for range of motion (ROM) and implement measures to prevent further decline. The facility failed to implement contracture prevention measures and failed to identify contractures of the left hand for Resident #48. There was no evidence of provision of restorative services as per the care plan to maintain ROM and to prevent contracture development. The findings included: Multiple observations on all days of the survey revealed Resident #48 holding the left hand in a fisted position. No handroll or positioning device was observed in place at any time. Significant [MEDICAL CONDITION] of the left hand was noted on 11-13-12 and 11-15-12. During the Staff Interview during Stage 1 of the survey process, the 100 Hall Unit Manager stated that Resident #48 had no contractures. Resident #48 was not noted on the contracture list provided to the surveyors on 11-13-12 after discussion related to the definition of contracture as identified during the staff interviews Review of the 10-22-12 Quarterly and 5-13-12 Annual Minimum Data Set (MDS) Assessments on 11-14-12 at 11:19 AM revealed that Resident was vision-impaired, rarely/never understood, displayed both verbal and physical behaviors toward staff, and was totally dependent for all activities of daily living (ADL's). ROM was noted as impaired in both lower extremities. Skilled therapy nor restorative nursing services were not noted as having been provided. During an interview and observation on 11-14-12 at 12:50 PM, the MDS Coordinator assessed the resident in the presence of the surveyor and verified the [MEDICAL CONDITION] of the upper extremities. The resident's left hand was fisted and no positioning was noted for the [MEDICAL CONDITION] of upper extremities or for the fisted hand. The MDS Coordinator noted that the resident had had the [MEDICAL CONDITION] for a long time and confirmed that the left hand would not fully straighten with passive ROM. S/he reviewed the MDS and verified that no restorative nursing had been documented as having been provided. During interviews at 2 PM and 2:30 PM on 11-14-12, Certified Nursing Assistants (CNA) #2 and #1 (assigned to 100 Hall), respectively, were asked to describe the daily care provided to Resident #48. Neither mentioned that ROM exercises were provided with daily care. CNA #1 stated that s/he hadn't noticed the [MEDICAL CONDITION] in the upper extremities. Both CNAs noted that special care/items to be provided, such as ROM and positioning devices, should be on the PCR (CNA Care Plan). During an interview and observation on 11-15-12 at 8:36 AM, Certified Nursing Assistant (CNA) #1, assigned to the resident's care, attempted to straighten the fingers of the resident's left hand. Three fingers were noted as contracted. CNA #1 stated, They've been like that as long as I've known the resident. This was clarified to mean greater than one year. The CNA verified the [MEDICAL CONDITION] and that no positioning devices had been used in the hand to prevent progression of the contracture. On 11-15-12 at 8:45 AM, an interview was conducted with the 100 Hall Unit Manager and the Director of Nurses (DON). Both reviewed the CNA Care Plan and verified there was no instruction for CNAs to perform routine ROM as an intervention to prevent contracture development. The DON reviewed the medical record and verified that the resident was last screened by Physical Therapy on 10-25-11 following a toe amputation. No skilled services were determined as needed at that time. There was no evidence of an Occupational Therapy screening or evaluation at that time or since. There was no evidence in the medical record that the resident was provided restorative nursing services. During an interview on 11-15-12 at 9:15 AM, the MDS Coordinator stated that s/he was responsible for the resident assessment of ROM and was unaware that Resident #48 had the contractures of the upper extremity at the time the most recent MDS had been completed. The Interdisciplinary Care Plan was reviewed and the MDS Coordinator noted that no contractures were noted on the Care Plan. There was no specific Care Plan problem noted related to the limited ROM in the lower extremities identified on the MDS Assessments. Approaches related to Problem #5 Resident totally dependent for ADL's due to dementia and immobility and Problem #7 In the past, res(ident) has voiced preference to remain in bed/room included Staff to provide PROM to all ext(remities) Q (every) shift when giving care. When asked what preventive interventions should have been implemented for Resident #48 related to the hand contracture, s/he stated, ROM, an appliance or handroll.",2016-07-01
9233,"ABBEVILLE NURSING HOME, INC.",425057,83 THOMSON CIRCLE,ABBEVILLE,SC,29620,2011-09-07,309,D,0,1,RKDK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification survey, based on interviews and record review, the facility failed to ensure that pacemaker checks were performed timely for Resident #9, 1 of 4 residents reviewed with pacemakers. The findings included: The facility admitted Resident #9 on 4/28/10 with [DIAGNOSES REDACTED]. Record Review of the hospital Discharge Summary on 9/6/11 at 2:40 PM revealed the resident had Pacemaker placement due to Sick Sinus Syndrome. After reviewing the record , the Director of Nursing (DON) was asked on 9/7/11 at approximately 10:15 AM where Pacemaker checks were documented. The DON stated that the Pacemaker checks were documented on the Treatment Administration Record (TAR.) She further stated that the due date for the Pacemaker check was documented on the monthly physician's orders [REDACTED]. At approximately 10:35 AM on 9/7/11, Licensed Practical Nurse (LPN) #1 confirmed she was unable to locate any documentation of a pacemaker check on the record. During an interview at 1:55 PM on 9/7/11, LPN #1 stated Resident #9 should have had an appointment at the Cardiologist's in January. She stated the resident missed that appointment and had not had a pacemaker check done since October of 2010.",2015-06-01
3109,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2017-04-12,247,D,0,1,V7AN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify Residents #21 and #38 that they were receiving a new roommate, 2 of 30 sampled residents reviewed on Stage 1 of the Recertification survey. Resident's #21 and #38 received a new roommate and were not given written or verbal notification prior to the roommate change. The findings included: The facility admitted Resident #21 with [DIAGNOSES REDACTED]. During an interview with Resident #21 on 4/10/2017 at 11:49 AM, Resident #21 stated she/he had recently had a new roommate move into her/his room. Resident #21 stated she/he was given no notice that she/he was receiving a new roommate. Record review of Resident #21's medical record on 4/10/2017 at 2:37 PM revealed no documentation indicating Resident #21 had been notified prior to receiving a new roommate. During an interview with the Social Worker/Admissions Coordinator (SW/AC) on 4/11/2017 at 12:03 PM, the SW/AC confirmed that Resident #21 had recently received a new roommate and was not given any notice prior to the new roommate moving in. The SW/AC stated that she/he did not know that notification was required for residents receiving a new roommate. The SW/AC stated she/he thought that notification was only required for a resident that was moving into a new room. Interview with Resident #38 on 4/9/17 at approximately 4:47 PM revealed that s/he was not given notice before a change in roommate. Interview with Social Worker #1 on 4/11/17 at approximately 12:18 PM confirmed that Resident #38 was not notified prior to receiving new roommate. Review of facility policy for Room & Roommate Assignment on 4/11/17 at approximately 2:05 PM revealed that, The facility will promptly notify the residents and the residents' legal representatives or interested family members (if known) when there is a change in room or roommate assignment. The policy clarified that, Prior to making a room change, all parties involved (residents and their legal representatives) will be provided with a 48 - hour advance notice of such change whenever possible.",2020-09-01
3110,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2017-04-12,253,D,0,1,V7AN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview the facility failed to provide effective housekeeping and maintenance services with observed environmental concerns during initial tour and all days of the survey. Resident #30 had bilateral torn arm rests on his/her wheelchair with the foam exposed and a shared bathroom between 2 rooms had a leaking toilet that kept the floor of the bathroom wet. The findings included: The facility admitted Resident # 30 on 12/09/2016 with [DIAGNOSES REDACTED]. On 04/09/2017 during initial tour and all days of the survey the resident's wheelchair was noted to have bilateral torn arm rests with foam exposed. During an interview on 04/10/2017 at 3:53 pm, the Director of Nursing verified the arm rest were torn. Observation of the shared bathroom for rooms 113 and 115 on 4/9/2017 at 4:41 PM revealed multiple, soaked paper towels in a puddle of water around the base of the toilet. Observation of the same bathroom on 4/10/2017 at 12:21 PM revealed that the bathroom floor had been cleaned, but water was leaking from the base of the toilet. Observation of the same bathroom on 4/10/2017 at 3:39 PM, revealed multiple, soaked paper towels in a puddle of water around the base of the toilet. During an interview with Resident #4 on 4/10/2017 at 11:55 AM, Resident #4 stated that the toilet had been leaking about 2-3 weeks. He/she stated that he had told maintenance staff about the leaking toilet. Resident #4 believed the seal on the toilet needed to be replaced. During an interview with Resident #40 on 4/10/2017 at 12:14 PM, Resident #40 stated that the toilet had been leaking for about 2-3 weeks. He/she stated that the seal on the toilet probably needed to be replaced. Resident #40 stated that when he used the toilet his pants would get wet from the puddle of water around the base of the toilet. He/she stated he had told staff about the leaking toilet. During an observation and interview with the Maintenance Director on 4/10/2017 at 3:50 PM, the Maintenance Director observed and confirmed multiple, soaked paper towels in a puddle of water around the base of the toilet. The Maintenance Director stated that he had been in to fix the leaking toilet in the past 2 weeks, but was not aware the toilet was still leaking.",2020-09-01
3111,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2017-04-12,274,D,0,1,V7AN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview with the Minimum Data Set (MDS) Coordinator, the facility failed to assess significant change in 1 of 2 residents reviewed for accidents. Resident #24 experienced a decline in mental status and activities of daily living (ADLs), yet no significant change assessment was done. The findings included: Resident #24 was admitted to the facility 12/12/16 with [DIAGNOSES REDACTED]. Review of Admission MDS Assessment for Resident #24 dated 12/19/16 on 4/10/17 at approximately 3:21 PM revealed that s/he scored 7/15 on his/her Brief Interview for Mental Status (BIMS). Review of Quarterly MDS Assessment for Resident #24 dated 3/21/17 on 4/10/17 at approximately 3:21 PM revealed that s/he scored 3/15 on his/her BIMS. Review of Admission MDS Assessment for Resident #24 dated 12/19/16 on 4/10/17 at approximately 3:21 PM revealed that s/he required extensive one-person physical assistance for locomotion off unit and limited one-person physical assistance for eating. Review of Quarterly MDS Assessment for Resident #24 dated 3/21/17 on 4/10/17 at approximately 3:21 PM revealed that s/he was newly coded as requiring total one-person physical assistance for locomotion off unit and extensive one-person physical assistance for eating. Interview with the MDS Coordinator on 4/11/17 at approximately 11 AM confirmed the decline in BIMS and ADLs and revealed no significant change assessment was done because it was considered an expected decline. The MDS Coordinator confirmed there was no documentation that would verify that the significant change assessment had not been performed because the decline was considered expected. At the time of exit, no documentation was produced that indicated a significant change assessment was not done because the resident decline was expected.",2020-09-01
3112,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2017-04-12,278,D,0,1,V7AN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to code the Minimal Data Set (MDS) accurately for one of one resident sampled for a prosthesis. Resident #30 was admitted with a prosthesis but was coded on the Admission MDS and again on the quarterly MDS as not having a prosthesis. The Findings included: The facility admitted Resident # 30 on 12/09/2016 with [DIAGNOSES REDACTED]. On 04/10/2017 at 3:15 pm review of the MDS Admission assessment dated [DATE] and the Quarterly assessment dated [DATE] revealed question G0600 D- limb prosthesis coded no. During an interview on 04/10/2017 at 3:37 pm with Licensed Practical Nurse (LPN) # 1 revealed that the resident had the prosthesis since he was admitted . Interview 4/10/2017 at 4:25 pm, the MDS Coordinator confirmed that Section G0600 D was coded inaccurately on the Admission and Quarterly Assessments.",2020-09-01
3113,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2017-04-12,279,D,0,1,V7AN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan in 1 of 2 residents reviewed for range of motion (ROM). Resident #6 had no care plan addressing ROM limitations. The findings included: Resident #6 was admitted to the facility 9/26/13 with [DIAGNOSES REDACTED]. Observation of Resident #6 on 4/10/17 at approximately 11:34 AM revealed that the resident had a contracture with no splint device in place. Review of care plan for Resident #6 on 4/11/17 at approximately 11:47 AM revealed there was no care plan for contracture or ROM limitations. Interview with Certified Nursing Assistant (CNA) #1 on 4/11/17 at approximately 12 PM revealed that Resident #6 had a contracture with no splint device in place or ROM services. Interview with Licensed [MEDICATION NAME] Nurse (LPN) #1 on 4/11/17 at approximately 12:10 PM revealed that Resident #6 had a contracture with no splint device in place or ROM services. Interview with the Director of Nursing (DON) on 4/11/17 at approximately 12:13 PM revealed that Resident #6 had a contracture of his/her arms at least since July. S/he confirmed there were no splint or ROM services.",2020-09-01
3114,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2017-04-12,318,D,0,1,V7AN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop interventions to prevent decline in range of motion (ROM) in 1 of 2 residents reviewed for ROM. Resident #6 had a contracture of both arms with no interventions in place to prevent decline or worsening of contractures. The findings included: Resident #6 was admitted to the facility 9/26/13 with [DIAGNOSES REDACTED]. Observation of Resident #6 on 4/10/17 at approximately 11:34 AM revealed that the resident had a contracture with no splint device in place. Review of care plan for Resident #6 on 4/11/17 at approximately 11:47 AM revealed there was no care plan for contracture or ROM limitations. Review of physician's orders [REDACTED]. Interview with Certified Nursing Assistant (CNA) #1 on 4/11/17 at approximately 12 PM revealed that Resident #6 had a contracture with no splint device in place or ROM services. Interview with Licensed [MEDICATION NAME] Nurse (LPN) #1 on 4/11/17 at approximately 12:10 PM revealed that Resident #6 had a contracture with no splint device in place or ROM services. Interview with the Director of Nursing (DON) on 4/11/17 at approximately 12:13 PM revealed that Resident #6 had a contracture of his/her arms at least since July. S/he confirmed there were no splint or ROM services. S/he revealed the resident risk factors for developing contractures included immobility, dementia, debility, vitamin D deficiency, altered mental status, and chronic pain. Interview with Physical Therapist Assistant (PTA) #1 on 4/11/17 at approximately 12:27 PM revealed that the resident had splints ordered in therapy and that the order was never discharged . Review of Occupational Therapy Discharge Summary from 7/19/16 - 10/13/16 on 4/11/17 at approximately 1:49 PM revealed that Occupational Therapy's recommendation on discharge was for bilateral elbow splints to be worn daily for 4 hour periods 1 - 2 times daily. Interview with DON on 4/11/17 at on 4/11/17 at approximately 1:49 PM revealed that s/he had never seen the discharge summary or therapy recommendation. S/he also confirmed no splints were ever used for Resident #6. Interview with PTA #1 on 4/11/17 at approximately 2 PM revealed that an order for [REDACTED]. Review of Physician order [REDACTED]. Interview with Certified Occupational Therapy Assistant #1 on 4/11/17 at approximately 2:11 PM confirmed that the recommendations made by therapy were to maintain and prevent decline in the ROM of Resident #6. COTA #1 explained the process was for therapy to fill out an order and leave it in the physician folder to be signed and then carried out by nursing. COTA #1 revealed the order for the splint had been found in the chart for Resident #6, but the order had never been placed after it was signed by the physician. Review of In-Service Training Report dated (MONTH) 30, (YEAR) on 4/11/17 at approximately 2:11 PM revealed that therapy had trained CNA staff to use splints for Resident #6.",2020-09-01
3115,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2017-04-12,323,D,0,1,V7AN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to check Resident #30's bed alarm for placement and function every shift as ordered. Staff were not signing off on the treatment record that they were checking the alarm for Resident #30, 1 of 2 sampled residents reviewed for Accidents. The finding included : The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the care plan on 4/12/2017 at 8:45 AM revealed an intervention to ensure that the resident's bed alarm is in place and functioning every shift. Record review of the Fall Risk assessment, dated 2/15/2017, on 4/12/2017 at approximately 8:45 AM indicated that the resident was at high risk for falls. Record review of the progress notes on 4/11/2017 at 3:34 PM revealed that the resident had a fall without injury on the day of admission to the facility. In addition, the resident had a fall on 4/4/2017 that resulted in the fracture of the left radius. The Incident Report indicated the alarm was functioning at the time of the accident. Record review of the Treatment Administration Records (TARs) from February, (YEAR)-April, (YEAR) revealed that there was no documentation to indicate that staff were checking the bed alarm for placement and functioning every shift per the physician's orders [REDACTED]. The (MONTH) TAR indicated that the alarm was not checked 7 times. The (MONTH) TAR indicated the alarm was not checked 27 times. The (MONTH) TAR indicated the alarm was not checked on the night shift on 4/1, on the day shift on 4/3, on the day shift on 4/8 and on the evening shift on 4/9. During an interview with the DON (Director of Nursing) on 4/11/2017 at 1:21 PM, the DON stated that care that is not documented as done on the TARs means we can't prove that we did the care that was ordered. During an interview with the DON (with the Nursing Home administrator present) on 4/12/2017 at 11:27 AM, the DON confirmed that the treatment record indicated that the bed alarm was not checked on multiple occasions. The DON did not provide any additional documentation to indicate the alarm was checked as ordered. In addition, the DON stated the facility did not have a policy related to bed alarms.",2020-09-01
3116,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2017-04-12,356,B,0,1,V7AN11,"Based on observation, interview, and record review the facility failed to correctly fill out staff posting information. Daily postings of licensed and unlicensed care staff were incomplete for 2 of 4 days of survey and 3 days of a 30-day look back. The findings included: Observation of the posting for nursing staff on 4/11/17 at approximately 12:06 PM revealed that cumulative hours of nursing staff were not posted for each shift. Observation of posting for nursing staff on 4/12/17 at approximately 8:48 AM revealed that the posting was incomplete. The number of licensed and registered nurses for each shift as well as the cumulative hours worked were not listed for each shift. Interview with the DON on 4/12/17 at approximately 9 AM confirmed that the nurse staffing information sheet was incomplete. S/he then corrected the posting by filling out the blank sheet. Review of the previous 30 days of nurse staffing information on 4/12/17 at approximately 10:42 AM revealed that days 3/15/17, 3/25/17, and 3/26/17 were incomplete. These days were missing either the number of nurses worked or the cumulative hours worked.",2020-09-01
3117,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2017-04-12,514,D,0,1,V7AN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain a complete and accurate medical record for resident #13, 1 of 1 sampled residents reviewed for Pressure Ulcers. Multiple treatments and interventions were not documented as done as ordered. The findings included: The facility admitted Resident #13 with [DIAGNOSES REDACTED]. Record review of the Treatment Administration Records (TAR) for February, (YEAR)- (MONTH) (YEAR) on 4/11/2017 at 10:31 AM revealed multiple treatments and interventions not documented as done. Review of the (MONTH) TAR revealed a treatment order for daily wound care for a left buttock wound that was not documented as done 8 times. A foam pad to the right lower back every shift was not documented as done 6 times. Wound care for an abrasion to the left thigh was ordered to be done every shift and was not documented as done 16 times. Review of the (MONTH) TAR revealed daily wound care orders for an abraded area to the right posterior thigh that was not documented as done on 3/28. Daily wound care to the right lower back was not documented as done on 3/17. A wound vac dressing change was not documented as done on 3/28. Wound care to the right lower back was not documented as done on 3/7 and 3/8. A foam pad to the right lower back every shift was not documented as done 25 times. An order to check the wound vac every shift was not documented as done 6 times. Wound care every shift to the left inner buttocks was not documented as done 11 times. Skin prep every shift to heeled area on left inner buttock was not documented as done 11 times. An order to turn and position every 2 hours every shift was not documented as done 14 times. Review of the (MONTH) TAR revealed that an order for [REDACTED]. An order to check the wound vac every shift was not documented as done 4 times. An order to turn and position every 2 hours every shift was not documented as done 4 times. During an interview with the DON (Director of Nursing) on 4/11/2017 at 1:21 PM, the DON confirmed that nursing was not documenting that treatments were done as ordered. The DON stated care that is not documented as done on the TARs means we can't prove that we did the care that was ordered. Based on additional documentation, wound care and skin observations, and additional staff interviews it was concluded that the resident most likely received the care as ordered, but the nurses failed to document the care as done.",2020-09-01
3118,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-06-08,637,D,0,1,IV8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify changes and conduct a Significant Change in Status MDS (Minimal Data Set) assessment on 2 occasions for Resident #7, 1 of 1 resident reviewed with a significant change. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. On 06/08/18 at 10:13 AM Comparison of the 10/6/17 Admission MDS and the 12/28/17 Quarterly MDS assessment revealed improvement in 3 areas of ADLs (Activities of Daily LIving): transfers improved from extensive assistance to supervision, locomotion and eating. Further review revealed an improvement in bed mobility, dressing and continence from the 12/28/17 Quarterly to the 03/30/18 Quarterly MDS assessment. During an interview on 06/08/17 at 10:52 AM, Registered Nurse (RN) #1 confirmed there was a significant improvement in the resident's status on the 12/28/17 Quarterly MDS, stating Yes, (s/he) got better. The RN also confirmed the resident had a significant improvement on the 03/30/18 MDS assessment and that no Significant Change in Status MDS assessment was conducted in (MONTH) or (MONTH) and that a Significant Change in Assessment should have been conducted.",2020-09-01
3119,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-06-08,660,D,0,1,IV8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement discharge planning with the Interdisciplinary team for Resident #29, 1 of 1 reviewed for planned discharge. The findings included: The facility admitted Resident #29 on 03/05/18 with [DIAGNOSES REDACTED]. On 06/07/18 at 08:43 AM, review of the closed record revealed no discharge documentation related to discharge planning. Review of the record indicated the nurse contacted the resident's group home by phone and reviewed medications, (Representative) stated (s/he) has all (his/her) medications there. I told (her/him) I would send a copy of medication list from here and the packet for (his/her) port a cath. There was no documentation that information related to follow-up appointments or any need for home health was provided to the receiving facility. During an interview on 06/07/18 at 10:11 AM, the Director of Nursing (DON) stated that the Admissions Coordinator (AD) was the person that coordinated residents' discharges. During an interview at 10:14 AM, the AD stated that s/he usually documents all information related to a resident's discharge plan and stated I know I had it. I don't know where it went. I don't see it in the record. The admissions coordinator confirmed there was no documentation in the record related to follow-up appointments or if there was a need for home health. The AD further confirmed that s/he did not know what qualifications the person at the group home possessed.",2020-09-01
3120,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-06-08,661,D,0,1,IV8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a discharge summary for Resident #29, 1 of 1 resident reviewed for discharge. The findings included: The facility admitted Resident #29 on 03/05/18 with [DIAGNOSES REDACTED]. On 06/07/18 at 08:43 AM, review of the closed record revealed no discharge summary in the record that included a recapitulation of the residents stay involving the IDT (Interdisciplinary Team) and the resident's needs and goals. Review of the record indicated the nurse contacted the resident's group home by phone and reviewed medications, (Representative) stated (s/he) has all (his/her) medications there. I told (her/him) I would send a copy of medication list from here and the packet for (his/her) port a cath. There was no documentation that information related to follow-up appointments or any need for home health was provided to the receiving facility. During an interview on 06/07/18 at 10:11 AM, the Director of Nursing (DON) confirmed there was no Discharge Summary in the resident's record. The DON further stated that the Admissions Coordinator (AD) was the person that coordinated residents' discharges. During an interview at 10:14, the AD stated that s/he usually documents all information for a resident's discharge and stated I know I had it. I don't know where it went. I don't see it in the record. The AD further confirmed that s/he did not know what qualifications the person at the group home possessed.",2020-09-01
3121,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-06-08,679,E,0,1,IV8V11,"Based on resident and staff interviews, the facility failed to provide an ongoing weekend activities program to meet the interests of residents and to support the physical, mental, and psychosocial well-being of residents on 1 of 1 unit. During the recertification survey, 5 interviewable residents stated that the facility did not provide activities on the weekends. (Residents B, D, E, F, and G) The findings included: A review of the facility's Activity Calendars for the past six months revealed that three activities were listed as occurring on Saturdays and Sundays for each of those months. During the recertification survey, 7 interviewable residents (Residents A, B, C, D, E, F, and G)were asked if the facility provided activities that met their interests. Residents B, D, E, F, and G stated that they needed more activities. When asked if activities were provided on the weekends, Residents B, D, E, F, and G stated that they did not have activities on the weekend. When the surveyor commented that the Activity Calendar indicated activities were scheduled on Saturdays and Sundays, the residents stated that those activities did not occur. During an interview on 6/7/18, the surveyor asked the Activity Director to provide documentation related to resident participation in the activities programs. The Activity Director stated that he/she did not keep attendance records for any of the activity programs. The Activity Director stated that he/she documents a quarterly or annual activities notation in each residents' medical record. The Activity Director stated that these notations do not document the number of activities the residents attend. When asked how he/she would document activities provided by community volunteers on the weekend, the Activity Director stated that he/she also did not keep documentation on the weekend activities. When asked how he/she would know if the activities were provided or occurred on the weekends, the Activity Director stated the residents would tell him/her.",2020-09-01
3122,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-06-08,689,D,0,1,IV8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to identify the risk for resident-to-resident altercation and take adequate precautions to prevent further altercations for Residents #7 and #19, 2 of 2 residents reviewed for resident-to-resident altercations. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the progress notes on 06/08/18 revealed the following documentation: 01/18/18 Res. (resident) rolled to desk very upset stating that (his/her) fell ow resident was yelling at (him/her) and picking at (him/her) because (s/he) was old. staff (sic) one on one to calm (him/her) down. Adm. (Admission) And (sic) social worker made aware of situation. Stated they will go and speak to them or (him/her). 01/22/18 This nurse was called r/t (related to) increased agitation and anger of res. refusing to go back to bed because that (person) is standing over me. Stated that (s/he) calls me old all the time. res. was assisted to another room for the rest of the night. 01/23/18 Res. is refusing to go back to the room for BR privileges. Began yelling that that (person) will hit me. I'm not going to that room, I'm going to sit here. staff assisted to another room for BRP (bathroom privileges). which (s/he) did without difficulty. 01/24/18 Res. encouraged to go back to room, but became very upset and talking loud. that (person) is going to hit me. Staff I on I to calm down. Review of the medical record for Resident #19 revealed on 05/01/18 this nurse called to res room. res noted arguing with (Resident #7). (Resident #19) was in res face. when asked what (s/he) was doing (s/he) states well (s/he) said come on, so I was gone give it to (him/her) dispute is over the temperature in the room. res in bed (Resident#7) states (s/he) is cold and the other 2 res in the room states they are not cold. thermostat is set at 64*, and the room does feel very cold. this nurse stated to res that there has to be a compromise since this is a shared room. temp set on 72*. (Resident #7) states. (s/he) better not put (his/her) hands back on me res (#19) denies touching res (#7) at first but a staff member heard (Resident #7) tell this res to get (his/her) hands off of (him/her) during the argument. when asked about this (s/he) (#19) states. well I grabbed (his/her) arm, but I thought (s/he) was going to hit me res separated and social services, don and administrator made aware. Review of the Social Services Notes revealed Social Services asked resident to come into the office to talk to the administrator and resident asked why (s/he) could not come to (his/her) room and talk and SS (Social Services) told (him/her) (s/he) wanted to talk in private. Had a report of (him/her) grabbing hold of another resident and also having the air conditioner on 64 degrees and freezing the other resident. (S/he) did state that (s/he) grabbed the other resident on the arm. administrator (sic) and SS told (him/her) not to put (his/her) hands on anyone and to put (his/her) call light on for help. (S/he) also needed to keep the air conditioner on 70 degrees which is suitable for everyone. Then (s/he) starts about (his/her) roommate peeing in the floor in the bathroom and spiting on the toilet seat. We also told (him/her) to put (his/her) call light on and get someone there to help (him/her) even in the middle of the night. (S/he) stated that (s/he) would. There was no documentation to confirm that Resident #7 was voiding in the floor or spitting on the toilet seat. During an interview on 06/08/18, the Nursing Home Administrator confirmed the altercations between the 2 residents and stated that the facility had spoken to Resident #19. The Administrator also stated that since Resident #19 reported that s/he grabbed Resident #7's arm because s/he thought Resident #7 was going to hit him/her, the facility did not feel like it constituted abuse and that they had spoken to resident #19 about not touching other residents. The Administrator also stated the facility might not have been as aggressive as they should have been to prevent further altercations, but there have been no problems since that time.",2020-09-01
3123,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-06-08,725,F,0,1,IV8V11,"Based on record review and interviews, the facility failed to assure that there is sufficient staff available at all times to provide services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 1 of 1 unit reviewed. During the recertification survey, 7 interviewable residents stated that there was not enough staff working at the facility. (Residents A, B, C, D, E, F, and G) The findings included: During the recertification survey, 7 interviewable residents (Residents A, B, C, D, E, F, and G) were asked if they received the help and care they needed without waiting a long time. Residents B, D, E, F, and G stated that they had to wait a long time. All of the residents stated that there was not enough staff. When asked for examples, Residents [NAME] and F stated that sometimes if they went to the bathroom, they might have to wait 30 minutes to an hour. The residents all stated that there was not enough staff, specifically that there were not enough Certified Nurses Assistants (CNAs) working in the facility. One resident stated that there were usually 2 CNAs working per shift, but sometimes there was only 1 CNA working in the entire facility. One resident stated that they only had 1 CNA working evening shift the week prior to the survey. The surveyor reviewed staffing documentation which included the Daily Schedule, the Posting of Licensed and Unlicensed Direct Care Staff, and the Weekly Schedule from 5/1/18 through 6/6/18. Review of this documentation revealed that during that period of 30 days, there were 7 times that only 1 CNA per shift was documented as working in the facility. The facility census was noted as between 25-30 with a census of 29 on most days during that period.",2020-09-01
3124,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-06-08,729,F,0,1,IV8V11,"Based on interview, the facility failed to ensure that Certified Nurse Aides (CNAs) who were not employed as a CNA for a period of 24 consecutive months received a new training and competency evaluation program prior to employment as a nurse aide. The findings included: During a review of CNA inservice files during the recertification survey, the surveyor asked the Director of Nursing (DON) about the education process for hiring CNAs who had not worked as a CNA for a period of 24 consecutive months. During an interview on 6/7/18 at approximately 5:30 PM, the DON stated that they would go through new employee orientation. When asked if they would attend a new training and competency evaluation program, the DON stated, No. The DON again stated that they would go through new employee orientation.",2020-09-01
3125,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-06-08,759,D,0,1,IV8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a medication error rate of 5% or less. The facility had a 7.41% medication error rate with 2 errors out of 27 opportunities. The findings included: On 06/06/18 at 09:44 AM, LPN (Licensed Practical Nurse) #1 was observed administering medications to Resident #24. Among the medications administered was Pramipexole [MEDICATION NAME] 1.5 mg (milligram) tablet. LPN #1 administered 1 and 1/2 tablets. Review of the unit dose package and reconciliation with the medical record at 2:24 PM revealed the order was for Pramipexole [MEDICATION NAME] 1.5 mg give 1 tablet. During an interview at 3:01 PM, the LPN confirmed the unit dose package stated give 1 tablet and that s/he administered 1/1/2 tablets. On 06/07/18 at 9:59 AM, LPN #1 was observed administering medications to Resident #12. The LPN administered folic acid 400 mcg (microgram) 1 tablet. At 2:54 PM, reconciliation revealed the order was for Folic Acid 1 mg. During an interview at 3:01 PM, the LPN confirmed that s/he used the stock bottle of folic acid and that it was 400 mcg.",2020-09-01
3126,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-06-08,880,F,0,1,IV8V11,"Based on record review, interview, and review of CMS S&C 17-30, the facility failed to develop and implement policies and procedures to reduce the risk and spread of Legionella. The facility's Infection Control policies failed to address the risk of Legionella within the facility. The findings included: A review of the facility's Infection Control Policies and Procedures revealed there were no policies that addressed the risk of Legionella. When asked for documentation related to addressing the risk and prevention of Legionella, the facility provided an Inservice Monthly Attendance Form dated 4/14/18 which addressed Shower Head Cleaning wkly/mnthly and a facility Cleaning Shower Heads log. During an interview on 6/7/18 at approximately 5:00 PM, the Director of Nursing (DON) confirmed that there were no written policies to address Legionella. When asked what actions the facility was taking to address the prevention of Legionella, the DON stated that nursing would not take action until there was a case of Legionella. Review of CMS S&C 17-30 revealed the following: Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water.",2020-09-01
3127,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-06-08,947,F,0,1,IV8V11,"Based on record review and interview, the facility failed to ensure the adequacy of the Certified Nurse Aide (CNA) in-service education program for all employed CNAs. The facility failed to track and ensure the in-service training for nurse aides included the 12 hours per year as required. The findings included: During a review of CNA inservice files, the Director of Nursing (DON) provided folders with inservice attendance sheets for the past 12 months. The surveyor requested documentation related to the required 12 hours of inservice training per year based on the date of hire for CNAs. During an interview on 6/7/18 at approximately 4:30 PM, the DON informed the surveyor that he/she did not have any process of tracking the required yearly CNA inservice hours. When asked how he/she ensured that CNAs received the required number of inservice hours, the DON stated that he/she just kept up with it, but did not have a running total of hours documented. He/she stated that he/she knew when the CNAs had been hired and just kept up with it.",2020-09-01
3128,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2019-06-12,580,D,0,1,T4Z811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to notify the resident representative (RR) of significant weight loss for Resident #4, 1 of 1 sampled resident reviewed for Nutrition. Resident #4 experienced significant weight loss greater than 5% over 30 days and the RR was not notified. The findings including: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review of Resident #4's weights on 06/10/19 at 09:14 AM, revealed from the week of 4/15/19 to the week of 5/14/19 the resident lost 6.2 pounds, a 5.86% weight loss. Record review of Resident #4's Dietary notes on 6/11/19 at 10:21 AM, revealed a note from 5/16/19 indicating the resident had a 5.9% weight loss over the past month. The notes did not indicate the RR was notified of the weight loss. During an interview with the Director of Nursing (DON) on 6/11/19 at 11:24 AM, the DON confirmed there was no documentation the RR was notified of the significant weight loss. The DON stated it was the responsibility of nursing, the Certified Dietary Manager (CDM) or the Minimum Data Set (MDS) nurse to ensure that the RR was notified of the weight loss. The DON stated nursing, the CDM and the MDS nurse failed to ensure the RR was notified of the weight loss During an interview with the CDM on 6/12/19 at 9:23 AM, the CDM was asked if it was dietary's responsibility to notify the RR of significant weight loss. The CDM stated it was her/his understanding it was dietary's responsibility to notify nursing of the significant weight loss and nursing's responsibility to notify the RR. The CDM confirmed the RR was not notified of the significant weight loss until yesterday, 6/11/19. The CDM stated s/he called the RR yesterday to report the weight loss. Resident #4's most recent weight from (MONTH) indicated the resident had gained weight since the facility implemented shakes on 5/18/19.",2020-09-01
3129,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2019-06-12,656,D,0,1,T4Z811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to implement the care plan for Resident #4, 1 of 1 sampled resident reviewed for Nutrition. The resident representative (RR) was not notified of significant weight changes per the care plan. The findings including: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review of Resident #4's care plan on 06/11/19 at 10:08 AM, revealed the resident was at risk for weight changes related to [DIAGNOSES REDACTED]. Record review of Resident #4's progress notes on 6/11/19 at 10:21 AM, revealed a dietary note, from 5/16/19, indicating the resident had a 5.9% weight loss over that past month. Further review of the progress notes did not indicate the RR was notified of the significant weight loss. During an interview with the Certified Dietary Manager (CDM) on 6/12/19 at 9:23 AM, the CDM was asked if it was dietary's responsibility to notify the RR of significant weight changes per the care plan. The CDM stated it was her/his understanding it was dietary's responsibility to notify nursing of the significant weight loss and nursing's responsibility to notify the RR. The CDM confirmed the RR was not notified of the significant weight loss, per the care plan, until yesterday, 6/11/19. The CDM stated s/he called the RR yesterday to report the weight loss.",2020-09-01
3130,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2019-06-12,657,D,0,1,T4Z811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to revise the care plans for Resident #11 and #16 with new interventions related to falls, 2 of 3 sampled residents reviewed for falls. Documentation indicated new interventions were initiated or needed, but those interventions were not added to the care plans. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Record Review of the Investigation Follow-Up reports on 6/10/19 at 1:49 PM, revealed Resident #16 had a fall on 4/22/19. Past interventions implemented were to monitor the resident every 1-2 hours. An Investigation Follow-Up report from a fall on 5/1/19 indicated past interventions implemented were a bed and chair alarm. Record review of Resident #16's care plan on 6/10/19 at 12:03 PM, revealed the above interventions for monitoring and alarms were not added to the care plan. During an interview with Registered Nurse (RN) #1 on 6/10/19 at 3:21 PM, RN #1 confirmed the interventions for every 1-2 hour monitoring and bed/chair alarm were not added to Resident #16's care plan. RN #1 stated that s/he is supposed to be given the Investigation Follow-Up reports after all resident falls so those interventions can be added to the care plans. RN #1 stated Resident #16's care plan was not revised because s/he did not get the Investigation Follow-Up reports. RN #1 stated the facility needed a better process, so the care plans would be updated timely. RN #1 stated s/he was going to start a performance improvement project related to that. RN #1 updated Resident #16's care plan on 6/11/16 to include the above interventions. The facility admitted Resident #11 on 10/5/16 with [DIAGNOSES REDACTED]. BIMS score 13. Record Review of the Incident Reports and Investigation Follow-Up reports on 6/11/19 at 3:08 PM revealed Resident #11 had multiple falls as a result of his wheelchair brakes not being locked and for refusing to wear non-skid footwear. The Investigation Follow-Up report from 2/8/19 revealed Resident #11 fell while coming out of the bathroom. The resident was not wearing non-skid footwear. The report indicated the resident refused to wear non-skid socks. The resident was educated on the need to wear non-skid footwear. The Investigation Follow-Up report from 2/28/19 revealed Resident #11 slipped and fell when attempting to get into his/her wheelchair when the breaks were not locked. The resident was educated on locking the brakes to his/her wheelchair prior to using it. Review of the incident report from 3/17/19 revealed Resident #11 fell while going to his/her wheelchair. The resident was re-educated on calling for assistance before walking to his wheelchair and to ensure the wheelchair brakes are on. Review of Resident #11's care plan on 6/11/19 at 12:23 PM, revealed an intervention to Ensure the resident is wearing appropriate no-skid footwear when ambulating or mobilizing in wheelchair. The care plan did not reflect the resident's refusals of non-skid footwear. In addition, there were no interventions related to educating the resident on locking the wheelchair breaks or ensuring the wheelchair breaks were locked. During an interview with RN #1 on 6/12/19 at 10:21 AM, RN #1 confirmed Resident #11's care plan had not been revised related to the above falls. RN #1 stated it is a communication issue and the fall reports are not getting to her/him timely for care plan updates.",2020-09-01
3131,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2019-06-12,684,D,0,1,T4Z811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to collaborate with Hospice in the development of a coordinated care plan for Resident #16, 1 of 1 sampled resident reviewed for Hospice. The findings included: The facility admitted Resident #16 with [DIAGNOSES REDACTED]. Record review of Resident #16's facility care plan on 6/10/19 at 11:41 AM, revealed the care plan indicated the resident was on Hospice, but did not identify what interventions Hospice was responsible for. A care plan intervention indicated the facility would work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. The care plan interventions did not identify how this would be done. In addition, the care plan did not indicate Hospice was involved in developing the care plan with the facility. Review of Resident #16's Hospice care plan on 6/10/19 at 2:45 PM, revealed no facility involvement in the development of the Hospice care plan. During an interview with the Director of Nursing (DON) on 6/10/19 at 2:58 PM, the DON stated the facility was not involved in the development of the Hospice care plan and Hospice was not involved in the development of the facility care plan. The DON confirmed the facility care plan did not identify what interventions were the responsibility of Hospice. The DON also stated Hospice did not attend Resident #16's care plan meetings when the care plan was developed or at the last quarterly meeting.",2020-09-01
3132,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2019-06-12,689,E,0,1,T4Z811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and interview the facility failed to evaluate for fall risk for Residents #2, #11, and #16, 3 of 3 sampled Residents reviewed for Accidents. The residents received a Fall Risk Assessment on admission to the facility, then received no further Fall Risk Assessments despite multiple falls. The findings included: The facility admitted Resident #16 on 1/18/19 with [DIAGNOSES REDACTED]. Record review of Resident #16's Fall Risk assessments on 6/10/19 at 8:50 AM, revealed the resident had a Fall Risk Assessment on 1/18/19. The resident was assessed as a low fall risk. The resident had no additional Fall Risk Assessments. Record review of Resident #16's progress notes on 6/10/19 at 8:51 AM, revealed the resident had falls on 4/19/19 with a skin tear to the elbow, 4/22/19 with an abrasion to the elbow, 4/25/19 with no injury and 5/1/19 with no injury. The resident's Fall Risk was not re-assessed after the falls. Review of the Incident Reports for Resident #16 on 6/10/19 at 1:49 PM, revealed the falls were investigated and interventions were implemented related to the resident's falls. Review of the facility's Fall Management policy on 6/10/19 at 11:20 AM, revealed All residents will be assessed for risk quarterly, annually and for significant change using the Fall Risk Assessment. During an interview with Licensed Practical Nurse (LPN) #1 on 6/10/19 at 2:26 PM, LPN #1 stated that after a resident fall s/he would complete an Incident Report, a nurse's note, notify the physician and responsible party and complete a Fall Risk Assessment. During an interview with the Director of Nursing (DON) on 6/10/19 at 2 :58 PM, the DON initially stated Fall Risk Assessments should be done within 3 days of a fall and quarterly, as well. The DON also stated the facility has not been doing Fall Risk Assessments since 3/31/19 because the facility implemented a new Fall Risk Assessment on the electronic medical record and they hadn't started using that form yet. The DON then stated Fall Risk Assessments are not required to be done after each fall but required on admission and quarterly. The DON confirmed the resident had no further Fall Risk Assessments since admission. The DON confirmed the resident was assessed as a low fall risk on admission. During an interview with the DON on 06/11/19 at 03:39 PM, the DON was asked why residents were not receiving Fall Risk Assessments at least quarterly, the DON stated she did not know. When asked how the facility knows if a resident's risk for falls increases or decreases, the DON stated they would know based on increased or decreased falls, by changes in status and by doing a Fall Risk Assessment. The DON also stated the facility used to have a Risk Management meeting every Friday to review falls, but this group stopped meeting at the end of (MONTH) 2019 after the facility was acquired by new ownership. The DON stated the meetings were used to review falls, documentation, interventions and fall risks. During an interview with Registered Nurse (RN) #1 on 6/12/19 at 10:21 AM, RN #1 stated s/he had just initiated a performance improvement project (PIP) for post fall follow-up and care planning. A copy of the PIP was provided. The PIP was not dated as to when it was initiated, when corrective actions were put in place and when changes and education occurred. Review of the PIP revealed, as part of corrective action, the facility would complete Fall Risk Assessments within 48 hours of falls. The facility admitted Resident #11 on 10/5/16 with [DIAGNOSES REDACTED]. Review of Fall Risk Assessments for Resident #11 on 6/11/19 at 12:14 PM, revealed the resident had an annual Fall Risk Assessment on 10/24/17. The resident scored as a high fall risk. No additional Fall Risk Assessments had been completed. Record review of the Incident Reports for Resident #11 on 6/11/18 at 3:08 PM, revealed the resident had falls with no injuries on 2/8/19, 2/28/19, 3/17/19, 4/13/19 and 5/13/19. The falls were investigated, and interventions were implemented related to the resident's falls. During an interview with the DON on 06/11/19 at 03:39 PM, the DON confirmed Resident #11 had no Fall Risk Assessments since 10/24/17. When asked how nurse aides know which residents are a high fall risk, the DON stated they are given a verbal report on who is at risk and by the care plans. During an interview with Certified Nursing Assistant (CNA) #1, on 6/11/19 at 3:51 PM, CNA #1 stated s/he is given verbal report on who is a fall risk and it should also be noted on the care plan. The facility admitted Resident #2 on 11/27/17 with [DIAGNOSES REDACTED]. Review of Fall Risk Assessments for Resident #2 on 6/11/19 at 2:24 PM, revealed the resident had no Fall Risk Assessments since 11/28/17. The resident scored as a high fall risk. Review of the Incident Reports on 06/11/19 at 02:19 PM, revealed on 5/13/19 the resident was coming out of the bathroom in sock feet, slipped and fell to the floor with no injuries. An investigation was completed, and interventions were implemented. During an interview with the DON on 06/11/19 at 03:39 PM, the DON confirmed Resident #2 had no Fall Risk Assessments since 11/28/17.",2020-09-01
3133,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-08-01,567,F,1,0,RRDO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to credit all interest earned on resident's funds to each resident's account. The facility reported misappropriation of resident funds by the Business Office Director to the State Agency. During review of the information provided and interview it was noted the residents were not reimbursed interest on the misappropriated funds. 9 of 15 residents with resident trust withdrawals. 2 of 2 residents with cash deposits. The findings included: The facility reported an allegation of misappropriation of resident funds to the State Agency on 7/10/18. Review of the Initial 24-hour report dated 7/10/18 revealed general accounting staff questioned signatures on Resident Trust withdrawal slips. District Business Office staff initiated a review to validate signatures and/or disbursements. Review of the Trial Balance form provided revealed there were 15 resident accounts with one of those closed on 7/23/18 related to the resident discharging. Review of facility files revealed three residents were listed as their own responsible party (one of those residents was noted to have a Brief Interview for Mental Status score of 3). All other residents had someone else listed as their responsible parties, with five of those having someone listed as their financial power of attorney. The facility provided documentation that they had interviewed eight residents with Resident Trust Accounts and they all said they received cash and were never asked to sign for it. The District Director of Business Office Services provided documentation that the current summary of findings of misappropriation totaled $18,705.00 including Resident Trust withdrawals and cash receipts. In an interview with the surveyor on [DATE] at approximately 10:40 AM, the facility administrator stated originally the auditors in [STATE] noted some signatures that were questionable and they contacted the District Director of Business Office Services. The auditors in [STATE] first noted the questionable signatures and contacted the District Director of Business Office Services in May 2018. The auditors in [STATE] noticed the handwriting on the signatures was similar to the handwriting that filled in the rest of the slip. The facility sends copies of the disbursement ledger to [STATE] monthly for review. At that point, they assumed it was not following policy. The District Director of Business Office Services came to the facility unannounced to perform a review on [DATE]. S/he pulled documents to compare signatures during his/her review. The Business Office Director was suspended on [DATE] pending an investigation. The Business Office Director resigned on 5/22/18, which prompted a more in depth review. The administrator stated at first they thought the Business Office Director had not followed policy related to disbursement of resident money, it looked like s/he had signed the residents' names on the disbursement slips. The disbursement sheets are used to keep account of petty cash. During the review, there were several inconsistencies. There were multiple beauty shop charges close together, charges that they could not verify the resident had beauty shop work done. The beautician would get a list and check with the business office to make sure those residents had funds to cover beauty shop services. Then the beautician would provide services and at the end of the day s/he would bring a roster with names and services provided with the cost of the service. At the bottom of the page would be a total, then the Business Office Director would cut the beautician a check from the resident trust account. The Business Office Director would allocate the individual charges to their individual accounts. When you look at the statement, it would have that the money was released to the beautician for beauty shop services. There would be no reason for the resident to get money out to pay the beautician. The disbursement is petty cash for resident spending. There were multiple charges that didn't seem reasonable. Like people getting services twice a week, and also people that typically didn't get their hair done were charged for services. The Business Office Director was changing the names on the beauty shop roster after the services had been rendered. The administrator and District Director of Business Office Services interviewed residents about beauty shop services and if they get money. Some of the residents said they did not get beauty shop services, one resident who stated s/he didn't get money disbursed. They had one resident who acknowledge s/he got money and did not sign for it, they would let staff sign for them. The District Director of Business Office Services kept a list of what s/he found during the audit. The administrator stated they did not think it was misappropriation, they thought the Business Office Director was not following policy in the beginning. The Business Office Director had been at the facility for [AGE] years. The administrator stated in late June, they begin to wonder about some things. There seemed to be multiple things, more than just a few inconsistencies. The District Director of Business Office Services found some white out things on the beauty shop rosters. After the Business Office Director left, they found out several people were paying cash for their stays. They are still reviewing the information and they cannot account for the money. The amounts people were paying was inconsistent. They have not been able to find out if people who paid cash had their accounts credited appropriately. They talked with residents in May and June and residents reported some inconsistencies. The administrator did not think it was intentional and so s/he did not report it. The administrator stated they do not have to have a witness for a signature for a resident cash withdrawal, they do have to have two witnesses for a mark made by the resident. In an interview with the surveyor on [DATE] at approximately 12:30 PM, the District Director of Business Office Services stated s/he assigned to the building in November 2016. S/he provides support and training to business office staff and conducts audits as needed. They audit each building annually per corporate policy. Every month, the business office prepares a copy of all resident trust transactions, withdrawals, deposits, copies of checks. They send that to the corporate office in Houston that does general accounting. General accounting reconciles the resident trust monthly. It was one of the auditors that noticed what they felt to be forged signatures on resident trust withdrawal slips. They sent the concern to the District Director of Business Office Services and asked him/her to review the attachment in mid-May. In looking at the copies, s/he felt they were forged. The District Director of Business Office Services came to the facility and started an investigation by just looking through the resident trust files. After looking at a couple of months of resident trust files, it appeared that the same handwriting was signing the slips as residents. The administrator and District Director of Business Office Services called and suspended the Business Office Director via phone for falsification of records and suspended him/her pending investigation. During that conversation, the District Director of Business Office Services asked the Business Office Director if s/he knew the policies related to residents withdrawing money. S/he also asked if the Business Office Director had ever forged any resident signatures and s/he said no. The Business Office Director stated s/he knew the policy and was able to explain the process as it should be done. The process was that the residents come in and the Business Office Director would fill out a withdrawal slip for how much money they wanted, name, and date would also be on the slip. The resident would sign the withdrawal slip. If a resident cannot sign, then 2 witnesses are required. The administrator would be back up at the facility and give out money when the Business Office Director was not in the building. The person giving out the money would not sign the withdrawal slips. There would be two witnesses who watched the person give out the money if a resident could not sign. The District Director of Business Office Services continued to look through and continued to find signed withdrawal slips that were forged. Initially s/he just looked at 2018, then worked his/her way back from May to January 2018. At that time, the District Director of Business Office Services worked with the Area Human Resources Manager and they were going to terminate the Business Office Director, but s/he resigned before s/he was terminated. The District Director of Business Office Services stated s/he had reviewed all files before talking with Human Resources to start the process for terminating the Business Office Director. In May, the District Director of Business Office Services and the administrator did some resident interviews and asked them about their accounts. The residents did state they got money sometimes, but they had not been asked to sign for the money. One resident stated s/he had never gotten money out of his/her account, but they found a forged signature on a withdrawal slip for the resident. All residents consistently stated they had not been asked to sign for cash they received. After the Business Office Director resigned, they continued to look through accounts. The Vice President of Operations Finance also came to look through the accounts, they came once in June and again in July. They looked at the files January 2018- May 2018. They also looked at the actual RF[CONDITION] (resident funds management system) instead of just looking in the files. The files include the withdrawal slips, any deposits, and copies of checks (checks that were written to the beautician or to replenish the resident petty cash.) They looked at the individual accounts for residents in June. They were looking for excessive transactions or transactions where the resident said they had never taken out money. During the July visit they looked through the receipt book and found where cash payments had been receipted but found no record of the money being credited to the resident account or deposited into the resident trust account. After going through the receipt books at the facility they wrapped up their investigation and that is when the misappropriation was reported to the State Agency and police department. They went back a couple of years during the investigation. The District Director of Business Office Services stated they have refunded residents that they identified as having money misappropriated or cash payments not credited. They looked at current residents for resident trust accounts and they looked at all for cash receipts (the cash receipt book). They reimbursed based on the resident interviews and excessive transactions. One resident was not able to be interviewed, the resident had questionable beauty charges and also cash withdrawals. They could not confirm if the transactions were valid or not, so the resident was not been reimbursed. For the reimbursement of cash withdrawals, they based it on resident interviews on if they received the money and how much. The exact amount for the facility was $13,218 in the cash receipts and $5,032 for resident trust. Those are the amounts that have been refunded back to residents. Resident trust includes a combination of withdrawal slips and beauty charges. They do not have a dollar amount on the cash withdrawal slips that were forged. The Business Office would key the withdrawal slips into the RF[CONDITION] system and then that is transmitted and it removes the amount from each resident account. It transfers from the resident trust account into the resident trust checking account. The Business Office Director would print those checks and then have either the administrator or DON (director of nursing) or MDS (minimum data set) nurse sign the check and then the check would be taken to the bank to be cashed. It should not have been taken to the bank by the Business Office Director, but it was s/he who would go to the bank with the check to be cashed. Anyone other than the Business Office Director and whoever signed the check should go to the bank to get the cash. In an interview with the surveyor on 8/1/18 at approximately 1:35 PM the District Director of Business Office Services stated cash receipt books were reviewed from 2016 until now. The RF[CONDITION] withdrawal slips were reviewed from 2017 until now and all had forged signatures. The District Director of Business Office Services stated they did not add interest back into the reimbursements to the residents whose accounts were affected by the misappropriation. Review of the facility's Resident Trust Accounts policy revealed the Business Office is responsible for keeping appropriate, accurate records of each resident's personal money in accordance with State and Federal regulations. The Resident Trust Fund is managed by the facility and is kept in an interest bearing checking account. Interest earned on these funds is computed daily and applied monthly. The administrator will ensure that the facility is compliant with Federal and State regulations. Federal regulations require the following: each resident's funds must be fully and separately accounted for in accordance with generally accepted accounting principles and individual State and Federal regulations, all resident cash must be posted into the Resident Trust Account, a resident's funds in excess of $100.00 must be deposited in an interest bearing account, and all resident trust documentation must be kept in the facility or in off-site storage in accordance with the Record Retention policy.",2020-09-01
3134,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-08-01,568,F,1,0,RRDO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. The facility reported misappropriation of resident funds by the Business Office Director to the State Agency. The Business Office Director did not maintain a system for cash withdrawals and cash deposits for resident funds. 9 of 15 residents with resident trust fund withdrawals. 2 of 2 residents with cash deposits. The findings included: The facility reported an allegation of misappropriation of resident funds to the State Agency on 7/10/18. Review of the Initial 24-hour report dated 7/10/18 revealed general accounting staff questioned signatures on Resident Trust withdrawal slips. District Business Office staff initiated a review to validate signatures and/or disbursements. The allegation of misappropriation of resident property by the Business Office Director was noted on the form as occurring on 7/10/18 at 11:00 AM. The form was faxed to the State Agency on 7/10/18 at 11:06 AM. Review of the Trial Balance form provided revealed there were 15 resident accounts with one of those closed on 7/23/18 related to the resident discharging. Review of facility files revealed three residents were listed as their own responsible party (one of those residents was noted to have a Brief Interview for Mental Status score of 3). All other residents had someone else listed as their responsible parties, with five of those having someone listed as their financial power of attorney. The facility provided documentation that they had interviewed eight residents with Resident Trust Accounts and they all said they received cash and were never asked to sign for it. The District Director of Business Office Services provided documentation that the current summary of findings of misappropriation totaled $18,705.00 including Resident Trust withdrawals and cash receipts. In an interview with the surveyor on [DATE] at approximately 10:40 AM, the facility administrator stated originally the auditors in [STATE] noted some signatures that were questionable and they contacted the District Director of Business Office Services. The auditors in [STATE] first noted the questionable signatures and contacted the District Director of Business Office Services in May 2018. The auditors in [STATE] noticed the handwriting on the signatures was similar to the handwriting that filled in the rest of the slip. The facility sends copies of the disbursement ledger to [STATE] monthly for review. At that point, they assumed it was not following policy. The District Director of Business Office Services came to the facility unannounced to perform a review on [DATE]. S/he pulled documents to compare signatures during his/her review. The Business Office Director was suspended on [DATE] pending an investigation. The Business Office Director resigned on 5/22/18, which prompted a more in depth review. The administrator stated at first they thought the Business Office Director had not followed policy related to disbursement of resident money, it looked like s/he had signed the residents' names on the disbursement slips. The disbursement sheets are used to keep account of petty cash. During the review, there were several inconsistencies. There were multiple beauty shop charges close together, charges that they could not verify the resident had beauty shop work done. The beautician would get a list and check with the business office to make sure those residents had funds to cover beauty shop services. Then the beautician would provide services and at the end of the day s/he would bring a roster with names and services provided with the cost of the service. At the bottom of the page would be a total, then the Business Office Director would cut the beautician a check from the resident trust account. The Business Office Director would allocate the individual charges to their individual accounts. When you look at the statement, it would have that the money was released to the beautician for beauty shop services. There would be no reason for the resident to get money out to pay the beautician. The disbursement is petty cash for resident spending. There were multiple charges that didn't seem reasonable. Like people getting services twice a week, and also people that typically didn't get their hair done were charged for services. The Business Office Director was changing the names on the beauty shop roster after the services had been rendered. The administrator and District Director of Business Office Services interviewed residents about beauty shop services and if they get money. Some of the residents said they did not get beauty shop services, one resident who stated s/he didn't get money disbursed. They had one resident who acknowledge s/he got money and did not sign for it, they would let staff sign for them. The District Director of Business Office Services kept a list of what s/he found during the audit. The administrator stated they did not think it was misappropriation, they thought the Business Office Director was not following policy in the beginning. The Business Office Director had been at the facility for [AGE] years. The administrator stated in late June, they begin to wonder about some things. There seemed to be multiple things, more than just a few inconsistencies. The District Director of Business Office Services found some white out things on the beauty shop rosters. After the Business Office Director left, they found out several people were paying cash for their stays. They are still reviewing the information and they cannot account for the money. The amounts people were paying was inconsistent. They have not been able to find out if people who paid cash had their accounts credited appropriately. They talked with residents in May and June and residents reported some inconsistencies. The administrator did not think it was intentional and so s/he did not report it. The administrator stated they do not have to have a witness for a signature for a resident cash withdrawal, they do have to have two witnesses for a mark made by the resident. In an interview with the surveyor on [DATE] at approximately 12:30 PM, the District Director of Business Office Services stated s/he assigned to the building in November 2016. S/he provides support and training to business office staff and conducts audits as needed. They audit each building annually per corporate policy. Every month, the business office prepares a copy of all resident trust transactions, withdrawals, deposits, copies of checks. They send that to the corporate office in Houston that does general accounting. General accounting reconciles the resident trust monthly. It was one of the auditors that noticed what they felt to be forged signatures on resident trust withdrawal slips. They sent the concern to the District Director of Business Office Services and asked him/her to review the attachment in mid-May. In looking at the copies, s/he felt they were forged. The District Director of Business Office Services came to the facility and started an investigation by just looking through the resident trust files. After looking at a couple of months of resident trust files, it appeared that the same handwriting was signing the slips as residents. The administrator and District Director of Business Office Services called and suspended the Business Office Director via phone for falsification of records and suspended him/her pending investigation. During that conversation, the District Director of Business Office Services asked the Business Office Director if s/he knew the policies related to residents withdrawing money. S/he also asked if the Business Office Director had ever forged any resident signatures and s/he said no. The Business Office Director stated s/he knew the policy and was able to explain the process as it should be done. The process was that the residents come in and the Business Office Director would fill out a withdrawal slip for how much money they wanted, name, and date would also be on the slip. The resident would sign the withdrawal slip. If a resident cannot sign, then 2 witnesses are required. The administrator would be back up at the facility and give out money when the Business Office Director was not in the building. The person giving out the money would not sign the withdrawal slips. There would be two witnesses who watched the person give out the money if a resident could not sign. The District Director of Business Office Services continued to look through and continued to find signed withdrawal slips that were forged. Initially s/he just looked at 2018, then worked his/her way back from May to January 2018. At that time, the District Director of Business Office Services worked with the Area Human Resources Manager and they were going to terminate the Business Office Director, but s/he resigned before s/he was terminated. The District Director of Business Office Services stated s/he had reviewed all files before talking with Human Resources to start the process for terminating the Business Office Director. In May, the District Director of Business Office Services and the administrator did some resident interviews and asked them about their accounts. The residents did state they got money sometimes, but they had not been asked to sign for the money. One resident stated s/he had never gotten money out of his/her account, but they found a forged signature on a withdrawal slip for the resident. All residents consistently stated they had not been asked to sign for cash they received. After the Business Office Director resigned, they continued to look through accounts. The Vice President of Operations Finance also came to look through the accounts, they came once in June and again in July. They looked at the files January 2018- May 2018. They also looked at the actual RF[CONDITION] (resident funds management system) instead of just looking in the files. The files include the withdrawal slips, any deposits, and copies of checks (checks that were written to the beautician or to replenish the resident petty cash.) They looked at the individual accounts for residents in June. They were looking for excessive transactions or transactions where the resident said they had never taken out money. During the July visit they looked through the receipt book and found where cash payments had been receipted but found no record of the money being credited to the resident account or deposited into the resident trust account. After going through the receipt books at the facility they wrapped up their investigation and that is when the misappropriation was reported to the State Agency and police department. They went back a couple of years during the investigation. The District Director of Business Office Services stated they have refunded residents that they identified as having money misappropriated or cash payments not credited. They looked at current residents for resident trust accounts and they looked at all for cash receipts (the cash receipt book). They reimbursed based on the resident interviews and excessive transactions. One resident was not able to be interviewed, the resident had questionable beauty charges and also cash withdrawals. They could not confirm if the transactions were valid or not, so the resident was not been reimbursed. For the reimbursement of cash withdrawals, they based it on resident interviews on if they received the money and how much. The exact amount for the facility was $13,218 in the cash receipts and $5,032 for resident trust. Those are the amounts that have been refunded back to residents. Resident trust includes a combination of withdrawal slips and beauty charges. They do not have a dollar amount on the cash withdrawal slips that were forged. The Business Office would key the withdrawal slips into the RF[CONDITION] system and then that is transmitted and it removes the amount from each resident account. It transfers from the resident trust account into the resident trust checking account. The Business Office Director would print those checks and then have either the administrator or DON (director of nursing) or MDS (minimum data set) nurse sign the check and then the check would be taken to the bank to be cashed. It should not have been taken to the bank by the Business Office Director, but it was s/he who would go to the bank with the check to be cashed. Anyone other than the Business Office Director and whoever signed the check should go to the bank to get the cash. In an interview with the surveyor on 8/1/18 at approximately 1:35 PM the District Director of Business Office Services stated cash receipt books were reviewed from 2016 until now. The RF[CONDITION] withdrawal slips were reviewed from 2017 until now and all had forged signatures. The District Director of Business Office Services stated they did not add interest back into the reimbursements to the residents whose accounts were affected by the misappropriation. In an interview with the surveyor on 8/1/18 at approximately 3:05 PM, the District Director of Business Office Services provided copies of the checks reimbursements for the resident funds they reimbursed. The District Director of Business Office Services stated they did not have a check for one resident who had been discharged because the check has not cleared the bank yet. The District Director of Business Office Services stated they did not contact the resident about the check being mailed. In an interview with the surveyor on 8/1/18 at approximately 4:00 PM, the administrator and District Director of Business Office Services stated the resident petty cash amount is $200 that is kept on hand. It is replenished as it is disbursed and should be replaced within one business day. They will take the day's withdrawals and enter them into the RF[CONDITION] system to replenish the cash that was given out the prior day. RF[CONDITION] generates a check in that amount. The check is signed by the administrator, DON or MDS nurse and then taken to the bank to be cashed. A staff member other than the check signer and Business Office Director will take the check to the bank to cash. The cash is placed in the locked petty cash box in the business office. The Business Office Director should count the cash when it is received to the box. There were instances where the Business Office Manager went to the bank to cash checks when s/he should not have. The administrator stated s/he has given out petty cash usually a couple of times a week. At the time, the administrator was just filling out a sticky note with the date, resident name, amount, and what the money was for. The resident would sign the sticky note. If the resident could not sign the sticky note, the administrator would get a witness, typically the receptionist or social services staff because they were in the office. The administrator stated s/he would usually only get small amounts for residents. The administrator never had any concerns when s/he looked through the petty cash box. The Business Office Director would take the sticky note and reconcile them to the resident trust account. The sticky notes were not found during the audit. The resident who the administrator usually disbursed money to did not have any withdrawal slips, but the resident told the District Director of Business Office Services that s/he gets money all the time. Review of the facility's Resident Trust Accounts policy revealed the Business Office is responsible for keeping appropriate, accurate records of each resident's personal money in accordance with State and Federal regulations. The Resident Trust Fund is managed by the facility and is kept in an interest bearing checking account. Interest earned on these funds is computed daily and applied monthly. The administrator will ensure that the facility is compliant with Federal and State regulations. Federal regulations require the following: each resident's funds must be fully and separately accounted for in accordance with generally accepted accounting principles and individual State and Federal regulations, all resident cash must be posted into the Resident Trust Account, a resident's funds in excess of $100.00 must be deposited in an interest bearing account, and all resident trust documentation must be kept in the facility or in off-site storage in accordance with the Record Retention policy. The facility must ensure that the following duties are segregated: posting of resident trust transactions and receipt of Trust Fund Deposits/Disbursement of Resident Trust Cash. The facility must use the Resident Fund Management System to manage Resident Trust Fund accounts, individuals that handle Resident Trust Funds are not authorized to be signers on the account. The only valid signers on the Resident Trust Fund account are: administrator, director of nursing, Rehab program manager, or the Resident Care Management Director. Personnel that may NOT be signers are Business Office, Activities, and Social Service personnel. The Resident Trust Accounts policy contained a section related to Resident Trust Petty Cash. Review of the policy revealed a Petty Cash Voucher is completed with a signature obtained for all transactions. The RF[CONDITION] pegboard system must be used to track the Resident Trust disbursements. Only the resident or authorized individual can make a cash withdrawal. Authorized individuals are the financial power of attorney, legal guardian or rep payee (excluding facility). If a physical impairment affects a resident's quality of penmanship, and the resident is able to sign with a mark s/he considers a signature, the mark is legally acceptable regardless of how illegible it is. However, the mark requires 2 witnesses, by someone other than the petty cash custodian, as proof the resident signed the document. Resident petty cash must be reconciled weekly and reimbursed as needed, at minimum once a month. In most cases, Petty Cash checks must be issued with the name of the Administrator or DON as the Payee. The person issuing and/or signing the check may NOT be the payee. The Resident Trust Accounts policy indicated cash received for deposit must be witnessed by two employees, must have a completed receipt, and must have a money order purchased for the deposit amount. Charges for beauty and barber services provided to a resident are paid through the Resident Trust Account. The resident must sign, authorizing the services provided. An invoice is not sufficient documentation. Use the Beauty and Barber Shop Disbursement form to document the transaction. If resident is unable to sign, two witness signatures are required.",2020-09-01
3135,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-08-01,580,F,1,0,RRDO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to inform the resident or resident representative when there was a change. The facility did not notify residents or resident representatives of misappropriation of resident funds. 15 of 15 residents with resident accounts. The findings included: The facility reported an allegation of misappropriation of resident funds to the State Agency on 7/10/18. Review of the Initial 24-hour report dated 7/10/18 revealed general accounting staff questioned signatures on Resident Trust withdrawal slips. District Business Office staff initiated a review to validate signatures and/or disbursements. Review of the Trial Balance form provided revealed there were 15 resident accounts with one of those closed on 7/23/18 related to the resident discharging. Review of facility files revealed three residents were listed as their own responsible party (one of those residents was noted to have a Brief Interview for Mental Status score of 3). All other residents had someone else listed as their responsible parties, with five of those having someone listed as their financial power of attorney. The facility provided documentation that they had interviewed eight residents with Resident Trust Accounts and they all said they received cash and were never asked to sign for it. The District Director of Business Office Services provided documentation that the current summary of findings of misappropriation totaled $18,705.00 including Resident Trust withdrawals and cash receipts. In an interview with the surveyor on [DATE] at approximately 10:40 AM, the facility administrator stated originally the auditors in [STATE] noted some signatures that were questionable and they contacted the District Director of Business Office Services. The auditors in [STATE] first noted the questionable signatures and contacted the District Director of Business Office Services in May 2018. The auditors in [STATE] noticed the handwriting on the signatures was similar to the handwriting that filled in the rest of the slip. The facility sends copies of the disbursement ledger to [STATE] monthly for review. At that point, they assumed it was not following policy. The District Director of Business Office Services came to the facility unannounced to perform a review on [DATE]. S/he pulled documents to compare signatures during his/her review. The Business Office Director was suspended on [DATE] pending an investigation. The Business Office Director resigned on 5/22/18, which prompted a more in depth review. The administrator stated at first they thought the Business Office Director had not followed policy related to disbursement of resident money, it looked like s/he had signed the residents' names on the disbursement slips. The disbursement sheets are used to keep account of petty cash. During the review, there were several inconsistencies. There were multiple beauty shop charges close together, charges that they could not verify the resident had beauty shop work done. The beautician would get a list and check with the business office to make sure those residents had funds to cover beauty shop services. Then the beautician would provide services and at the end of the day s/he would bring a roster with names and services provided with the cost of the service. At the bottom of the page would be a total, then the Business Office Director would cut the beautician a check from the resident trust account. The Business Office Director would allocate the individual charges to their individual accounts. When you look at the statement, it would have that the money was released to the beautician for beauty shop services. There would be no reason for the resident to get money out to pay the beautician. The disbursement is petty cash for resident spending. There were multiple charges that didn't seem reasonable. Like people getting services twice a week, and also people that typically didn't get their hair done were charged for services. The Business Office Director was changing the names on the beauty shop roster after the services had been rendered. The administrator and District Director of Business Office Services interviewed residents about beauty shop services and if they get money. Some of the residents said they did not get beauty shop services, one resident who stated s/he didn't get money disbursed. They had one resident who acknowledge s/he got money and did not sign for it, they would let staff sign for them. The District Director of Business Office Services kept a list of what s/he found during the audit. The administrator stated they did not think it was misappropriation, they thought the Business Office Director was not following policy in the beginning. The Business Office Director had been at the facility for [AGE] years. The administrator stated in late June, they begin to wonder about some things. There seemed to be multiple things, more than just a few inconsistencies. The District Director of Business Office Services found some white out things on the beauty shop rosters. After the Business Office Director left, they found out several people were paying cash for their stays. They are still reviewing the information and they cannot account for the money. The amounts people were paying was inconsistent. They have not been able to find out if people who paid cash had their accounts credited appropriately. They talked with residents in May and June and residents reported some inconsistencies. The administrator did not think it was intentional and so s/he did not report it. The administrator stated they do not have to have a witness for a signature for a resident cash withdrawal, they do have to have two witnesses for a mark made by the resident. In an interview with the surveyor on [DATE] at approximately 12:30 PM, the District Director of Business Office Services stated s/he assigned to the building in November 2016. S/he provides support and training to business office staff and conducts audits as needed. They audit each building annually per corporate policy. Every month, the business office prepares a copy of all resident trust transactions, withdrawals, deposits, copies of checks. They send that to the corporate office in Houston that does general accounting. General accounting reconciles the resident trust monthly. It was one of the auditors that noticed what they felt to be forged signatures on resident trust withdrawal slips. They sent the concern to the District Director of Business Office Services and asked him/her to review the attachment in mid-May. In looking at the copies, s/he felt they were forged. The District Director of Business Office Services came to the facility and started an investigation by just looking through the resident trust files. After looking at a couple of months of resident trust files, it appeared that the same handwriting was signing the slips as residents. The administrator and District Director of Business Office Services called and suspended the Business Office Director via phone for falsification of records and suspended him/her pending investigation. During that conversation, the District Director of Business Office Services asked the Business Office Director if s/he knew the policies related to residents withdrawing money. S/he also asked if the Business Office Director had ever forged any resident signatures and s/he said no. The Business Office Director stated s/he knew the policy and was able to explain the process as it should be done. The process was that the residents come in and the Business Office Director would fill out a withdrawal slip for how much money they wanted, name, and date would also be on the slip. The resident would sign the withdrawal slip. If a resident cannot sign, then 2 witnesses are required. The administrator would be back up at the facility and give out money when the Business Office Director was not in the building. The person giving out the money would not sign the withdrawal slips. There would be two witnesses who watched the person give out the money if a resident could not sign. The District Director of Business Office Services continued to look through and continued to find signed withdrawal slips that were forged. Initially s/he just looked at 2018, then worked his/her way back from May to January 2018. At that time, the District Director of Business Office Services worked with the Area Human Resources Manager and they were going to terminate the Business Office Director, but s/he resigned before s/he was terminated. The District Director of Business Office Services stated s/he had reviewed all files before talking with Human Resources to start the process for terminating the Business Office Director. In May, the District Director of Business Office Services and the administrator did some resident interviews and asked them about their accounts. The residents did state they got money sometimes, but they had not been asked to sign for the money. One resident stated s/he had never gotten money out of his/her account, but they found a forged signature on a withdrawal slip for the resident. All residents consistently stated they had not been asked to sign for cash they received. After the Business Office Director resigned, they continued to look through accounts. The Vice President of Operations Finance also came to look through the accounts, they came once in June and again in July. They looked at the files January 2018- May 2018. They also looked at the actual RF[CONDITION] (resident funds management system) instead of just looking in the files. The files include the withdrawal slips, any deposits, and copies of checks (checks that were written to the beautician or to replenish the resident petty cash.) They looked at the individual accounts for residents in June. They were looking for excessive transactions or transactions where the resident said they had never taken out money. During the July visit they looked through the receipt book and found where cash payments had been receipted but found no record of the money being credited to the resident account or deposited into the resident trust account. After going through the receipt books at the facility they wrapped up their investigation and that is when the misappropriation was reported to the State Agency and police department. They went back a couple of years during the investigation. The District Director of Business Office Services stated they have refunded residents that they identified as having money misappropriated or cash payments not credited. They looked at current residents for resident trust accounts and they looked at all for cash receipts (the cash receipt book). They reimbursed based on the resident interviews and excessive transactions. One resident was not able to be interviewed, the resident had questionable beauty charges and also cash withdrawals. They could not confirm if the transactions were valid or not, so the resident was not been reimbursed. For the reimbursement of cash withdrawals, they based it on resident interviews on if they received the money and how much. The exact amount for the facility was $13,218 in the cash receipts and $5,032 for resident trust. Those are the amounts that have been refunded back to residents. Resident trust includes a combination of withdrawal slips and beauty charges. They do not have a dollar amount on the cash withdrawal slips that were forged. The Business Office would key the withdrawal slips into the RF[CONDITION] system and then that is transmitted and it removes the amount from each resident account. It transfers from the resident trust account into the resident trust checking account. The Business Office Director would print those checks and then have either the administrator or DON (director of nursing) or MDS (minimum data set) nurse sign the check and then the check would be taken to the bank to be cashed. It should not have been taken to the bank by the Business Office Director, but it was s/he who would go to the bank with the check to be cashed. Anyone other than the Business Office Director and whoever signed the check should go to the bank to get the cash. In an interview with the surveyor on 8/1/18 at approximately 10:45 AM. The District Director of Business Office Services stated that other than the resident interviews they did, there was no notification related to the incident. There was no notification of responsible parties. In an interview with the surveyor on 8/1/18 at approximately 11:15 AM, the administrator stated they did not notify responsible parties or residents about the misappropriation of resident funds. The only thing they did was interview residents about their money withdrawals. In an interview with the surveyor on 8/1/18 at approximately 3:05 PM, the District Director of Business Office Services provided copies of the checks reimbursements for the resident funds they reimbursed. The District Director of Business Office Services stated they did not have a check for one resident who had been discharged because the check has not cleared the bank yet. The District Director of Business Office Services stated they did not contact the resident about the check being mailed.",2020-09-01
3136,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-08-01,602,F,1,0,RRDO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure residents remained free from misappropriation of resident property. The facility Business Office Director misappropriated resident funds from resident trust accounts and cash deposits. 9 of 15 resident trust accounts and 2 of 2 residents with cash deposits. The findings included: The facility reported an allegation of misappropriation of resident funds to the State Agency on 7/10/18. Review of the Initial 24-hour report dated 7/10/18 revealed general accounting staff questioned signatures on Resident Trust withdrawal slips. District Business Office staff initiated a review to validate signatures and/or disbursements. The allegation of misappropriation of resident property by the Business Office Director was noted on the form as occurring on 7/10/18 at 11:00 AM. The form was faxed to the State Agency on 7/10/18 at 11:06 AM. Review of the facility's Elder Justice Act Facility Reporting Form revealed the facility notified local law enforcement on 7/10/18 at 12:02 PM. Review of the Trial Balance form provided revealed there were 15 resident accounts with one of those closed on 7/23/18 related to the resident discharging. Review of facility files revealed three residents were listed as their own responsible party (one of those residents was noted to have a Brief Interview for Mental Status score of 3). All other residents had someone else listed as their responsible parties, with five of those having someone listed as their financial power of attorney. The facility provided documentation that they had interviewed eight residents with Resident Trust Accounts and they all said they received cash and were never asked to sign for it. Review of documentation revealed the Business Office Director resigned, effective that day, on 5/22/18. The District Director of Business Office Services provided documentation that the current summary of findings of misappropriation totaled $18,705.00 including Resident Trust withdrawals and cash receipts. In an interview with the surveyor on [DATE] at approximately 10:40 AM, the facility administrator stated originally the auditors in [STATE] noted some signatures that were questionable and they contacted the District Director of Business Office Services. The auditors in [STATE] first noted the questionable signatures and contacted the District Director of Business Office Services in May 2018. The auditors in [STATE] noticed the handwriting on the signatures was similar to the handwriting that filled in the rest of the slip. The facility sends copies of the disbursement ledger to [STATE] monthly for review. At that point, they assumed it was not following policy. The District Director of Business Office Services came to the facility unannounced to perform a review on [DATE]. S/he pulled documents to compare signatures during his/her review. The Business Office Director was suspended on [DATE] pending an investigation. The Business Office Director resigned on 5/22/18, which prompted a more in depth review. The administrator stated at first they thought the Business Office Director had not followed policy related to disbursement of resident money, it looked like s/he had signed the residents' names on the disbursement slips. The disbursement sheets are used to keep account of petty cash. During the review, there were several inconsistencies. There were multiple beauty shop charges close together, charges that they could not verify the resident had beauty shop work done. The beautician would get a list and check with the business office to make sure those residents had funds to cover beauty shop services. Then the beautician would provide services and at the end of the day s/he would bring a roster with names and services provided with the cost of the service. At the bottom of the page would be a total, then the Business Office Director would cut the beautician a check from the resident trust account. The Business Office Director would allocate the individual charges to their individual accounts. When you look at the statement, it would have that the money was released to the beautician for beauty shop services. There would be no reason for the resident to get money out to pay the beautician. The disbursement is petty cash for resident spending. There were multiple charges that didn't seem reasonable. Like people getting services twice a week, and also people that typically didn't get their hair done were charged for services. The Business Office Director was changing the names on the beauty shop roster after the services had been rendered. The administrator and District Director of Business Office Services interviewed residents about beauty shop services and if they get money. Some of the residents said they did not get beauty shop services, one resident who stated s/he didn't get money disbursed. They had one resident who acknowledge s/he got money and did not sign for it, they would let staff sign for them. The District Director of Business Office Services kept a list of what s/he found during the audit. The administrator stated they did not think it was misappropriation, they thought the Business Office Director was not following policy in the beginning. The Business Office Director had been at the facility for [AGE] years. The administrator stated in late June, they begin to wonder about some things. There seemed to be multiple things, more than just a few inconsistencies. The District Director of Business Office Services found some white out things on the beauty shop rosters. After the Business Office Director left, they found out several people were paying cash for their stays. They are still reviewing the information and they cannot account for the money. The amounts people were paying was inconsistent. They have not been able to find out if people who paid cash had their accounts credited appropriately. They talked with residents in May and June and residents reported some inconsistencies. The administrator did not think it was intentional and so s/he did not report it. The administrator stated they do not have to have a witness for a signature for a resident cash withdrawal, they do have to have two witnesses for a mark made by the resident. In an interview with the surveyor on [DATE] at approximately 12:30 PM, the District Director of Business Office Services stated s/he assigned to the building in November 2016. S/he provides support and training to business office staff and conducts audits as needed. They audit each building annually per corporate policy. Every month, the business office prepares a copy of all resident trust transactions, withdrawals, deposits, copies of checks. They send that to the corporate office in Houston that does general accounting. General accounting reconciles the resident trust monthly. It was one of the auditors that noticed what they felt to be forged signatures on resident trust withdrawal slips. They sent the concern to the District Director of Business Office Services and asked him/her to review the attachment in mid-May. In looking at the copies, s/he felt they were forged. The District Director of Business Office Services came to the facility and started an investigation by just looking through the resident trust files. After looking at a couple of months of resident trust files, it appeared that the same handwriting was signing the slips as residents. The administrator and District Director of Business Office Services called and suspended the Business Office Director via phone for falsification of records and suspended him/her pending investigation. During that conversation, the District Director of Business Office Services asked the Business Office Director if s/he knew the policies related to residents withdrawing money. S/he also asked if the Business Office Director had ever forged any resident signatures and s/he said no. The Business Office Director stated s/he knew the policy and was able to explain the process as it should be done. The process was that the residents come in and the Business Office Director would fill out a withdrawal slip for how much money they wanted, name, and date would also be on the slip. The resident would sign the withdrawal slip. If a resident cannot sign, then 2 witnesses are required. The administrator would be back up at the facility and give out money when the Business Office Director was not in the building. The person giving out the money would not sign the withdrawal slips. There would be two witnesses who watched the person give out the money if a resident could not sign. The District Director of Business Office Services continued to look through and continued to find signed withdrawal slips that were forged. Initially s/he just looked at 2018, then worked his/her way back from May to January 2018. At that time, the District Director of Business Office Services worked with the Area Human Resources Manager and they were going to terminate the Business Office Director, but s/he resigned before s/he was terminated. The District Director of Business Office Services stated s/he had reviewed all files before talking with Human Resources to start the process for terminating the Business Office Director. In May, the District Director of Business Office Services and the administrator did some resident interviews and asked them about their accounts. The residents did state they got money sometimes, but they had not been asked to sign for the money. One resident stated s/he had never gotten money out of his/her account, but they found a forged signature on a withdrawal slip for the resident. All residents consistently stated they had not been asked to sign for cash they received. After the Business Office Director resigned, they continued to look through accounts. The Vice President of Operations Finance also came to look through the accounts, they came once in June and again in July. They looked at the files January 2018- May 2018. They also looked at the actual RF[CONDITION] (resident funds management system) instead of just looking in the files. The files include the withdrawal slips, any deposits, and copies of checks (checks that were written to the beautician or to replenish the resident petty cash.) They looked at the individual accounts for residents in June. They were looking for excessive transactions or transactions where the resident said they had never taken out money. During the July visit they looked through the receipt book and found where cash payments had been receipted but found no record of the money being credited to the resident account or deposited into the resident trust account. After going through the receipt books at the facility they wrapped up their investigation and that is when the misappropriation was reported to the State Agency and police department. They went back a couple of years during the investigation. The District Director of Business Office Services stated they have refunded residents that they identified as having money misappropriated or cash payments not credited. They looked at current residents for resident trust accounts and they looked at all for cash receipts (the cash receipt book). They reimbursed based on the resident interviews and excessive transactions. One resident was not able to be interviewed, the resident had questionable beauty charges and also cash withdrawals. They could not confirm if the transactions were valid or not, so the resident was not been reimbursed. For the reimbursement of cash withdrawals, they based it on resident interviews on if they received the money and how much. The exact amount for the facility was $13,218 in the cash receipts and $5,032 for resident trust. Those are the amounts that have been refunded back to residents. Resident trust includes a combination of withdrawal slips and beauty charges. They do not have a dollar amount on the cash withdrawal slips that were forged. The Business Office would key the withdrawal slips into the RF[CONDITION] system and then that is transmitted and it removes the amount from each resident account. It transfers from the resident trust account into the resident trust checking account. The Business Office Director would print those checks and then have either the administrator or DON (director of nursing) or MDS (minimum data set) nurse sign the check and then the check would be taken to the bank to be cashed. It should not have been taken to the bank by the Business Office Director, but it was s/he who would go to the bank with the check to be cashed. Anyone other than the Business Office Director and whoever signed the check should go to the bank to get the cash. In an interview with the surveyor on 8/1/18 at approximately 1:35 PM the District Director of Business Office Services stated cash receipt books were reviewed from 2016 until now. The RF[CONDITION] withdrawal slips were reviewed from 2017 until now and all had forged signatures. The District Director of Business Office Services stated they did not add interest back into the reimbursements to the residents whose accounts were affected by the misappropriation. In an interview with the surveyor on 8/1/18 at approximately 3:05 PM, the District Director of Business Office Services provided copies of the checks reimbursements for the resident funds they reimbursed. The District Director of Business Office Services stated they did not have a check for one resident who had been discharged because the check has not cleared the bank yet. The District Director of Business Office Services stated they did not contact the resident about the check being mailed. In an interview with the surveyor on 8/1/18 at approximately 4:00 PM, the administrator and District Director of Business Office Services stated the resident petty cash amount is $200 that is kept on hand. It is replenished as it is disbursed and should be replaced within one business day. They will take the day's withdrawals and enter them into the RF[CONDITION] system to replenish the cash that was given out the prior day. RF[CONDITION] generates a check in that amount. The check is signed by the administrator, DON or MDS nurse and then taken to the bank to be cashed. A staff member other than the check signer and Business Office Director will take the check to the bank to cash. The cash is placed in the locked petty cash box in the business office. The Business Office Director should count the cash when it is received to the box. There were instances where the Business Office Manager went to the bank to cash checks when s/he should not have. The administrator stated s/he has given out petty cash usually a couple of times a week. At the time, the administrator was just filling out a sticky note with the date, resident name, amount, and what the money was for. The resident would sign the sticky note. If the resident could not sign the sticky note, the administrator would get a witness, typically the receptionist or social services staff because they were in the office. The administrator stated s/he would usually only get small amounts for residents. The administrator never had any concerns when s/he looked through the petty cash box. The Business Office Director would take the sticky note and reconcile them to the resident trust account. The sticky notes were not found during the audit. The resident who the administrator usually disbursed money to did not have any withdrawal slips, but the resident told the District Director of Business Office Services that s/he gets money all the time. Review of the facility's Abuse and Neglect Prohibition policy revealed each resident has the right to be from misappropriation of resident property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The section on Prevention indicated facility supervisors will immediately investigate and correct reported or identified situations in which misappropriation of resident property is at risk for occurring. The section for Investigation indicated the facility will timely conduct an investigation of any alleged misappropriation of resident property in accordance with state law. The section for Reporting and Response indicted the facility will report all allegations and substantiated occurrences of misappropriation of property to the State Survey Agency and law enforcement officials in accordance with Federal and State law through established procedures. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after the management staff becomes aware of the allegation.",2020-09-01
3137,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-08-01,607,F,1,0,RRDO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent misappropriation of resident property. The facility Business Office Director misappropriated resident funds including money from resident trust accounts and cash deposits made to resident trust accounts. The Business Office Director was noted to take resident fund management system generated checks to the bank when s/he should not have been the one to cash the check. 9 of 15 residents with resident trust fund withdrawals and 2 of 2 residents with cash deposits. The findings included: The facility reported an allegation of misappropriation of resident funds to the State Agency on 7/10/18. Review of the Initial 24-hour report dated 7/10/18 revealed general accounting staff questioned signatures on Resident Trust withdrawal slips. District Business Office staff initiated a review to validate signatures and/or disbursements. The allegation of misappropriation of resident property by the Business Office Director was noted on the form as occurring on 7/10/18 at 11:00 AM. The form was faxed to the State Agency on 7/10/18 at 11:06 AM. Review of the facility's Elder Justice Act Facility Reporting Form revealed the facility notified local law enforcement on 7/10/18 at 12:02 PM. Review of the Trial Balance form provided revealed there were 15 resident accounts with one of those closed on 7/23/18 related to the resident discharging. Review of facility files revealed three residents were listed as their own responsible party (one of those residents was noted to have a Brief Interview for Mental Status score of 3). All other residents had someone else listed as their responsible parties, with five of those having someone listed as their financial power of attorney. The facility provided documentation that they had interviewed eight residents with Resident Trust Accounts and they all said they received cash and were never asked to sign for it. Review of documentation revealed the Business Office Director resigned, effective that day, on 5/22/18. The District Director of Business Office Services provided documentation that the current summary of findings of misappropriation totaled $18,705.00 including Resident Trust withdrawals and cash receipts. In an interview with the surveyor on [DATE] at approximately 10:40 AM, the facility administrator stated originally the auditors in [STATE] noted some signatures that were questionable and they contacted the District Director of Business Office Services. The auditors in [STATE] first noted the questionable signatures and contacted the District Director of Business Office Services in May 2018. The auditors in [STATE] noticed the handwriting on the signatures was similar to the handwriting that filled in the rest of the slip. The facility sends copies of the disbursement ledger to [STATE] monthly for review. At that point, they assumed it was not following policy. The District Director of Business Office Services came to the facility unannounced to perform a review on [DATE]. S/he pulled documents to compare signatures during his/her review. The Business Office Director was suspended on [DATE] pending an investigation. The Business Office Director resigned on 5/22/18, which prompted a more in depth review. The administrator stated at first they thought the Business Office Director had not followed policy related to disbursement of resident money, it looked like s/he had signed the residents' names on the disbursement slips. The disbursement sheets are used to keep account of petty cash. During the review, there were several inconsistencies. There were multiple beauty shop charges close together, charges that they could not verify the resident had beauty shop work done. The beautician would get a list and check with the business office to make sure those residents had funds to cover beauty shop services. Then the beautician would provide services and at the end of the day s/he would bring a roster with names and services provided with the cost of the service. At the bottom of the page would be a total, then the Business Office Director would cut the beautician a check from the resident trust account. The Business Office Director would allocate the individual charges to their individual accounts. When you look at the statement, it would have that the money was released to the beautician for beauty shop services. There would be no reason for the resident to get money out to pay the beautician. The disbursement is petty cash for resident spending. There were multiple charges that didn't seem reasonable. Like people getting services twice a week, and also people that typically didn't get their hair done were charged for services. The Business Office Director was changing the names on the beauty shop roster after the services had been rendered. The administrator and District Director of Business Office Services interviewed residents about beauty shop services and if they get money. Some of the residents said they did not get beauty shop services, one resident who stated s/he didn't get money disbursed. They had one resident who acknowledge s/he got money and did not sign for it, they would let staff sign for them. The District Director of Business Office Services kept a list of what s/he found during the audit. The administrator stated they did not think it was misappropriation, they thought the Business Office Director was not following policy in the beginning. The Business Office Director had been at the facility for [AGE] years. The administrator stated in late June, they begin to wonder about some things. There seemed to be multiple things, more than just a few inconsistencies. The District Director of Business Office Services found some white out things on the beauty shop rosters. After the Business Office Director left, they found out several people were paying cash for their stays. They are still reviewing the information and they cannot account for the money. The amounts people were paying was inconsistent. They have not been able to find out if people who paid cash had their accounts credited appropriately. They talked with residents in May and June and residents reported some inconsistencies. The administrator did not think it was intentional and so s/he did not report it. The administrator stated they do not have to have a witness for a signature for a resident cash withdrawal, they do have to have two witnesses for a mark made by the resident. In an interview with the surveyor on [DATE] at approximately 12:30 PM, the District Director of Business Office Services stated s/he assigned to the building in November 2016. S/he provides support and training to business office staff and conducts audits as needed. They audit each building annually per corporate policy. Every month, the business office prepares a copy of all resident trust transactions, withdrawals, deposits, copies of checks. They send that to the corporate office in Houston that does general accounting. General accounting reconciles the resident trust monthly. It was one of the auditors that noticed what they felt to be forged signatures on resident trust withdrawal slips. They sent the concern to the District Director of Business Office Services and asked him/her to review the attachment in mid-May. In looking at the copies, s/he felt they were forged. The District Director of Business Office Services came to the facility and started an investigation by just looking through the resident trust files. After looking at a couple of months of resident trust files, it appeared that the same handwriting was signing the slips as residents. The administrator and District Director of Business Office Services called and suspended the Business Office Director via phone for falsification of records and suspended him/her pending investigation. During that conversation, the District Director of Business Office Services asked the Business Office Director if s/he knew the policies related to residents withdrawing money. S/he also asked if the Business Office Director had ever forged any resident signatures and s/he said no. The Business Office Director stated s/he knew the policy and was able to explain the process as it should be done. The process was that the residents come in and the Business Office Director would fill out a withdrawal slip for how much money they wanted, name, and date would also be on the slip. The resident would sign the withdrawal slip. If a resident cannot sign, then 2 witnesses are required. The administrator would be back up at the facility and give out money when the Business Office Director was not in the building. The person giving out the money would not sign the withdrawal slips. There would be two witnesses who watched the person give out the money if a resident could not sign. The District Director of Business Office Services continued to look through and continued to find signed withdrawal slips that were forged. Initially s/he just looked at 2018, then worked his/her way back from May to January 2018. At that time, the District Director of Business Office Services worked with the Area Human Resources Manager and they were going to terminate the Business Office Director, but s/he resigned before s/he was terminated. The District Director of Business Office Services stated s/he had reviewed all files before talking with Human Resources to start the process for terminating the Business Office Director. In May, the District Director of Business Office Services and the administrator did some resident interviews and asked them about their accounts. The residents did state they got money sometimes, but they had not been asked to sign for the money. One resident stated s/he had never gotten money out of his/her account, but they found a forged signature on a withdrawal slip for the resident. All residents consistently stated they had not been asked to sign for cash they received. After the Business Office Director resigned, they continued to look through accounts. The Vice President of Operations Finance also came to look through the accounts, they came once in June and again in July. They looked at the files January 2018- May 2018. They also looked at the actual RF[CONDITION] (resident funds management system) instead of just looking in the files. The files include the withdrawal slips, any deposits, and copies of checks (checks that were written to the beautician or to replenish the resident petty cash.) They looked at the individual accounts for residents in June. They were looking for excessive transactions or transactions where the resident said they had never taken out money. During the July visit they looked through the receipt book and found where cash payments had been receipted but found no record of the money being credited to the resident account or deposited into the resident trust account. After going through the receipt books at the facility they wrapped up their investigation and that is when the misappropriation was reported to the State Agency and police department. They went back a couple of years during the investigation. The District Director of Business Office Services stated they have refunded residents that they identified as having money misappropriated or cash payments not credited. They looked at current residents for resident trust accounts and they looked at all for cash receipts (the cash receipt book). They reimbursed based on the resident interviews and excessive transactions. One resident was not able to be interviewed, the resident had questionable beauty charges and also cash withdrawals. They could not confirm if the transactions were valid or not, so the resident was not been reimbursed. For the reimbursement of cash withdrawals, they based it on resident interviews on if they received the money and how much. The exact amount for the facility was $13,218 in the cash receipts and $5,032 for resident trust. Those are the amounts that have been refunded back to residents. Resident trust includes a combination of withdrawal slips and beauty charges. They do not have a dollar amount on the cash withdrawal slips that were forged. The Business Office would key the withdrawal slips into the RF[CONDITION] system and then that is transmitted and it removes the amount from each resident account. It transfers from the resident trust account into the resident trust checking account. The Business Office Director would print those checks and then have either the administrator or DON (director of nursing) or MDS (minimum data set) nurse sign the check and then the check would be taken to the bank to be cashed. It should not have been taken to the bank by the Business Office Director, but it was s/he who would go to the bank with the check to be cashed. Anyone other than the Business Office Director and whoever signed the check should go to the bank to get the cash. In an interview with the surveyor on 8/1/18 at approximately 1:35 PM the District Director of Business Office Services stated cash receipt books were reviewed from 2016 until now. The RF[CONDITION] withdrawal slips were reviewed from 2017 until now and all had forged signatures. The District Director of Business Office Services stated they did not add interest back into the reimbursements to the residents whose accounts were affected by the misappropriation. In an interview with the surveyor on 8/1/18 at approximately 3:05 PM, the District Director of Business Office Services provided copies of the checks reimbursements for the resident funds they reimbursed. The District Director of Business Office Services stated they did not have a check for one resident who had been discharged because the check has not cleared the bank yet. The District Director of Business Office Services stated they did not contact the resident about the check being mailed. In an interview with the surveyor on 8/1/18 at approximately 4:00 PM, the administrator and District Director of Business Office Services stated the resident petty cash amount is $200 that is kept on hand. It is replenished as it is disbursed and should be replaced within one business day. They will take the day's withdrawals and enter them into the RF[CONDITION] system to replenish the cash that was given out the prior day. RF[CONDITION] generates a check in that amount. The check is signed by the administrator, DON or MDS nurse and then taken to the bank to be cashed. A staff member other than the check signer and Business Office Director will take the check to the bank to cash. The cash is placed in the locked petty cash box in the business office. The Business Office Director should count the cash when it is received to the box. There were instances where the Business Office Manager went to the bank to cash checks when s/he should not have. The administrator stated s/he has given out petty cash usually a couple of times a week. At the time, the administrator was just filling out a sticky note with the date, resident name, amount, and what the money was for. The resident would sign the sticky note. If the resident could not sign the sticky note, the administrator would get a witness, typically the receptionist or social services staff because they were in the office. The administrator stated s/he would usually only get small amounts for residents. The administrator never had any concerns when s/he looked through the petty cash box. The Business Office Director would take the sticky note and reconcile them to the resident trust account. The sticky notes were not found during the audit. The resident who the administrator usually disbursed money to did not have any withdrawal slips, but the resident told the District Director of Business Office Services that s/he gets money all the time. Review of the facility's Abuse and Neglect Prohibition policy revealed each resident has the right to be from misappropriation of resident property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The section on Prevention indicated facility supervisors will immediately investigate and correct reported or identified situations in which misappropriation of resident property is at risk for occurring. The section for Investigation indicated the facility will timely conduct an investigation of any alleged misappropriation of resident property in accordance with state law. The section for Reporting and Response indicted the facility will report all allegations and substantiated occurrences of misappropriation of property to the State Survey Agency and law enforcement officials in accordance with Federal and State law through established procedures. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after the management staff becomes aware of the allegation.",2020-09-01
3138,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-08-01,608,D,1,0,RRDO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to implement written policies and procedures that ensure reporting of crimes occurring in federally -funded long-term care facilities. The facility identified concerns with resident funds by the Business Office Director on May 17, 2018. The facility did not report those concerns to the State Agency or local law enforcement until July 10, 2018. One of one employees with allegation of misappropriation of resident funds. The findings included: The facility reported an allegation of misappropriation of resident funds to the State Agency on 7/10/18. Review of the Initial 24-hour report dated 7/10/18 revealed general accounting staff questioned signatures on Resident Trust withdrawal slips. District Business Office staff initiated a review to validate signatures and/or disbursements. The allegation of misappropriation of resident property by the Business Office Director was noted on the form as occurring on 7/10/18 at 11:00 AM. The form was faxed to the State Agency on 7/10/18 at 11:06 AM. Review of the facility's Elder Justice Act Facility Reporting Form revealed the facility notified local law enforcement on 7/10/18 at 12:02 PM. Review of documentation revealed the Business Office Director resigned, effective that day, on 5/22/18. The District Director of Business Office Services provided documentation that the current summary of findings of misappropriation totaled $18,705.00 including Resident Trust withdrawals and cash receipts. In an interview with the surveyor on [DATE] at approximately 10:40 AM, the facility administrator stated originally the auditors in [STATE] noted some signatures that were questionable and they contacted the District Director of Business Office Services. The auditors in [STATE] first noted the questionable signatures and contacted the District Director of Business Office Services in May 2018. The auditors in [STATE] noticed the handwriting on the signatures was similar to the handwriting that filled in the rest of the slip. The facility sends copies of the disbursement ledger to [STATE] monthly for review. At that point, they assumed it was not following policy. The District Director of Business Office Services came to the facility unannounced to perform a review on [DATE]. S/he pulled documents to compare signatures during his/her review. The Business Office Director was suspended on [DATE] pending an investigation. The Business Office Director resigned on 5/22/18, which prompted a more in depth review. The administrator stated at first they thought the Business Office Director had not followed policy related to disbursement of resident money, it looked like s/he had signed the residents' names on the disbursement slips. The disbursement sheets are used to keep account of petty cash. During the review, there were several inconsistencies. There were multiple beauty shop charges close together, charges that they could not verify the resident had beauty shop work done. The beautician would get a list and check with the business office to make sure those residents had funds to cover beauty shop services. Then the beautician would provide services and at the end of the day s/he would bring a roster with names and services provided with the cost of the service. At the bottom of the page would be a total, then the Business Office Director would cut the beautician a check from the resident trust account. The Business Office Director would allocate the individual charges to their individual accounts. When you look at the statement, it would have that the money was released to the beautician for beauty shop services. There would be no reason for the resident to get money out to pay the beautician. The disbursement is petty cash for resident spending. There were multiple charges that didn't seem reasonable. Like people getting services twice a week, and also people that typically didn't get their hair done were charged for services. The Business Office Director was changing the names on the beauty shop roster after the services had been rendered. The administrator and District Director of Business Office Services interviewed residents about beauty shop services and if they get money. Some of the residents said they did not get beauty shop services, one resident who stated s/he didn't get money disbursed. They had one resident who acknowledge s/he got money and did not sign for it, they would let staff sign for them. The District Director of Business Office Services kept a list of what s/he found during the audit. The administrator stated they did not think it was misappropriation, they thought the Business Office Director was not following policy in the beginning. The Business Office Director had been at the facility for [AGE] years. The administrator stated in late June, they begin to wonder about some things. There seemed to be multiple things, more than just a few inconsistencies. The District Director of Business Office Services found some white out things on the beauty shop rosters. After the Business Office Director left, they found out several people were paying cash for their stays. They are still reviewing the information and they cannot account for the money. The amounts people were paying was inconsistent. They have not been able to find out if people who paid cash had their accounts credited appropriately. They talked with residents in May and June and residents reported some inconsistencies. The administrator did not think it was intentional and so s/he did not report it. The administrator stated they do not have to have a witness for a signature for a resident cash withdrawal, they do have to have two witnesses for a mark made by the resident. In an interview with the surveyor on [DATE] at approximately 12:30 PM, the District Director of Business Office Services stated s/he assigned to the building in November 2016. S/he provides support and training to business office staff and conducts audits as needed. They audit each building annually per corporate policy. Every month, the business office prepares a copy of all resident trust transactions, withdrawals, deposits, copies of checks. They send that to the corporate office in Houston that does general accounting. General accounting reconciles the resident trust monthly. It was one of the auditors that noticed what they felt to be forged signatures on resident trust withdrawal slips. They sent the concern to the District Director of Business Office Services and asked him/her to review the attachment in mid-May. In looking at the copies, s/he felt they were forged. The District Director of Business Office Services came to the facility and started an investigation by just looking through the resident trust files. After looking at a couple of months of resident trust files, it appeared that the same handwriting was signing the slips as residents. The administrator and District Director of Business Office Services called and suspended the Business Office Director via phone for falsification of records and suspended him/her pending investigation. During that conversation, the District Director of Business Office Services asked the Business Office Director if s/he knew the policies related to residents withdrawing money. S/he also asked if the Business Office Director had ever forged any resident signatures and s/he said no. The Business Office Director stated s/he knew the policy and was able to explain the process as it should be done. The process was that the residents come in and the Business Office Director would fill out a withdrawal slip for how much money they wanted, name, and date would also be on the slip. The resident would sign the withdrawal slip. If a resident cannot sign, then 2 witnesses are required. The administrator would be back up at the facility and give out money when the Business Office Director was not in the building. The person giving out the money would not sign the withdrawal slips. There would be two witnesses who watched the person give out the money if a resident could not sign. The District Director of Business Office Services continued to look through and continued to find signed withdrawal slips that were forged. Initially s/he just looked at 2018, then worked his/her way back from May to January 2018. At that time, the District Director of Business Office Services worked with the Area Human Resources Manager and they were going to terminate the Business Office Director, but s/he resigned before s/he was terminated. The District Director of Business Office Services stated s/he had reviewed all files before talking with Human Resources to start the process for terminating the Business Office Director. In May, the District Director of Business Office Services and the administrator did some resident interviews and asked them about their accounts. The residents did state they got money sometimes, but they had not been asked to sign for the money. One resident stated s/he had never gotten money out of his/her account, but they found a forged signature on a withdrawal slip for the resident. All residents consistently stated they had not been asked to sign for cash they received. After the Business Office Director resigned, they continued to look through accounts. The Vice President of Operations Finance also came to look through the accounts, they came once in June and again in July. They looked at the files January 2018- May 2018. They also looked at the actual RF[CONDITION] (resident funds management system) instead of just looking in the files. The files include the withdrawal slips, any deposits, and copies of checks (checks that were written to the beautician or to replenish the resident petty cash.) They looked at the individual accounts for residents in June. They were looking for excessive transactions or transactions where the resident said they had never taken out money. During the July visit they looked through the receipt book and found where cash payments had been receipted but found no record of the money being credited to the resident account or deposited into the resident trust account. After going through the receipt books at the facility they wrapped up their investigation and that is when the misappropriation was reported to the State Agency and police department. They went back a couple of years during the investigation. The District Director of Business Office Services stated they have refunded residents that they identified as having money misappropriated or cash payments not credited. They looked at current residents for resident trust accounts and they looked at all for cash receipts (the cash receipt book). They reimbursed based on the resident interviews and excessive transactions. One resident was not able to be interviewed, the resident had questionable beauty charges and also cash withdrawals. They could not confirm if the transactions were valid or not, so the resident was not been reimbursed. For the reimbursement of cash withdrawals, they based it on resident interviews on if they received the money and how much. The exact amount for the facility was $13,218 in the cash receipts and $5,032 for resident trust. Those are the amounts that have been refunded back to residents. Resident trust includes a combination of withdrawal slips and beauty charges. They do not have a dollar amount on the cash withdrawal slips that were forged. The Business Office would key the withdrawal slips into the RF[CONDITION] system and then that is transmitted and it removes the amount from each resident account. It transfers from the resident trust account into the resident trust checking account. The Business Office Director would print those checks and then have either the administrator or DON (director of nursing) or MDS (minimum data set) nurse sign the check and then the check would be taken to the bank to be cashed. It should not have been taken to the bank by the Business Office Director, but it was s/he who would go to the bank with the check to be cashed. Anyone other than the Business Office Director and whoever signed the check should go to the bank to get the cash. In an interview with the surveyor on 8/1/18 at approximately 1:35 PM the District Director of Business Office Services stated cash receipt books were reviewed from 2016 until now. The RF[CONDITION] withdrawal slips were reviewed from 2017 until now and all had forged signatures. Review of the facility's Abuse and Neglect Prohibition policy revealed each resident has the right to be from misappropriation of resident property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The section on Prevention indicated facility supervisors will immediately investigate and correct reported or identified situations in which misappropriation of resident property is at risk for occurring. The section for Investigation indicated the facility will timely conduct an investigation of any alleged misappropriation of resident property in accordance with state law. The section for Reporting and Response indicted the facility will report all allegations and substantiated occurrences of misappropriation of property to the State Survey Agency and law enforcement officials in accordance with Federal and State law through established procedures. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after the management staff becomes aware of the allegation.",2020-09-01
3139,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-08-01,609,D,1,0,RRDO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving misappropriation of resident property were reported to the State Agency not later than 24 hours after the allegation is made. The facility identified concerns related to resident funds by the Business Office Director on [DATE]. The facility did not report the allegations of misappropriation of resident funds to the State Agency until 7/10/18. One of one employees with allegation of misappropriation. The findings included: The facility reported an allegation of misappropriation of resident funds to the State Agency on 7/10/18. Review of the Initial 24-hour report dated 7/10/18 revealed general accounting staff questioned signatures on Resident Trust withdrawal slips. District Business Office staff initiated a review to validate signatures and/or disbursements. The allegation of misappropriation of resident property by the Business Office Director was noted on the form as occurring on 7/10/18 at 11:00 AM. The form was faxed to the State Agency on 7/10/18 at 11:06 AM. Review of documentation revealed the Business Office Director resigned, effective that day, on 5/22/18. The District Director of Business Office Services provided documentation that the current summary of findings of misappropriation totaled $18,705.00 including Resident Trust withdrawals and cash receipts. In an interview with the surveyor on [DATE] at approximately 10:40 AM, the facility administrator stated originally the auditors in [STATE] noted some signatures that were questionable and they contacted the District Director of Business Office Services. The auditors in [STATE] first noted the questionable signatures and contacted the District Director of Business Office Services in May 2018. The auditors in [STATE] noticed the handwriting on the signatures was similar to the handwriting that filled in the rest of the slip. The facility sends copies of the disbursement ledger to [STATE] monthly for review. At that point, they assumed it was not following policy. The District Director of Business Office Services came to the facility unannounced to perform a review on [DATE]. S/he pulled documents to compare signatures during his/her review. The Business Office Director was suspended on [DATE] pending an investigation. The Business Office Director resigned on 5/22/18, which prompted a more in depth review. The administrator stated at first they thought the Business Office Director had not followed policy related to disbursement of resident money, it looked like s/he had signed the residents' names on the disbursement slips. The disbursement sheets are used to keep account of petty cash. During the review, there were several inconsistencies. There were multiple beauty shop charges close together, charges that they could not verify the resident had beauty shop work done. The beautician would get a list and check with the business office to make sure those residents had funds to cover beauty shop services. Then the beautician would provide services and at the end of the day s/he would bring a roster with names and services provided with the cost of the service. At the bottom of the page would be a total, then the Business Office Director would cut the beautician a check from the resident trust account. The Business Office Director would allocate the individual charges to their individual accounts. When you look at the statement, it would have that the money was released to the beautician for beauty shop services. There would be no reason for the resident to get money out to pay the beautician. The disbursement is petty cash for resident spending. There were multiple charges that didn't seem reasonable. Like people getting services twice a week, and also people that typically didn't get their hair done were charged for services. The Business Office Director was changing the names on the beauty shop roster after the services had been rendered. The administrator and District Director of Business Office Services interviewed residents about beauty shop services and if they get money. Some of the residents said they did not get beauty shop services, one resident who stated s/he didn't get money disbursed. They had one resident who acknowledge s/he got money and did not sign for it, they would let staff sign for them. The District Director of Business Office Services kept a list of what s/he found during the audit. The administrator stated they did not think it was misappropriation, they thought the Business Office Director was not following policy in the beginning. The Business Office Director had been at the facility for [AGE] years. The administrator stated in late June, they begin to wonder about some things. There seemed to be multiple things, more than just a few inconsistencies. The District Director of Business Office Services found some white out things on the beauty shop rosters. After the Business Office Director left, they found out several people were paying cash for their stays. They are still reviewing the information and they cannot account for the money. The amounts people were paying was inconsistent. They have not been able to find out if people who paid cash had their accounts credited appropriately. They talked with residents in May and June and residents reported some inconsistencies. The administrator did not think it was intentional and so s/he did not report it. The administrator stated they do not have to have a witness for a signature for a resident cash withdrawal, they do have to have two witnesses for a mark made by the resident. In an interview with the surveyor on [DATE] at approximately 12:30 PM, the District Director of Business Office Services stated s/he assigned to the building in November 2016. S/he provides support and training to business office staff and conducts audits as needed. They audit each building annually per corporate policy. Every month, the business office prepares a copy of all resident trust transactions, withdrawals, deposits, copies of checks. They send that to the corporate office in Houston that does general accounting. General accounting reconciles the resident trust monthly. It was one of the auditors that noticed what they felt to be forged signatures on resident trust withdrawal slips. They sent the concern to the District Director of Business Office Services and asked him/her to review the attachment in mid-May. In looking at the copies, s/he felt they were forged. The District Director of Business Office Services came to the facility and started an investigation by just looking through the resident trust files. After looking at a couple of months of resident trust files, it appeared that the same handwriting was signing the slips as residents. The administrator and District Director of Business Office Services called and suspended the Business Office Director via phone for falsification of records and suspended him/her pending investigation. During that conversation, the District Director of Business Office Services asked the Business Office Director if s/he knew the policies related to residents withdrawing money. S/he also asked if the Business Office Director had ever forged any resident signatures and s/he said no. The Business Office Director stated s/he knew the policy and was able to explain the process as it should be done. The process was that the residents come in and the Business Office Director would fill out a withdrawal slip for how much money they wanted, name, and date would also be on the slip. The resident would sign the withdrawal slip. If a resident cannot sign, then 2 witnesses are required. The administrator would be back up at the facility and give out money when the Business Office Director was not in the building. The person giving out the money would not sign the withdrawal slips. There would be two witnesses who watched the person give out the money if a resident could not sign. The District Director of Business Office Services continued to look through and continued to find signed withdrawal slips that were forged. Initially s/he just looked at 2018, then worked his/her way back from May to January 2018. At that time, the District Director of Business Office Services worked with the Area Human Resources Manager and they were going to terminate the Business Office Director, but s/he resigned before s/he was terminated. The District Director of Business Office Services stated s/he had reviewed all files before talking with Human Resources to start the process for terminating the Business Office Director. In May, the District Director of Business Office Services and the administrator did some resident interviews and asked them about their accounts. The residents did state they got money sometimes, but they had not been asked to sign for the money. One resident stated s/he had never gotten money out of his/her account, but they found a forged signature on a withdrawal slip for the resident. All residents consistently stated they had not been asked to sign for cash they received. After the Business Office Director resigned, they continued to look through accounts. The Vice President of Operations Finance also came to look through the accounts, they came once in June and again in July. They looked at the files January 2018- May 2018. They also looked at the actual RF[CONDITION] (resident funds management system) instead of just looking in the files. The files include the withdrawal slips, any deposits, and copies of checks (checks that were written to the beautician or to replenish the resident petty cash.) They looked at the individual accounts for residents in June. They were looking for excessive transactions or transactions where the resident said they had never taken out money. During the July visit they looked through the receipt book and found where cash payments had been receipted but found no record of the money being credited to the resident account or deposited into the resident trust account. After going through the receipt books at the facility they wrapped up their investigation and that is when the misappropriation was reported to the State Agency and police department. They went back a couple of years during the investigation. The District Director of Business Office Services stated they have refunded residents that they identified as having money misappropriated or cash payments not credited. They looked at current residents for resident trust accounts and they looked at all for cash receipts (the cash receipt book). They reimbursed based on the resident interviews and excessive transactions. One resident was not able to be interviewed, the resident had questionable beauty charges and also cash withdrawals. They could not confirm if the transactions were valid or not, so the resident was not been reimbursed. For the reimbursement of cash withdrawals, they based it on resident interviews on if they received the money and how much. The exact amount for the facility was $13,218 in the cash receipts and $5,032 for resident trust. Those are the amounts that have been refunded back to residents. Resident trust includes a combination of withdrawal slips and beauty charges. They do not have a dollar amount on the cash withdrawal slips that were forged. The Business Office would key the withdrawal slips into the RF[CONDITION] system and then that is transmitted and it removes the amount from each resident account. It transfers from the resident trust account into the resident trust checking account. The Business Office Director would print those checks and then have either the administrator or DON (director of nursing) or MDS (minimum data set) nurse sign the check and then the check would be taken to the bank to be cashed. It should not have been taken to the bank by the Business Office Director, but it was s/he who would go to the bank with the check to be cashed. Anyone other than the Business Office Director and whoever signed the check should go to the bank to get the cash. Review of the facility's Abuse and Neglect Prohibition policy revealed each resident has the right to be from misappropriation of resident property. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The section on Prevention indicated facility supervisors will immediately investigate and correct reported or identified situations in which misappropriation of resident property is at risk for occurring. The section for Investigation indicated the facility will timely conduct an investigation of any alleged misappropriation of resident property in accordance with state law. The section for Reporting and Response indicted the facility will report all allegations and substantiated occurrences of misappropriation of property to the State Survey Agency and law enforcement officials in accordance with Federal and State law through established procedures. If the events that cause the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after the management staff becomes aware of the allegation.",2020-09-01
3140,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-08-01,729,D,1,0,RRDO11,"> Based on review of faciliy files and interview, the facility failed to receive registry verification before allowing an individual to serve as a nurse aide. The CNA (certified nurse aide) registry was not verified for one CNA prior to hire. One of eleven CNAs reviewed for registry checks. The findings included: Review of Certified Nurse Aide personnel files revealed one nurse aide whose registry was not checked prior to hire. In an interview with the surveyor on 8/1/18 at approximately 2:38 PM, the Director of Nursing stated they could not find any documentation that the CNA registry was checked prior to hire for the CNA.",2020-09-01
3141,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-08-01,835,F,1,0,RRDO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, 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. The facility identified concerns with the Business Office Director and handling of resident cash funds. The concern was not reported timely to the State Agency or local law enforcement. The Business Office Director was handling resident fund management system checks inappropriately by taking them to the bank to be cashed. Residents and/or resident representatives were not notified of the misappropriation of resident funds by the Business Office Director. The facility did not reimburse all residents whose funds were affected by the misappropriation. The funds that were reimbursed by the facility did not include interest that would have accrued. One of one facility administrators. The findings included: The facility reported an allegation of misappropriation of resident funds to the State Agency on 7/10/18. Review of the Initial 24-hour report dated 7/10/18 revealed general accounting staff questioned signatures on Resident Trust withdrawal slips. District Business Office staff initiated a review to validate signatures and/or disbursements. The allegation of misappropriation of resident property by the Business Office Director was noted on the form as occurring on 7/10/18 at 11:00 AM. The form was faxed to the State Agency on 7/10/18 at 11:06 AM. Review of the facility's Elder Justice Act Facility Reporting Form revealed the facility notified local law enforcement on 7/10/18 at 12:02 PM. Review of the Trial Balance form provided revealed there were 15 resident accounts with one of those closed on 7/23/18 related to the resident discharging. Review of facility files revealed three residents were listed as their own responsible party (one of those residents was noted to have a Brief Interview for Mental Status score of 3). All other residents had someone else listed as their responsible parties, with five of those having someone listed as their financial power of attorney. The facility provided documentation that they had interviewed eight residents with Resident Trust Accounts and they all said they received cash and were never asked to sign for it. Review of documentation revealed the Business Office Director resigned, effective that day, on 5/22/18. The District Director of Business Office Services provided documentation that the current summary of findings of misappropriation totaled $18,705.00 including Resident Trust withdrawals and cash receipts. In an interview with the surveyor on [DATE] at approximately 10:40 AM, the facility administrator stated originally the auditors in [STATE] noted some signatures that were questionable and they contacted the District Director of Business Office Services. The auditors in [STATE] first noted the questionable signatures and contacted the District Director of Business Office Services in May 2018. The auditors in [STATE] noticed the handwriting on the signatures was similar to the handwriting that filled in the rest of the slip. The facility sends copies of the disbursement ledger to [STATE] monthly for review. At that point, they assumed it was not following policy. The District Director of Business Office Services came to the facility unannounced to perform a review on [DATE]. S/he pulled documents to compare signatures during his/her review. The Business Office Director was suspended on [DATE] pending an investigation. The Business Office Director resigned on 5/22/18, which prompted a more in depth review. The administrator stated at first they thought the Business Office Director had not followed policy related to disbursement of resident money, it looked like s/he had signed the residents' names on the disbursement slips. The disbursement sheets are used to keep account of petty cash. During the review, there were several inconsistencies. There were multiple beauty shop charges close together, charges that they could not verify the resident had beauty shop work done. The beautician would get a list and check with the business office to make sure those residents had funds to cover beauty shop services. Then the beautician would provide services and at the end of the day s/he would bring a roster with names and services provided with the cost of the service. At the bottom of the page would be a total, then the Business Office Director would cut the beautician a check from the resident trust account. The Business Office Director would allocate the individual charges to their individual accounts. When you look at the statement, it would have that the money was released to the beautician for beauty shop services. There would be no reason for the resident to get money out to pay the beautician. The disbursement is petty cash for resident spending. There were multiple charges that didn't seem reasonable. Like people getting services twice a week, and also people that typically didn't get their hair done were charged for services. The Business Office Director was changing the names on the beauty shop roster after the services had been rendered. The administrator and District Director of Business Office Services interviewed residents about beauty shop services and if they get money. Some of the residents said they did not get beauty shop services, one resident who stated s/he didn't get money disbursed. They had one resident who acknowledge s/he got money and did not sign for it, they would let staff sign for them. The District Director of Business Office Services kept a list of what s/he found during the audit. The administrator stated they did not think it was misappropriation, they thought the Business Office Director was not following policy in the beginning. The Business Office Director had been at the facility for [AGE] years. The administrator stated in late June, they begin to wonder about some things. There seemed to be multiple things, more than just a few inconsistencies. The District Director of Business Office Services found some white out things on the beauty shop rosters. After the Business Office Director left, they found out several people were paying cash for their stays. They are still reviewing the information and they cannot account for the money. The amounts people were paying was inconsistent. They have not been able to find out if people who paid cash had their accounts credited appropriately. They talked with residents in May and June and residents reported some inconsistencies. The administrator did not think it was intentional and so s/he did not report it. The administrator stated they do not have to have a witness for a signature for a resident cash withdrawal, they do have to have two witnesses for a mark made by the resident. In an interview with the surveyor on [DATE] at approximately 12:30 PM, the District Director of Business Office Services stated s/he assigned to the building in November 2016. S/he provides support and training to business office staff and conducts audits as needed. They audit each building annually per corporate policy. Every month, the business office prepares a copy of all resident trust transactions, withdrawals, deposits, copies of checks. They send that to the corporate office in Houston that does general accounting. General accounting reconciles the resident trust monthly. It was one of the auditors that noticed what they felt to be forged signatures on resident trust withdrawal slips. They sent the concern to the District Director of Business Office Services and asked him/her to review the attachment in mid-May. In looking at the copies, s/he felt they were forged. The District Director of Business Office Services came to the facility and started an investigation by just looking through the resident trust files. After looking at a couple of months of resident trust files, it appeared that the same handwriting was signing the slips as residents. The administrator and District Director of Business Office Services called and suspended the Business Office Director via phone for falsification of records and suspended him/her pending investigation. During that conversation, the District Director of Business Office Services asked the Business Office Director if s/he knew the policies related to residents withdrawing money. S/he also asked if the Business Office Director had ever forged any resident signatures and s/he said no. The Business Office Director stated s/he knew the policy and was able to explain the process as it should be done. The process was that the residents come in and the Business Office Director would fill out a withdrawal slip for how much money they wanted, name, and date would also be on the slip. The resident would sign the withdrawal slip. If a resident cannot sign, then 2 witnesses are required. The administrator would be back up at the facility and give out money when the Business Office Director was not in the building. The person giving out the money would not sign the withdrawal slips. There would be two witnesses who watched the person give out the money if a resident could not sign. The District Director of Business Office Services continued to look through and continued to find signed withdrawal slips that were forged. Initially s/he just looked at 2018, then worked his/her way back from May to January 2018. At that time, the District Director of Business Office Services worked with the Area Human Resources Manager and they were going to terminate the Business Office Director, but s/he resigned before s/he was terminated. The District Director of Business Office Services stated s/he had reviewed all files before talking with Human Resources to start the process for terminating the Business Office Director. In May, the District Director of Business Office Services and the administrator did some resident interviews and asked them about their accounts. The residents did state they got money sometimes, but they had not been asked to sign for the money. One resident stated s/he had never gotten money out of his/her account, but they found a forged signature on a withdrawal slip for the resident. All residents consistently stated they had not been asked to sign for cash they received. After the Business Office Director resigned, they continued to look through accounts. The Vice President of Operations Finance also came to look through the accounts, they came once in June and again in July. They looked at the files January 2018- May 2018. They also looked at the actual RF[CONDITION] (resident funds management system) instead of just looking in the files. The files include the withdrawal slips, any deposits, and copies of checks (checks that were written to the beautician or to replenish the resident petty cash.) They looked at the individual accounts for residents in June. They were looking for excessive transactions or transactions where the resident said they had never taken out money. During the July visit they looked through the receipt book and found where cash payments had been receipted but found no record of the money being credited to the resident account or deposited into the resident trust account. After going through the receipt books at the facility they wrapped up their investigation and that is when the misappropriation was reported to the State Agency and police department. They went back a couple of years during the investigation. The District Director of Business Office Services stated they have refunded residents that they identified as having money misappropriated or cash payments not credited. They looked at current residents for resident trust accounts and they looked at all for cash receipts (the cash receipt book). They reimbursed based on the resident interviews and excessive transactions. One resident was not able to be interviewed, the resident had questionable beauty charges and also cash withdrawals. They could not confirm if the transactions were valid or not, so the resident was not been reimbursed. For the reimbursement of cash withdrawals, they based it on resident interviews on if they received the money and how much. The exact amount for the facility was $13,218 in the cash receipts and $5,032 for resident trust. Those are the amounts that have been refunded back to residents. Resident trust includes a combination of withdrawal slips and beauty charges. They do not have a dollar amount on the cash withdrawal slips that were forged. The Business Office would key the withdrawal slips into the RF[CONDITION] system and then that is transmitted and it removes the amount from each resident account. It transfers from the resident trust account into the resident trust checking account. The Business Office Director would print those checks and then have either the administrator or DON (director of nursing) or MDS (minimum data set) nurse sign the check and then the check would be taken to the bank to be cashed. It should not have been taken to the bank by the Business Office Director, but it was s/he who would go to the bank with the check to be cashed. Anyone other than the Business Office Director and whoever signed the check should go to the bank to get the cash. In an interview with the surveyor on 8/1/18 at approximately 1:35 PM the District Director of Business Office Services stated cash receipt books were reviewed from 2016 until now. The RF[CONDITION] withdrawal slips were reviewed from 2017 until now and all had forged signatures. The District Director of Business Office Services stated they did not add interest back into the reimbursements to the residents whose accounts were affected by the misappropriation. In an interview with the surveyor on 8/1/18 at approximately 3:05 PM, the District Director of Business Office Services provided copies of the checks reimbursements for the resident funds they reimbursed. The District Director of Business Office Services stated they did not have a check for one resident who had been discharged because the check has not cleared the bank yet. The District Director of Business Office Services stated they did not contact the resident about the check being mailed. In an interview with the surveyor on 8/1/18 at approximately 4:00 PM, the administrator and District Director of Business Office Services stated the resident petty cash amount is $200 that is kept on hand. It is replenished as it is disbursed and should be replaced within one business day. They will take the day's withdrawals and enter them into the RF[CONDITION] system to replenish the cash that was given out the prior day. RF[CONDITION] generates a check in that amount. The check is signed by the administrator, DON or MDS nurse and then taken to the bank to be cashed. A staff member other than the check signer and Business Office Director will take the check to the bank to cash. The cash is placed in the locked petty cash box in the business office. The Business Office Director should count the cash when it is received to the box. There were instances where the Business Office Manager went to the bank to cash checks when s/he should not have. The administrator stated s/he has given out petty cash usually a couple of times a week. At the time, the administrator was just filling out a sticky note with the date, resident name, amount, and what the money was for. The resident would sign the sticky note. If the resident could not sign the sticky note, the administrator would get a witness, typically the receptionist or social services staff because they were in the office. The administrator stated s/he would usually only get small amounts for residents. The administrator never had any concerns when s/he looked through the petty cash box. The Business Office Director would take the sticky note and reconcile them to the resident trust account. The sticky notes were not found during the audit. The resident who the administrator usually disbursed money to did not have any withdrawal slips, but the resident told the District Director of Business Office Services that s/he gets money all the time.",2020-09-01
3142,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2018-08-01,836,D,1,0,RRDO11,"> Based on review of facility files and interview, the facility failed to be in compliance with Federal, State, and Local Laws and Professional Standards. The facility did not have background checks completed on all employees prior to hire. The facility failed to check all Registered Nurse licenses prior to hire. Two of eighteen personnel files revealed for background checks. Two of three RN files reviewed for license check. The findings included: Review of personnel files revealed one CNA and one RN whose background checks were not done prior to hire. Review of personnel files revealed two RNs whose license was not checked prior to hire. In an interview with the surveyor on 8/1/18 at approximately 2:38 PM, the Director of Nursing (DON) confirmed the background checks and license checks were not in the employee files. The DON stated that they could not locate proof that the checks were done. The DON stated that s/he had left the facility and was rehired 11 months later. There was no license check in his/her employee file and one could not be located that was done prior to his/her rehire.",2020-09-01
4683,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,174,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of the facility's policy entitled Residents' Personal Property, the facility failed to investigate missing personal items for Resident #4, 1 of 2 sampled residents reviewed for Personal Property. The resident's dentures went missing and the facility did not follow up on the missing dentures. The findings included: During an interview with Resident #4 on 6/13/2016 at 2:14 PM, Resident #4 stated that shortly after being admitted to the facility her dentures went missing. The resident stated that she/he had removed and cleaned her/his dentures and placed them in the denture cup. The next time she/he went to use her/his dentures, the dentures and denture cup were missing from her/his room. The resident stated that she/he reported the missing dentures to a staff member. The resident also stated that the facility did not follow up on the missing dentures with her/him or let her/him know if they were looking for the dentures. During an interview with the Social Services Director (SSD) on 6/14/2016 at 4:43 PM, the SSD stated that she/he was unaware that the residents dentures were missing prior to today. The SSD stated she/he had talked with the resident and resident's family member on 6/14/2016 to confirm that the dentures had gone missing. The SSD also stated that the resident's family member told her/him that she/he was aware the dentures were missing during a visit to the facility in April, but didn't think to notify staff. The SSD stated that the facility would replace the resident's dentures as soon as possible. The SSD also stated that during her/his investigation shehe discovered that a CNA (Certified Nursing Assistant) was told by the resident that her/his dentures were missing. During an interview with the SSD on 6/15/2016 at 8:25 AM, the SSD confirmed that a CNA was aware that the resident's dentures had gone missing, but this information did not get back to her/him and was not acted on until 6/14/2016. Review of the facility's policy entitled Residents' Personal Property on 6/15/2016 at 8:35 AM, revealed that any reports of misappropriation or mistreatment of [REDACTED].",2019-09-01
4684,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,241,E,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that staff knocked on residents' doors before entering their room or knocked on doors and waited for permission prior to entering a resident's room for 3 of 3 sampled residents reviewed for dignity and random observations of staff entering other residents' room without knocking. Staff was observed entering Resident #23, #35 and #60's room without knocking or getting permission to enter the room after they knocked. Random observations on hall with room numbers 113-118 revealed staff entering residents' rooms multiple times without knocking. The findings included: During the Stage I interview on 6/13/16 at approximately 10:05 AM with Resident #23, Certified Nursing Aide (CNA) #2 was observed entering the resident's room twice without knocking. A few minutes later a part-time nurse knocked on the resident's door and entered the room without getting the resident's permission. The part-time nurse then went into the resident's bathroom. Resident #23 stated he/she did not hear the staff knock on the door or got permission to enter the room. During the Stage I interview on 6/13/16 at approximately 10:29 AM with Resident #60, a staff member was observed knocking then entering a resident's room without permission. Random observation on 6/13/16 at approximately 11:02 AM, CNA #2 was observed entering the resident's rooms without knocking. Random observation on 6/13/16 at approximately 3:41 PM, Registered Nurse (RN) #3 was observed entering Resident #25's room (room [ROOM NUMBER]) and room [ROOM NUMBER] without knocking. An interview at approximately 3:42 PM revealed the nurse had been employed with the facility for a number of years. Random observations on 6/14/16 at approximately 9:22 AM CNA #2 was observed entering room [ROOM NUMBER] without knocking. At approximately 9:25 AM CNA #2 and another CNA was observed entering room [ROOM NUMBER] without knocking. During an interview on 6/14/16 at approximately 9:30 AM CNA #2 confirmed he/she did not knock on resident's doors on 6/13/16 or 6/14/16. CNA #2 further stated when he/she sees a door closed he/she feels a need to check on the resident and that's why he/she just goes in the resident's room. The CNA then stated he/she did not knock because one of the resident's in the room was hard of hearing. The CNA acknowledged the room was shared by four residents.",2019-09-01
4685,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,247,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of the facility's RESIDENT ADMISSION AGREEMENT packet, the facility failed to ensure that 1 of 1 sampled resident reviewed with a room or roommate changed received a notice of room change prior to the change. Resident #60 had a room change without advance notice. The findings included: The facility admitted Resident #60 with [DIAGNOSES REDACTED]. During an interview on 6/13/16 at approximately 10:29 AM, Resident #60 stated he/she was moved to another room without notice of the room change. The resident further stated he/she did not know why he/she had to move to the room he/she was in currently. A review of the medical record on 6/14/16 at approximately 12:05 PM revealed an Admission's Minimum Data Set MDS dated [DATE] indicated the resident was alert and interview-able with a Brief Interview Mental Status (BIMS)score of 10. Further record review revealed a nurses' note dated 3/25/16 that indicated the resident was in room [ROOM NUMBER] on admission. There was no documentation in the chart to indicate when Resident #60 was moved to room [ROOM NUMBER], his/her current room. There was no documentation in the chart to indicate if the resident and/or responsible party was notified prior to the room change. An interview on 6/14/16 at approximately 1:21 PM with the Social Services Director (SSD), revealed there was no discussion with the resident or family about the room change. The SSD confirmed there was no documentation in the medical record about a room change and there was no documentation of a discussion with the resident and/or responsible party about a room change. The SSD further stated Resident #60 was moved to another room on 5/10/16 after looking into the electronic record. Review of the facility's RESIDENT ADMISSION AGREEMENT packet on 6/14/16 at approximately 1:33 PM revealed under Section IV FACILITY OBLIGATIONS AND RIGHTS page 4 related to room change: The Facility reserves the right to change the Resident's room or roommate when the Facility determines it is appropriate to do so. Resident and Responsible Party will be notified prior to a transfer and will have an opportunity to provide input on roommate selection and location. The Facility will make changes in accordance with state and federal regulations.",2019-09-01
4686,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,250,E,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy entitled Social Service Program, the facility failed to provide medically appropriate Social Services for Resident #49 and Resident #60, 2 of 3 sampled residents reviewed for Social Services. Resident #49 had a history of [REDACTED]. In addition, Resident #49 wandered into the room of Resident #60 and got into the resident's bed. Resident #60 was not provided with any follow up by Social Services to assess the impact of Resident #49's actions. The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Record review of the Preadmission Screening and Resident Review (PASARR), dated [DATE], on [DATE] at 11:41 AM revealed that Resident #49 was most recently hospitalized for [REDACTED]. The PASARR also indicated that the resident has a mental illness for which he/she is in need of psychiatric/mental health treatment services. Record review of a hospital consult report on [DATE] at 11:43 AM, dated [DATE], revealed that the resident was admitted to the hospital from another facility after being physically abusive to another resident. Record review of the Nursing Home Admission H&P Worksheet on [DATE] at approximately 11:41 AM revealed that the facility was aware the resident had been hospitalized for [REDACTED]. Record review of the facility physician's History and Physical, dated [DATE], on [DATE] at approximately 11:41 AM, revealed that the resident had been admitted to the hospital because of violent behavior related to his Lewy Bodies Dementia and was treated and stabilized while there. The physician also dictated that managing the resident's behaviors will be challenging because medications do not work well in this condition. Record review of the physician's Progress Notes from [DATE] and [DATE] on [DATE] at 11:51 AM, revealed that the reason for the ,[DATE] visit was for Pacing, violent behavior. The physician dictated that the resident was swinging at people and being violent. The physician dictated in the ,[DATE] note that the resident was pacing continually and refusing to allow staff to feed him or clean him. In addition, it was dictated that the staff had to approach the resident in numbers to accomplish simple hygiene. The physician's notes indicated that anti-psychotic and mood stabilizer medications were the primary means of treating the resident's behavioral symptoms. Record review of the Nurse's Notes from [DATE] - [DATE] on [DATE] at 12:01 PM, revealed that the resident frequently refused medications, frequently refused personal care including incontinence care, had frequent restlessness and agitation, and continuously paced through the facility. In addition per the Nurse's Notes: On ,[DATE] the resident refused to allow staff to put shoes and socks on him/her and became extremely agitated and threatened to hit staff. On ,[DATE] the resident was refusing personal care, was very agitated and Still is pacing in halls most of the time. On ,[DATE] it was documented that Resident appears agitated this afternoon, pacing all over the hallway, unable to redirect, but able to eat sandwich and have a drink of juice, resident started hitting bathroom door near nurses station, unable to redirect, noted slight redness to knuckles on both hands, resident refused to be changed. will continue to monitor. On ,[DATE] the resident became combative with staff during incontinence care. The resident had to be changed with the assistance of 4 people. On ,[DATE] the resident was extremely agitated and walking around the hallway naked. He/she refused to put on clothes and became combative with staff when attempting to dress him/her. A Zyprexa (Anti-Psychotic) injection was given due to the severe agitation. An entry entered on [DATE] at 7:16 AM read Patient being belligerent and violent towards staff. Gave IM zyprexa. Patient fell asleep for 30 minutes and was back up ambulating into other patients rooms. A patient had deceased in another room and this patient .had went into deceased patient's room and was trying to pull him/her out of bed and when staff intervened, patient became violent again. After redirecting him/her and shutting all the doors on A hall, patient then went into a female/male residents room on B hall and climbed into her/his bed and would not get out. Female/male patient got very upset and stated she/he would be calling higher authorities. Record review of the Social Services Notes from [DATE]-[DATE] on [DATE] at 12:27 PM revealed 6 notes by the Social Services Director. On ,[DATE] the Social Services Director (SSD) noted that the resident walks in the hallways and mumbles to self. On ,[DATE] the SSD documented that the resident refused care today and staff provided incontinence care with 4 staff members - Resident continues to pace in hallway and mumbles under breath. Not easily redirected. On ,[DATE] the SSD documented that the resident was calmer, but continued to refuse care and was not easily redirected. An entry dated [DATE] at 2:45 PM read Resident has been up and walking in the hallway. Resident has been mumbling to self. Resident was redirected to dayroom where he sat on sofa and went to sleep. The two remaining SSD notes were dated [DATE]. There was no documentation in the record that the SSD had provided any kind of intervention, follow up or services related to the incident documented in the [DATE] Nurse's Note. There was no documentation by the SSD of any interventions, follow up or services implemented related to the other behavioral issues from the Nurses Notes. Record review of the comprehensive plan of care (care plan) on [DATE] at 2:27 PM, revealed that the resident's violent/combative behaviors and severe agitation were not care planned for prior to [DATE] and there were no interventions/services in place for the violent/combative behaviors prior to [DATE]. The care plan did not address the resident's history of violence towards other residents prior to [DATE]. The care plan did not address the safety of other resident's prior to [DATE]. The care plan did not address the resident's rejection/refusals of personal care or refusals of medications. The care plan did not address the resident's use of Anti-Psychotic medications. The care plan did not indicate that multiple staff members were needed to complete personal care tasks. The behaviors care planned for prior to [DATE] were pacing and wandering/elopement. The interventions and services in place prior to [DATE] were not appropriate based on the resident's history and documented behaviors. Those behavioral interventions and services in place prior to [DATE] were to check placement and function of wander guard every shift, distract the resident from wandering, observe the resident for fatigue and weight loss, orient resident to environment, provide structured activities, and reorient/validate and redirect resident as needed. The above interventions were initiated on [DATE]. There was no revision of the care plan related to the behavioral symptoms prior to [DATE]. The care plan do not list and mental health services or referrals. During an interview with the SSD and Nursing Home Administrator (NHA) on [DATE] at 1:10 PM, they were asked what rooms and beds the resident entered on [DATE]. Neither the NHA or the SSD knew whose bed the resident got into or who the deceased resident was that Resident #49 tried to pull out of the bed. The Incident Report for [DATE] was requested from the NHA. The SSD was asked for documentation indicating what services and/or interventions were in place to address the residents behaviors. The SSD looked at the NHA and stated that Resident #49 did not belong in this facility. The SSD confirmed that the Social Services Notes and the care plan did not identify interventions or services for the resident's violent, combative behavior, rejection of care, or resident safety prior to [DATE]. During an interview with the SSD on [DATE] at 2:02 PM, the SSD was asked if Resident #49 was a good candidate for this facility based on the documentation the facility had and what were her/his recommendations? The SSD stated that Resident #49 was not a good candidate for this facility based on his/her behavioral symptoms and was recommending that the resident be discharged from the facility. The SSD stated that she/he had recommended discharge for the resident at morning meetings prior to today based on the resident's behaviors. The SSD stated there was no documentation of this. The SSD also confirmed she/he had no documentation related to the events on [DATE]. In addition, the SSD confirmed the identities of the resident's involved in the [DATE] incident. She/he stated that an interview had been done with Resident #60 and she/he was the resident whose bed Resident #49 climbed into. The SSD stated that Resident #60 told her/him she/he was not in the bed when resident #49 got into it. At 2:08 PM the NHA stated that an Incident Report had not been completed for the events on [DATE]. During an interview with the SSD at 2:26 PM, the SSD stated she/he was arranging for the resident to be transferred to the geriatric psychiatry unit at the hospital. At 4:19 PM the SSD stated that the resident had been transferred to the hospital. During an interview with Registered Nurse (RN) #2 on [DATE] at 3:08 PM, RN #2 stated she/he was the nurse working during the events on [DATE]. RN #2 stated that Resident #60 was up walking in the hall when Resident #49 got into her/his bed. RN #2 stated it was common for resident #60 to walk during the night shift because it relieved discomfort in her/his legs. RN #2 also stated that Resident #60 entered her/his room while Resident #49 was in her/his bed, but went to the nurse's station when she/he realized Resident #49 was in her/his bed. During an interview with CNA #1 at 3:13 PM, CNA #1 had no additional information and confirmed RN #2's statements. During an interview with the SSD on [DATE] at 11:50 AM, with the NHA present, the SSD confirmed that there was no additional documentation indicating that the resident was receiving appropriate treatment and services for his/her behavioral symptoms nor was the resident receiving psychiatric/mental health services identified as needed in the PASARR. Review of the facility's policy entitled Social Service Program on [DATE] at 12:30 PM, revealed the following: Specific conditions to which the facility should respond with social services by staff or referrals include, but are not limited to: Behavioral symptoms Physical aggresion between residents (due to any reason or variable) Presence of a chronic disabling medical or psychological condition Coping difficulties The facility admitted Resident #60 with [DIAGNOSES REDACTED]. During an interview on [DATE] at approximately 10:29 AM, Resident #60 expressed concerns about a male resident (Resident #49) coming into his/her room and getting into his/her bed. Resident #60 further stated that he/she had expressed his/her concerns to the facility staff but nothing had been done to keep Resident #49 from coming back into his/her room. A review of Resident #60 medical record on [DATE] at approximately 12:05 PM revealed there was no documentation in the medical record to indicate the resident expressed concerns about a male resident getting into his/her bed. There was no documentation in the medical record to indicate the facility made an effort to address Resident #60 concerns of a male resident coming into the resident's room and getting into his/her bed. There was documentation in Resident #49 medical record that indicated Resident #49 was in Resident #60 bed with no interventions in place. During an interview on [DATE] at approximately 1:32 PM with the Social Services Director (SSD), the SSD stated he/she was not aware of Resident #49 getting into Resident #60's bed. The SSD further stated, there was no 24 hour report or incident report of Resident #49 getting into Resident #60's bed. When informed that there was documentation in Resident #49 medical record of the incident, the SSD stated he/she does not read nurse's notes in the medical record.",2019-09-01
4687,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,279,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive plan of care with measurable objectives related to Resident #49's behavioral symptoms, 1 of 1 sampled resident reviewed for Behaviors. Resident #49 had a known history of violent/aggressive behaviors towards other residents and this was not care planned. The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Record review of the Preadmission Screening and Resident Review (PASARR), dated 4/6/2016, on 6/14/2016 at 11:41 AM revealed that Resident #49 was most recently hospitalized for [REDACTED]. The PASARR also indicated that the resident has a mental illness for which he/she is in need of psychiatric/mental health treatment services. Record review of a hospital consult report on 6/14/2016 at 11:43 AM, dated 2/26/2016, revealed that the resident was admitted to the hospital from another facility after being physically abusive to another resident. Resident #49 had struck another resident and was acting aggressively towards another resident. Record review of the Nursing Home Admission H&P Worksheet on 6/14/2016 at approximately 11:41 AM, revealed that the facility was aware at the time of the resident's admission to the facility, that the resident had been hospitalized for [REDACTED]. Record review of the facility physician's History and Physical, dated 4/27/2016, on 6/14/2016 at approximately 11:41 AM, revealed that the resident had been admitted to the hospital because of violent behavior related to his Lewy Bodies Dementia and was treated and stabilized while there. The physician also dictated that managing the resident's behaviors will be challenging because medications do not work well in this condition. Record review of the comprehensive plan of care (care plan) on 6/14/2016 at 2:27 PM, revealed that the resident's violent/combative behaviors were not care planned for prior to 6/14/2016 and there were no interventions or services in place for the violent/combative behaviors prior to 6/14/2016. The care plan did not address the resident's history of violence towards other residents prior to 6/14/2016. The care plan did not address the safety of other resident's prior to 6/14/2016. The care plan did not address the resident's use of Anti-Psychotic medications. The behaviors that were care planned for upon initiation of the comprehensive plan of care were pacing and wandering/elopement. The interventions and services in place prior to 6/14/2016 were not appropriate based on the resident's history and documented behaviors. The behavioral interventions and services in place prior to 6/14/2016 were to check placement and function of wander guard every shift, distract the resident from wandering, observe the resident for fatigue and weight loss, orient resident to environment, provide structured activities, and reorient/validate and redirect resident as needed. There was no revision of the care plan related to behavioral symptoms prior to 6/14/2016. The care plan do not list any mental health services or referrals. There were no specific interventions in place to manage the resident's symptoms that the physician had documented would be difficult to manage. Record review of the Social Services Notes on 6/14/2016 at 12:27 PM, revealed no documentation of the resident's history of violent/aggressive behaviors or that any services or interventions were implemented related to the resident's behaviors. During an interview with the Social Services Director (SSD) and Nursing Home Administrator (NHA) on 6/14/2016 at 1:10 PM, the SSD confirmed that the Social Services Notes did not address the resident's history of behaviors. In addition, the SSD confirmed that the care plan did not identify interventions or services related to the resident's history of violent/aggressive behavior. The SSD was asked for documentation indicating what services and/or interventions were in place to address the resident's history of violent/aggressive behaviors. During an interview with the SSD on 6/14/2016 at 2:02 PM, the SSD was asked if Resident #49 was a good candidate for this facility based on the documentation the facility had and what were her/his recommendations? The SSD stated that Resident #49 was not a good candidate for this facility based on his/her behavioral symptoms and was recommending that the resident be discharged from the facility. The SSD stated that she/he had recommended discharge for the resident at morning meetings prior to today based on the resident's behaviors. The SSD stated there was no documentation of this. During an interview with the SSD and NHA on 6/15/2016 at 11:50 AM, the SSD confirmed that there was no additional documentation indicating that the resident was receiving appropriate treatment and services for his/her behavioral symptoms. The NHA stated that the resident's behaviors stabilized during his/her hospitalization and the resident was not displaying any violent/aggressive behaviors prior to admission to the facility.",2019-09-01
4688,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,282,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that care plans were followed for 1 of 3 sampled residents reviewed for nutrition. Resident #5's care plan was not followed related to notifying the medical doctor of any significant weight changes. The finding included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. A review of the medical record on 6/15/16 at approximately 9:46 AM revealed Resident #5 had an admission weight of 168 pounds on 2/16/16. The medical record further indicated the resident had a weight of 169 pounds on 3/09/16, weighed 170 pounds on 4/12/16, weighed 199 pounds and then weighed 157 pounds on 6/12/16. Further record review revealed a care plan initiated on 2/18/16 and updated on 5/24/16 that indicated Notify MD (Medical Doctor) and family of any significant wt (weight) changes. During an interview on 6/15/16 at approximately 10:20 AM with the Dietary Manager (DM), the DM confirmed significant change in weight and stated the medical doctor was not notified per the care plan.",2019-09-01
4689,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,319,E,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide appropriate treatment and services for Resident #49, 1 of 1 sampled resident reviewed for behaviors. Resident #49 had a history of [REDACTED]. The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Record review of the Preadmission Screening and Resident Review (PASARR), dated [DATE], on [DATE] at 11:41 AM, revealed that Resident #49 had 2 hospitalization s for psychiatric illnesses and was most recently hospitalized for [REDACTED]. The PASARR also indicated that the resident has a mental illness for which he/she is in need of psychiatric/mental health treatment services. Specific psychiatric/mental health services recommended on the PASARR were to continue the resident's anti-psychotic, anti-depressant and mood stabilizer medications, which the facility did. Record review of a hospital consult report on [DATE] at 11:43 AM, dated [DATE], revealed that the resident was admitted to the hospital from another facility after being physically abusive to another resident. Resident #49 had struck a resident and was acting aggressively towards another resident. Record review of the Nursing Home Admission H&P Worksheet on [DATE] at approximately 11:41 AM revealed that the facility was aware the resident had been hospitalized for [REDACTED]. Record review of the facility physician's History and Physical, dated [DATE], on [DATE] at approximately 11:41 AM, revealed that the resident had been admitted to the hospital because of violent behavior related to his Lewy Bodies Dementia and was treated and stabilized while there. The physician also dictated that managing the resident's behaviors will be challenging because medications do not work well in this condition. Record review of the physician's Progress Notes from [DATE] and [DATE] on [DATE] at 11:51 AM, revealed that the reason for the ,[DATE] visit was for Pacing, violent behavior. The physician dictated that the resident was swinging at people and being violent. The physician dictated in the ,[DATE] note that the resident was pacing continually and refusing to allow staff to feed him or clean him. In addition, it was dictated that the staff had to approach the resident in numbers to accomplish simple hygiene. The physician's notes indicated that anti-psychotic and mood stabilizer medications were the primary means of treating the resident's behavioral symptoms. Record review of the Nurse's Notes from [DATE] - [DATE] on [DATE] at 12:01 PM, revealed that the resident frequently refused medications, frequently refused personal care (including incontinence care), had frequent restlessness and agitation, and continuously paced through the facility. In addition, per the Nurse's Notes: On ,[DATE] the resident refused to allow staff to put shoes and socks on him/her and became extremely agitated and threatened to hit staff. On ,[DATE] the resident was refusing personal care, was very agitated and Still is pacing in halls most of the time. On ,[DATE] it was documented that Resident appears agitated this afternoon, pacing all over the hallway, unable to redirect, but able to eat sandwich and have a drink of juice, resident started hitting bathroom door near nurses station, unable to redirect, noted slight redness to knuckles on both hands, resident refused to be changed. will continue to monitor. On ,[DATE] the resident became combative with staff during incontinence care. The resident had to be changed with the assistance of 4 people. On ,[DATE] the resident was extremely agitated and walking around the hallway naked. He/she refused to put on clothes and became combative with staff when attempting to dress him/her. A [MEDICATION NAME] (Anti-Psychotic) injection was given due to the severe agitation. An entry entered on [DATE] at 7:16 AM read Patient being belligerent and violent towards staff. Gave IM [MEDICATION NAME]. Patient fell asleep for 30 minutes and was back up ambulating into other patients rooms. A patient had deceased in another room and this patient .had went into deceased patient's room and was trying to pull him/her out of bed and when staff intervened, patient became violent again. After redirecting him/her and shutting all the doors on A hall, patient then went into a female/male residents room on B hall and climbed into her/his bed and would not get out. Female/male patient got very upset and stated she/he would be calling higher authorities. Record review of the Social Services Notes from [DATE]-[DATE] on [DATE] at 12:27 PM revealed 6 notes by the Social Services Director. On ,[DATE] the Social Services Director (SSD) noted that the resident walks in the hallways and mumbles to self. On ,[DATE] the SSD documented that the resident refused care today and staff provided incontinence care with 4 staff members - Resident continues to pace in hallway and mumbles under breath. Not easily redirected. On ,[DATE] the SSD documented that the resident was calmer, but continued to refuse care and was not easily redirected. An entry dated [DATE] at 2:45 PM read Resident has been up and walking in the hallway. Resident has been mumbling to self. Resident was redirected to dayroom where he sat on sofa and went to sleep. The two remaining SSD notes were dated [DATE]. There was no documentation in the record that the SSD had provided any kind of intervention, follow up or services related to the incident documented in the [DATE] Nurse's Note. There was no documentation by the SSD of any interventions, follow up or services implemented related to the other behavioral issues from the Nurses Notes. The Social Services Notes revealed no documentation of the resident's history of violent/aggressive behaviors or that any services or interventions were implemented related to the resident's behaviors. Record review of the comprehensive plan of care (care plan) on [DATE] at 2:27 PM, revealed that the resident's violent/combative behaviors and severe agitation were not care planned for prior to [DATE] and there were no interventions/services in place for the violent/combative behaviors prior to [DATE]. The care plan did not address the resident's history of violence towards other residents prior to [DATE]. The care plan did not address the safety of other resident's prior to [DATE]. The care plan did not address the resident's rejection/refusals of personal care or refusals of medications. The care plan did not address the resident's use of Anti-Psychotic medications. The care plan did not indicate that multiple staff members were needed to complete personal care tasks. The behaviors care planned for prior to [DATE] were pacing and wandering/elopement. The interventions and services in place prior to [DATE] were not appropriate based on the resident's history and documented behaviors. Those behavioral interventions and services in place prior to [DATE] were to check placement and function of wander guard every shift, distract the resident from wandering, observe the resident for fatigue and weight loss, orient resident to environment, provide structured activities, and reorient/validate and redirect resident as needed. There was no revision of the care plan related to the behavioral symptoms prior to [DATE]. The care plan do not list any mental health services or referrals. There were no specific interventions in place to manage the resident's behavioral symptoms that the physician had documented would be difficult to manage During an interview with the SSD and Nursing Home Administrator (NHA) on [DATE] at 1:10 PM, they were asked what rooms and beds the resident entered on [DATE]. Neither the NHA or the SSD knew whose bed the resident got into or who the deceased resident was that Resident #49 tried to pull out of the bed. The Incident Report for [DATE] was requested from the NHA. The SSD was asked for documentation indicating what services and/or interventions were in place to address the residents behaviors. The SSD looked at the NHA and stated that Resident #49 did not belong in this facility. The SSD confirmed that the Social Services Notes and the care plan did not identify interventions or services for the resident's violent, combative behavior, rejection of care, or resident safety prior to [DATE]. During an interview with the SSD on [DATE] at 2:02 PM, the SSD was asked if Resident #49 was a good candidate for this facility based on the documentation the facility had and what were her/his recommendations? The SSD stated that Resident #49 was not a good candidate for this facility based on his/her behavioral symptoms and was recommending that the resident be discharged from the facility. The SSD stated that she/he had recommended discharge for the resident at morning meetings prior to today based on the resident's behaviors. The SSD stated there was no documentation of this. The SSD also confirmed she/he had no documentation related to the events on [DATE]. In addition, the SSD confirmed the identities of the resident's involved in the [DATE] incident. She/he stated that an interview had been done with Resident #60 and she/he was the resident whose bed Resident #49 climbed into. The SSD stated that Resident #60 told her/him she/he was not in the bed when resident #49 got into it. At 2:08 PM the NHA stated that an Incident Report had not been completed for the events on [DATE]. During an interview with the SSD at 2:26 PM, the SSD stated she/he was arranging for the resident to be transferred to the geriatric psychiatry unit at the hospital. At 4:19 PM the SSD stated that the resident had been transferred to the hospital. During an interview with Registered Nurse (RN) #2 on [DATE] at 3:08 PM, RN #2 stated she/he was the nurse working during the events on [DATE]. RN #2 stated that Resident #60 was up walking in the hall when Resident #49 got into her/his bed. RN #2 stated it was common for resident #60 to walk during the night shift because it relieved discomfort in her/his legs. RN #2 also stated that Resident #60 entered her/his room while Resident #49 was in her/his bed, but went to the nurse's station when she/he realized Resident #49 was in her/his bed. During an interview with CNA #1 at 3:13 PM, CNA #1 had no additional information and confirmed RN #2's statements. During an interview with the SSD on [DATE] at 11:50 AM, with the NHA present, the SSD confirmed that there was no additional documentation indicating that the resident was receiving appropriate treatment and services for his/her behavioral symptoms nor was the resident receiving psychiatric/mental health services, other than medication management. The NHA stated that the resident's behaviors stabilized during his/her hospitalization and the resident was not displaying any violent/aggressive behaviors prior to admission to the facility. The resident was observed independently ambulating throughout the facility on 2 of 3 days of the survey. The resident appeared to become agitated when staff attempted to redirect him. The resident was observed grabbing staff members and survey team members on 2 of 3 days of the survey. The resident was not observed threatening other residents or being aggressive towards other residents.",2019-09-01
4690,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,325,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility's Weight/Hydration Management policy, the facility failed to ensure that a resident with a significant weight loss was referred to the physician for 1 of 3 sampled residents reviewed for nutrition. Resident #5 had a significant weight loss with no referral to the physician. The finding included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. A review of the medical record on 6/15/16 at approximately 9:46 AM revealed Resident #5 had an admission's weight of 168 pounds on 2/16/16. The medical record further indicated the resident had a weight of 169 pounds on 3/09/16, weighed 170 pounds on 4/12/16 and weighed 157 pounds on 6/12/16. During an interview on 6/15/16 at approximately 10 AM with the Dietary Manager (DM), the DM confirmed the documented weights in the medical record and stated the 5/12/16 weight of 199 was incorrect and that staff did not subtract the wheel chart weight of 41 pounds. The DM indicated the weight would have been 158 pounds on 5/12/16 which was a significant weight loss of 12 pounds from the 4/12/16 weight of 170 pounds. The DM further stated the family was notified on 6/01/16 at the care plan meeting. There was no documentation to indicate the medical doctor was notified. A review of the facility's Weight/Hydration Management policy on 6/15/16 revealed under #1. Accurate weights are obtained by having the staff follow a consistent approach to weighing and by using an appropriately serviced an functioning scale. The weight management policy further indicated under #4. As residents are weighed, staff can compare current weight to previous weight. Residents with weight variance are reweigh within 24 hours. Per the facility's policy the weight variance would include residents with a weight change of 5 pounds. An interview on 6/15/16 at approximately 10:32 AM with the Director of Nursing (DON) revealed the facility did not follow there protocol related to monitoring resident weight loss. The DON further stated there was no documentation in the medical record to indicate the physician had been notified of the weight loss. An interview on 6/15/16 at approximately 10:43 AM with Registered Nurse #1 revealed the physician was not notified of the weight loss and a referral was made for the resident to be seen by the physician on 6/15/16.",2019-09-01
4691,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,334,C,0,1,VGC011,"Based on influenza regulation and record reviews, the facility failed to provide documentation of consent and education, and did not follow the facilities policy. Four of 5 resident records reviewed (Residents #34, #41, #51 and #15) did not contain in the medical record the required documentation. The findings included: The facility failed to include documentation that indicates at a minimum that the resident or resident's legal representative was provided education for the most recent Influenza season (2015-2016). The documentation must include the benefits and potential side effects of influenza immunization, and that the resident received or did not receive the influenza immunization due to medical contraindications or refusal. The findings included that 4 of 5 resident records reviewed did not have the education documentation for the influenza (YEAR)-2016 season and obtained consent or refusal. Resident #34, #41, #51 and #15 did not contain in the medical record the required documentation.",2019-09-01
4692,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,356,C,0,1,VGC011,"Based on initial tour of the facility on 6/16/2016 at 09:30 AM and staff interviews, the facility failed to post the staffing data required and resident census in a prominent place readily accessible to residents and visitors. The findings included: The findings upon staff interviews of RN #4, RN #1 and the DON, did not know where it was posted. Upon further interview at approximately 10:30 AM, RN #4 located posting information on a clipboard behind the nursing station and stated usually kept on the nurses station, but we have a resident that will take it and tear the papers up.",2019-09-01
4693,GOLDEN AGE INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-15,502,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy entitled Laboratory (labs) Management, the facility failed to draw labs as ordered for Resident #49, 1 of 5 sampled residents reviewed for Unnecessary Medications. The facility did not draw a [MEDICATION NAME] level as ordered. The findings included: The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Record review of the Physician Orders and lab reports on 06/14/2016 at 12:35 PM, revealed an order, dated 5/11/2016, for a [MEDICATION NAME] (an Anti-Psychotic medication) level to be drawn in the morning. There was no lab report on the medical record with results of the [MEDICATION NAME] level. During an interview with the Director of Nursing(DON) on 6/15/2016 at 9:51 AM, the DON stated that there was no lab report for the [MEDICATION NAME] level. The DON stated she/he called the lab and was told that the [MEDICATION NAME] level was not drawn. The DON was asked why the [MEDICATION NAME] level was not drawn as ordered. The DON stated I don't know. The DON provided a copy of the lab slip filled out for the resident which indicated a valporic acid level and [MEDICATION NAME] level were to be drawn. The DON also provided a lab report that indicated the valporic acid level was drawn as ordered. During an interview at 10:30 AM, the DON stated that the charge nurse is supposed to follow up on lab orders daily to ensure that labs are drawn as ordered. If labs are not done as ordered then the lab is to be contacted to have the labs redrawn and new orders are obtained as necessary. Review of the facility policy entitled Laboratory Management on 6/15/2016 at 11:30 AM, revealed that the facility is responsible for the quality and timeliness of laboratory services.",2019-09-01
5871,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2015-03-05,155,D,0,1,YNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of the facility policy entitled Advance Directives, and review of the South Carolina Adult Healthcare Consent Act, the facility failed to ensure that 1 of 15 sampled residents reviewed had the opportunity to develop their own advance directive. There was no documentation in the record to indicate Resident #23 desired a Do Not Resuscitate DNR status. An Emergency Medical Services EMS order for DNR was signed by the resident's Responsible Party. Two physicians had not determined that Resident #23 was unable to make his/her own healthcare decisions. The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Record review on 3/4/15 at 3:18 PM revealed current Physician's Orders for a DNR code status for Resident #23. Further review revealed a Physician's Telephone Order dated 8/13/13 stating Res(ident) is DNR since 8-8-13. A Progress Note Addressing Decisional Capacity dated 8/15/13 revealed one physician had signed that the resident was not able to make healthcare decisions for him/herself. A Nurse Practitioner's Progress Note dated 7/31/13 documented This patient lacks decision-making capacity. There was no documentation noted that a second physician had certified that the resident lacked decisional capacity. There was nothing noted in the record to indicate that facility staff had spoken with the resident about his/her code status and that a DNR status was what the resident desired. There was nothing noted in the record to indicate the resident was on hospice. During an interview on 3/4/15 at 3:40 PM, the Director of Nursing (DON) reviewed the documentation in the medical record and verified there was no evidence that 2 physicians had determined that Resident #23 was unable to make his/her own healthcare decisions. The DON stated s/he would check the thinned records to see if additional documentation could be found. During an interview on 3/5/15 at 11:27 AM, the Social Services Director (SSD) stated they could find no additional information. The SSD verified that 2 physicians had not determined that Resident #23 was unable to make his/her own healthcare decisions. When asked, the SSD stated s/he could not find documentation that the DNR was the resident's wishes. A review of the policy provided by the facility entitled Advance Directives revealed The resident has a right to .formulate an advance directive in accordance with state and federal law . According to the policy, on admission, .If a resident has not executed an advance directive and the resident has the capacity to make health care decisions, the social services department should contact the resident to determine whether the resident wishes to make an advance directive . Review of the South Carolina Adult Healthcare Consent Act Section 44-66-20 revealed that Unable to consent means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner . A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient. However, in an emergency the patient's inability to consent may be certified by a health care professional responsible for the care of the patient if the health care professional states in writing in the patient's record that the delay occasioned by obtaining certification from two licensed physicians would be detrimental to the patient's health. A certifying physician or other health care professional shall give an opinion regarding the cause and nature of the inability to consent, its extent, and its probable duration",2018-08-01
5872,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2015-03-05,279,D,0,1,YNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a care plan related to the use and monitoring of psychoactive medications for 1 of 5 sampled residents reviewed for unnecessary medications. Resident #24 was receiving multiple psychoactive medications but had no care plan related to their use, monitoring, or managing of risk factors. Also, based on observations, record review, and interviews, the facility failed to develop a behavioral care plan for 1 of 2 sampled residents reviewed for respiratory care. Resident #30 was observed multiple times with no oxygen on or with 2 liters of oxygen infusing when physician's orders [REDACTED]. The Comprehensive Care Plan for Resident #30 did not include behaviors of removing the oxygen and/or changing the oxygen settings. The findings included: Cross Refer to F-329 The facility admitted Resident #24 with [DIAGNOSES REDACTED]. On 3/4/15, review of the physician's orders [REDACTED].#24 was receiving multiple psychoactive medications including [MEDICATION NAME] Oxalate once daily for Depression, [MEDICATION NAME] Sprinkles two times a day for Senile Dementia with Depressive Features, [MEDICATION NAME] three times daily for Anxiety, and [MEDICATION NAME] every 24 hours as needed for Anxiety. A review of the Comprehensive Care Plan on 3/4/15 revealed that it did not include a focus area for psychoactive medications. There were no goals or interventions listed to direct nursing staff as to the care and monitoring required for Resident #24 related to his/her psychoactive medication use. During an interview on 3/4/15 at approximately 4:00 PM, the Director of Nursing verified a care plan had not been developed relative to Resident #24's psychoactive medications. Cross Refer to F-328 The facility admitted Resident #30 with [DIAGNOSES REDACTED]. The resident was admitted to hospice care on 2/9/15 with [DIAGNOSES REDACTED]. Review of the 2-18-15 Readmission Minimum Data Set Assessment revealed that the resident had a Brief Interview for Mental Status Score of 8, indicating moderate cognitive impairment. No rejection of care was documented under the behavior section of the assessment. Record review on 3/5/15 at 10:25 AM revealed 2/9/15 physician's orders [REDACTED]. Observation on 3/3/15 from 10:40 AM to 10:50 AM revealed the resident sitting in his/her wheelchair in the room with Oxygen infusing via nasal cannula at 2 liters per minute by Oxygen concentrator. Observation on 3/4/15 at 8:46 AM revealed the resident sitting at the dining room table feeding her/himself. The resident was on room air. There was no oxygen tank or concentrator present for the 15 minute meal observation. Observation with the Director of Nursing (DON) on 3/5/15 at 10:30 AM revealed Resident #30 sitting in his/her wheelchair in the room with oxygen infusing via nasal cannula by concentrator at 2 liters per minute. According to the DON, hospice had ordered the oxygen at 5 liters upon return from the hospital in early February. S/he stated Resident #30 did not like to wear the oxygen at times, and turned the oxygen down or took it off. Review of the Care Plan with the DON revealed the resident had not been care planned for removing or turning down the oxygen. The DON was informed of previous surveyor observations of the resident without oxygen for a breakfast meal and with the oxygen at 2 liters. A review of the care plan revealed the resident was to have oxygen settings per orders via nasal cannula, and that If the resident is allowed to eat, oxygen still must be given to the resident . During an interview on 3/5/15 at 11;58 AM, Licensed Practical Nurse (LPN) #1 stated that s/he had been aware that the resident turned down and/or took off his/her oxygen. According to the nurse, the resident got confused and thought the oxygen was his/her nebulizer treatment and the resident would state s/he was only to get this treatment for 15 minutes. During an interview on 3/5/15 at 11:53 AM, the MDS (Minimum Data Set) Coordinator stated s/he had been aware that the resident took off his/her oxygen at times. When asked, the MDS Coordinator stated the care plan probably should have been updated with this information under behaviors.",2018-08-01
5873,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2015-03-05,282,G,0,1,YNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement the Care Plan for 1 of 1 sampled resident reviewed for pressure ulcers. Skin care and pressure ulcer treatments were not provided per the Care Plan for Resident #37, resulting in a Stage IV pressure ulcer. The findings included: The facility admitted Resident #37 with [DIAGNOSES REDACTED]. Review of the 2/25/2015 Weekly Pressure Ulcer Record on 3/4/2015 at 12:06 PM revealed that Resident #37 acquired a new pressure ulcer to the sacrum with an onset date of 2/20/2015. The Pressure Ulcer was identified as a Stage IV Pressure Ulcer. Review of the Care Plan on 3/4/2014 at 11:30 AM revealed an intervention for the Pressure Ulcer to: Administer treatments as ordered and observe for effectiveness. Another problem area on the Care Plan was the potential for impaired skin integrity r/t (related to) incontinence episodes, catheter, [MEDICAL CONDITION], and decreased mobility. A listed intervention for this problem was tx (treatment)/care of cyst per physicians orders. Review of the physician's orders [REDACTED]. Pack with normal saline gauze and apply [MEDICATION NAME] adhesive. Change qd (daily) and prn (as needed). Further review of the physician's orders [REDACTED]. Apply dry dressing over area on sacrum everyday and prn soiling one time a day for cyst. This treatment started 11/6/2014. 2. Apply Calazyyme cream to area on buttocks below the coccyx every night shift for irritation (of the skin). This treatment started 9/1/2014. The Calazyme cream treatment was not listed as an intervention on the Care Plan. Review of the Treatment Administration Record (TAR) on 3/4/2015 at 11:05 AM revealed that pressure ulcer treatments (start date 2/20/2015) were not documented as done daily as ordered on (MONTH) 20, 23, 24, 26, 27, and 28, (YEAR). The treatment for [REDACTED]. Eighteen of 28 daily treatments for the cyst were not done in February, (YEAR). Three daily treatments for the cyst to the sacrum were not documented as done in December, (YEAR). treatment for [REDACTED]. The Calazyme cream to the buttocks was also not documented as done daily as ordered. The documentation noted that the Calazyme cream was applied to the buttocks on only 10 of 28 days in February, (YEAR). During an interview on 3/4/2015 at 1:41 PM, the Director of Nursing (DON) confirmed that the daily pressure ulcer treatment had not been documented as done daily as ordered and per the Care Plan. S/he confirmed that the treatment for [REDACTED]. The DON verified that the Calazyme cream for skin irritation was not listed on the Care Plan and not documented as done daily as ordered",2018-08-01
5874,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2015-03-05,309,D,0,1,YNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that 1 of 1 sampled resident reviewed with a pacemaker received the necessary care and services. Resident #4 had no physician's orders for pacemaker checks and there was no documentation to determine the type of pacemaker the resident had or how often the pacemaker should be checked/monitored. The findings included: The facility admitted Resident #4 with a [DIAGNOSES REDACTED]. Record review on 3/05/15 at approximately 10 AM revealed a radiology report dated 10/25/14 and 12/30/14 that indicated the resident had a pacemaker. There was an Electrocardiogram (EKG) dated 5/29/14 that indicated the physician was notified with no new orders. There was no documentation in the chart to indicate the type of pacemaker the resident had or how often the pacemaker should be checked/monitored. Review of the February, (YEAR) cumulative physician's orders and treatment sheets and review of the resident's care plan revealed no reference to a pacemaker. During an interview on 3/05/15, the Director of Nursing (DON) confirmed that Resident #4 had a pacemaker and stated the pacemaker checks were to be done yearly. The surveyor requested documentation to confirm the pacemaker should be checked yearly. The DON reviewed the resident's medical record and stated s/he was unable to find the verification in the chart. During an interview on 3/05/15 at approximately 11:31 AM, the Care Plan Coordinator (CPC) stated that residents with pacemakers would be care planned for monitoring/precautions and how often the pacemaker would be checked. The CPC confirmed Resident #4 was not care planned for the pacemaker care and services. During an interview on 3/05/15 at approximately 11:39 AM, the DON stated s/he had spoken with the resident's cardiologist and was informed that the type of pacemaker the resident had required checks every 6 months.",2018-08-01
5875,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2015-03-05,314,G,0,1,YNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy entitled Skin Management Program, the facility failed to provide treatments and services to prevent development of a Stage IV pressure ulcer for 1 of 1 sampled resident reviewed for pressure ulcers. The facility failed to complete weekly skin audits and provide skin treatments as ordered for Resident #37, resulting in the Stage IV ulcer. The findings included: The facility admitted Resident #37 with [DIAGNOSES REDACTED]. Review of the 2/25/2015 Weekly Pressure Ulcer Record on 3/4/2015 at 12:06 PM revealed that Resident #37 acquired a new pressure ulcer to the sacrum on 2/20/2015. The pressure ulcer was identified as Stage IV. Review of the Physician's Orders on 3/4/2015 at 10:43 AM revealed a 2/20/2015 treatment order to: Clean open areas to buttocks. Pack with normal saline gauze and apply [MEDICATION NAME] adhesive. Change qd (daily) and prn (as needed). Further review of the Physician's Orders revealed the following treatment orders: 1.Apply calazyyme cream (a skin protectant) to area on buttocks below the coccyx (tail bone area) every night shift for irritation (of the skin). This treatment started 9/1/2014. 2. Apply dry dressing over area on sacrum everyday and prn soiling one time a day for cyst. This treatment started 11/6/2014. Review of the Care Plan on 3/4/2014 at 11:30 AM revealed a problem of (Resident #37) has pressure ulcer (to) buttocks or potential for pressure development r/t (related to) Immobility, poor nutrition. Interventions included: 1. Administer treatments as ordered and observe for effectiveness. 2. Complete a full body check weekly and document. Another problem on the Care Plan for this resident was the potential for impaired skin integrity r/t incontinence episodes, catheter, [MEDICAL CONDITION], and decreased mobility. A listed intervention for this problem was for tx (treatment)/care of cyst per physicians orders. Calazyme cream to the buttocks was not listed as an intervention on the Care Plan. Review of the Treatment Administration Record (TAR) on 3/4/2015 at 11:05 AM revealed that pressure ulcer treatments (start date 2/20/2015) were not documented as done daily as ordered on (MONTH) 20, 23, 24, 26, 27, and 28, (YEAR). Further review revealed that the Calazyme cream to the buttocks had not been documented as done daily as ordered on 18 out of 28 days in February, (YEAR). In addition, the treatment for [REDACTED]. 3 daily treatments for the cyst to the sacrum were not documented as done in December, (YEAR). treatment for [REDACTED]. Review of the weekly Head to Toe Skin Checks on 3/4/2015 at 12:28 PM revealed that the skin audits had not been done weekly. The weekly Head to Toe Skin Check was documented as done 1 time in (MONTH) (12/6/2014) and 1 time in (MONTH) (1/14/2015). The weekly skin check was not documented as done in February, (YEAR) prior to identifying the Stage IV Pressure Ulcer. During an interview on 3/4/2015 at 1:41 PM, the Director of Nursing (DON) confirmed that the weekly Head to Toe Skin Checks should have been done and were not documented as done weekly. S/he confirmed that the daily pressure ulcer treatment had not been documented as done daily as ordered. In addition, the DON confirmed that the treatment for [REDACTED]. Review of the facility policy entitled Skin Management Program on 3/4/2015 at 2:45 PM revealed that newly identified residents with skin breakdown should have weekly skin checks.",2018-08-01
5876,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2015-03-05,323,E,0,1,YNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure the safety of 1 of 1 sampled resident on aspiration precautions during meal service. Resident #41 was served an incorrect diet during one of one meal observed. Based on observations and interview, the facility failed to ensure there was a safe and systematic method of identifying residents for 4 of 4 residents observed during the medication (med pass). There was no picture or wrist band information available for nursing staff to use to ensure proper identification of residents. The findings included: During med pass observations of 4 residents on 3/3/15 at approximately 4:00 PM and on 3/4/15 between 10:00 AM and 10:30 AM, the surveyor noted that nursing staff were not identifying residents through the use of wrist bands or through the use of pictures. During med pass observation on 3/3/15 at approximately 4:00 PM, Registered Nurse (RN) #1 was not observed to check a wrist identification band prior to giving Resident #28 his/her medications. (Review of the 1-13-15 Annual Minimum Data Set (MDS) Assessment revealed that Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.) During a med pass observation on 3/4/15 at 10:11 AM, Licensed Practical Nurse (LPN) #1 was asked how s/he identified residents in order to administer their medications. LPN #1 was asked to check for a wrist band for Resident #20 but found none. According to the nurse, the resident was oriented to his/her name and would answer if his/her name was called. (Review of the 2-14-15 5-Day MDS revealed that Resident #20 had a BIMS score of 1, indicating severe cognitive impairment.) During med pass observation on 03/04/2015 at 10:26 AM, LPN #1 stated Resident #7 answered to his/her name and was alert and oriented. (Review of the 1-13-15 Quarterly MDS Assessment revealed that Resident #28 had a BIMS score of 15, indicating the resident was cognitively intact.) LPN #1 verified there was no wrist identification band for the resident. According to the nurse, the residents' pictures didn't show up in their computer system used for med pass. During med pass observation on 3/4/15 at 10:33 AM, LPN #1 stated Resident #44 was alert and oriented. The resident had no wrist band identification. Review of the 1-26-15 MDS Assessment revealed that Resident #44 had a BIMS score of 14, indicating the resident was cognitively intact. During an interview on 03/04/2015 at 10:40 AM, the Director of Nursing (DON) was informed that the residents observed on med pass had no identification bands on and that there were no pictures of the residents in the computerized record for the nurses to use for identification during med pass. The DON stated that residents in the facility did not use armbands for identification. According to the DON, they had previously used picture identification when they used paper charting. The DON stated that when the computerized system rolled out the previous year, there had been a place to add pictures, but they had not been added. S/he stated they would take pictures and upload them. The DON also stated that there was always a staff member at the facility who would be able to identify the residents. During an interview on 3/5/15 at 12:51 PM, the Administrator stated that s/he had been at the facility since (MONTH) and there had been no medication errors reported related to misidentification of residents since s/he started. The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Resident #41 was observed eating lunch on 3/3/2015 at 12:29 PM. The resident was served foods that had not been mechanically altered and were of a regular consistency and texture. S/he was also served liquids that had not been thickened. Shortly after the resident began eating, s/he was observed coughing, and a staff member took the regular meal from the resident and exchanged it for a meal that consisted of pureed foods and thickened liquids. Record review of a 2/17/2015 Physician order [REDACTED]. During an interview on 3/4/2015 at 3:37 PM, Licensed Practical Nurse (LPN) #1 confirmed that s/he served the resident the wrong tray for lunch on 3/3/2015. LPN #1 stated s/he served the resident another resident's lunch tray that had unaltered foods of a regular consistency and thin liquids. The nurse stated s/he must not have looked closely enough at the name on the ticket on the lunch tray. LPN #1 confirmed the resident was eating from the regular tray and did cough, but was immediately given the correct lunch tray. LPN #1 stated s/he stayed with the resident for the rest of the meal to make sure s/he was ok. The nurse also stated that the Nurse Practitioner had been notified of the incident and ordered a chest x-ray. Review of the chest x-ray results on 3/4/2015 at approximately 3:37 PM revealed no evidence of aspiration.",2018-08-01
5877,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2015-03-05,325,D,0,1,YNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to obtain weekly weights due to significant weight loss per the recommendation of the Registered Dietician (RD) for Resident # 26, 1 of 3 sampled residents reviewed for nutrition. The findings included: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Record review of the residents Weights and Vitals Summary on 3/5/2015 at 8:39 AM revealed a 9% weight loss in 30 days. The resident's weight on 1/8/2015 was 157.8 pounds. The resident's weight on 2/11/2015 was 145.4 pounds. The last weight documented for the resident was on 2/17/2015 with a result of 95 pounds. Review of a Nutrition Note at approximately 8:39 AM revealed that the RD had identified a significant weight loss on 2/12/2015. Review of the physician's orders [REDACTED]. During an interview on 3/5/2015 at 8:20 AM, the RD stated that after identifying the significant weight loss s/he implemented multiple interventions, including weekly weights. The RD was interviewed again at 9:06 AM and confirmed there was no order for weekly weights and that weekly weights were not noted on the Care Plan. In addition, the RD stated the weight for 2/17/2015 (95 pounds) was incorrect and confirmed the last accurate weight for the resident had been on 2/11/2015. The RD confirmed s/he recommended weekly weights for the resident, but the weekly weights had not been done. When asked how the staff would know to weigh the resident weekly, the RD stated s/he gave the Director of Nursing a list of residents s/he recommended for weekly weights. When asked if s/he could show documentation of this list the RD produced a photocopy of a sticky note at 9:25 AM. Written on the sticky note was Weekly Weights and 3 residents' names (including Resident #26 due to significant weight loss). The note did not indicate the author, nor was it signed or dated. During another interview at 9:38 AM, the RD stated Resident #26 had been weighed that morning (3/5/2015). The resident's weight was 143.2 pounds - a loss of 2.2 pounds.",2018-08-01
5878,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2015-03-05,328,D,0,1,YNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide oxygen (O2) as ordered for 1 of 2 sampled residents reviewed for respiratory care. Resident #30 was observed with no oxygen on or with 2 liters of oxygen infusing when physician's orders [REDACTED]. The Comprehensive Care Plan for Resident #30 was not updated to include behaviors of removing the Oxygen and/or changing the Oxygen settings. The findings included: The facility admitted Resident #30 with [DIAGNOSES REDACTED]. The resident was admitted to hospice care on 2/9/15 with [DIAGNOSES REDACTED]. Review of the 2-18-15 Readmission Minimum Data Set Assessment revealed that the resident had a Brief Interview for Mental Status Score of 8, indicating moderate cognitive impairment. No rejection of care was documented under the behavior section of the assessment. Record review on 3/5/15 at 10:25 AM revealed 2/9/15 physician's orders [REDACTED]. Observation on 3/3/15 from 10:40 AM to 10:50 AM revealed the resident sitting in his/her wheelchair in the room with Oxygen infusing via nasal cannula at 2 liters per minute by Oxygen concentrator. Observation on 3/4/15 at 8:46 AM revealed the resident sitting at the dining room table feeding her/himself. The resident was on room air. There was no oxygen tank or concentrator present for the 15 minute meal observation. Observation with the Director of Nursing (DON) on 3/5/15 at 10:30 AM revealed Resident #30 sitting in his/her wheelchair in the room with oxygen infusing via nasal cannula by concentrator at 2 liters per minute. According to the DON, hospice had ordered the oxygen at 5 liters upon return from the hospital in early February. S/he stated Resident #30 did not like to wear the oxygen at times, and turned the oxygen down or took it off. Review of the Care Plan with the DON revealed the resident had not been care planned for removing or turning down the oxygen. The DON was informed of previous surveyor observations of the resident without oxygen for a breakfast meal and with the oxygen at 2 liters. A review of the care plan revealed the resident was to have oxygen settings per orders via nasal cannula, and that If the resident is allowed to eat, oxygen still must be given to the resident . During an interview on 3/5/15 at 10:35 AM, Licensed Practical Nurse (LPN) #1 stated that oxygen saturations weren't routinely monitored for Resident #30. LPN #1 reviewed the documentation in the record that showed the resident's oxygen saturation had been taken (with oxygen) on 2/10/15 with a saturation of 99% and on 2/12/15 with a saturation of 92%. Further interview at 11:58 AM with LPN #1 revealed that s/he had been aware that the resident turned down and/or took off his/her oxygen. According to the nurse, the resident got confused and thought the oxygen was his/her nebulizer treatment and the resident would state s/he was only to get this treatment for 15 minutes. During an interview on 3/5/15 at 11:53 AM, the MDS (Minimum Data Set) Coordinator stated s/he had been aware that the resident took off his/her oxygen at times. When asked, the MDS Coordinator stated the care plan probably should have been updated with this information under behaviors.",2018-08-01
5879,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2015-03-05,329,E,0,1,YNC111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and a review of the facility policy entitled [MEDICAL CONDITION] Management, the facility failed to appropriately monitor the use of psychoactive medications for 1 of 5 sampled residents reviewed for unnecessary medications. Facility nursing staff failed to adequately document behaviors and interventions used prior to the administration of As Needed (PRN) [MEDICATION NAME] to justify its use for Resident #24. There were multiple blanks in Behavior Monthly Flow Sheets and there was no Behavior Monthly Flow Sheet in the record for March, (YEAR). where the nursing staff failed to document whether the resident did or did not have behaviors and/or to indicate what interventions had been used for Resident #24 related to the use of antidepressant and anti-anxiety medications. The findings included: The facility admitted Resident #24 with [DIAGNOSES REDACTED]. A review of the record on 3/4/15 revealed Resident #24 had orders for and/or had received the following psychoactive medications in (MONTH) 2014, and in January, February, and (MONTH) of (YEAR). The medications included [MEDICATION NAME] Oxalate once daily for Depression, [MEDICATION NAME] sprinkles two times a day for Senile Dementia with Depressive Features, [MEDICATION NAME] three times daily for Anxiety, and [MEDICATION NAME] every 24 hours as needed for Anxiety. On 3/4/15, a review of the Behavior Monthly Flow Sheets for (MONTH) 2014, (MONTH) (YEAR), and (MONTH) (YEAR) revealed multiple blanks where facility nursing staff had failed to document whether the resident had exhibited behaviors relative to the administration of antidepressant or anti-anxiety medications. The facility was unable to provide a (MONTH) (YEAR) Behavior Flow Sheet. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of Nursing Progress Notes revealed the PRN doses of [MEDICATION NAME] had been administered for anxiety or agitation. A note dated 2/16/15 at 5:46 PM documented the medication had been given for grabbing at others. A note dated 2/26/15 at 3:59 PM documented the PRN [MEDICATION NAME] had been given for continued grabbing at others. There was no documentation in the record of any behavioral interventions attempted prior to giving the medication or documentation to indicate the duration or intensity of the behavior justified the use of the PRN [MEDICATION NAME]. During an interview on 3/4/15 at approximately 3:45 PM, the Director of Nursing (DON) verified there were blanks on the Behavior Flow Sheets. The DON stated there was no (MONTH) Behavior Flow Sheet for Resident #24. After reviewing the (MONTH) Medication Administration Record [REDACTED]. A review of the resident's comprehensive care plan with the DON revealed a care plan had not been developed related to the use or monitoring of psychoactive medications. A review of the facility policy entitled [MEDICAL CONDITION] Management, Copyright 2011, revealed A psychoactive drug is considered a chemical restraint when it is used as the first intervention to control behavior, mood, or mental status .The facility will use psychoactive drug therapy only when appropriate to enhance the quality of life, while maximizing functional potential and well being of the resident. Qualified staff will monitor for potential undesirable side effects that are associated with the use of psychoactive drugs according to CMS .",2018-08-01
7113,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2014-06-12,280,D,0,1,ZFVU11,"**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 care plan for 1 of 1 sampled residents reviewed with concerns related to the revision of the careplan after having multiple changes in orders. The care plan for Resident #50 was not updated to reflect discontinuation of Physical Therapy, Occupational Therapy, Speech Therapy, TED Hose, and medication orders. In addition, Resident #27's family was not afforded the right to participate in planning care and treatment. ( 1 of 1 sampled residents with no evidence of the right to participate in care plan meetings.) The findings included: The facility admitted Resident #50 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Physician's Telephone Order dated 5/05/14 which indicated [MEDICATION NAME] was to be discontinued in 14 days. A Physician's Telephone Order dated 5/22/14 stated that Ted Hose was to be discontinued per family request and MD approval. An order dated 5/25/14 indicated that Speech Therapy (ST) was to be discontinued with a clarification order dated 5/27/14 which stated that discontinuation of ST was effective 5/28/14. A Telephone Order dated 5/29/14 indicated that Physical Therapy (PT) was discontinued with Resident #50 being referred to Restorative Therapy 5 times per week for 3 months. In addition, a Telephone Order dated 6/2/14 indicated that Occupational Therapy (OT) was discontinued effective 5/29/14. Record reviewed revealed that the current care plan indicated Resident #50 was receiving PT, ST, and OT. The care plan further indicated that Resident #50 was receiving [MEDICAL CONDITION] medications that included [MEDICATION NAME]. In addition, the care plan indicated that Ted Hose were used as an intervention related to hypertension. During an interview on 6/12/14, the MDS-Care Plan Coordinator was asked about the process for updating care plans. The Care Plan Coordinator stated that a copy of Physician's Telephone Orders is used to update and revise resident care plans. At that time, the Care Plan Coordinator reviewed Resident #50's care plan and Physician's Telephone Orders as referenced above and confirmed that the care plan was not revised related to Ted Hose, PT, ST, OT, and [MEDICATION NAME]. The facility admitted Resident #27 with [DIAGNOSES REDACTED]. During family interview it was stated that the facility did not inform the responsible party/family of the quarterly care plan meeting(s). An interview on 6/10/14 at approximately 3:38 PM with the Social Services Director revealed he/she would send a letter or make a telephone to call to inform family/responsible party of care plan meetings. Review of the Social Services notes revealed there was no documentation to indicate the family/responsible party was informed of the care plan meeting. The Social Services Director confirmed the findings and stated he/she did not have any documentation to confirm the family/responsible party was notified of the care plan meeting.",2017-06-01
7114,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2014-06-12,323,E,0,1,ZFVU11,"On the days of the Recertification survey, based on observations, record reviews and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Elevated hot water temperatures existed in 10 of 18 resident rooms and 1 of 2 shower rooms. The findings included: During a tour of the facility on 6/9/14 at approximately 11:50 AM, hot water temperatures were checked in rooms 117-118 . The bathroom hot water temperature was checked at the sink and was 130 degrees Fahrenheit using a digital thermometer. The surveyor conducted further observations and measured the water temperature at the bathroom sink in additional resident rooms which revealed the following: Rooms 113-115: 130 degrees Fahrenheit Rooms 114-116: 127 degrees Fahrenheit Rooms 110-111: 127 degrees Fahrenheit Shower room 123 degrees Fahrenheit Room 109: 130 degrees Fahrenheit Room 106-108: 126 degrees Fahrenheit Room 105-107: 124 degrees Fahrenheit Room 102-104: 123 degrees Fahrenheit Room 101-103: 125 degrees Fahrenheit The Maintenance Supervisor on 6/9/14 at approximately 1:00 PM, toured the facility with the surveyor to evaluate the elevated hot water readings. The Maintenance Supervisor obtained following readings using his/her digital thermometer: Rooms 117-118: 122 Fahrenheit Rooms 113-115: 128 Fahrenheit Shower room: 123 degrees Fahrenheit Rooms 114-116: 124 degrees Fahrenheit Rooms 105-107:124 degrees Fahrenheit Rooms 106-108: 122 degrees Fahrenheit During the tour with the Maintenance Supervisor, s/he stated the lines and the mixing valve had been replaced and stated sometimes the system has to be adjusted. Observation of the hot water tank revealed a temperature of 100 degrees, and the Maintenance Supervisor stated that the water heater has a booster to help the temperature to increase. Review of the water temperature log revealed instructions on the form which noted, Let the water run for at least three minutes before taking your reading .Ensure patient room water temperatures are between 105 degrees and 115 degrees Fahrenheit test temperature in shower areas, test temperature at the mixing valve and check resident rooms at the end of each wing on a rotating basis Record results in the water temperature log .1.) note any discrepancies .2. Adjust water heater setting as required. 3. Retest as necessary. Review of the Logbook documentation of water temperatures provided by the facility did not note any discrepancies for the month of June 2014. On 6/9/14 at approximately 4:18 PM during an interview with Registered Nurse #1 s/he stated the residents in the rooms of concern were not able to access the bathrooms independently and are accompanied to the shower rooms by the Certified Nursing Assistants.",2017-06-01
7115,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2014-06-12,325,D,0,1,ZFVU11,"**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 Resident #9 maintained an acceptable parameter of nutritional status. Resident #9 sustained a significant weight loss from 105 pounds in December 2013 to 79 pounds in June 2014. The resident was not observed to be assisted with his/her meal and was not offered supplements as ordered by the physician. ( 1 of 3 residents reviewed for maintenance of acceptable parameters of their nutritional status.) The findings include: The facility admitted Resident #9 with the [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set assessment with the Assessment Reference Date of 5/7/14 revealed that Resident # 9 had severe cognitive impairment, required supervision and assistance with eating and indicated the resident had a significant weight loss. The medical record documented the resident weighed 105 pounds in December of 2013, 84 pounds in 5/19/14 and 79 pounds on 6/2/14. Review of the Resident's care plan on 6/11/14 at approximately 11:58 AM noted, Resident leaves 25 % or more of food uneaten. Resident may have weight fluctuations related to [MEDICAL CONDITION] in both legs. History of significant weight loss. The interventions/approaches were to: Document percentage of meal intake in the clinical record, medications as ordered, supplements as ordered and monitor appetite. Review of Resident #9's medical record on 6/11/14 at approximately 12:00 PM, revealed a nutritional review dated 5/23/14 which noted Weight loss of 17 %, current weight 84 pounds, appetite poor. House Supplement three times a day which provides 720 kilo calories (kcal), suggest milkshakes with meals to provided added 600 kcal. Review of Resident #9's physician's orders [REDACTED]. On 6/11/14 at approximately 12:18 PM, Resident #9 was observed seated in the main dining room during lunch. The resident was served his/her meal tray which did not include the ice cream supplement, pudding or custard. Resident #9 was observed not eating and not being assisted with eating. During an interview with the Director of Nursing (DON) on 6/11/14 at approximately 12:30 PM, s/he stated the resident required assistance and supervision with eating, however, refuses. The DON asked the resident if s/he could provide assistance, the resident agreed and began eating the meal with assistance provided. The DON further confirmed the resident had not received his/her supplement (ice cream) with the lunch meal and verified that it was not on the tray card provided by Dietary.",2017-06-01
7116,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2014-06-12,371,F,0,1,ZFVU11,"On the days of the survey, based on observations and interview the facility failed to store, prepare and distribute food under sanitary conditions. Dietary staff failed to fully restrain their hair; 6 of 6 ceiling vents were observed with a heavy accumulation of grease and dust and a soiled fan was blowing on clean dishes. The deficient practices had the potential to affect all resident's who received their meals through the Dietary Department. The findings included: During the initial tour of the facility on 6/9/14 at approximately 9:54 AM, an observation was made of heavy accumulation of dust and grease like build up on all the ceiling vents in the food production area of the kitchen. The surveyor also observed a dusty and heavily soiled fan blowing on the clean dishes. During an interview with the Dietary Aide on 6/9/14 at approximately 10:06 AM s/he confirmed that the soiled fan was blowing on the clean dishes. During an interview with the Maintenance Supervisor on 6/10/14 at approximately 12:00 PM, s/he stated that Maintenance was responsible for cleaning the vents and equipment in the kitchen and verified the accumulation of debris on the vents. During a follow up observation of the kitchen on 6/10/14 at approximately 12:00 PM and 4:32 PM the Certified Dietary Manager was observed walking throughout the kitchen with the his//her hair not fully restrained under a hair net.",2017-06-01
7117,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2014-06-12,431,D,0,1,ZFVU11,"On the days of the survey, based on observations, interviews and review of the facility policy titled Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles last revised 12/7, the facility failed to follow procedure for dating an insulin syringe after opening. (1 of 2 medications carts reviewed for appropriate medication storage) The finding included: During an observation of the medication cart on 6/10/14 at approximately 9:15 AM, the surveyor observed (1)-3 mililiter insulin syringe Novolog Flex pen opened and not dated. The instructions on the syringe stated: Discard unused medication after 28 days. During an interview with Licensed Practical Nurse #1 on 6/10/14 at approximately 9:38 AM, s/he confirmed the surveyor's finding. Reveiw of the facility policy titled Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles it stated: Once any drug or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration daes for opened medications.",2017-06-01
8045,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,174,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of the facility's policy entitled Residents' Personal Property, the facility failed to investigate missing personal items for Resident #4, 1 of 2 sampled residents reviewed for Personal Property. The resident's dentures went missing and the facility did not follow up on the missing dentures. The findings included: During an interview with Resident #4 on 6/13/2016 at 2:14 PM, Resident #4 stated that shortly after being admitted to the facility her dentures went missing. The resident stated that she/he had removed and cleaned her/his dentures and placed them in the denture cup. The next time she/he went to use her/his dentures, the dentures and denture cup were missing from her/his room. The resident stated that she/he reported the missing dentures to a staff member. The resident also stated that the facility did not follow up on the missing dentures with her/him or let her/him know if they were looking for the dentures. During an interview with the Social Services Director (SSD) on 6/14/2016 at 4:43 PM, the SSD stated that she/he was unaware that the residents dentures were missing prior to today. The SSD stated she/he had talked with the resident and resident's family member on 6/14/2016 to confirm that the dentures had gone missing. The SSD also stated that the resident's family member told her/him that she/he was aware the dentures were missing during a visit to the facility in April, but didn't think to notify staff. The SSD stated that the facility would replace the resident's dentures as soon as possible. The SSD also stated that during her/his investigation shehe discovered that a CNA (Certified Nursing Assistant) was told by the resident that her/his dentures were missing. During an interview with the SSD on 6/15/2016 at 8:25 AM, the SSD confirmed that a CNA was aware that the resident's dentures had gone missing, but this information did not get back to her/him and was not acted on until 6/14/2016. Review of the facility's policy entitled Residents' Personal Property on 6/15/2016 at 8:35 AM, revealed that any reports of misappropriation or mistreatment of [REDACTED].",2016-09-01
8046,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,241,E,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that staff knocked on residents' doors before entering their room or knocked on doors and waited for permission prior to entering a resident's room for 3 of 3 sampled residents reviewed for dignity and random observations of staff entering other residents' room without knocking. Staff was observed entering Resident #23, #35 and #60's room without knocking or getting permission to enter the room after they knocked. Random observations on hall with room numbers 113-118 revealed staff entering residents' rooms multiple times without knocking. The findings included: During the Stage I interview on 6/13/16 at approximately 10:05 AM with Resident #23, Certified Nursing Aide (CNA) #2 was observed entering the resident's room twice without knocking. A few minutes later a part-time nurse knocked on the resident's door and entered the room without getting the resident's permission. The part-time nurse then went into the resident's bathroom. Resident #23 stated he/she did not hear the staff knock on the door or got permission to enter the room. During the Stage I interview on 6/13/16 at approximately 10:29 AM with Resident #60, a staff member was observed knocking then entering a resident's room without permission. Random observation on 6/13/16 at approximately 11:02 AM, CNA #2 was observed entering the resident's rooms without knocking. Random observation on 6/13/16 at approximately 3:41 PM, Registered Nurse (RN) #3 was observed entering Resident #25's room (room [ROOM NUMBER]) and room [ROOM NUMBER] without knocking. An interview at approximately 3:42 PM revealed the nurse had been employed with the facility for a number of years. Random observations on 6/14/16 at approximately 9:22 AM CNA #2 was observed entering room [ROOM NUMBER] without knocking. At approximately 9:25 AM CNA #2 and another CNA was observed entering room [ROOM NUMBER] without knocking. During an interview on 6/14/16 at approximately 9:30 AM CNA #2 confirmed he/she did not knock on resident's doors on 6/13/16 or 6/14/16. CNA #2 further stated when he/she sees a door closed he/she feels a need to check on the resident and that's why he/she just goes in the resident's room. The CNA then stated he/she did not knock because one of the resident's in the room was hard of hearing. The CNA acknowledged the room was shared by four residents.",2016-09-01
8047,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,247,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of the facility's RESIDENT ADMISSION AGREEMENT packet, the facility failed to ensure that 1 of 1 sampled resident reviewed with a room or roommate changed received a notice of room change prior to the change. Resident #60 had a room change without advance notice. The findings included: The facility admitted Resident #60 with [DIAGNOSES REDACTED]. During an interview on 6/13/16 at approximately 10:29 AM, Resident #60 stated he/she was moved to another room without notice of the room change. The resident further stated he/she did not know why he/she had to move to the room he/she was in currently. A review of the medical record on 6/14/16 at approximately 12:05 PM revealed an Admission's Minimum Data Set MDS dated [DATE] indicated the resident was alert and interview-able with a Brief Interview Mental Status (BIMS)score of 10. Further record review revealed a nurses' note dated 3/25/16 that indicated the resident was in room [ROOM NUMBER] on admission. There was no documentation in the chart to indicate when Resident #60 was moved to room [ROOM NUMBER], his/her current room. There was no documentation in the chart to indicate if the resident and/or responsible party was notified prior to the room change. An interview on 6/14/16 at approximately 1:21 PM with the Social Services Director (SSD), revealed there was no discussion with the resident or family about the room change. The SSD confirmed there was no documentation in the medical record about a room change and there was no documentation of a discussion with the resident and/or responsible party about a room change. The SSD further stated Resident #60 was moved to another room on 5/10/16 after looking into the electronic record. Review of the facility's RESIDENT ADMISSION AGREEMENT packet on 6/14/16 at approximately 1:33 PM revealed under Section IV FACILITY OBLIGATIONS AND RIGHTS page 4 related to room change: The Facility reserves the right to change the Resident's room or roommate when the Facility determines it is appropriate to do so. Resident and Responsible Party will be notified prior to a transfer and will have an opportunity to provide input on roommate selection and location. The Facility will make changes in accordance with state and federal regulations.",2016-09-01
8048,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,250,E,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy entitled Social Service Program, the facility failed to provide medically appropriate Social Services for Resident #49 and Resident #60, 2 of 3 sampled residents reviewed for Social Services. Resident #49 had a history of [REDACTED]. In addition, Resident #49 wandered into the room of Resident #60 and got into the resident's bed. Resident #60 was not provided with any follow up by Social Services to assess the impact of Resident #49's actions. The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Record review of the Preadmission Screening and Resident Review (PASARR), dated [DATE], on [DATE] at 11:41 AM revealed that Resident #49 was most recently hospitalized for [REDACTED]. The PASARR also indicated that the resident has a mental illness for which he/she is in need of psychiatric/mental health treatment services. Record review of a hospital consult report on [DATE] at 11:43 AM, dated [DATE], revealed that the resident was admitted to the hospital from another facility after being physically abusive to another resident. Record review of the Nursing Home Admission H&P Worksheet on [DATE] at approximately 11:41 AM revealed that the facility was aware the resident had been hospitalized for [REDACTED]. Record review of the facility physician's History and Physical, dated [DATE], on [DATE] at approximately 11:41 AM, revealed that the resident had been admitted to the hospital because of violent behavior related to his Lewy Bodies Dementia and was treated and stabilized while there. The physician also dictated that managing the resident's behaviors will be challenging because medications do not work well in this condition. Record review of the physician's Progress Notes from [DATE] and [DATE] on [DATE] at 11:51 AM, revealed that the reason for the ,[DATE] visit was for Pacing, violent behavior. The physician dictated that the resident was swinging at people and being violent. The physician dictated in the ,[DATE] note that the resident was pacing continually and refusing to allow staff to feed him or clean him. In addition, it was dictated that the staff had to approach the resident in numbers to accomplish simple hygiene. The physician's notes indicated that anti-psychotic and mood stabilizer medications were the primary means of treating the resident's behavioral symptoms. Record review of the Nurse's Notes from [DATE] - [DATE] on [DATE] at 12:01 PM, revealed that the resident frequently refused medications, frequently refused personal care including incontinence care, had frequent restlessness and agitation, and continuously paced through the facility. In addition per the Nurse's Notes: On ,[DATE] the resident refused to allow staff to put shoes and socks on him/her and became extremely agitated and threatened to hit staff. On ,[DATE] the resident was refusing personal care, was very agitated and Still is pacing in halls most of the time. On ,[DATE] it was documented that Resident appears agitated this afternoon, pacing all over the hallway, unable to redirect, but able to eat sandwich and have a drink of juice, resident started hitting bathroom door near nurses station, unable to redirect, noted slight redness to knuckles on both hands, resident refused to be changed. will continue to monitor. On ,[DATE] the resident became combative with staff during incontinence care. The resident had to be changed with the assistance of 4 people. On ,[DATE] the resident was extremely agitated and walking around the hallway naked. He/she refused to put on clothes and became combative with staff when attempting to dress him/her. A Zyprexa (Anti-Psychotic) injection was given due to the severe agitation. An entry entered on [DATE] at 7:16 AM read Patient being belligerent and violent towards staff. Gave IM zyprexa. Patient fell asleep for 30 minutes and was back up ambulating into other patients rooms. A patient had deceased in another room and this patient .had went into deceased patient's room and was trying to pull him/her out of bed and when staff intervened, patient became violent again. After redirecting him/her and shutting all the doors on A hall, patient then went into a female/male residents room on B hall and climbed into her/his bed and would not get out. Female/male patient got very upset and stated she/he would be calling higher authorities. Record review of the Social Services Notes from [DATE]-[DATE] on [DATE] at 12:27 PM revealed 6 notes by the Social Services Director. On ,[DATE] the Social Services Director (SSD) noted that the resident walks in the hallways and mumbles to self. On ,[DATE] the SSD documented that the resident refused care today and staff provided incontinence care with 4 staff members - Resident continues to pace in hallway and mumbles under breath. Not easily redirected. On ,[DATE] the SSD documented that the resident was calmer, but continued to refuse care and was not easily redirected. An entry dated [DATE] at 2:45 PM read Resident has been up and walking in the hallway. Resident has been mumbling to self. Resident was redirected to dayroom where he sat on sofa and went to sleep. The two remaining SSD notes were dated [DATE]. There was no documentation in the record that the SSD had provided any kind of intervention, follow up or services related to the incident documented in the [DATE] Nurse's Note. There was no documentation by the SSD of any interventions, follow up or services implemented related to the other behavioral issues from the Nurses Notes. Record review of the comprehensive plan of care (care plan) on [DATE] at 2:27 PM, revealed that the resident's violent/combative behaviors and severe agitation were not care planned for prior to [DATE] and there were no interventions/services in place for the violent/combative behaviors prior to [DATE]. The care plan did not address the resident's history of violence towards other residents prior to [DATE]. The care plan did not address the safety of other resident's prior to [DATE]. The care plan did not address the resident's rejection/refusals of personal care or refusals of medications. The care plan did not address the resident's use of Anti-Psychotic medications. The care plan did not indicate that multiple staff members were needed to complete personal care tasks. The behaviors care planned for prior to [DATE] were pacing and wandering/elopement. The interventions and services in place prior to [DATE] were not appropriate based on the resident's history and documented behaviors. Those behavioral interventions and services in place prior to [DATE] were to check placement and function of wander guard every shift, distract the resident from wandering, observe the resident for fatigue and weight loss, orient resident to environment, provide structured activities, and reorient/validate and redirect resident as needed. The above interventions were initiated on [DATE]. There was no revision of the care plan related to the behavioral symptoms prior to [DATE]. The care plan do not list and mental health services or referrals. During an interview with the SSD and Nursing Home Administrator (NHA) on [DATE] at 1:10 PM, they were asked what rooms and beds the resident entered on [DATE]. Neither the NHA or the SSD knew whose bed the resident got into or who the deceased resident was that Resident #49 tried to pull out of the bed. The Incident Report for [DATE] was requested from the NHA. The SSD was asked for documentation indicating what services and/or interventions were in place to address the residents behaviors. The SSD looked at the NHA and stated that Resident #49 did not belong in this facility. The SSD confirmed that the Social Services Notes and the care plan did not identify interventions or services for the resident's violent, combative behavior, rejection of care, or resident safety prior to [DATE]. During an interview with the SSD on [DATE] at 2:02 PM, the SSD was asked if Resident #49 was a good candidate for this facility based on the documentation the facility had and what were her/his recommendations? The SSD stated that Resident #49 was not a good candidate for this facility based on his/her behavioral symptoms and was recommending that the resident be discharged from the facility. The SSD stated that she/he had recommended discharge for the resident at morning meetings prior to today based on the resident's behaviors. The SSD stated there was no documentation of this. The SSD also confirmed she/he had no documentation related to the events on [DATE]. In addition, the SSD confirmed the identities of the resident's involved in the [DATE] incident. She/he stated that an interview had been done with Resident #60 and she/he was the resident whose bed Resident #49 climbed into. The SSD stated that Resident #60 told her/him she/he was not in the bed when resident #49 got into it. At 2:08 PM the NHA stated that an Incident Report had not been completed for the events on [DATE]. During an interview with the SSD at 2:26 PM, the SSD stated she/he was arranging for the resident to be transferred to the geriatric psychiatry unit at the hospital. At 4:19 PM the SSD stated that the resident had been transferred to the hospital. During an interview with Registered Nurse (RN) #2 on [DATE] at 3:08 PM, RN #2 stated she/he was the nurse working during the events on [DATE]. RN #2 stated that Resident #60 was up walking in the hall when Resident #49 got into her/his bed. RN #2 stated it was common for resident #60 to walk during the night shift because it relieved discomfort in her/his legs. RN #2 also stated that Resident #60 entered her/his room while Resident #49 was in her/his bed, but went to the nurse's station when she/he realized Resident #49 was in her/his bed. During an interview with CNA #1 at 3:13 PM, CNA #1 had no additional information and confirmed RN #2's statements. During an interview with the SSD on [DATE] at 11:50 AM, with the NHA present, the SSD confirmed that there was no additional documentation indicating that the resident was receiving appropriate treatment and services for his/her behavioral symptoms nor was the resident receiving psychiatric/mental health services identified as needed in the PASARR. Review of the facility's policy entitled Social Service Program on [DATE] at 12:30 PM, revealed the following: Specific conditions to which the facility should respond with social services by staff or referrals include, but are not limited to: Behavioral symptoms Physical aggresion between residents (due to any reason or variable) Presence of a chronic disabling medical or psychological condition Coping difficulties The facility admitted Resident #60 with [DIAGNOSES REDACTED]. During an interview on [DATE] at approximately 10:29 AM, Resident #60 expressed concerns about a male resident (Resident #49) coming into his/her room and getting into his/her bed. Resident #60 further stated that he/she had expressed his/her concerns to the facility staff but nothing had been done to keep Resident #49 from coming back into his/her room. A review of Resident #60 medical record on [DATE] at approximately 12:05 PM revealed there was no documentation in the medical record to indicate the resident expressed concerns about a male resident getting into his/her bed. There was no documentation in the medical record to indicate the facility made an effort to address Resident #60 concerns of a male resident coming into the resident's room and getting into his/her bed. There was documentation in Resident #49 medical record that indicated Resident #49 was in Resident #60 bed with no interventions in place. During an interview on [DATE] at approximately 1:32 PM with the Social Services Director (SSD), the SSD stated he/she was not aware of Resident #49 getting into Resident #60's bed. The SSD further stated, there was no 24 hour report or incident report of Resident #49 getting into Resident #60's bed. When informed that there was documentation in Resident #49 medical record of the incident, the SSD stated he/she does not read nurse's notes in the medical record.",2016-09-01
8049,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,279,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive plan of care with measurable objectives related to Resident #49's behavioral symptoms, 1 of 1 sampled resident reviewed for Behaviors. Resident #49 had a known history of violent/aggressive behaviors towards other residents and this was not care planned. The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Record review of the Preadmission Screening and Resident Review (PASARR), dated 4/6/2016, on 6/14/2016 at 11:41 AM revealed that Resident #49 was most recently hospitalized for [REDACTED]. The PASARR also indicated that the resident has a mental illness for which he/she is in need of psychiatric/mental health treatment services. Record review of a hospital consult report on 6/14/2016 at 11:43 AM, dated 2/26/2016, revealed that the resident was admitted to the hospital from another facility after being physically abusive to another resident. Resident #49 had struck another resident and was acting aggressively towards another resident. Record review of the Nursing Home Admission H&P Worksheet on 6/14/2016 at approximately 11:41 AM, revealed that the facility was aware at the time of the resident's admission to the facility, that the resident had been hospitalized for [REDACTED]. Record review of the facility physician's History and Physical, dated 4/27/2016, on 6/14/2016 at approximately 11:41 AM, revealed that the resident had been admitted to the hospital because of violent behavior related to his Lewy Bodies Dementia and was treated and stabilized while there. The physician also dictated that managing the resident's behaviors will be challenging because medications do not work well in this condition. Record review of the comprehensive plan of care (care plan) on 6/14/2016 at 2:27 PM, revealed that the resident's violent/combative behaviors were not care planned for prior to 6/14/2016 and there were no interventions or services in place for the violent/combative behaviors prior to 6/14/2016. The care plan did not address the resident's history of violence towards other residents prior to 6/14/2016. The care plan did not address the safety of other resident's prior to 6/14/2016. The care plan did not address the resident's use of Anti-Psychotic medications. The behaviors that were care planned for upon initiation of the comprehensive plan of care were pacing and wandering/elopement. The interventions and services in place prior to 6/14/2016 were not appropriate based on the resident's history and documented behaviors. The behavioral interventions and services in place prior to 6/14/2016 were to check placement and function of wander guard every shift, distract the resident from wandering, observe the resident for fatigue and weight loss, orient resident to environment, provide structured activities, and reorient/validate and redirect resident as needed. There was no revision of the care plan related to behavioral symptoms prior to 6/14/2016. The care plan do not list any mental health services or referrals. There were no specific interventions in place to manage the resident's symptoms that the physician had documented would be difficult to manage. Record review of the Social Services Notes on 6/14/2016 at 12:27 PM, revealed no documentation of the resident's history of violent/aggressive behaviors or that any services or interventions were implemented related to the resident's behaviors. During an interview with the Social Services Director (SSD) and Nursing Home Administrator (NHA) on 6/14/2016 at 1:10 PM, the SSD confirmed that the Social Services Notes did not address the resident's history of behaviors. In addition, the SSD confirmed that the care plan did not identify interventions or services related to the resident's history of violent/aggressive behavior. The SSD was asked for documentation indicating what services and/or interventions were in place to address the resident's history of violent/aggressive behaviors. During an interview with the SSD on 6/14/2016 at 2:02 PM, the SSD was asked if Resident #49 was a good candidate for this facility based on the documentation the facility had and what were her/his recommendations? The SSD stated that Resident #49 was not a good candidate for this facility based on his/her behavioral symptoms and was recommending that the resident be discharged from the facility. The SSD stated that she/he had recommended discharge for the resident at morning meetings prior to today based on the resident's behaviors. The SSD stated there was no documentation of this. During an interview with the SSD and NHA on 6/15/2016 at 11:50 AM, the SSD confirmed that there was no additional documentation indicating that the resident was receiving appropriate treatment and services for his/her behavioral symptoms. The NHA stated that the resident's behaviors stabilized during his/her hospitalization and the resident was not displaying any violent/aggressive behaviors prior to admission to the facility.",2016-09-01
8050,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,282,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that care plans were followed for 1 of 3 sampled residents reviewed for nutrition. Resident #5's care plan was not followed related to notifying the medical doctor of any significant weight changes. The finding included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. A review of the medical record on 6/15/16 at approximately 9:46 AM revealed Resident #5 had an admission weight of 168 pounds on 2/16/16. The medical record further indicated the resident had a weight of 169 pounds on 3/09/16, weighed 170 pounds on 4/12/16, weighed 199 pounds and then weighed 157 pounds on 6/12/16. Further record review revealed a care plan initiated on 2/18/16 and updated on 5/24/16 that indicated Notify MD (Medical Doctor) and family of any significant wt (weight) changes. During an interview on 6/15/16 at approximately 10:20 AM with the Dietary Manager (DM), the DM confirmed significant change in weight and stated the medical doctor was not notified per the care plan.",2016-09-01
8051,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,319,E,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide appropriate treatment and services for Resident #49, 1 of 1 sampled resident reviewed for behaviors. Resident #49 had a history of [REDACTED]. The findings included: The facility admitted Resident #40 with [DIAGNOSES REDACTED]. Record review of the Preadmission Screening and Resident Review (PASARR), dated [DATE], on [DATE] at 11:41 AM, revealed that Resident #49 had 2 hospitalization s for psychiatric illnesses and was most recently hospitalized for [REDACTED]. The PASARR also indicated that the resident has a mental illness for which he/she is in need of psychiatric/mental health treatment services. Specific psychiatric/mental health services recommended on the PASARR were to continue the resident's anti-psychotic, anti-depressant and mood stabilizer medications, which the facility did. Record review of a hospital consult report on [DATE] at 11:43 AM, dated [DATE], revealed that the resident was admitted to the hospital from another facility after being physically abusive to another resident. Resident #49 had struck a resident and was acting aggressively towards another resident. Record review of the Nursing Home Admission H&P Worksheet on [DATE] at approximately 11:41 AM revealed that the facility was aware the resident had been hospitalized for [REDACTED]. Record review of the facility physician's History and Physical, dated [DATE], on [DATE] at approximately 11:41 AM, revealed that the resident had been admitted to the hospital because of violent behavior related to his Lewy Bodies Dementia and was treated and stabilized while there. The physician also dictated that managing the resident's behaviors will be challenging because medications do not work well in this condition. Record review of the physician's Progress Notes from [DATE] and [DATE] on [DATE] at 11:51 AM, revealed that the reason for the ,[DATE] visit was for Pacing, violent behavior. The physician dictated that the resident was swinging at people and being violent. The physician dictated in the ,[DATE] note that the resident was pacing continually and refusing to allow staff to feed him or clean him. In addition, it was dictated that the staff had to approach the resident in numbers to accomplish simple hygiene. The physician's notes indicated that anti-psychotic and mood stabilizer medications were the primary means of treating the resident's behavioral symptoms. Record review of the Nurse's Notes from [DATE] - [DATE] on [DATE] at 12:01 PM, revealed that the resident frequently refused medications, frequently refused personal care (including incontinence care), had frequent restlessness and agitation, and continuously paced through the facility. In addition, per the Nurse's Notes: On ,[DATE] the resident refused to allow staff to put shoes and socks on him/her and became extremely agitated and threatened to hit staff. On ,[DATE] the resident was refusing personal care, was very agitated and Still is pacing in halls most of the time. On ,[DATE] it was documented that Resident appears agitated this afternoon, pacing all over the hallway, unable to redirect, but able to eat sandwich and have a drink of juice, resident started hitting bathroom door near nurses station, unable to redirect, noted slight redness to knuckles on both hands, resident refused to be changed. will continue to monitor. On ,[DATE] the resident became combative with staff during incontinence care. The resident had to be changed with the assistance of 4 people. On ,[DATE] the resident was extremely agitated and walking around the hallway naked. He/she refused to put on clothes and became combative with staff when attempting to dress him/her. A [MEDICATION NAME] (Anti-Psychotic) injection was given due to the severe agitation. An entry entered on [DATE] at 7:16 AM read Patient being belligerent and violent towards staff. Gave IM [MEDICATION NAME]. Patient fell asleep for 30 minutes and was back up ambulating into other patients rooms. A patient had deceased in another room and this patient .had went into deceased patient's room and was trying to pull him/her out of bed and when staff intervened, patient became violent again. After redirecting him/her and shutting all the doors on A hall, patient then went into a female/male residents room on B hall and climbed into her/his bed and would not get out. Female/male patient got very upset and stated she/he would be calling higher authorities. Record review of the Social Services Notes from [DATE]-[DATE] on [DATE] at 12:27 PM revealed 6 notes by the Social Services Director. On ,[DATE] the Social Services Director (SSD) noted that the resident walks in the hallways and mumbles to self. On ,[DATE] the SSD documented that the resident refused care today and staff provided incontinence care with 4 staff members - Resident continues to pace in hallway and mumbles under breath. Not easily redirected. On ,[DATE] the SSD documented that the resident was calmer, but continued to refuse care and was not easily redirected. An entry dated [DATE] at 2:45 PM read Resident has been up and walking in the hallway. Resident has been mumbling to self. Resident was redirected to dayroom where he sat on sofa and went to sleep. The two remaining SSD notes were dated [DATE]. There was no documentation in the record that the SSD had provided any kind of intervention, follow up or services related to the incident documented in the [DATE] Nurse's Note. There was no documentation by the SSD of any interventions, follow up or services implemented related to the other behavioral issues from the Nurses Notes. The Social Services Notes revealed no documentation of the resident's history of violent/aggressive behaviors or that any services or interventions were implemented related to the resident's behaviors. Record review of the comprehensive plan of care (care plan) on [DATE] at 2:27 PM, revealed that the resident's violent/combative behaviors and severe agitation were not care planned for prior to [DATE] and there were no interventions/services in place for the violent/combative behaviors prior to [DATE]. The care plan did not address the resident's history of violence towards other residents prior to [DATE]. The care plan did not address the safety of other resident's prior to [DATE]. The care plan did not address the resident's rejection/refusals of personal care or refusals of medications. The care plan did not address the resident's use of Anti-Psychotic medications. The care plan did not indicate that multiple staff members were needed to complete personal care tasks. The behaviors care planned for prior to [DATE] were pacing and wandering/elopement. The interventions and services in place prior to [DATE] were not appropriate based on the resident's history and documented behaviors. Those behavioral interventions and services in place prior to [DATE] were to check placement and function of wander guard every shift, distract the resident from wandering, observe the resident for fatigue and weight loss, orient resident to environment, provide structured activities, and reorient/validate and redirect resident as needed. There was no revision of the care plan related to the behavioral symptoms prior to [DATE]. The care plan do not list any mental health services or referrals. There were no specific interventions in place to manage the resident's behavioral symptoms that the physician had documented would be difficult to manage During an interview with the SSD and Nursing Home Administrator (NHA) on [DATE] at 1:10 PM, they were asked what rooms and beds the resident entered on [DATE]. Neither the NHA or the SSD knew whose bed the resident got into or who the deceased resident was that Resident #49 tried to pull out of the bed. The Incident Report for [DATE] was requested from the NHA. The SSD was asked for documentation indicating what services and/or interventions were in place to address the residents behaviors. The SSD looked at the NHA and stated that Resident #49 did not belong in this facility. The SSD confirmed that the Social Services Notes and the care plan did not identify interventions or services for the resident's violent, combative behavior, rejection of care, or resident safety prior to [DATE]. During an interview with the SSD on [DATE] at 2:02 PM, the SSD was asked if Resident #49 was a good candidate for this facility based on the documentation the facility had and what were her/his recommendations? The SSD stated that Resident #49 was not a good candidate for this facility based on his/her behavioral symptoms and was recommending that the resident be discharged from the facility. The SSD stated that she/he had recommended discharge for the resident at morning meetings prior to today based on the resident's behaviors. The SSD stated there was no documentation of this. The SSD also confirmed she/he had no documentation related to the events on [DATE]. In addition, the SSD confirmed the identities of the resident's involved in the [DATE] incident. She/he stated that an interview had been done with Resident #60 and she/he was the resident whose bed Resident #49 climbed into. The SSD stated that Resident #60 told her/him she/he was not in the bed when resident #49 got into it. At 2:08 PM the NHA stated that an Incident Report had not been completed for the events on [DATE]. During an interview with the SSD at 2:26 PM, the SSD stated she/he was arranging for the resident to be transferred to the geriatric psychiatry unit at the hospital. At 4:19 PM the SSD stated that the resident had been transferred to the hospital. During an interview with Registered Nurse (RN) #2 on [DATE] at 3:08 PM, RN #2 stated she/he was the nurse working during the events on [DATE]. RN #2 stated that Resident #60 was up walking in the hall when Resident #49 got into her/his bed. RN #2 stated it was common for resident #60 to walk during the night shift because it relieved discomfort in her/his legs. RN #2 also stated that Resident #60 entered her/his room while Resident #49 was in her/his bed, but went to the nurse's station when she/he realized Resident #49 was in her/his bed. During an interview with CNA #1 at 3:13 PM, CNA #1 had no additional information and confirmed RN #2's statements. During an interview with the SSD on [DATE] at 11:50 AM, with the NHA present, the SSD confirmed that there was no additional documentation indicating that the resident was receiving appropriate treatment and services for his/her behavioral symptoms nor was the resident receiving psychiatric/mental health services, other than medication management. The NHA stated that the resident's behaviors stabilized during his/her hospitalization and the resident was not displaying any violent/aggressive behaviors prior to admission to the facility. The resident was observed independently ambulating throughout the facility on 2 of 3 days of the survey. The resident appeared to become agitated when staff attempted to redirect him. The resident was observed grabbing staff members and survey team members on 2 of 3 days of the survey. The resident was not observed threatening other residents or being aggressive towards other residents.",2016-09-01
8052,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,325,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility's Weight/Hydration Management policy, the facility failed to ensure that a resident with a significant weight loss was referred to the physician for 1 of 3 sampled residents reviewed for nutrition. Resident #5 had a significant weight loss with no referral to the physician. The finding included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. A review of the medical record on 6/15/16 at approximately 9:46 AM revealed Resident #5 had an admission's weight of 168 pounds on 2/16/16. The medical record further indicated the resident had a weight of 169 pounds on 3/09/16, weighed 170 pounds on 4/12/16 and weighed 157 pounds on 6/12/16. During an interview on 6/15/16 at approximately 10 AM with the Dietary Manager (DM), the DM confirmed the documented weights in the medical record and stated the 5/12/16 weight of 199 was incorrect and that staff did not subtract the wheel chart weight of 41 pounds. The DM indicated the weight would have been 158 pounds on 5/12/16 which was a significant weight loss of 12 pounds from the 4/12/16 weight of 170 pounds. The DM further stated the family was notified on 6/01/16 at the care plan meeting. There was no documentation to indicate the medical doctor was notified. A review of the facility's Weight/Hydration Management policy on 6/15/16 revealed under #1. Accurate weights are obtained by having the staff follow a consistent approach to weighing and by using an appropriately serviced an functioning scale. The weight management policy further indicated under #4. As residents are weighed, staff can compare current weight to previous weight. Residents with weight variance are reweigh within 24 hours. Per the facility's policy the weight variance would include residents with a weight change of 5 pounds. An interview on 6/15/16 at approximately 10:32 AM with the Director of Nursing (DON) revealed the facility did not follow there protocol related to monitoring resident weight loss. The DON further stated there was no documentation in the medical record to indicate the physician had been notified of the weight loss. An interview on 6/15/16 at approximately 10:43 AM with Registered Nurse #1 revealed the physician was not notified of the weight loss and a referral was made for the resident to be seen by the physician on 6/15/16.",2016-09-01
8053,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,334,C,0,1,VGC011,"Based on influenza regulation and record reviews, the facility failed to provide documentation of consent and education, and did not follow the facilities policy. Four of 5 resident records reviewed (Residents #34, #41, #51 and #15) did not contain in the medical record the required documentation. The findings included: The facility failed to include documentation that indicates at a minimum that the resident or resident's legal representative was provided education for the most recent Influenza season (2015-2016). The documentation must include the benefits and potential side effects of influenza immunization, and that the resident received or did not receive the influenza immunization due to medical contraindications or refusal. The findings included that 4 of 5 resident records reviewed did not have the education documentation for the influenza 2015-2016 season and obtained consent or refusal. Resident #34, #41, #51 and #15 did not contain in the medical record the required documentation.",2016-09-01
8054,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,356,C,0,1,VGC011,"Based on initial tour of the facility on 6/16/2016 at 09:30 AM and staff interviews, the facility failed to post the staffing data required and resident census in a prominent place readily accessible to residents and visitors. The findings included: The findings upon staff interviews of RN #4, RN #1 and the DON, did not know where it was posted. Upon further interview at approximately 10:30 AM, RN #4 located posting information on a clipboard behind the nursing station and stated usually kept on the nurses station, but we have a resident that will take it and tear the papers up.",2016-09-01
8055,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2016-06-16,502,D,0,1,VGC011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy entitled Laboratory (labs) Management, the facility failed to draw labs as ordered for Resident #49, 1 of 5 sampled residents reviewed for Unnecessary Medications. The facility did not draw a [MEDICATION NAME] level as ordered. The findings included: The facility admitted Resident #49 with [DIAGNOSES REDACTED]. Record review of the Physician Orders and lab reports on 06/14/2016 at 12:35 PM, revealed an order, dated 5/11/2016, for a [MEDICATION NAME] (an Anti-Psychotic medication) level to be drawn in the morning. There was no lab report on the medical record with results of the [MEDICATION NAME] level. During an interview with the Director of Nursing(DON) on 6/15/2016 at 9:51 AM, the DON stated that there was no lab report for the [MEDICATION NAME] level. The DON stated she/he called the lab and was told that the [MEDICATION NAME] level was not drawn. The DON was asked why the [MEDICATION NAME] level was not drawn as ordered. The DON stated I don't know. The DON provided a copy of the lab slip filled out for the resident which indicated a valporic acid level and [MEDICATION NAME] level were to be drawn. The DON also provided a lab report that indicated the valporic acid level was drawn as ordered. During an interview at 10:30 AM, the DON stated that the charge nurse is supposed to follow up on lab orders daily to ensure that labs are drawn as ordered. If labs are not done as ordered then the lab is to be contacted to have the labs redrawn and new orders are obtained as necessary. Review of the facility policy entitled Laboratory Management on 6/15/2016 at 11:30 AM, revealed that the facility is responsible for the quality and timeliness of laboratory services.",2016-09-01
8160,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2013-01-23,225,D,0,1,CIQG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, review of resident incident report and interview, the facility failed to conduct a thorough investigation and report a injury of unknown origin for Resident #9. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. The residents Admission Minimum Data Set ((MDS) dated [DATE], documented the resident as having a long and short term memory problems and has impaired decision making. He/She was coded to be independent with locomotion on unit and required extensive assistance with Activities of Daily Living. Review of the Daily Skilled Nurse's Notes on 1/23/13 revealed: 1/19/13 at 5:10 PM, Resident was found in another resident room in floor with pants down. She/he struck her head during fall. She/He suffered a large hematoma above left eye .he/she was sent out to (hospital) for further evaluation. Review of the Patient/Resident incident/accident investigation worksheet revealed the incident as an unwitnessed fall with an injury. Further review of the facility Patient/Resident incident/accident investigation worksheet revealed the facility did not have a statement from the Certified Nursing Assistant (CNA) that was assigned to the resident during the incident. There was no indication or evidence that the facility investigated the residents accident or resultant injury. During an interview with the Director of Nursing on 1/23/13 at 4:45 PM, she/he confirmed that the incident was an injury of unknown origin and that it should have been reported to Certification.",2016-07-01
8161,GOLDEN AGE - INMAN,425316,82 N MAIN STREET,INMAN,SC,29349,2013-01-23,323,D,0,1,CIQG11,"**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 Resident #9 recieved adequate supervision and assistance devices to prevent accidents. Resident #9 was observed without a wheel chair alarm.1 of 4 residents reviewed for falls The findings included: The facility admitted Resident with [DIAGNOSES REDACTED]. Record review on 1/23/12 at approximately 3:30 PM revealed a Fall Risk Assessment which had been done on 12/27/12 and 1/3/13 noting the resident to be a fall risk. Review of the residents Daily Skilled Nurse's Notes revealed the resident had fallen on two seperate occassions: 1/3/13 and 1/19/13. 1/3/13: Resident was observed sitting on floor near w/c (wheelchair) just outside BR (bathroom) door of her/his room 1/19/13: Resident was found in another resident room on floor with pants down. She/he struck her/his head during fall. She/he suffered a large hematoma above left eye Review of the residents Comprehensive Plan of Care dated 1/4/13 stated Resident has a history of falls and is at risk for increased falls and fractures. The approach to the problem was to provide the resident with a w/c alarm which was a nursing intervention. On 1/23/13 at approximately 3:30 PM and 4:30 PM, the surveyor observed Resident #9 sitting in a w/c and propelling self around facility with no w/c alarm intact. During an interview with the Assistant Director of Nursing s/he confirmed the alarm was not in place.",2016-07-01
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
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
3179,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2018-02-28,609,D,1,0,OWFK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility policy titled Alleged Abuse/ Incident of Unknown Origin/ Accident-Injury Complaint/ Complaint Responsibilities, the facility failed to report allegations of abuse to the State Agency within the required 2 hour time frame for 1 of 3 sampled residents reviewed for abuse. The facility failed to report the initial allegations of abuse by Resident #4 within the two-hour timeframe to the state agency. The findings included: Review of the medical record on 2/28/18 revealed Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Review on 2/28/18 of the Initial 24-hour Report submitted to state agencies reveals that the allegation of verbal abuse was reported by staff on 12/28/17 at approximately 9:30 PM. Further review reveals that the information was submitted and accepted via facsimile (FAX) transmissions on 12/30/17 at 9:30 AM. During an interview with the DON (Director of Nursing) and ADON (Assistant Director of Nursing) on 2/28/18 at 3:00 PM, they both acknowledged that the report of allegation of verbal abuse by Resident #4 was not submitted within the required 2 hour time frame to the state agencies as required by the facility policy. Review of the facility policy Alleged Abuse/ Incident of Unknown Origin/ Accident-Injury Complaint/ Complaint Responsibilities on 2/28/18 revealed the following on page 3: Department of Health and Environmental Control (DHEC) Certification and the facility Administrator shall be notified immediately but not later than 2 hours after alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property are made if the events that cause the allegation involve abuse or result in serious bodily injury .",2020-09-01
3180,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,157,E,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility failed to notify the physician and responsible party of resident to resident physical and sexual altercations, in which R215 was the aggressor, for 6 of 57 stage 2 sampled residents (R) (R215, R405, R400, R236, R326, and R406). In addition, R215's responsible party was not notified of a new medication prescribed. These failures created the potential for a lack of physician intervention and family involvement and support when abuse incidents occurred. Findings include: Review of R215's Annual Minimum Data Set assessment (MDS) (a resident assessment tool), dated 1/20/17, revealed the resident was admitted to the facility on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. The 1/20/17 MDS assessment revealed R215 was moderately cognitively impaired (Brief Interview for Mental Status (BIMS) score of 10 out of 15). Section E, Behavior, documented R215's physical and sexual behavioral symptoms directed toward others. Seven incidents of physical or sexual aggression, in which R215 was the aggressor, occurred between 8/7/16 and 4/19/17. R215 was physically or sexually aggressive towards R405, R236, R400, R326, R406 and an unidentified female resident. The facility failed to notify R215's physician and responsible party (RP) as well as the RP and physician for R405, R236, R400, R326, R406 of these incidents. 1) 8/7/16 Incident Between R215 and R405 Review of R215's nursing progress notes on 4/21/17 revealed on 8/7/16 at 6:23 p.m.Resident (R215) observed attempting to kiss R405. When stopped by this nurse R215 briefly became argumentative and made one attempt to repeat behavior. Residents were physically separated by this nurse . No documentation was found which indicated the RP or the physician of R215 were notified of the incident. R405's medical record was reviewed. No documentation was found which indicated the RP or physician for R405 were notified of the incident. 2) 8/21/16 Incident Between R215 and R236 Review of R215's nursing progress notes on 4/21/17 revealed on 8/21/16 at 9:41 a.m.resident (R215) observed with his left hand under the gown of R236. R215 was informed this was not acceptable behavior and to the nurse's station . No documentation was found which indicated the RP or the physician were notified of the incident. Review of R236's clinical record revealed no documentation indicating R236's RP or her physician were notified of the incident. 3) 8/21/16 Incident Between R215 and R400 Review of R215's nursing progress notes revealed on 8/21/16 at 7:10 p.m.resident (R215) observed rubbing buttocks of R400. R400 was not receptive to behavior. Informed R215 touching of this nature was not appropriate, resident became agitated loudly stating 'Why don't you keep your hands to yourself' and 'You go on.' Residents separated by staff . No documentation was found which indicated R215's RP or the physician were notified of the incident. Review of R400's clinical record revealed neither R400's RP nor her physician were notified of the incident. 4) 10/25/16 Incident Between R215 and R326 Review of R215's nursing progress notes on 4/21/17 revealed on 10/25/16 at 5:15 p.m.Resident (R215) seen by CNA striking (R326). Strike an open-handed swipe. Resident (R215) stated 'I didn't mean to, I was trying to hit her hand' and 'She was trying to take my hat.' . No documentation was found which indicated the RP or the physician were notified of the incident. Review of R326's medical record revealed neither R326's RP nor her physician were notified of the incident. 5) 11/17/16 Incident Between R215 and R405 Review of R215's nursing progress notes on 4/21/17 revealed on 11/17/16 at 7:07 p.m.Resident inappropriately touching R405. This resident (R215) had his right hand reaching up resident's shirt and was attempting to kiss other (sic) resident . No documentation was found which indicated R215's RP or the physician were notified of the incident. Review of R326's medical record revealed neither R405's RP nor her physician were notified of the incident. 6) 2/14/17 Incident Between R215 and Unknown Female Resident Review of R215's nursing progress notes on 4/21/17 revealed on 2/14/17 at 10:43 pm .Resident (215) swung at another resident (female) with closed fist because she touched his friend. Only touched her arm out of [MEDICATION NAME] but (R215) swung at resident with open fist . The facility was unable to determine who the female resident was. No documentation could be found which indicated the RP or the physician were notified of the incident. 7) 4/19/17 Incident Between R215 and R406 Review of nursing progress notes on 4/21/17 revealed on 4/19/17 at 8:54 p.m.Resident (R215) in altercation with Resident (R406). Resident (R215) punched resident (R406) in the face because he said resident (R406) was talking to his 'girlfriend.' Redirection was given to Resident (R215). Altercation broken up by staff. Closed fist altercation . R215's responsible party was not notified of the resident-to-resident altercation until 4/21/17 at 6:41 p.m. R406's record was reviewed and revealed no documentation of R406's physician being notified of the incident. A pharmacist note and interview with a staff member revealed R215's RP was not notified of the initiation of a new medication. The pharmacist progress note dated 1/13/17, revealed on 12/13/16 Depo-[MEDICATION NAME] 150 mg IM (intramuscular) was prescribed to be administered every 3 months. The medication Depo-[MEDICATION NAME] was a hormone of the progestin type commonly used as a contraceptive for women. No [DIAGNOSES REDACTED]. During an interview with Nurse Manager (NM)1 on 4/21/17 at 11:50 a.m., she stated no consent was needed from the RP for the Depo-[MEDICATION NAME] and the RP was not notified prior to starting the medication. Review of the physician progress notes [REDACTED]. On 4/21/17 at 5:08 p.m., the medical director stated the incidents that were criminal in nature were reported to the state licensing body and to the QA committee; otherwise, only the family would be notified of resident to resident abuse.",2020-09-01
3181,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,221,D,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, manufacturer guidelines, policy and procedure, and record review, the facility failed to ensure 3 of 57 stage 2 sampled residents (R) (R228, R323 and R197) were free from the use of restraints; the restraints were not applied according to manufacturer guidelines or the facility policy and procedure. Findings include: 1. Review of the Resident Face Sheet revealed R228 was admitted to the facility on [DATE] with a pertinent [DIAGNOSES REDACTED]. rising. The computerized physician order for [REDACTED]. Review of R228's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R228 had short and long-term memory problems, was severely impaired and never/rarely made decisions related to cognitive skills for daily decision-making. R228 used a trunk restraint while seated in the chair or out of bed. The manufacturer's guidelines for the Economy Wheelchair Belt listed the following contraindications for use: Slides down in the wheelchair and is in a geri-chair or lounge chair. This device is intended for wheelchair use only. Review of the facility's policy Protective Device/Restraint Policy dated 9/16/15 indicated Physical Restraints are 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 . Before a resident is restrained, the facility must demonstrate the presence of a specific medical symptom that would require the use of restraints, and how the use of restraints would treat the cause of the symptom . Appropriate exercise, therapeutic interventions . pillows, pads . often assist in achieving proper body position, balance and alignment, without the potential negative effects associated with restraint use. The procedures for this policy indicated . require a physician's order . medical condition requiring use . Nursing should ensure the restraint consent form describing the risks and benefits has been signed by the resident or responsible party . Restraints are applied properly and checked . The Plan of care will reflect use of restraints and safety devices. Observation on 4/20/17 at 9:23 a.m. revealed R228 was in a tilted seat Broda chair with a belt around her waist; the belt was tied to the back of the chair frame . An additional observation on 4/20/17 at 10:41 a.m. revealed R228 was in a tilted seat Broda Chair with the restraint belt still tied to the back of the chair frame. On 4/20/17 at 10:41 a.m. Licensed Practical Nurse (LPN)4 was interviewed. She stated, It (belt) should not be tied to the chair. LPN4 stated she did not know how R228's belt worked with the Broda chair. During an interview with the Director of Nursing (DON) on 4/20/17 at 11:48 a.m., she stated the Economy Wheelchair Belt was the belt in use for R228 and acknowledged it was not being used correctly. Observation on 4/20/2017 at 2:44 p.m. revealed R228 was in the tilted seat Broda chair with the belt restraint attached to the wheel brakes on the back of the chair. The resident did not attempt to rise from chair and was not interviewable. During an interview on 4/21/2017 at 2:58 p.m., Nurse Manager (NM)1 stated R228 had no physician order, consent, or assessment for the tilted seat Broda chair that prevented R228 from rising. She stated the tilted seat Broda chair was initiated for R228 on 12/23/16. R228 was observed during stage 2 of the survey from 4/20/17 to 4/21/17 and was noted to have two restraints in place without a documented medical condition to support the use of devices. There was no physician order, informed consent, or assessment for the tilt seat chair that prevented R228 from rising. The Economy Wheelchair Belt was secured to R228's Broda chair in an unsafe manner and according to the manufacturer guidelines, was not appropriate for use with a Broda chair. 2. Record review revealed R323 had [DIAGNOSES REDACTED]. Review of the 2/10/17 quarterly MDS assessment indicated the resident was severely impaired in cognition and required extensive assistance of one person for bed mobility, transfers, walking in corridor, dressing, toilet use and bathing; R323 was coded for a restraint chair prevents rising and was used daily. The quarterly MDS indicated R323 had a behavior of rejection of care which occurred 1 to 3 days; there were no other behaviors coded in the MDS. Review of the facility's Event Report, dated 12/29/16 and completed on 1/2/17, indicated the resident's last fall occurred on 12/29/16 in the resident's bathroom during an assisted transfer. Review of the Informed Consent for Physical Restraints signed by the responsible party on 1/27/15 indicated Seatbelt c/ (with) alarm 2 (secondary) to impaired gait & (and) decreased (arrow pointing down) safety awareness. Review of the restraint consent form signed by the responsible party on 4/21/17 indicated Seat belt due to nonfunctional gait and decreased safety awareness secondary to dementia. Review of a Nursing Rehab Time Log indicated the resident was ambulating 150 feet using a walker with two person physical assist. Review of a physician's order dated (MONTH) (YEAR), indicated Seat belt due to nonfunctional gait and decreased safety awareness secondary to dementia. Review of a Fall care plan, dated 6/2/16 with a target date of 6/1/17, indicated will be free of complications R/T (related to) falls through the next review . Protective/safety devices as ordered; SCB (secure bracelet) seat belt and 1/2 SR (side rails). Review of the care plan for Protective/Safety Devices, dated 4/25/17 with a target date of 6/10/17, indicated Periodic review of protective/safety devices to determine continued need or benefit. 4/25/16 . Place in w/c (wheelchair) Q (every) day and ensure SB (seat belt) is functioning properly. Review of Resident Progress Notes from 1/1/17 to 4/21/17 revealed no documentation of the resident falling or attempting to remove the seat belt. Review of a Nursing Monthly Comprehensive Summary, dated 4/8/17, indicated the resident did not have any behaviors to place the resident at risk for physical illness or injury. The nursing summary indicated the resident was coded for not having any behaviors of rejecting care or wandering. The Nursing Monthly Comprehensive Summary was not coded for the resident's restraint. Review of the Physical Restraint Reduction Assessment, dated 11/30/16, indicated there were no attempts to reduce the restraint and continue current plan of care. Review of the Physical Restraint Reduction Assessment, dated 2/21/17, indicated there were no attempts to reduce the restraint and to continue current plan of care. During an observation on 4/20/17 at 4:10 p.m., R323 was observed up in her wheelchair sitting in the dining room on the Lexington Unit. The resident was observed with a Crisscross trunk restraint on, while sitting at the table. The resident's restraint was tied to the metal oxygen holder connected to the back of the wheelchair. Certified Nurse Aide (CNA)8 indicated the restraint was not assembled correctly. During an interview on 4/21/17 at 1:00 p.m., NM1 indicated the nurse had coded the entry wrong on the 4/8/17 Nursing Monthly Comprehensive Summary. During an interview with the DON (Director of Nursing) on 4/21/17 at 3:20 p.m., when asked about the resident's restraint, she said the restraint had been applied incorrectly on 4/20/17. The DON was unable to provide any further information concerning attempts to reduce the resident's restraint. The DON indicated she would continue to search around; however, nothing else was provided by the exit. 3. Review of manufacturer guidelines, New York Orthopedic USA documented in pertinent part Procedure for application of seatbelt includes . Place the resident's restraint belt at their waist. Review of the Resident Face Sheet indicated resident R197 was admitted on [DATE] with the following Diagnoses: [REDACTED]. According to the 1/12/17 quarterly Minimum Data Assessment (MDS), R197 scored 5/15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment and used a trunk restraint daily while seated in the chair or out of bed. Review of the computerized physician orders for 4/17 revealed a signed order dated 3/6/17 for a seatbelt to wheelchair due to frequent falls and impulsiveness, check and release per policy. Review of the 2/1/17 Physical Restraint Reduction Assessment indicated R197 leaned to the side, forward and backward, and she was disoriented. R197 attempted to stand, walk and transfer without waiting for assistance. R197's restraint reduction score was 41, indicating she was a poor candidate for reduction. On 4/18/17 at 10:30 a.m. resident R197 was observed sitting upright in her wheelchair in the dayroom with her restraint belt positioned across her chest and under her arm pits. The belt crossed under her wheelchair and buckled to the back of wheelchair. The belt was never observed above the resident's chest, and she was not able to slide out of the chair. On 4/19/17 at 12:05 p.m. R197 was sitting in the dayroom upright in her wheelchair; her restraint belt was positioned across her chest and under her arm pits. The belt crossed under her wheelchair and buckled to the back of wheelchair. On 4/20/17 at 12:20 p.m. R197 was observed sitting upright in her wheelchair in the dining room. R197's restraint belt was positioned across her chest and under her arm pits. The belt crossed under her wheelchair and buckled to the back of wheelchair. The belt had been loosened during the meal, but not removed. During an interview with CNA9 at 12:20 p.m. on 4/20/17 regarding R197's seat belt being across her chest, the CNA stated, She scoots, she'll ask for scissors at times because she wants to cut it off'. The belt is on because of all her falls. LPN7 was interviewed at 12:25 p.m. on 4/20/17 regarding R197's seat belt being across her chest; she confirmed the resident scooted and the seat belt was used due to a history of falls. The DON was interviewed on 4/21/17 at approximately 3:30 p.m. She stated nurses had been signing off that the restraint was checked and released per policy and it was her expectation for staff to ensure the restraint was in the proper position.",2020-09-01
3182,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,225,K,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to report to the state survey agency and to the administrator incidents of potential abuse, thoroughly investigate incidents of resident to resident physical and sexual altercations/abuse perpetuated by resident (R) R215 and R369, and implement follow up interventions for 7 of 57 stage 2 sampled residents (R) (R37, R215, R405, R236, R400, R326, R406 and an unknown female resident). Additionally, a reported incident of staff to resident abuse towards R471 was not adequately investigated. Specifically: The facility failed to ensure aggressive behaviors of R215 towards other residents were thoroughly investigated by the facility, reported to the state survey agency and administrator, and sufficient interventions were implemented to keep the remaining 43 residents who resided on the secure unit safe from harm inflicted by R215. R215, who was cognitively impaired but at a higher cognitive level than the residents he targeted, exhibited aggressive physical behaviors towards residents on 3 occasions and sexually aggressive behaviors towards residents on 4 occasions between 8/7/16 and 4/19/17. The residents assaulted by R215 were R405, R236, R400, R326, R406 and an unknown female resident. Investigations into the incidents and protective measures to prevent recurrence were lacking creating an unsafe environment in the secure unit which perpetuating future incidents of abuse. The facility's failure to report, investigate, and implement interventions to prevent abuse was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified to have existed on 8/7/16 at 6:23 p.m. when R215 was first sexually aggressive towards R405. The administrator and director of nursing (DON) were informed of the Immediate Jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received on 4/21/17 and the immediate jeopardy was removed on 4/21/17 at 6:20 p.m. The scope and severity was lowered to a E, a pattern with potential for more than minimal harm, once the immediate jeopardy was removed. Findings include: 1. Abuse Policies and Procedures a. Per the facility policy and procedure Facility Wide Abuse/Neglect/Misappropriation, dated 2/2004, under Prevention Bullet D, .the facility will thoroughly investigate any suspected abuse, neglect and/or misappropriation of resident property and take appropriate action to prevent recurrence . Under Investigation bullet 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 . b. The facility's 5/27/16 policy addressing Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Complaint (sic) Responsibilities documented: (The state licensing body) shall be notified within 24 hours of a serious accident/incident .A written report will be sent within five (5) days of the serious accident or incident .A serious incident shall be considered as, but not limited to . 7. Confirmed or suspected cases or resident abuse, neglect, or exploitation .There is no requirement to report resident-to-resident abuse where the incident fails to meet other reporting criteria. Though the above policy specifically referred to reportable occurrences as determined by the state licensing entity, the facility failed to address resident-to-resident abuse as a facility system. The facility interpreted the above policy as meaning an incident report, investigation into the root cause and nature of the incident, as well as interventions to keep residents safe from further abuse did not need to be completed for resident-to-resident incidents. Thus, the facility did not have a system to determine whether a resident-to-resident incident constituted confirmed or suspected cases of resident abuse . and would have therefore been considered reportable to the state licensing entity. c. The facility's 2/5/04 Abuse/Neglect/Misappropriation policy documented, (Name of facility) is committed to the prohibition of any mistreatment, neglect, and abuse of residents or the misappropriation of resident property. The policy went on to address screening and training of employees, prevention of abuse through staff training and supervision, and policies on suspending an employee pending investigation of staff to resident abuse. Resident-to-resident abuse was not addressed in the policy. d. The facility's 3/15/00 Resident (to) Resident Abuse policy documented procedures to assess a potential for abusive behavior and develop interventions to prevent aggression toward other residents. The policy did not address reporting and investigating these incidents. 2. Review of R215's Annual Minimum Data Set assessment (MDS) (a resident assessment tool), dated 1/20/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the MDS assessment dated [DATE], the resident's Brief Interview for Mental Status (BIMS) score, measuring cognition, was 10 out of 15. A score of 10 indicated moderate cognitive impairment. The MDS, Section E, Behavior, indicated R215 exhibited physical and sexual, behavioral symptoms toward others. The MDS, Section G, Functional Status, indicated R215 could move about on the unit (locomotion) with limited assistance once he was in his wheelchair Observation of R215 on 4/19/17, 4/20/17 and 4/21/17 at various times of the day, revealed he could independently maneuver his wheelchair throughout the secure unit. He was talkative with staff; however, at times became argumentative when he was not allowed to exit the unit. R215 had a non-releasing seat belt and pommel cushion while in his wheelchair. Review of R215's behavior care plan revealed his physical, verbal and sexually aggressive behaviors were not addressed. a. Seven incidents of physical or sexual abuse, in which R215 was the aggressor, occurred between 8/7/16 and 4/19/17. Cross -reference F323. R215 was physically or sexually aggressive towards R405, R236, R400, R326, R406 and an unknown female resident: 1) 8/7/16 Incident Between R215 and R405 Review of nursing progress notes on 4/21/17 revealed on 8/7/16 at 6:23 pm .Resident observed attempting to kiss R405. When stopped by this nurse R215 briefly became argumentative and made one attempt to repeat behavior. Residents were physically separated by this nurse . A significant change MDS dated [DATE] revealed R405 was severely, cognitively impaired. 2) 8/21/16 Incident Between R215 and R236 Review of nursing progress notes on 4/21/17 revealed on 8/21/16 at 9:41 a.m.resident observed with his left hand under the gown of R236. R215 was informed this was not acceptable behavior and to the nurse's station. R215 gave no verbal or physical reply and was not resistive . The quarterly MDS dated [DATE] revealed R236 was severely, cognitively impaired. 3) 8/21/16 Incident Between R215 and R400 Review of nursing progress notes on 4/21/17 revealed on 8/21/16 at 7:10 p.m.resident observed rubbing buttocks of R400. R400 was not receptive to behavior. Informed R215 touching of this nature was not appropriate, resident became agitated loudly stating 'Why don't you keep your hands to yourself' and 'You go on.' Residents separated by staff . The MDS dated [DATE] revealed R400 was severely, cognitively impaired. 4) 10/25/16 Incident Between R215 and R326 Review of nursing progress notes on 4/21/17 revealed on 10/25/16 at 5:15 p.m.Resident seen by CNA striking (R326). Strike an open-handed swipe . The quarterly MDS dated [DATE] revealed R326 was severely, cognitively impaired. 5) 11/17/16 Incident Between R215 and R405 Review of nursing progress notes on 4/21/17 revealed on 11/17/16 at 7:07 p.m.Resident inappropriately touching R405. This resident (R215) had his right hand reaching up resident's shirt and was attempting to kiss other (sic) resident. When confronted about this behavior resident (R215) laughed, stated 'She wants it.' Informed resident this was not acceptable behavior, separated residents . This was second resident-to-resident sexual altercation between R215 and R405. A significant change MDS dated [DATE] revealed R405 was severely, cognitively impaired. 6) 2/14/17 Incident Between R215 and Unknown Female Resident Review of nursing progress notes on 4/21/17 revealed on 2/14/17 at 10:43 pm .Resident (215) swung at another resident (female) with closed fist because she touched his friend. Only touched her arm out of [MEDICATION NAME] but (R215) swung at resident with open fist . The facility was unable to determine who the female resident was. 7) 4/19/17 Incident Between R215 and R406 Review of nursing progress notes on 4/21/17 revealed on 4/19/17 at 8:54 p.m.Resident (215) in altercation with Resident (R406). Resident 215 punched R406 in the face because he said resident (R406) was talking to his 'girlfriend.' Redirection was given to Resident 215. Altercation broken up by staff. Closed fist altercation . The quarterly MDS dated [DATE] revealed R406 was severely, cognitively impaired. No evidence was found or provided to demonstrate any of the incidents were reported to the state agency. Furthermore, there was a lack of evidence staff reported the incidents to the administrator. None of the incidents were investigated. b. Staff interviews During an interview with the DON on 4/21/17 at 10:30 a.m., she stated I am not aware of the specifics of R215's resident-to-resident altercations, but more on the fringe of things. During an interview with the DON and (nursing manager) NM1 on 4/21/17 at 11:50 a.m., the DON confirmed the facility did not complete incident reports, or conduct any type of investigation when resident-to-resident altercations occurred. She stated We (the facility) just never have. The DON also stated, according to their abuse policy, We are not required to report resident-to-resident abuse to the state. Additionally, neither the DON nor NM1 could say how they tracked or monitored resident-to-resident altercations, and how they determined correct interventions had been implemented. During the same interview with the DON and NM1 on 4/21/17 at 11:50 a.m., they were asked what interventions were implemented to prevent further resident-to-resident altercations. The DON stated They were separated at the time of the incident. Neither the DON or NM1 could state what, if any, additional interventions were put into place following each altercation, other than what was already charted in R215's clinical record. On 4/21/17 at 6:31 p.m., the administrator stated resident-to-resident abuse, physical aggression, or sexually inappropriate behavior had not been brought to his attention. He stated, We don't know about it. With (R215), it appears the nurse made a note and did not tell anybody. My expectation is an incident report be completed. (An incident report) should have been done for every instance. The administrator also stated, I would agree there is a problem with the investigation process. As of the exit on 4/21/17 at 9:15 p.m., the facility had discharged R215 and inserviced all staff currently working on the secure unit on how to recognize abuse, intervention techniques, and proper reporting. 3. An incident of physical abuse was observed during the survey in which R369 hit R37. On 4/18/17 at 12:50 p.m., when R37 commented to R369 regarding her missing shoe, R369 exclaimed, Mind your own damn business! She then hit R37 in the left arm. Three staff members witnessed the altercation; one redirected R369 back to the dining room. R37 wheeled toward his room down the hall; staff were not observed to assess R37 for injury. a. Background Information R369 According to the undated Resident Face Sheet, R369 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/17/17 quarterly MDS assessment documented R369 had severely impaired cognition (section C1000). She had unclear speech (section B0600) and was rarely/never able to understand others (section B0800). R369 exhibited physical and verbal behavioral symptoms directed toward others (section E0200). R369's Care Plan, revised 3/28/17, documented poor safety awareness and impaired decision-making ability due to her dementia and was anxious at times. The approaches included: continuously remind resident of boundaries, .frequently monitor for safety issues and address as needed, .re-direct if wandering and/or any other behaviors are effecting (sic) safety and/or health, .(and) identify environmental factors that may increase anxiety b. Background Information R37 According to the undated Resident Face Sheet, R37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/7/17 quarterly MDS assessment documented R37 had moderately impaired cognition (section C1000). He was rarely/never able to make himself understood or understand others (sections B0700 and B0800). R37's 5/1/14 Care Plan, revised 4/11/17, documented he had cognitive loss (related to) ETOH (alcoholic) dementia with impaired decision making ability and decreased safety awareness with potential for injury and/or elopement. The approaches included, frequently monitor for safety issues and address as needed .continuously remind resident of boundaries .decrease external stimuli and provide a safe environment .(and) identify environmental factors that may increase anxiety. R369's 4/18/17 Progress Note documented, (R37) yelled at this resident, 'Where are your shoes' - This resident made verbal response and slapped (R37) on the left arm - No injuries occurred and staff intervention was successful. Cross-reference F323: the facility failed to identify R369's physical and verbal behavioral symptoms directed toward others in the care plan and include approaches to ensure the safety of the residents on the secure unit for additional aggressive behaviors. Additionally, the facility failed to address the incident in R37's record and there was no evidence the staff assessed R37 to ensure he was not injured by the incident and was not afraid of R369. c. Facility Investigation - 4/18/17 Incident On 4/20/17 at 10:42 a.m., an incident report of the 4/18/17 resident-to-resident altercation was requested from the assistant director of nursing (ADON). The ADON responded that there was no incident report or investigation, as the facility did not complete incident reports for resident-to-resident altercations (cross-reference F226: failure to develop policies to address resident-to-resident altercations and/or abuse). The ADON added the facility did not internally report these incidents or document them on incident reports because the state licensing body did not require them to be reported. On 4/20/17 at 3:45 p.m., the director of nursing (DON) provided the policy addressing resident-to-resident altercations and confirmed these incidents were not reported and no incident reports or other investigations were completed for resident-to-resident altercations. On 4/20/17 at 6:35 p.m., the DON was alerted to the observed resident-to-resident altercation that occurred on 4/18/17 and follow up information was requested. On 4/21/17 at 4:21 p.m., NM 1 stated a progress note for R37 regarding the incident was written on 4/20/17, but should have been done at the time of the incident on 4/18/17. She stated the staff verbally reported the incident to her, but there was no incident report/investigation because these were not completed for any resident-to-resident altercations. However, she stated she would have expected the staff to assess R37 for injury and address the incident in R369's care plan at the time the incident occurred. On 4/21/17 at 5:08 p.m., the medical director stated, with resident-to-resident incidents, they did not complete incident reports or report to the state licensing authority unless the incident was criminal in nature. He stated he would have preferred the facility investigate and implement approaches to prevent recurrence at the time of the incident rather than several days later. 4. R471 The undated Resident Face Sheet documented R471 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R471's closed record was reviewed. The 2/27/17 admission MDS assessment documented R471 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. She exhibited physical behavioral symptoms directed toward others and behavioral symptoms not directed toward others (section E0200) and several mood symptoms of depression (section D0200). R471's 3/15/17, 2:15 p.m. Progress Note documented, Resident went to cardiac appointment with son .and daughter-in- law .While there she voiced concerns to son. Daughter-in-law spoke with Nurse Manager. The ambulance company called and asked what to do as the son had said to take the resident to his home. Nurse Manager spoke with son who stated he was not bringing his mother back that she was going home . A 3/15/17 investigation report documented this statement, written by the director of nursing (DON): At 2:14 p.m., I received a call from Nurse Manager (NM) 3), (who) spoke with (R471's) daughter-in-law who stated that the resident was saying she was mistreated last night. (R471) was going to the bathroom and the (certified nursing assistant (CNA)) began cursing and hit the wall. She was unable to say who the person was but knew that it was not CNA15 or CNA14; that it was someone at night who had worked with (R471) but she couldn't (sic) say who. During this time, (NM3) received a call from the ambulance company transporting (R471) stating the son was telling them not to go back to the facility but take her to his home. (NM3) and I discussed this issue. (NM3) called the son .to speak to him about a discharge against medical advice. (NM3) tried to talk with the son but he kept interrupting her. At one point, she hands me the phone. (R471's) son states he is taking his mother home, that the night (CNA) had verbally abused her and hit the wall with her fist. At one point he uses the word accosted his mother At 3:28 p.m. I received a phone call from (the insurance company representative) .He had been told by (R471's son) that a night shift (CNA) had verbally abused his mother, hit the wall with her fist, and punched a hole in the wall. The representative was calling to inform us that he was filing a quality of care grievance. He asked what we were doing. I told him it had been reported and we would be investigating. He stated it wasn't right that staff should be cussing out people and beating on walls. I again stated this was being investigated.R471is alert and oriented with confusion at times. Her BIMS score is 14 out of 15. She is a very anxious person who had told therapy staff she wanted to go home. During this investigation, the evening CNA .was here. She explained that evening, she was taking (R471) to the bathroom to get ready for bed. She was very anxious, didn't (sic) want to stand up, when the CNA got the sit to stand lift, she became even more anxious. She got assistance and they were able to assist (R471) and get her into bed, a statement to be obtained. Review of the incident investigation, conducted by the facility on 3/15/17 to 3/17/17, revealed it included interviews with 5 staff members as well as observation of R471's bathroom wall, which did not have a hole in it. However, the investigation did not include interviews with other residents who would have had the same caregiver as R471 to rule out similar incidence of abuse. On 4/21/17 at 8:55 a.m., the assistant director of nursing (ADON), whom the facility had designated as their abuse coordinator, stated she had not done any interviews with other residents who lived near R471. She stated, We don't (sic) normally do that. If there was a resident in the room, we would interview them, but we usually don't (sic) interview other residents. On 4/21/17 at 9:53 a.m., the DON stated, it depends on what the complaint is whether we do resident interviews. In the past, we have interviewed the other residents in the same group to see if there are similar complaints. We could not speak with (R471) as she had been discharged from the facility before making the allegation, but we did speak with her CNAs. The story changed as it went along. The family said there was a hole punched in the (bathroom) wall, but we went to look and there was no hole. The DON confirmed there were no interviews conducted with residents as part of this investigation and agreed interviews with residents who might have had the same care givers would be an integral part of an abuse investigation. Although the facility 2/5/04 Abuse/Neglect/Misappropriation policy documented, All suspicious incidents will be thoroughly investigated in a timely fashion The policy did not address all necessary components of the investigation. Except for the resident involved in the incident, the policy did not address the need to obtain witness statements and/or interviews from additional residents. Cross-reference F226 for the failure to develop a comprehensive abuse policy in the area of investigation. Immediate Jeopardy (IJ) was identified in the areas of 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration at F490 and F501, and 42 CFR 483.75 Quality Assurance & Performance Improvement at F520, all cited at a Scope and Severity of a K. Substandard Quality of Care was identified at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation and Quality of Care. Immediate Jeopardy was identified on 4/21/17 and determined to exist starting on 8/7/16 when R215's first sexually aggressive incident occurred towards R405. The facility Administrator was informed of the immediate jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received on 4/21/17. The State Survey Agency validated the IJ was removed on 4/21/17 at 6:20 p.m. The A[NAME] included: Removal plan for Resident #215 for Psychological Evaluation Until Resident #215 can be discharged from the facility, he will be supervised by staff one-on-one. Transport is being arranged for Resident #215 to be discharged immediately to (name of) emergency room for evaluation. He will be evaluated for return following appropriate evaluations and treatment as required . Immediate Plan to Prevent Future Occurrence Residents on the secure unit with known potential for aggressive behaviors will have their care plan reviewed and updated as required. All other residents on the secure unit will have their care plans reviewed and updated as required. All staff currently on duty on the secure unit will be in-serviced during immediately on how to recognize abuse, intervention techniques, and proper reporting. All other staff reporting for future shifts on the secure unit will be in-serviced as above prior to beginning their shift. This will continue until all staff on the secure unit have been in-serviced. All staff will be in-serviced on how to recognize abuse, intervention techniques. All residents in the facility will be assessed for resident-to-resident abuse potential and actions taken as necessary (to include discharge from the facility) to alleviate any concerns. The resident-to-resident abuse policy will be reviewed and amended to include tracking, monitoring, and reporting of any incidents. As of the exit on 4/21/17 at 9:15 p.m., the facility had discharged R215 and inserviced all staff currently working on the secure unit on how to recognize abuse, intervention techniques, and proper reporting. The Scope and Severity was lowered to a [NAME] at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration, at F490; while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes.",2020-09-01
3183,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,226,K,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and interview, the facility failed to ensure the abuse policy and procedure was adequate, providing sufficient detail and direction to staff in the areas of reporting, investigating, and follow up in response to incidents of resident to resident abuse. The facility's current policies and procedures were insufficient in these areas. Staff failed to report and investigate 7 instances of resident to resident sexually or physically aggressive behaviors by resident (R) R215 towards 6 residents (R400, R406, R405, R236, R326, and one unknown female resident) and 1 incident of resident to resident physically aggressive behavior by R369 towards R37. All 8 instances took place in the secure unit where a total of 44 residents resided. In none of these 8 instances, was a report made to the state agency, a thorough investigation completed or sufficient interventions implemented to prevent recurrence. Additionally, R471 reported an allegation of abuse; a thorough investigation was not conducted. The facility's failure to ensure the abuse policy was adequate to prevent the occurrence of resident to resident abuse was determined to be likely to cause serious injury, harm, impairment, or death to a resident; thus, immediate jeopardy was identified on 4/21/17 at 2:42 p.m. All 43 residents who resided on the secure unit with R215 were at risk of abuse from R215 as well as other residents with allegations of abuse that might not be thoroughly investigated. The immediate jeopardy was determined to first exist on 8/7/16 at 6:23 p.m., when R215 was first sexually aggressive towards another resident on the secure unit. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received, and approved, by the state survey agency on 4/21/17 at 6:20 p.m. Following removal of the immediate jeopardy, the deficient practice remained at an [NAME] scope and severity, indicating a pattern of potential for more than minimal harm. Findings include: 1. Abuse Policies and Procedures a. The facility's 3/15/00 policy on Resident (to) Resident Abuse documented, Each resident has the right to be free from mistreatment, neglect, and misappropriation of property by anyone. Although the policy identified residents having the right to be free from mistreatment, neglect and misappropriation of property, the policy failed to identify the right of residents to be free from abuse. b. The Abuse/Neglect/Misappropriation Standard Policy/Procedure dated 2/5/14 documented, the facility was committed to the prohibition of any mistreatment, neglect, and abuse of residents or the misappropriation of resident property. The terms Neglect and Misappropriation of resident property were defined; however, the definition of abuse was not defined or addressed. c. The facility's 5/27/16 policy addressing Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Complaint (sic) Responsibilities documented: All alleged abuse, neglect, exploitation of an adult, incidents of unknown origin with suspicious circumstances, and accident or serious injury such as fractures, severe burns, severe lacerations, severe hematoma; will be investigated, documented and reported to the appropriate state agency as further described in this policy .DHEC (state agency) Licensure shall be notified within 24 hours of a serious accident/incident by phone, email or fax .A serious incident shall be considered as, but not limited to: .7. Confirmed or suspected cases of resident abuse, neglect, or exploitation .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) .There is no requirement to report resident-to-resident abuse where the incident fails to meet other reporting criteria. Although the policy directed staff to report and investigate allegations of abuse, the policy was not clear to direct staff to report and investigate alleged abuse allegations if they were resident to resident incidents. Staff interpreted the policy to mean resident to resident incidents did not need to be reported or investigated without an injury or a crime being obvious or present (see staff interviews below). d. The facility's 5/27/16 policy addressing Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Complaint (sic) Responsibilities documented: Documentation to include but not limited to: 1. All information and forms included in abuse packet 2. Face sheet from resident's chart 3. Pertinent lab or x-ray results 4. Nurse's notes pertinent to the incident 5. Event documentation 6. Physician's Progress Notes pertinent to the incident if available 7. Care Plan pertinent to the incident 8. Copies of all information sent back with the resident if they were seen in the emergency room for treatment or if they were admitted to the hospital and released back (to the facility) 9. Statements from staff that may have been involved in or who have knowledge of the incident 10. Statement from the resident involved if they are alert, oriented, and interviewable 11. All statements must be signed and dated by the writer and witnessed by two individuals. This policy did not address the need to obtain witness statements and interviews from other residents. Cross-reference F225 for the failure to thoroughly investigate allegations of abuse. e. The facility's 2/5/04 Abuse/Neglect/Misappropriation policy documented, All suspicious incidents will be thoroughly investigated in a timely fashion The policy did not address necessary components of the investigation to ensure the investigation was thorough. 2. Review of R215's Annual Minimum Data Set assessment (MDS) (a resident assessment tool), dated 1/20/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the MDS assessment dated [DATE], the resident's Brief Interview for Mental Status (BIMS) score, measuring cognition, was 10 out of 15. A score of 10 indicated moderate cognitive impairment. The MDS, Section E, Behavior, indicated R215 exhibited physical and sexual, behavioral symptoms toward others. The MDS, Section G, Functional Status, indicated R215 could move about on the unit (locomotion) with limited assistance once he was in his wheelchair. Observation of R215 on 4/19/17, 4/20/17 and 4/21/17 at various times of the day, revealed he could independently maneuver his wheelchair throughout the secure unit. He was talkative with staff; however, at times became argumentative with staff when he was not allowed to exit the unit. R215 had a non-releasing seat belt and pommel cushion while in his wheelchair. Review of R215's behavior care plan revealed his physical, verbal and sexually aggressive behaviors were not addressed. Seven incidents of physical or sexual abuse, in which R215 was the aggressor, occurred between 8/7/16 and 4/19/17. R215 was physically or sexually aggressive towards R405, R236, R400, R326, R406 and an unknown female resident. Cross-reference F323 for specific information regarding the incidents. During an interview with the DON on 4/21/17 at 11:50 a.m. she confirmed the facility did not complete incident reports, or conduct any type of investigation when resident-to-resident altercations occurred. She stated .we (the facility) just never have . The DON also stated, according to their abuse policy, .we are not required to report resident-to-resident abuse to the state . Additionally, neither the DON or Nurse Manager (NM)1 could state how they track, or monitor, resident-to-resident altercations, in which to determine correct interventions have been implemented. 3. An incident of physical abuse was observed during the survey in which R369 hit R37. On 4/18/17 at 12:50 p.m., when R37 commented to R369 regarding her missing shoe, R369 exclaimed, Mind your own damn business! She then hit R37 in the left arm. Three staff members witnessed the altercation; one redirected R369 back to the dining room. R37 wheeled toward his room down the hall; staff were not observed to assess R37 for injury. Cross-reference F323: the facility failed to identify R369's physical and verbal behavioral symptoms directed toward others in the care plan and did not include approaches designed to ensure the safety of the residents on the secure unit for additional aggressive behaviors. Additionally, the facility failed to address the incident in R37's record and there was no evidence the staff had assessed R37 to ensure he was not injured by the incident and was not afraid of R369. On 4/20/17 at 10:42 a.m., an incident report of the 4/18/17 resident to resident altercation was requested from the assistant director of nursing (ADON). The ADON responded that there was no incident report, as the facility did not complete incident reports for resident to resident altercations. The ADON stated the facility did not internally report these incidents or document them on incident reports because the state licensing body did not require them to be reported. On 4/20/17 at 3:45 p.m., the director of nursing (DON) provided the policy addressing resident to resident altercations and confirmed that these incidents were not reported and no incident report or investigation was completed for resident to resident altercations. On 4/20/17 at 6:35 p.m., the DON was alerted to the observed resident to resident altercation on 4/18/17 and follow up information was requested. On 4/21/17 at 4:21 p.m., nurse manager (NM) 1 stated a progress note for R37 regarding the incident was written on 4/20/17, but should have been done at the time of the incident on 4/18/17. She stated the staff verbally reported the incident to her, but there was no incident report done as these were not completed for any resident to resident altercations. She stated she would have expected the staff to assess R37 for injury and address the incident in R369's care plan at the time the incident occurred. On 4/21/17 at 5:08 p.m., the medical director stated with resident-to-resident incidents, the facility would typically notify the family. They did not complete incident reports or report to the state licensing authority unless the incident was criminal in nature. The medical director stated he had not been alerted to many of the resident to resident incidents that occurred in the facility. He stated he would have preferred the facility investigate and implement approaches to prevent recurrence at the time of the incident. 4. The undated Resident Face Sheet documented R471 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 2/27/17 admission MDS assessment documented R471 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. R471's 3/15/17, 2:15 p.m. Progress Note documented, Resident went to cardiac appointment with son .and daughter-in- law .While there she voiced concerns to son. Daughter-in-law spoke with Nurse Manager. The ambulance company called and asked what to do as the son had said to take the resident to his home. Nurse Manager spoke with son who stated he was not bringing his mother back that she was going home . A 3/15/17 investigation report, written by the director of nursing (DON), indicated she received a report from R471's family members that R471 was mistreated at night while going to the bathroom. A family member reported to the DON the certified nurse aide (CNA) verbally abused and accosted the resident as well as hitting the wall with her fist. Cross-reference F225 for details regarding the incident. Review of the incident investigation, conducted by the facility on 3/15/17 to 3/17/17, revealed it included interviews with 5 staff members. However, the investigation did not include interviews with other residents who would have had the same caregiver as R471 to rule out similar incidence of abuse. On 4/21/17 at 9:53 a.m., the DON stated, it depends on what the complaint is whether we do resident interviews. In the past, we have interviewed the other residents in the same group to see if there are similar complaints. We could not speak with (R471) as she had been discharged from the facility before making the allegation. The DON confirmed there were no interviews conducted with residents as part of this investigation and agreed interviews with residents who might have had the same care givers would be an integral part of an abuse investigation. Apart from interviewing the resident who was the potential recipient of an abuse incident, the facility policy (see above) did not direct staff to conduct interviews with additional residents. No residents were interviewed during this investigation. Immediate Jeopardy (IJ) was identified in the areas of 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration at F490 and F501, and 42 CFR 483.75 Quality Assurance & Performance Improvement at F520, all cited at a Scope and Severity of a K. Substandard Quality of Care was identified at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation and Quality of Care. Immediate Jeopardy was identified on 4/21/17 and determined to exist starting on 8/7/16 when R215's first sexually aggressive incident occurred towards R405. The facility Administrator was informed of the immediate jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received on 4/21/17. The State Survey Agency validated the IJ was removed on 4/21/17 at 6:20 p.m. The A[NAME] included: Removal plan for Resident #215 for Psychological Evaluation Until Resident #215 can be discharged from the facility, he will be supervised by staff one-on-one. Transport is being arranged for Resident #215 to be discharged immediately to (name of) emergency room for evaluation. He will be evaluated for return following appropriate evaluations and treatment as required . Immediate Plan to Prevent Future Occurrence Residents on the secure unit with known potential for aggressive behaviors will have their care plan reviewed and updated as required. All other residents on the secure unit will have their care plans reviewed and updated as required. All staff currently on duty on the secure unit will be in-serviced during immediately on how to recognize abuse, intervention techniques, and proper reporting. All other staff reporting for future shifts on the secure unit will be in-serviced as above prior to beginning their shift. This will continue until all staff on the secure unit have been in-serviced. All staff will be in-serviced on how to recognize abuse, intervention techniques. All residents in the facility will be assessed for resident-to-resident abuse potential and actions taken as necessary (to include discharge from the facility) to alleviate any concerns. The resident-to-resident abuse policy will be reviewed and amended to include tracking, monitoring, and reporting of any incidents. As of the exit on 4/21/17 at 9:15 p.m., the facility had discharged R215 and inserviced all staff currently working on the secure unit on how to recognize abuse, intervention techniques, and proper reporting. The Scope and Severity was lowered to a [NAME] at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration, at F490, while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes.",2020-09-01
3184,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,242,D,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident and/or representative were given a choice regarding the frequency of bathing for 2 of 57 stage 2 sampled residents (R) (R205 and R208). Findings include: 1. R205 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 1/20/17 annual Minimum Data Set (MDS) assessment indicated the resident had a BIMs (brief interview for mental status) score of 15 out of 15 demonstrating no cognitive impairment; the resident was coded for receiving extensive assistance of one person for bathing. Review of the 2/14/17 care plan for continence indicated the resident experienced occasional episodes of urinary incontinence. The 2/14/17 care plan for Activities of Daily Living (ADLs) lacked approaches for the frequency of the resident's shower. Review of R205's shower sheets indicated the resident received 13 showers and 6 bed baths (19 bathing experiences) from 1/26/17 through 4/18/17 (11.5 weeks, or 83 days). During an interview on 4/18/17 at 10:40 a.m., resident 205 indicated I just need more showers. I am a lady and I like to be clean. The resident indicated she had told the staff before she wanted more showers. During an interview on 4/20/17 at 9:33 a.m., resident 205 indicated they give us a shower two times a week and I want a shower every day. 2. R208 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 2/10/17 quarterly MDS assessment indicated the resident had short and long term memory problems, and was severely impaired with decision-making. The MDS indicated the resident had no behavior problems and was dependent on staff for her activities of daily living. The MDS indicated the resident was always incontinent of bowel and bladder. The 5/28/16 care plan for ADLs, with the target date of 6/10/17, lacked documentation of approaches for the frequency of the resident's bathing. Review of R208's facility's shower sheets from 1/1/17 through 4/18/17 (15.5 weeks, 108 days) indicated the resident had received 9 bed baths and 15 showers (24 bathing experiences), averaging 1.5 bathing experience per week, or 3 in each 2 week period. During a family interview on 4/19/17 at 1:35 p.m., the family indicated the resident received a bath two times a week, but sometimes the resident smelled bad when the family came to the facility and there was crud behind the resident's ears. The family member indicated she had told the staff the resident needed more bathing. During an interview on 4/21/17 at 7:58 a.m., LPN2 indicated the residents receive two showers a week and then AM and PM care. LPN2 indicated there was a shower aide on the first shift through the week, but not on the weekend. The LPN indicated she had not heard of a resident wanting showers every day. During an interview with Registered Nurse (RN)3 on 4/21/17 at 8:40 a.m., she indicated the facility's routine was to provide two showers a week. During an interview on 4/21/17 at 9:45 a.m., RN3 indicated shower assignments were made according to room assignment, not resident preference. During an interview on 4/21/17 at 10:00 a.m., RN3 indicated R205 was not always getting two showers a week. Review of a facility policy Standard Policy/Procedure, dated 10/1/97, indicated All residents will receive a shower/bath at least two times per week and whenever necessary.",2020-09-01
3185,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,246,D,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure 3 of 57 stage 2 sampled residents (R) (R147, R287 and R358) were provided with accommodations during meals related to dining room tables being too high. Findings include: 1. R147 had [DIAGNOSES REDACTED]. Review of the 1/6/17 quarterly Minimum Data Set (MDS) assessment demonstrated the resident was severely impaired in cognition. Coding on the 1/6/17 MDS indicated the resident required extensive, 1 person assist at meals. R358 had [DIAGNOSES REDACTED]. Review of the 3/10/17 annual MDS assessment demonstrated the resident was severely impaired in cognition. Coding on the 3/10/17 MDS indicated the resident required extensive, 1 person assist at meals. On 4/20/17 during the noon meal at 1:00 p.m., R147 and R358 were observed sitting in low geri-chairs being assisted by 2 CNAs in the Lexington dining room. Overbed tables were placed across the resident's chairs. There were a total of 5 adjustable tables with 1 empty adjustable table near where they were sitting, as well as an empty non-adjustable table. CNA5 was interviewed at this time and said, We use these tables because a regular table is too high for these low chairs. Further observation indicated there were five adjustable tables in the Lexington dining room, one which was empty. 2. R287 had [DIAGNOSES REDACTED]. Review of the 2/10/17 annual MDS assessment demonstrated the resident was severely impaired in cognition (Brief Interview for Mental Status score of 2 out of a possible 15). Coding on the 2/10/17 MDS indicated the resident required extensive, 1 person assist during meals. An observation on 4/20/17 at 12:45 p.m. revealed the resident was sitting in a low geri-chair. The height of the dining table came across the resident's chest. The resident was having difficulty seeing over her cups to see what kind of liquid was in them. During an interview on 4/20/17 at 12:50 p.m., CNA13 indicated the table was too high for the resident. CNA13 indicated the dining table was higher than the others. During an interview on 4/21/17 at 7:58 a.m., LPN2 indicated she would talk with staff to make sure the residents were placed at a dining table. During an interview on 4/21/17 at 9:10 a.m., the DM (Director of Maintenance) indicated the facility had adjustable tables. The DM indicated he was unsure if staff were trained to adjust the height of the tables.",2020-09-01
3186,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,252,E,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to provide a homelike environment during the meal service related to not removing dishes, silverware or glasses from trays and placing the tray in front of the residents for 2 of 9 dining rooms (Caughman and Lexington Units). Findings include: During the meal service in the Caughman dining room on 4/18/17 at 12:38 p.m., the Certified Nurse Aides (CNAs) were observed placing the residents' meal trays in front of them. The CNAs did not remove the dishes, glasses or silverware from the trays. The dining room tables did not have tablecloths or decorations on them. During the meal service in the Lexington dining room on 4/18/17 at 1:27 p.m., the CNAs were observed serving the residents' meals on trays and placing the trays in front of them. The tables were bare of tablecloths and/or decorations. During a meal observation in the Lexington dining room on 4/20/17 at 1:00 p.m., the CNAs were observed serving the residents' meals on trays and placing the trays in front of them. The tables remained void of tablecloths and/or decorations. During the exit conference on 4/21/17 beginning at 8:45 p.m., the Administrator indicated he had eaten off trays for [AGE] years and was never bothered by it.",2020-09-01
3187,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,280,D,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, review of the facility's policy and procedure, and medical record review, the facility failed to ensure the staff developed and implemented a person-centered, comprehensive plan of care for 3 out of 57 stage 2 sampled residents (R) (R72, R400 and R228). Specifically, the facility did not revise R72's care plan for falls, R400's care plan for behaviors, or R228's care plan for mobility status and wandering behaviors. Findings Include: Review of the facility's Standard Policy/Procedure, No. 12-07 Subject: Fall Prevention Program, dated 2/26/16, indicated, Evaluating . The Falls Incident Report is completed by the nurse on the unit the fall occurred. It is important to collect the facts surrounding the fall at the time they occur. This nurse will initiate the Falls Event in the electronic health record. 3. An Acute Care Plan for falls will be initiated unless a care plan for falls is already in place. The current care plan would then be updated to reflect the fall. 1. Review of R72's Resident Face Sheet, printed on 4/21/17, indicated the facility admitted the resident on 1/14/10 with a re-admission on 2/1/17. R72 had [DIAGNOSES REDACTED]. Review of R72's quarterly Minimum Data Set (MDS), a comprehensive assessment completed by facility staff that drives the care planning process, with an assessment reference date (ARD) of 2/13/17, documented R72 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating no cognitive impairment. R72 exhibited verbal behavioral symptoms not directed toward others. R72 required extensive assistance of one for bed mobility, dressing, and toilet use and limited assistance of one for transfers. She was frequently incontinent of bladder and occasionally incontinent of bowel, and she was not on a toileting program. R72 also received a daily diuretic and antianxiety medication. Review of R72's Care Plan, dated 6/1/14 and last edited on 3/1/17, documented, Potential for falls/injury due to unsteady gait, decreased safety awareness, and HX (history) of fall. The resident's goal was she would be free of complications related to falls through next review. The pertinent interventions included: Administer PRN (as needed) medication as ordered. Consult doctor regarding medications. Monitor effectiveness and document on Medication Administration Record [REDACTED]. Encourage to use call light for assistance, keep within reach and answer call light promptly. Instruct to call for assistance prior to attempting to ambulate/transfer. Keep environment free of obstacles that may cause falls/injuries. Monitor for location, duration, and severity of compliant of pain unrelieved by medications. Observe for unsafe actions and intervene. Observe frequently when out of bed to monitor safety needs. On 4/18/17 at 2:43 p.m. R72 stated she fell a week ago in the bathroom and hurt her left shoulder. R72 attempted to move her arm, but grimaced and was unable to raise it more than 10 degrees off the bed as she was lying in bed with the head of the bed raised approximately 25 degrees. Review of R72's Resident Progress Notes, dated 4/11/17 at 7:53 a.m., read, Resident stated she fell in bathroom earlier today. No report given of a fall. No report given to CNA (Certified Nurse Aide). Resident in bed all shift. On 4/20/17 at approximately 11:00 a.m. the Director of Nursing (DON) was asked to provide the incident/investigation report for R72's self-reported fall on 4/10/17-4/11/17. On 4/20/17 at 2:41 p.m. the Assistant Director of Nursing (ADON) stated she had not been able to find a report, and the DON was talking to the managers. On 4/20/17 at 4:55 p.m. the DON provided an investigation summary, Investigative Report Statement Form and PRN Medications Administration History: 4/1/2017-4/20/2017, and stated there had been no report or follow-up to R72's alleged fall on 4/11/17. Review of R72's care plan indicated staff had not updated the care plan since 3/1/17 and did not address the resident's history of self-transferring or that staff needed to follow up on any documented falls/injuries or circumstances of an incident. 2. Review of the 1/27/17 quarterly MDS indicated R400's (admitted on [DATE]) active diagnoses, included but were not limited to, hypertension, [MEDICAL CONDITION], anxiety disorder, depression and pseudobulbar. The resident had long and short term memory problems, and was severely impaired in decision-making. Review of a physician's orders [REDACTED]. Review of the R400's care plan dated 5/17/16 with a target date of 5/27/16 indicated no documentation of the [MEDICATION NAME] being added to the medication care plans. During an interview on 4/21/17 at 8:11 a.m., Registered Nurse (RN)3 indicated the care plan had not been updated with the [MEDICATION NAME]. 3. Review of the Resident Face Sheet revealed R228 was admitted to the facility on [DATE] with a pertinent [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] indicated R228 had short and long-term memory problems, was severely impaired and never/rarely made decision related to cognitive skills for daily decision-making. R228 experienced delusions, rejected care and did not have any wandering behaviors during this period. R228 did not use a mobility device The care plan dated 4/12/17 for R228 included the following problems: -falls related to unsteady gait and safety awareness related to dependent on staff to provide oversight on all safety needs, with approaches to encourage to use call light for assistance, instruct to call for assistance prior to attempting to ambulate/transfer, and provide appropriate assistance of staff . before attempting to ambulate; -wanders around the unit; and -potential for elopement. Observation on 4/20/17 at 9:23 a.m. revealed R228 was in a tilted seat Broda chair. On 4/21/2017 at 10:20 a.m. Licensed Practical Nurse (LPN)1 stated, (R228's) feet did not touch the floor (when in the tilted seat Broda chair), only her toes, but she can move the chair. The resident was observed pushing the Broda chair backwards with the toes of her shoes, but she could not move the chair forward. On 4/21/17 at 10:25 a.m. LPN4 stated R228 had a change in condition about two months ago and she no longer was able to walk. Certified Nurse Aide (CNA)31 stated, Resident cannot straighten her legs any further than that (90 degrees). CNA31 and LPN4 stated the resident did not stand or walk, and was only able to move the wheelchair a short distance. On 4/21/17 at 2:58 p.m. Nurse Manager (NM)1 said R228's tilted seat Broda chair was initiated on 12/23/16, and she quit walking and her legs became contracted in (MONTH) (YEAR) after a decline while in the hospital. On 4/21/17 at 6:10 p.m. the Resident Assessment Coordinator (RAC) reviewed R228's care plan and said the care plans regarding falls related to unsteady gait, wandering and elopement were no longer appropriate because R228 had not walked since 11/16/17 and could not move herself in the Broda chair.",2020-09-01
3188,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,323,K,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to provide adequate supervision and implement interventions to prevent resident to resident altercations and/or a fall for 8 of 57 stage 2 sampled residents (R) (R37, R72, R215, R405, R236, R400, R326, R406), an unknown female resident, and 43 residents residing on the secure unit with R215. Specifically, -The facility failed to ensure aggressive behaviors of R215 towards other residents were addressed and sufficient interventions were implemented to keep the remaining 43 residents who resided on the secure unit safe from harm inflicted by R215. R215, who was cognitively impaired yet at a higher cognitive level than his victims, exhibited aggressive physical behaviors towards residents on 3 occasions and sexually aggressive behaviors towards residents on 4 occasions between 8/7/16 and 4/19/17. The residents assaulted by R215 were R405, R236, R400, R326, R406 and an unknown female resident. The facility failed to notify R215's physician of the physically and sexually aggressive incidents; subsequently, there was a lack of physician response to the incidents. Investigations into the incidents and protective measures to prevent recurrence were lacking creating an unsafe environment in the secure unit. The facility's failure to provide supervision to keep residents safe from R215 was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified to have existed on 8/7/16 at 6:23 p.m. when R215 was first sexually aggressive towards R405. The administrator and director of nursing (DON) were informed of the Immediate Jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received on 4/21/17 and the immediate jeopardy was removed on 4/21/17 at 6:20 p.m. The scope and severity was lowered to a E, pattern at potential for more than minimal harm, once the immediate jeopardy was removed. -The facility failed to respond appropriately to an incident of resident-to-resident aggression between R369 and R37 to address potential injury and develop interventions to prevent recurrence. -The facility failed to investigate, address potential injury and develop interventions to prevent recurrence for a self-reported incident for R72 which met the criteria for a fall. Findings include: 1. Review of R215's Annual Minimum Data Set assessment (MDS) (a resident assessment tool), dated 1/20/17, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], the resident's Brief Interview for Mental Status (BIMS) score, measuring cognition, was 10 out of 15. A score of 10 indicated moderate cognitive impairment. Section E, Behavior of the MDS indicated R215 exhibited physical and sexual, behavioral symptoms toward others. Under Section G, Functional Status, R215's locomotion on the unit was coded as limited assistance once he was in his wheelchair. Observation of R215 on 4/19/17, 4/20/17 and 4/21/17 at various times of the day, revealed he was able to independently maneuver his wheelchair throughout the secure unit. He was talkative with staff; however, at times became argumentative with them when he was not allowed to exit the unit. R215 had a non-releasing seat belt and pommel cushion in place while in the wheelchair. Although R215 had a care plan addressing behaviors, his physical, verbal and sexually aggressive behaviors were not identified or addressed. a. Seven incidents of physical or sexual abuse, in which R215 was the aggressor, occurred between 8/7/16 and 4/19/17. R215 was physically or sexually aggressive towards R405, R236, R400, R326, R406 and an unknown female resident: 1) 8/7/16 Incident Between R215 and R405 Review of R215's nursing progress notes on 4/21/17 revealed on 8/7/16 at 6:23 pm .Resident observed attempting to kiss R405. When stopped by this nurse R215 briefly became argumentative and made one attempt to repeat behavior. Residents were physically separated by this nurse . This was the first resident-to-resident sexual altercation between R215 and R405. Review of R405's nursing progress notes on 4/21/17 R405 revealed . Resident observed holding hands with R215. R215 was attempting to kiss resident. R405 was neutral towards behavior with no attempt to withdrawal (sic) or return kiss, and talking in confused speech. Resident's currently separated by this nurse. R405 making no attempt to return to R215. Will continue to monitor . A significant change MDS dated [DATE] revealed R405 was severely, cognitively impaired. 2) 8/21/16 Incident Between R215 and R236 Review of R215's nursing progress notes on 4/21/17 revealed on 8/21/16 at 9:41 a.m.resident observed with his left hand under the gown of R236. R215 was informed this was not acceptable behavior and to the nurse's station. R215 gave no verbal or physical reply and was not resistive . Review of R236's clinical record revealed no documentation of the observed sexually aggressive incident of R215 towards R236. The quarterly MDS dated [DATE] revealed R236 was severely, cognitively impaired. 3) 8/21/16 Incident Between R215 and R400 Review of R215's nursing progress notes on 4/21/17 revealed on 8/21/16 at 7:10 p.m.resident observed rubbing buttocks of R400. R400 was not receptive to behavior. Informed R215 touching of this nature was not appropriate, resident became agitated loudly stating 'Why don't you keep your hands to yourself' and 'You go on.' Residents separated by staff . Review of R400's clinical record revealed no documentation of the observed sexually aggressive incident of R215 towards R400. The MDS dated [DATE] revealed R400 was severely, cognitively impaired. 4) 10/25/16 Incident Between R215 and R326 Review of R215's nursing progress notes on 4/21/17 revealed on 10/25/16 at 5:15 p.m.Resident seen by CNA striking (R326). Strike an open-handed swipe. Resident (R215) stated 'I didn't mean to, I was trying to hit her hand' and 'She was trying to take my hat.' Informed resident (R215) to notify staff if residents attempt to take his belongings, that striking other residents was not acceptable behavior. Resident apologized, did not repeat incident through shift . Review of R326's nursing progress notes on 4/21/17 R326 revealed .resident seen by CNA being struck open-handed by R215. Resident was reported as attempting to take R215's hat. Resident free from injury, non-distressed, talking in confused babbling speech, reaching for other residents and staff per baseline. Resident (R326) witnessed returning to R215 once to take that resident's hat. Resident (R326) redirect herself away from R215 after being unable to reach hat. Will continue to monitor . The quarterly MDS dated [DATE] revealed R326 was severely, cognitively impaired. 5) 11/17/16 Incident Between R215 and R405 Review of R215's nursing progress notes on 4/21/17 revealed on 11/17/16 at 7:07 p.m.Resident inappropriately touching R405. This resident (R215) had his right hand reaching up resident's shirt and was attempting to kiss other (sic) resident. When confronted about this behavior resident (R215) laughed, stated 'She wants it.' Informed resident this was not acceptable behavior, separated residents . This was second resident-to-resident sexual altercation between R215 and R405. Review of R405's nursing progress notes on 4/21/17 of R405 revealed .resident observed by this nurse being inappropriately touched by R215. This resident (R405) was passive during this episode, was seen talking but was not able to be heard by this nurse. Separated residents. When asked if she (R405) is ok resident states 'I'm fine.' Will continue to monitor . A significant change MDS dated [DATE] revealed R405 was severely, cognitively impaired. 6) 2/14/17 Incident Between R215 and Unknown Female Resident Review of R215's nursing progress notes on 4/21/17 revealed on 2/14/17 at 10:43 pm .Resident (215) swung at another resident (female) with closed fist because she touched his friend. Only touched her arm out of compassion but (R215) swung at resident with open fist . The facility was unable to determine who the female resident was. 7) 4/19/17 Incident Between R215 and R406 Review of nursing progress notes on 4/21/17 revealed on 4/19/17 at 8:54 p.m.Resident (215) in altercation with Resident (R406). Resident (215) punched resident (R406) in the face because he said resident (R406) was talking to his 'girlfriend.' Redirection was given to Resident 215. Altercation broken up by staff. Closed fist altercation . Review of R215's nursing progress notes on 4/21/17 revealed .on 4/21/17 at 8:40 am was able to reach RP (responsible party) this morning and discuss altercation between his father and resident (R406). RP stated, 'I thought he was doing better on the Zoloft.' RP informed that the resident has shown an improvement with aggressive behaviors since his increase in Zoloft back in February, but due to his lasted (sic) altercation, it may benefit the resident to have a psychiatric consult. The RP agreed . Review of nursing progress notes on 4/21/17 of R406 revealed R406 had .No apparent injuries noted . The quarterly MDS dated [DATE] revealed R406 was severely, cognitively impaired. b. The facility failed to implement adequate interventions directed at R215 to prevent resident to resident altercations and to keep residents on the secure unit safe from R215. Interventions consisted of medication changes and separating residents at the time the incident occurred. Interventions implemented were as follows: According to the pharmacist progress note dated 3/24/16, R215 was started on Seroquel (an antipsychotic) 25 mg daily on 3/3/16. The Seroquel was increased to 25 mg twice a day on 3/9/16. Pharmacy recommendation stated .resident displaying aggressive behaviors . The social work quarterly progress note dated 7/27/16, revealed R215 .was recently transferred to the secure unit and is alert with a BIMS of 13/15. It was noted that he can be aggressive and has an order for [REDACTED]. The nursing progress notes dated 8/22/16 at 10:49 p.m., revealed R215 was started on Zoloft (an antidepressant) 25 mg daily .related to resident's inappropriate behavior towards female residents. Message left on answering machine for RP to call facility . No additional documentation could be found which indicated the RP was aware of the new order for Zoloft. Cross reference F157. On 2/14/17 the medication was increased to 50 mg daily. According to the social work progress note dated 8/22/16 at 4:59 p.m., .social work (SW) spoke with R215 regarding his inappropriate sexual behaviors. R215 reported that he needed others to behave as well. SW explained that he did not need to touch anyone that did not want to be touched and that some of the females that may allow it did not understand all that was going on when/if he touched them in a sexual manner. SW not sure of all that was understood, but SW reiterated that he need (sic) to behave himself and he stated that he would 'try.' SW will continue to provide support and assistance as needed . The pharmacist progress note dated 10/11/16, revealed .Tolerating medications well. Recommend physician consider GDR (gradual dose reduction) of Seroquel . The physician progress notes [REDACTED].history of aggressive behaviors, ok today. Stable and continue current treatment . Nursing progress notes dated 10/24/16 at 2:24 p.m., revealed .bath certified nursing assistant (CNA) reported that resident was combative-hitting-during his shower . Further review of the nursing progress notes dated 10/25/16 at 2:20 p.m., revealed .new order noted to decreased (sic) Seroquel to 25 mg at night . The social work quarterly progress note dated 10/24/16, revealed R215 .was alert with a BIMS of 9/15, but does have some confusion at times. He has been adjusting to his current unit and has taken to some of the female residents on the unit. It was noted he can be aggressive at times. He is not followed by psych; however, it will be available to him if needed . The pharmacist progress note dated 1/13/17, revealed .12/13/16 Depo-Provera 150 mg IM (intramuscular) every 3 months. Recommend physician add [DIAGNOSES REDACTED]. No documentation could be located for the Depo-Provera as of 4/21/17 and R215 was still receiving the medication. During an interview with Nurse Manager (NM)1on 4/21/17 at 11:50 a.m., she stated the RP was not notified prior to starting the medication. Cross-reference F157. The social work annual progress note dated 1/25/17, revealed R215 .was alert with a BIMS of 10/15. During this assessment, he exhibited physical aggression towards others. R215 is known for engaging with the females in which sometimes he has to be redirected for inappropriate touching and/or comments. He is not followed by psych . A Physician order [REDACTED].increase Seroquel to 25 mg twice a day . As of 4/21/17 R215 was still receiving the medication at this dose. Review of the physician progress notes [REDACTED]. Furthermore, there was a lack of documentation in R215's medical record to show the physician was notified of the resident to resident altercations initiated by R215 towards other residents. Cross reference F157 for specific findings. No individualized interventions for R215 were developed or implemented in response to resident-to resident altercations. The only intervention, in addition to medication management, was the immediate separation of R215 and R400, R406, R405, R236 and R326. Since R215's admission to the facility on [DATE], and subsequent transfer to the facility secure unit on 7/27/16, no referral for psychiatric consult or any other professional service to address the resident's mood and behaviors was obtained. c. Staff Interviews On 4/21/17, multiple requests to administration to interview the social worker for the secure unit were made; however, an interview did not occur. During an interview with the DON and nurse manager (NM)1 on 4/21/17 at 11:50 a.m., they were asked what interventions were implemented to prevent further resident-to-resident altercations. The DON stated They were separated at the time of the incident. Neither the DON or NM1 could state what, if any, additional interventions were put into place following each altercation, other than what was already charted in R215's clinical record. When NM1 was asked about obtaining a psychiatric consult, she stated .The son (RP) refused . NM1 was also asked if R215's RP was aware of the number of resident-to-resident altercations and she stated he was. NM1 further stated R215's RP stated to her That's dad. Dad will be dad. During the same interview with the DON on 4/21/17 at 11:50 a.m. she confirmed the facility did not complete incident reports, or any other investigation when resident-to-resident altercations occurred. She stated We (the facility) just never have. On 4/21/17 at 6:31 p.m., the administrator stated resident-to-resident abuse, physical aggression, or sexually inappropriate behavior had not been brought to his attention, or to the attention of the QA committee, for root cause analysis, tracking and trending of incidents, or development of a plan to prevent additional occurrences. He stated, We don't know about it. With (R215), it appears the nurse made a note and did not tell anybody. My expectation is an incident report be completed. (An incident report) should have been done for every instance. d. Policy and Procedure According to the facility policy and procedure Resident-Resident Abuse, dated 3/00, Each resident has the right to be free from mistreatment, neglect and misappropriation of property. This includes the facility's identification of residents, whose personal histories render them at risk for abusing other residents, and development of intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis. According to the facility policy and procedure Facility Wide Abuse/Neglect/Misappropriation, dated 2/04, under Prevention - bullet D .the facility will thoroughly investigate any suspected abuse, neglect and/or misappropriation of resident property and take appropriate action to prevent recurrence . 2. According to the undated Resident Face Sheet, R369 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 3/17/17 quarterly MDS assessment documented R369 had severely impaired cognition (section C1000). She had unclear speech (section B0600) and was rarely/never able to understand others (section B0800). R369 exhibited physical and verbal behavioral symptoms directed toward others (section E0200). R369's Care Plan, revised 3/28/17, documented R369 had poor safety awareness and impaired decision-making ability due to her dementia and was anxious at times. The approaches included: continuously remind resident of boundaries, .frequently monitor for safety issues and address as needed, .re-direct if wandering and/or any other behaviors are effecting (sic) safety and/or health, .(and) identify environmental factors that may increase anxiety R369's Care Plan did not address physical or verbal behaviors toward others. On 4/18/17 at 12:50 p.m., R369 was observed in an altercation with R37. When R37 commented to R369 regarding her missing shoe, R369 exclaimed, Mind your own damn business! She (R369) then hit R37 in the left arm and he raised his fist in a threatening gesture. Three staff members witnessed the altercation, and one redirected R369 back to the dining room. R37 wheeled himself toward his room down the hall; staff were not observed to assess R37 for injury or ask about how he was doing. According to the undated Resident Face Sheet, R37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/7/17 quarterly MDS assessment documented R37 had moderately impaired cognition (section C1000). He was rarely/never able to make himself understood or understand others (sections B0700 and B0800). R37's 5/1/14 Care Plan, revised 4/11/17, documented he had cognitive loss (related to) ETOH (alcoholic) dementia with impaired decision making ability and decreased safety awareness with potential for injury and/or elopement. The approaches included, frequently monitor for safety issues and address as needed .continuously remind resident of boundaries, .decrease external stimuli and provide a safe environment, .(and) identify environmental factors that may increase anxiety. R369's 4/18/17 Progress Note documented, (R37) yelled at this resident, 'Where are your shoes' - This resident made verbal response and slapped (R37) on the left arm - No injuries occurred and staff intervention was successful. Review of R369's Care Plan on 4/20/17 revealed it had not been updated to reflect her physical and verbal behavioral symptoms directed toward others and did not include approaches designed to ensure the safety of the residents on the secure unit for additional aggressive behaviors. Review of R37's Progress Notes on 4/19/17 revealed there was no documentation addressing the incident described in R369's notes above. There was no evidence the staff had assessed R37 to ensure he was not injured by the incident and was not afraid of R369. On 4/20/17 at 10:42 a.m., an incident report of the 4/18/17 resident-to-resident altercation was requested from the assistant director of nursing (ADON). The ADON responded that there was no incident report, as the facility did not complete incident reports for resident-to-resident altercations (cross-reference F225: failure to report and investigate resident-to-resident altercations and F226: failure to develop policies to address resident-to-resident altercations and/or abuse). On 4/20/17 at 3:45 p.m., the director of nursing (DON) provided the policy addressing resident-to-resident altercations and confirmed that these incidents were not reported and no incident reports were completed for resident-to-resident altercations. On 4/20/17 at 6:35 p.m., the DON was alerted to the observed resident-to-resident altercation on 4/18/17 and follow up information was requested. On 4/21/17 at 4:21 p.m., NM1 stated a progress note for R37 regarding the incident was written on 4/20/17, but should have been done at the time of the incident on 4/18/17. She stated the staff verbally reported the incident to her, but there was no incident report done as these were not completed for any resident-to-resident altercation. She stated she would have expected the staff to assess R37 for injury and address the incident in R369's care plan at the time the incident occurred. On 4/21/17 at 5:08 p.m., the medical director stated with resident-to-resident incidents, the facility would typically notify the family. They did not complete incident reports or report to the state licensing authority unless the incident was criminal in nature. The medical director stated he was not alerted to many of the resident-to-resident incidents in the facility. He stated he would have preferred the facility investigate and implement approaches to prevent recurrence at the time of the incident. 3. Review of R72's undated Resident Face Sheet, the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of R72's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 2/13/17, documented R72 with a BIMS score of 15/15 indicating no cognitive impairment. R72 required extensive assistance of one staff for bed mobility, dressing, and toilet use and limited assistance of one staff for transfers (section G0110). She was frequently incontinent of bladder and occasionally incontinent of bowel (section H0300 and H0400). R72 also received daily diuretic and antianxiety medications (section N0410). Review of R72's Care Plan, edited on 3/1/17 documented, Potential for falls/injury due to unsteady gait, decreased safety awareness, and HX (history) of fall. The goal was to be free of complications related to falls through next review. The pertinent interventions included: Document any falls/injuries and circumstances of incident, intervene as needed. Encourage to use call light for assistance, keep within reach and answer call light promptly. Instruct to call for assistance prior to attempting to ambulate/transfer. Keep environment free of obstacles that may cause falls/injuries . Observe for unsafe actions and intervene. Observe frequently when out of bed to monitor safety needs. On 4/18/17 at 2:43 p.m. R72 was interviewed and stated she fell approximately a week ago in the bathroom and hurt her left shoulder. R72 attempted to move her arm but grimaced and was unable to lift it more than 10 degrees off the bed. She was lying in bed with the head of the bed raised approximately 25 degrees. Several minutes later, at 2:45 p.m. R72 was noted without her call light in reach. Upon further review the call light was found on the floor towards the head of R72's bed. Review of the Resident Progress Note, dated 4/11/17 at 7:53 a.m. revealed, Resident stated she fell in bathroom earlier today. No report given of a fall. No report given to CN[NAME] Resident in bed all shift. Review of the Resident Progress Note dated 4/20/17 at 1:30 a.m. indicated LPN10, Went in to draw blood and member (R72) c/o (complained of) pain in the left arm and appeared to guard arm. When asked what happened, resident stated that she fell but she could not remember when. Pain medicine offered and resident refused and stated, 'It don't help anyway.' Will report to supervisor. Review of the Resident Progress Notes dated 4/20/17 at 6:50 a.m. indicated R72 complained of left arm and side pain. LPN10 reported it to her supervisor and was advised to fill out a doctor concern form, which she placed in R72's chart. Review of the Resident Progress Notes dated 4/20/17 at 10:40 a.m. indicated the resident complained of left shoulder pain to LPN11. The resident requested Tramadol for pain. R72 remained in bed reading the newspaper. An order was obtained for x-rays to the left humerus (bone in the arm), the forearm and a chest x-ray, two views. LPN11 notified and spoke to resident's responsible party. Review of the x-ray taken on 4/20/17 revealed that there were no fractures, bony lesions, or calcifications. However, the resident was noted to have degenerative changes in both shoulders. On 4/20/17 at approximately 11:00 a.m., the Director of Nursing (DON) was asked for the fall investigation/incident report for R72's report of falling in the bathroom on 4/11/17. On 4/20/17 at 4:55 p.m. The DON provided a copy of a typed one page report, two Investigative Report Statement Form(s) and the PRN Medication Administration History 4/1/17-4/21/17. The DON stated the fall had not been investigated. The DON acknowledged, that although the resident reported she did not fall, the definition of a fall was any change in plane and because no one witnessed the incident, it should have been investigated as a fall when it was reported on 4/11/17. On 4/20/17 at 5:00 p.m. during an interview with R72 and the Director of Nursing (DON), R72 reported that she almost fell a week ago on either 4/10/17 or 4/11/17. R72 stated that she got herself out of bed on her own and went to the bathroom. She stated, When going to get up my head got all funny and I went forward but used my left arm to hold myself up. I was there awhile but reached my wheelchair with my right hand and then managed to get into my chair by myself. Ever since then my shoulder has been hurting me. She discussed that there were two CNAs that came in and put her back to bed, but she could not remember their names. She was asked why she did not pull the emergency cord and she stated, I had my arm in the bar and could not pull the string, I was dangling forward and holding myself up with my left arm. Review of the report titled Follow up report on (resident's name) reported fall in the bathroom by on 4/10/17, provided on 4/20/17 at 4:55 p.m. by the DON revealed, the resident was being re-positioned in bed and was observed to have both arms overhead, using trapeze (a bar used to assist residents with re-positioning) to assist certified nursing assistant (CNA) with positioning in the bed. The report documented that both R72's arms were fully extended, and no favoring of either side, resident observed moving from side to side for positioning devices to be placed. Per the report, R72 gave the following statement, I was in my bed coloring after lunch. I had to go to the bathroom, so I got myself up. Once I was in the bathroom, my head got weird, and I thought I was going to fall. l grabbed the bar with my arm, and hung until I felt better. I did not want to hit my face. After my head cleared, I used my other arm to reach out for my wheelchair. I got it over to me, and got myself in it. When I got back over by my bed, 2 aides came in and asked what I was doing. I told them I had gone to the bathroom, and they helped me back into bed. The nurse conducting the interview documented the following, When asked if she knew when this happened, she said after lunch, probably 2:00 or 2:30 p.m. When asked what day, she stated 'last Monday.' She reported that while she hung on to the bar in the bathroom, all her weight was on her left shoulder, and that is why it now hurt. When asked when it started hurting, she stated 'that day' and says she reported the pain to the nurse that day. When this writer referred to a 'fall' she corrected me and stated she never fell . She reported she used the bar and her arm to hold herself up so she would not fall and hit her face. When asked if she went to the bathroom alone normally, she stated it depended. On days she felt good, she could go to the bathroom independently. Staff reported she sporadically went to the bathroom without help, but was encouraged to ask for assistance. When asked if she knew to use the call light for assistance, in both the bathroom and her bed, she stated she did. On 4/21/17 at 9:33 a.m. LPN11 was interviewed and stated if a resident said they fell , an investigation should be initiated and would include assessing for pain, looking for bruising (head-to-toe assessment), and offering pain medication. LPN11 stated the policy directed staff to notify the family, check with other staff members who worked with resident to see if anything happened, and to notify the nurse supervisor. On 4/21/17 at 9:39 a.m. CNA1 was interviewed and stated on Tuesday R72 had told her that she had gone to the bathroom by herself on Monday night and complained that her left shoulder had been hurting. CNA1 stated there were no bruises on the resident's upper arm or shoulder and she had reported this to the nurse, but could not remember which nurse. CNA1 stated R72 has a history of getting herself up and going to the bathroom on her own. On 4/21/17 at 9:48 a.m. NM3 was interviewed and stated if a resident fell , an incident report must be completed and reported. She stated the form went to the nurse manager, there were standing orders for vital signs and depending on if head contact occurred, standing orders for that. She stated per the protocol, the nurse should have reported it on 4/11/17 and should have initiated the fall protocol with a follow up progress note, notification of the doctor and responsible party and updated the care plan. Review of the facility's Standard Policy/Procedure, NO. 12-07 Subject: Fall Prevention Program, dated 2/26/16, indicated in pertinent part .Reporting and Documenting 1. All resident falls are reported on a Falls Incident Report. 2. Nurses shall document a fall as an event in the electronic health record. Documentation includes the assessment of the resident every shift for 24 hours unless there has been head contact, it will then be for 48 hours. The Nurse manager or designee will close the event once all assessments are completed and will include an evaluation or summary of the fall in the event before closing. 3. The Falls Incident Reports are routed to the Nurse Manager, Director of Nursing and Staff Development Assistant . Evaluating 1. Initial evaluation of the fall is made by the nurse following the fall. The Supervisor or a Registered Nurse will be notified to assess the resident and contact the physician if orders are needed. The nurse shall contact the responsible party. 2. The Falls Incident Report is completed by the nurse on the unit the fall occurred. It is important to collect the facts surrounding the fall at the time they occur. This nurse will initiate the Falls Event in the electronic health record. 3. An Acute Care Plan for falls will be initiated unless a care plan for falls is already in place. The current care plan would then be updated to reflect the fall. Immediate Jeopardy (IJ) was identifi (TRUNCATED)",2020-09-01
3189,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,332,D,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure medication errors were prevented for 2 of 27 medications observed being administered. Resident (R)7 did not receive the entire dose of medication ordered and staff did not ensure an injectable medication was given to the correct resident, R527. The facility medication error rate was 7.41 percent. Findings include: 1. Review of (MONTH) (YEAR)'s Physician order [REDACTED]. On 4/7/17, a physician order [REDACTED]. Observation on 4/20/17 at 8:44 a.m. revealed Licensed Practical Nurse (LPN)3 handed a prepared [MEDICATION NAME] nebulizer mouthpiece to R7, who slowly and weakly held it to his mouth. LPN3 informed him she would be back when it was completed and exited the room. At 8:46 a.m., R7 was observed with his eyes closed, no longer holding the nebulizer to his mouth and mist was observed continuing to come out of the mouth piece as it lay on the bed next to R7's thigh. LPN3 did not enter R7's room during the continuous observation. However, Registered Nurse (RN) 1 entered the room at 8:48 a.m. and stated she found the mouth piece lying on the bed; since he was finished with the medication, she turned the nebulizer off and put it back in the respiratory bag. Upon request, RN1 held it up, revealing there was still liquid medication remaining in the reservoir. RN1 exited R7's room [ROOM NUMBER] seconds later stating she had turned the nebulizer back on. After speaking with LPN3 in the hall, leaving R7 out of site, RN1 walked down the hallway away from R7's room. LPN3 continued to prepare medications for other residents out of sight of R7. The surveyor maintained continuous observation of R7 revealing he again was not holding the nebulizer to his mouth, as it was lying on the bed, still running with mist coming from the mouthpiece. Interview on 4/21/17 at 10:05 a.m. with Nurse Manager (NM)2, revealed, When the nebulizer is handed to the resident and they (nurses) see them (the resident) hold it, they leave; it is not common practice to stand there and watch them. Interview with the Director of Nursing on 4/21/17 at 5:30 p.m. revealed it was her expectation that the nurses should ensure medications were fully administered as ordered. Review of the facility's policy Administration of Nebulized Solutions Policy indicated to encourage resident to breathe in deeply until no more mist is formed in the nebulizer chamber (usually 5-15 minutes). 2. Review of R527's physician order, dated 3/29/17, indicated, Humalog Insulin was to be given per sliding scale for blood sugar of 201 - 250, 4 units were to be administered by subcutaneous injection before meals and at bedtime. Observation on 4/20/17 at 12:30 p.m. revealed LPN9 drew up 4 units of insulin in a syringe stating it was for R527. LPN9 stated he was ready to go to R527's room. Review of the insulin prescription bottle revealed it was the same medication as ordered, however, the typed prescription label did not list R527's name; it had a different resident's name on the prescription label. Upon knowledge of the name difference, LPN9 immediately disposed of the syringe, opened a drawer and pulled out another insulin bottle with R527's name typed on the label. LPN9 pointed to the 2 bottle caps that had names hand written in black marker with smudges, stating they were hard to read. LPN9 drew up the 4 units of insulin. This time verifying the typed name was correct for R527. The National Institute of Health recommends assuring the rights of medication administration include right patient, right drug, right time, right route and right dose are critical for nurses to perform to prevent medication errors. An interview with the Director of Nursing on 4/21/17 at 5:30 p.m. revealed it was her expectation that the nurses should carefully examine of the medication containers to assure it for the correct resident.",2020-09-01
3190,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,431,D,0,1,ZZ1W12,Deficiency Text Not Available,2020-09-01
3191,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,441,E,0,1,ZZ1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to maintain accepted infection control standards for 2 of 57 stage 2 sampled residents in 1 of 9 dining rooms (Resident (R)7 and R63). Specifically, the facility: -failed to ensure sanitation of nasal medication, -failed to ensure sanitation of respiratory equipment, and -failed to ensure staff handled clothing protectors properly. Findings Include: 1. Respiratory equipment During the initial tour on 4/18/17 at 10:15 a.m., the nebulized mist treatment (NMT) set-ups for R7 and R63 were observed still intact, with the masks and medication cups still attached to the tubing, contained in closed plastic bags. Condensation was noted in the medication cups. The NMT mouthpiece for R7 was observed to have dried brown residue on it. On 4/19/17 at 2:00 p.m., the NMT set-ups for R7 and R63 were observed still intact, with the masks and medication cups still attached to the tubing, contained in closed plastic bags. Condensation was noted in the medication cups. The NMT mouthpiece for R7 had dried brown residue on it. During an interview with the Respiratory Therapist Director (RTD) on 4/19/16 at 1:00 p.m., she stated the NMT set-ups were to be changed weekly and we follow the manufacturer's instructions for cleaning after use. According to the Air Care, NMT manufacturer's website, instructions for cleaning after each use were Rinse the mask or mouthpiece with warm water for at least half a minute. Shake off excess water and place parts on a clean towel for air-drying. Review of the Hand Held Nebulizer policy dated 5/12/11 indicated, in pertinent part, Step 13 following therapy, discard any residual medication and cover unit with dry plastic bag. Review of the Administration of Nebulized Solutions Policy revealed Step 14 clean nebulizer per manufacturer's instructions. 2. Nasal medication According to the undated admission face sheet, R7 was admitted to the facility on [DATE]. The face sheet indicated the resident had [DIAGNOSES REDACTED]. According to the Minimum Data Set Assessment (MDS) (a resident assessment tool) dated 1/23/17, Resident (R) 7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. According to the 60-day MDS, dated [DATE], R7 required extensive assistance with bed mobility, transfers and personal hygiene. Review of the 4/10/17 Infection report revealed R7 had symptoms of nasal congestion, new or increased sputum, and new or increased cough which began on 4/7/17. On 4/8/17, R7 had a temperature of 99.1 degrees Fahrenheit. [MEDICATION NAME] solution for nebulization; 15 micrograms/2 milliliters; 1 vial inhalation twice a day was included with Antibiotics in physician orders [REDACTED]. The 1/9/17 physician's orders [REDACTED]. There was a physician's orders [REDACTED]. Observation on 4/20/17 at 8:44 a.m. revealed Licensed Practical Nurse (LPN)3 carried the bottle of [MEDICATION NAME] into the resident's room to administer (by spraying in each nostril), without cleaning the insertion tip between each nostril or before replacing the cap and returning it to the box. LPN3 added [MEDICATION NAME] nebulizer solution to the nebulizer set-up, then handed the prepared nebulizer to resident R7; at this time, the surveyor stopped LPN 3 asking her to re-examine the mouth piece of the nebulizer. There was brown matter the size of a nickel with multicolored debris scattered in it. Upon visualization, she responded, Oh, that's some of his medication from his last administration, he tends to hold it in his mouth and it gets on there. She then removed the mouth piece and rinsed it with flowing water from the sink until it was no longer visible. LPN3 acknowledged she should have cleaned the nasal tip of the [MEDICATION NAME] prior to administering it to R7. 3. Infection control standards for clothing protectors were not followed in the Caughman dining room. On 4/18/17 at 12:38 p.m., Certified Nurse Aide (CNA)3 was observed passing out clean paper clothing protectors to the residents, CNA3 was holding the clothing protectors against her uniform. On 4/18/17 at 12:44 p.m., CNA4 was observed passing out clean paper clothing protectors to the residents; CNA4 was holding the clothing protectors against her uniform. On 4/18/17 at 12:46 p.m., CNA4 was observed holding the remaining clothing protectors against her uniform, then putting them back in the box of clean paper clothing protectors. During an interview on 4/21/17 at 8:25 a.m., the Infection Control Nurse, RN4, indicated the paper clothing protectors should be treated just like linens and not held against the uniform/clothing. She indicated the CNAs' uniforms were contaminated, which then contaminated the residents and the paper clothing protectors in the box of clean protectors.",2020-09-01
3192,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2017-04-21,490,K,0,1,ZZ1W11,"Based on observations, interviews, record review, and policy review, the facility failed to ensure it was administered in a manner to ensure effective use of its resources to prevent abuse, investigate abuse, and promote a culture and environment free of abuse for 42 residents who lived on the secure unit (all residents on the secure unit except for resident (R) R369 and R215) and for 1 resident (R471) with a reported allegation of abuse. Specifically: The facility failed to ensure aggressive behaviors of R215 towards other residents were reported, investigated, and sufficient interventions were implemented to keep the additional 43 residents who resided on the secure unit safe from potential harm. R215 was found to have exhibited aggressive physical behaviors on 3 different occasions and sexual behaviors on 4 different occasions toward residents R400, R406, R405, R236, R326 and an unknown female resident. The facility's failure to be administered in an effective manner to keep residents safe from R215 was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified to have existed on 8/7/16 at 6:23 p.m. when R215 was first sexually aggressive towards R405. The facility's administrator and director of nursing (DON) were informed of the Immediate Jeopardy on 4/21/17 at 2:42 p.m. Findings include: 1. Job Descriptions According to the administrator's job description, dated 5/2014, under Miscellaneous it read .assure that all residents receive care in a manner and in an environment, that maintains or enhances their quality of life without abridging the safety and rights of other residents . According to the Director of Nursing's (DON) job description, dated 7/02, it stated under Major Duties and Responsibilities - Administrative Functions bullet 1.plan, develop, organize, implement, evaluate and direct the Nursing Services Department, as well as its programs and activities in accordance with current rules, regulations and guidelines that govern the long-term care facility . 2. Six citations were cited at immediate jeopardy during the recertification survey ending on 4/21/17: Cross-reference F323: Accidents and Supervision - The facility failed to respond appropriately to incidents of resident-to-resident aggression and/or sexually inappropriate behaviors and address any potential injury or psychological harm to the victims as well as develop interventions to prevent recurrence. Cross-reference F225: Abuse Investigation - The facility failed to ensure incidents of potential resident-to-resident physical and sexual abuse were reported, investigated and sufficient measures were implemented afterward to ensure the safety of the victims and prevent recurrence. Cross-reference F226: Abuse Policies and Procedures - The facility's current policies and procedures did not address the reporting, investigating, or monitoring of resident-to-resident abuse adequately and thus, facility staff did not report or investigate any of these incidents, and did not develop interventions to prevent recurrence. Cross-reference F501: Responsibilities of the Medical Director - The facility failed to ensure the medical director was involved in the development and implementation of an adequate and appropriate policy to address resident-to-resident abuse. Cross-reference F520: Quality Assurance (QA) - The facility failed to systematically report, monitor, and address incidents of resident-to-resident abuse. The facility's administration failed to ensure incidents of resident-to-resident abuse were reported, tracked and monitored for trends, or appropriately addressed to ensure new interventions after continued abusive behaviors to ensure the residents on the secure unit were protected from additional occurrences. The facility's administration also failed to promote a safe, homelike milieu for the residents in the secure unit free from abuse, which negatively affected the residents' quality of life and overall well-being. 3. On 4/21/17 at 6:31 p.m., the administrator was interviewed and stated resident-to-resident abuse, physical aggression, or sexually inappropriate behavior had not been brought to his attention, or to the attention of the QA committee, for root cause analysis, tracking and trending of incidents, or development of a plan to prevent additional occurrences. He stated, We don't know about it. With (R215), it appears the nurse made a note and did not tell anybody. My expectation is an incident report be completed. (An incident report) should have been done for every instance. The administrator also stated, I would agree there is a problem with the investigation process. Immediate Jeopardy (IJ) was identified in the areas of 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration at F490 and F501, and 42 CFR 483.75 Quality Assurance & Performance Improvement at F520, all cited at a Scope and Severity of a K. Substandard Quality of Care was identified at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation and Quality of Care. Immediate Jeopardy was identified on 4/21/17 and determined to exist starting on 8/7/16 when R215's first sexually aggressive incident occurred towards R405. The facility Administrator was informed of the immediate jeopardy on 4/21/17 at 2:42 p.m. An acceptable Allegation of Compliance (AoC) for removal was received on 4/21/17. The State Survey Agency validated the IJ was removed on 4/21/17 at 6:20 p.m. The A[NAME] included: Removal plan for Resident #215 for Psychological Evaluation Until Resident #215 can be discharged from the facility, he will be supervised by staff one-on-one. Transport is being arranged for Resident #215 to be discharged immediately to (name of) emergency room for evaluation. He will be evaluated for return following appropriate evaluations and treatment as required . Immediate Plan to Prevent Future Occurrence Residents on the secure unit with known potential for aggressive behaviors will have their care plan reviewed and updated as required. All other residents on the secure unit will have their care plans reviewed and updated as required. All staff currently on duty on the secure unit will be in-serviced during immediately on how to recognize abuse, intervention techniques, and proper reporting. All other staff reporting for future shifts on the secure unit will be in-serviced as above prior to beginning their shift. This will continue until all staff on the secure unit have been in-serviced. All staff will be in-serviced on how to recognize abuse, intervention techniques. All residents in the facility will be assessed for resident-to-resident abuse potential and actions taken as necessary (to include discharge from the facility) to alleviate any concerns. The resident-to-resident abuse policy will be reviewed and amended to include tracking, monitoring, and reporting of any incidents. As of the exit on 4/21/17 at 9:15 p.m., the facility had discharged R215 and inserviced all staff currently working on the secure unit on how to recognize abuse, intervention techniques, and proper reporting. The Scope and Severity was lowered to a [NAME] at 42 CFR 483.12 Freedom of Abuse, Neglect and Exploitation at F225 and F226; 42 CFR 483.25 Quality of Care at F323; 42 CFR 483.70 Administration, at F490, while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes.",2020-09-01
3193,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2018-08-23,604,D,0,1,TNXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview it was determined the facility failed to assess one resident out of the four sampled residents for the use of a restraint. Specifically, Resident (R)180 had a non-release seat belt applied after she/he fell from a wheelchair and no restraint assessment was initiated. Findings include: Record review of the Resident Progress Notes, on 06/07/2018 at 2:36 PM for R180 revealed the facility readmitted her/him on 06/07/2018 with [DIAGNOSES REDACTED]. Record review of the significant change Minimum Data Set (MDS), an assessment tool completed by the facility staff used to identify resident care problems and assist with care planning, with an Assessment Reference Date (ARD), the end-point of the evaluation period, of 07/09/18 revealed under Section C: Cognitive Patterns, the resident had a Brief Interview for Mental Status (BIMS) (a cognitive evaluation) score of four out of 15, which indicated the resident had cognitive impairment. Review of Section G: Functional Status, showed R180 needed extensive assistance for bed mobility, transfer, dressing, hygiene and was totally dependent for locomotion. Review of subsection G0400 Functional Limitation in Range of Motion, revealed the resident had impairment on both sides of the lower extremities. Record review of Section P Restraints and Alarms, revealed a trunk restraint had been used daily in a chair. Record review of the Care Area Assessment (CAA), under CAA 18, Physical Restraints, revealed an attempt to discontinue the seat belt had been done but the resident sustained [REDACTED]. Record review of the last Safety Assessment, done on 06/20/18, revealed a restraint was in use which was the non-release belt in the wheelchair related to a decrease in safety awareness and a newly repaired right [MEDICAL CONDITION] from a fall at the psychiatric hospital. The assessment indicated the non-release seat belt was the least restrictive device for the resident. Record review of the Progress Notes for 07/04/18 revealed at 3:00 PM R180 was found on the floor in front of her/his wheelchair. No injuries were noted. Record review further revealed the Responsible Party (RP) had been notified of the fall and requested the non-release seat belt to be put back on the resident. The notes revealed the restraint was reactivated and put back on the resident. Record review of the Safety Event - Fall report dated 07/04/18 revealed a fall had occurred and one of the immediate measures taken was to put a non-release seat belt on the resident. Review of the progress notes and restraint assessments revealed a restraint assessment had not been done prior to putting R180 back into a restraint. Record review of the Physician order [REDACTED]. Record review of the Progress Notes for 07/07/18 revealed R180 went out to the hospital for low blood sugars and came back to the facility on [DATE] with orders for a non-release seat belt. However, record review of the restraint assessments and restraint reduction assessment revealed a restraint assessment had not been done until a restraint reduction assessment was done on (MONTH) 23, (YEAR), the last day of the survey. Observation of R180 on 08/21/18 at 10:38 AM revealed he/she was sitting up in a wheelchair in the community room watching a movie with a non-release seat belt around him. Interview on 08/23/18 at 10:37 AM with Certified Nursing Assistant (CNA)2 revealed R180 cannot release the seat belt when she/he was up in the wheelchair. She revealed she/he had the non-release seat belt because she/he was a falls risk. She stated they released the seat belt a few times during the day and at meals. She revealed they chart the release in the computer, however after reviewing the Point of Care Report in the computer there was no place to chart that the restraint was released just that it was used. Interview on 08/23/18 at 10:46 AM with Nurse Manager (NM)1 revealed R180 had come to their unit from the hospital with a non-releasing seat belt in place. NM1 stated normally a restraint assessment had to be done before putting the restraint back on a resident and she did not see a restraint assessment done when the non-releasing seat belt was put back on the resident on 07/04/18, but there was a restraint reduction assessment done today, 08/23/18. NM1 stated you should do a restraint assessment to see if a restraint is warranted. NM1 revealed if you put a restraint on someone and it was not assessed for appropriateness then it could pose a risk of skin breakdown, distress, decreased mobility, and the resident could continue to have falls. She revealed it looked like when R180 went out to the hospital on (MONTH) 7, (YEAR) the order for the non-releasing seat belt was automatically discontinued because all their orders are discontinued when a resident went out to the hospital. NM1 revealed she had not done a restraint assessment when he/she came to their unit from the hospital because R180 already had one done in (MONTH) (YEAR) but agreed that R180's condition had changed from (MONTH) (YEAR) to (MONTH) (YEAR). She revealed the Unit Managers and nurses can do a restraint assessment. Interview on 08/23/18 at 12:17 PM with the Minimum Data Set (MDS) Coordinator 1 revealed a safety assessment which included the restraint assessment and a restraint reduction assessment should be done with each quarterly, significant change, annual, and admission MDS. She revealed a safety assessment would be done to see if a safety device was needed, such as a restraint. MDS1 revealed the last restraint assessment was one done in (MONTH) (YEAR) and she had completed a restraint reduction assessment on (MONTH) 23, (YEAR). MDS1 stated she assessed R180 as having a self-releasing belt and it was appropriate for her/him. However, later MDS1 stated she had gone to look at the device and it was a non-releasing belt that she/he had utilized, and this too was appropriate for R180. Interview on 08/23/18 at 12:30 PM with the Administrator and the Director of Nursing (DON) revealed a restraint assessment should have been done before applying the restraint to R180 on 07/04/18. They revealed she/he probably came back from the hospital and was bedbound at that time and that was why there was no restraint on her/ him when she/he fell while up in the wheelchair. That was probably why the nurse charted that the restraint was to be reactivated. Record review of the Standard Policy/Procedure with an approved date of 11/13/17 revealed LMC Extended Care prohibits the use of restraints for discipline or convenience. Review of the procedure section of the policy indicated if a restraint was being considered then a safety evaluation must be performed to determine the appropriate least restrictive device. Review of the Restraint policy with no date revealed self-releasing and non-releasing seat belts may be a restraint.",2020-09-01
3194,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2018-08-23,684,D,0,1,TNXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews for one of five Residents (R) 225 reviewed for positioning. The facility failed to ensure the appropriate size wheelchair was provided to afford R225 proper positioning. Findings include: The Face Sheet identified R225 was admitted to the facility on [DATE] with a readmission on 05/03/18 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS),a comprehensive assessment of the resident conducted by the facility, with an Assessment Reference Date (ARD), observation end date of 07/07/18, identified Section C: Cognitive Patterns a Brief Interview of Mental Status (BIMS), score of 15 out of 15 indicating intact cognition and Section G: Functional Status, identified extensive assistance of one for transfers, limited assistance of one for locomotion on the unit, and a wheelchair was normally used as a mobility device. The MDS Section K: Swallowing/Nutrition identified a height of 73 inches. The care plan dated 07/23/18 identified an alteration in the ability to perform activities of daily living with interventions that included physical/occupational/speech therapy (PT/OT/ST) referral per treatment, wheelchair required for mobility, and to provide appropriate assistance with transfers. The Physical Therapy Evaluation dated 08/20/18 identified impaired coordination in the left lower extremity, a manual wheelchair was used, and fair to poor sitting balance. The evaluation failed to identify the wheelchair was the appropriate size for the resident. Observations on 08/20/18, 08/21/18, and 08/22/18 identified R225 seated in a wheelchair. The wheelchair seat did not extend to the end of the resident's thighs but ended half way down the thigh area. The resident's legs bent approximately 6 inches beyond the end of the seat and extended outward in front of the wheelchair. R 225's back was not completely supported because the back support of the wheelchair only reached halfway up the resident's back. Interview with R225 on 08/21/18 at 11:30 AM identified he thought the wheelchair was too small for him, but stated, No one provided a larger wheelchair. R225 stated, The wheelchair was given to me when I came here. Interview with the Therapy Director on 08/22/18 at 1:40 PM admitted she was aware R225's wheelchair was not the proper size and she stated, A larger wheelchair would be provided. Review of the Physical Therapy Progress Note dated 08/23/18 at 10:37 AM identified As a follow up to the care plan dated 08/10/18, although Resident had no c/o (complaints) of his W/C (wheelchair) and he self propels throughout the facility, Resident may receive new W/C due to current chair being too low for his height. Resident used high back W/C this date for trial .Education provided, and he will be able to use it indefinitely. Resident expressed appreciation .",2020-09-01
3195,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2018-08-23,692,D,0,1,TNXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and interviews for 1 of 4 Residents (R) 121 reviewed for nutrition, the facility failed to conduct a nutrition assessment when a significant weight loss was identified resulting in a delay in implementation of interventions to prevent further weight loss. Findings include: R121's Face Sheet identified [DIAGNOSES REDACTED]. The (MONTH) (YEAR) Physician order [REDACTED]. The quarterly Minimum Data Set (MDS),(a comprehensive assessment of the resident conducted by the facility, with an Assessment Reference Date (ARD), observation end date, of 08/09/18 identified under Section G: Functional Status R121 was independent for eating after set up help only, and Section K Swallowing/Nutritional Status, no 5% weight gain or loss in the last month or gain of 10% or more in the last 6 months. R121 received a therapeutic diet. The care plan dated 05/10/18 identified a high risk for altered nutrition related to a [DIAGNOSES REDACTED]. Interventions included monitor/record intake at meals and supplements, monitor/record weight as ordered, and nutrition assessment as needed for significant weight change and decreased intake. Review of the Weight Variance Report, dated 07/01/18 through 08/22/18 identified R121 weighed 116 pounds (lbs.) on 07/10/18 and 104 lbs. on 08/03/18, which identified a 10.3% weight loss in less than 2 months. Review of the Nutrition Review dated 08/22/18 identified Med Pass (liquid supplement) 3 ounces QID (four times a day) related to low weight and variable PO (oral) intake. PO meal intake ranges between 25-50% and is inadequate to meet nutrition needs. Acceptance of Med Pass 80% per day. Weight trend -10.3% times 30 days (significant). Weight loss is new and unplanned. Will order Magic cup (supplement) TID (three times a day) and weight every week times 4 weeks. Interview with Dietitian 1 on 08/22/18 at 10:45 PM identified the nutrition review was completed on 08/22/18 because that was when she found out R121 had a significant weight loss. Dietitian 1 stated, I have access to all weights entered in the electronic medical record by the aides. I review weights weekly to determine loss or gain. Dietitian 1 stated, If a resident has a significant weight loss, I should conduct the nutrition assessment at the time the weight loss is identified. Dietitian 1 could not explain why there was a delay in conducting the nutrition assessment when the significant weight loss was documented on 08/03/18. Interview with Certified Nurse Aide (CNA) 1 on 08/22/18 at 12:00 PM identified a Weight Variance Report is generated and provided to the CNA who obtains the weight. After the CNA obtains a resident's weight, it is compared to the previous months weight. If there is a big difference the CNA reports the weight to the nurse who would notify the dietitian. CNA 1 could not explain why the weight on 08/03/18 was not reported to the nurse. Interview with the Director of Nurses (DON) on 08/22/18 at 12:45 PM identified the CNA should report big weight changes to the charge nurse. The DON did not clarify what big meant. A weight obtained on 08/22/18 at 12:50 PM identified R121 weighed 109 lbs. Review of the facility Height and Weight policy last dated 02/13/15 identified .Monthly weights are recorded in point of care. Monthly weights are reviewed by Nutritional Services and weight variances are determined. The dietitians work with nursing services and the physician to plan the appropriate interventions. Significant weight variances are one month 5% and six months 10% .",2020-09-01
3196,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2019-12-04,600,G,1,1,GRSS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure an environment free from neglect for 1 of 6 sampled residents reviewed for abuse/neglect (Resident #14) as evidenced by failure to follow the Care Plan related to method of transfer resulting in injury to the resident. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review on 12/04/19 at approximately 9:01 AM revealed an Incident Report dated 11/25/19 at 10:42 AM which stated Licensed Practical Nurse (LPN) #1 was called to Resident #14's room by Certified Nursing Assistant (CNA) #2. LPN #1 found Resident #14 on the floor sitting up being supported by CNA #2. CNA #2 stated Resident #14 slipped during transfer and was lowered to the floor. Resident #14 denied any pain and vitals were taken after being assisted off of the floor. Further review revealed a Progress Note from the Social Worker stating that the Resident Representative (RR) asked that Resident #14 be transferred to the emergency room (ER). Resident #14 refused to be transferred to the ER. The RR was notified of the refusal. A Progress Note dated 11/25/19 at 7:46 PM by LPN #2 stated Resident #14 complained of pain in his/her left shoulder and upper arm. An x-ray obtained by a mobile provider revealed an acute impacted left humeral neck fracture. In an interview on 12/04/19 at approximately 1:50 PM, CNA #2 admitted to using the Sit to Stand lift on 11/25/19 to transfer Resident #14 out of bed. CNA #2 stated it was the first time s/he had attempted to get Resident #14 up alone. CNA #2 also stated that s/he was aware that a Full Body Lift (which requires 2 people) was the correct device to use for Resident #14 but there was not another CNA available to assist in using the Full Body Lift. In an interview on 12/04/19 at approximately 12:37 PM, the Director of Nursing (DON) confirmed that CNA #2 failed to follow policy and protocol by not using the correct device for the transfer of Resident #14 as per the Care Plan. In an interview on 12/04/19 at approximately 2:22 PM, the Medical Director stated the expectation for CNA #2 would be to follow the Care Plan which called for the use of the Full Body lift, which is a two-person transfer.",2020-09-01
3197,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2019-12-04,641,D,1,1,GRSS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide accurate assessments for 1 of 40 residents on initial pool. Resident #2[AGE]'s Minimum Data Set (MDS) was inaccurate. The resident was marked as having a stage 4 pressure ulcer when s/he had none. The findings included: Resident #2[AGE] was admitted to the facility on [DATE]. Interview with family of Resident #2[AGE] on 12/2/19 at approximately 5:38 PM revealed the resident had a bed sore on arrival, though it had healed completely since then. Review of 11/9/19 quarterly MDS on 12/3/19 at approximately 11:08 AM revealed Resident #2[AGE] had been coded for a stage 4 pressure ulcer. Review of nursing notes on 12/3/19 at approximately 11:10 AM revealed a 9/22/19 note that the sacral wound had closed. Interview with Registered Nurse (RN) #3 on [DATE] at approximately 12:46 PM confirmed the miscoded MDS. RN #1 stated a trainee had filled out the MDS and had made a mistake.",2020-09-01
3198,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2019-12-04,689,G,1,1,GRSS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure an environment free from accident hazards for 1 of 5 sampled residents reviewed for accidents (Resident #14) as evidenced by failure to follow the Care Plan related to method of transfer resulting in injury to the resident. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review on 12/04/19 at approximately 9:01 AM revealed an Incident Report dated 11/25/19 at 10:42 AM which stated Licensed Practical Nurse (LPN) #1 was called to Resident #14's room by Certified Nursing Assistant (CNA) #2. LPN #1 found Resident #14 on the floor sitting up being supported by CNA #2. CNA #2 stated Resident #14 slipped during transfer and was lowered to the floor. Resident #14 denied any pain and vitals were taken after being assisted off of the floor. Further review revealed a Progress Note from the Social Worker stating that the Resident Representative (RR) asked that Resident #14 be transferred to the emergency room (ER). Resident #14 refused to be transferred to the ER. The RR was notified of the refusal. A Progress Note dated 11/25/19 at 7:46 PM by LPN #2 stated Resident #14 complained of pain in his/her left shoulder and upper arm. An x-ray obtained by a mobile provider revealed an acute impacted left humeral neck fracture. Review of the Care Plan for Resident #14 revealed an approach/intervention with a start date of 11/17/16, last updated on 0[DATE], instructing to Provide appropriate assistance of staff members before attempting to transfer. Use Full Body Mechanical Lift as designated. In an interview on 12/04/19 at approximately 1:50 PM, CNA #2 admitted to using the Sit to Stand lift on 11/25/19 to transfer Resident #14 out of bed. CNA #2 stated it was the first time s/he had attempted to get Resident #14 up alone. CNA #2 also stated that s/he was aware that a Full Body Lift (which requires 2 people) was the correct device to use for Resident #14 but there was not another CNA available to assist in using the Full Body Lift. In an interview on 12/04/19 at approximately 12:37 PM, the Director of Nursing (DON) confirmed that CNA #2 failed to follow policy and protocol by not using the correct device for the transfer of Resident #14 as per the Care Plan. In an interview on 12/04/19 at approximately 2:22 PM, the Medical Director stated the expectation for CNA #2 would be to follow the Care Plan, which called for the use of the Full Body lift which is a two-person transfer.",2020-09-01
3199,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2019-12-04,732,C,1,1,GRSS11,"> Based on observation, interview, and record review, the facility failed to post staffing hours worked per shift for 3 of 3 months reviewed. The findings included: Observation of postings in Maxie and Cherokee units on [DATE] at approximately 11:18 AM revealed the census and staff numbers were posted, but not the actual hours worked by staff per shift. Review of previous 90 days of staff postings on [DATE] at approximately 12:45 PM confirmed the staff postings did not list the actual hours worked by staff per shift. Interview with the Assistant Director of Nursing (ADON) on [DATE] at approximately 12:55 PM confirmed staff postings were not calculating the cumulative hours correctly. The ADON stated it was a glitch in the program s/he had not been notified of.",2020-09-01
3200,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2019-12-04,880,D,1,1,GRSS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and review of facility's Catheterization of Female/Male policy, the facility failed to ensure that a resident with a catheter had their catheter bag off the floor. Resident #196's catheter bag was observed laying flat on the floor near the resident's bed. The findings included: The facility admitted Resident #196 on 10/20/17 with [DIAGNOSES REDACTED]. Observations on 12/02/19 at 3 PM and 3:25 PM revealed Resident #196's catheter bag lying fat on the floor. On 12/02/19 at 3:30 PM during the interview with Resident #196, two Certified Nursing Aides (CNAs) knocked on door and entered room. The resident interview ceased until the aides left the room. The two CNAs checked Resident #196's oxygen sats and left the room. The resident's catheter bag remained lying flat on the floor. On 12/02/19 at 3:38 PM, CNA #1 entered the room to wipe a wet substance off the floor near Resident #196's bed. He/she made no effort to remove the resident's catheter off the floor. An interview on 12/02/19 at 3:30 PM with CNA #1 confirmed the observation that Resident #196's catheter bag was lying flat on floor and further stated the catheter bag should not be lying on the floor. CNA #1 put on gloves, wiped the wet substance from the floor, hooked the resident's catheter bag on the bed, and exited the room. A review of the medical record on 12/03/19 at 2:37 PM revealed no documentation to indicate when the resident's catheter bag was last emptied. An interview on 12/03/19 at 3:15 PM with Registered Nurse (RN) #1 revealed that the CNAs are supposed to empty the catheter bag and put it back on the hook on the resident's bed. The surveyor requested documentation to indicate when the last time the resident's catheter was emptied. No documentation was provided. A review of the facility's Catheterization of Female/Male policy reviewed under #9 revealed: Complete the procedure b) Position the bag to avoid urine reflux into the bladder, kinking, or gross contamination of the bag. Position the bag hanger on the bed rail near the foot of the bed using the clip to secure the drainage tube to the sheet. Keep the bag below the level of the bladder at all times to prevent the back flow of urine and decrease the risk for infection. Never leave the catheter hanging to be pulled by the weight of the bag. Do not leave the bag lying on the floor.",2020-09-01
4236,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2016-06-16,156,B,0,1,3I0411,"Based on record review and interviews, the facility failed to provide in writing a list, of services that the resident on Medicaid, may and may not be billed for, for one of one resident sampled, (resident #382). Findings included - Interview with the responsible party for resident #382 by telephone on 6/14/16 at 2:24 PM revealed the facility did not provide a copy of services Medicaid would and would not pay for. Review of resident #382's business office file lacked evidence the facility provided the resident's responsible party a copy of the list of services that Medicaid would and would not pay for. Interview with administrative staff 1 in her office on 6/16/16 at 11:02 am revealed, the facility would discuss verbally with the resident and/or responsible party what the financial liability would be. But if the resident was going to have a service that was not covered by Medicaid, the facility would notify the resident or responsible party prior to the resident receiving the service. The facility failed to provide a written list of services that Medicaid would and would not cover for this resident",2020-05-01
4237,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2016-06-16,166,D,0,1,3I0411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that that prompt efforts were made by the facility to resolve a grievance for one of twenty-two (22) sampled residents. (Resident #395) Findings include: Record review revealed Resident #395 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident ' s last quarterly minimum data set ((MDS) dated [DATE] noted that the resident's brief interview for mental status (BIMS) score was a 99. The resident was unable to recall, had memory problems as well as cognitive issues. A complaint had been filed by the resident ' s daughter for several issues including a concern regarding missing items. The complaint narrative was documented to indicate that the resident was missing a set of dentures and a pair of glasses. Review of the facility's Customer Concern Log dated (MONTH) (YEAR) through (MONTH) (YEAR) revealed that there was no documentation suggesting that issues was brought up to the facility staff regarding the missing items. An interview with unit secretary on the dementia unit was conducted on 6/16/16 at approximately 1:02 PM. The staff member confirmed that the resident ' s items were missing and that staff searched for item. An interview with the Social Services staff (Admin staff #7) in her office was conducted on 6/16/16 at approximately 1:15 PM. The staff explained the process for reporting missing items and stated that she learned of Resident #395's issue on 5/25/16 regarding missing items and referred to the administrator for follow up. A request was made to the Administrator for follow up on resident #395 ' s missing items on 6/16/16 at 1:33 PM after surveyor intervention. An interview was conducted with the Administrator and Director of Nursing in the Administrator ' s office on 6/16/16 at approximately 1:45 PM. The Administrator stated that the issue regarding the missing items was actually 3 months old and nothing was ever done. The Administrator confirmed that the resident ' s daughter wrote a letter and several emails were passed between staff and social worker 5/26/16 but there was no resolution. The Administrator stated that normally a concern form would be filled out by the staff presented with the issue and items would be replaced if the facility was at fault in anyway.",2020-05-01
4238,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2016-06-16,225,D,0,1,3I0411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Sample size included 22 residents of which 1 was reviewed for investigations. Based on observation, record review, and interviews, the facility failed to investigate the loss of dentures for 1 (#49) resident of the sample. Findings included: Resident #49 was admitted on [DATE] and the [DIAGNOSES REDACTED]. The 4/29/16 significant change Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status score of 9, moderate cognitive impairment. The MDS also revealed the resident required limited assistance with eating, received a therapeutic diet and had no natural teeth. The Care Area Assessment for dental dated 5/12/16, revealed the resident had no natural teeth and had upper and lower dentures. The up-dated care plan dated 6/10/16 revealed the resident had upper and lower dentures, required assistance with oral hygiene, received a regular pureed diet, staff would assist with the insertion of dentures as needed, monitor for chewing and swallowing issues during meals and report to appropriate staff/discipline as indicated, provide/assist with mouth care every shift and as needed, and referral to oral health professional as needed. Interview with the resident on 6/14/16 at 2:51 P.M. revealed the resident's dentures were lost and the resident wanted to get a new set or find the old ones. Observation at that time revealed the resident did not have dentures in place. Interview with direct care staff #3, on 6/15/16 at 12:07 P.M. revealed he/she thought they lost the resident's dentures while the resident was at the hospital. Observation at that time revealed this staff assisted the resident with a pureed diet and the resident did not have dentures in place. Interview with licensed nurse #8, on 6/15/16 at 2:23 P.M. revealed the resident did not have his/her dentures when the resident returned from the hospital, (on 6/1/16). Review of the clinical record on 6/15/16 at 2:23 P.M. lacked documentation regarding the missing dentures. Further interview with licensed nurse # 8 on 6/15/16 at 2:58 P.M. revealed he/she had talked with the social worker and found out the resident had lost their dentures at the facility prior to going to the hospital (on 5/29/16). Licensed nurse #8 also stated he/she did not know if anyone started an investigation regarding the missing dentures. Interview with administrative staff #4, on 6/16/16 at 8:48 [NAME]M. revealed on 6/2/16 he/she met with the resident and the spouse. The spouse reported the resident's lower dentures were missing since the week of 5/23/16 and requested the resident's diet be changed from a regular diet to a pureed diet. This staff stated he/she sent an e-mail to the resident's unit manager, the nurse manager on the floor, the housekeeping manager and the dietary manager regarding the missing dentures. This staff should let administrative staff #4, know if they found the dentures. Interview with administrative staff #9 during this time revealed the facility did not complete a grievance form/complaint form if the family is not upset about the missing items. The staff would complete a form if the resident and/or family asked to go to the administrator or they were requesting a replacement or refund of the missing item. He/she further stated the facility did not investigate the missing dentures. Interview with licensed nurse #5 on 6/16/16 at 11:28 [NAME]M. revealed if an item is reported missing the staff will start a search immediately and notify laundry and dietary, so they can also start a search for the item. He/she stated the facility was not responsible for lost items. Licensed nurse #5 also stated the social worker would start the form to begin the investigation. Upon asking for a policy regarding the completion of investigations, the facility provided a copy of the Non-Care Related Concern Form. The facility's policy for Complaints dated 10/24/97, documented the nurse manager or shift supervisor would immediately investigate the complaint and conclude whether or not the complaint was valid, resolve factors which may have contributed to the complaint, communicate the complaint and contributing factors to to the employees directly involved with the area of complaint, and inform the director of nursing of the ongoing complaint investigation. The facility failed to investigate the reported loss of dentures.",2020-05-01
4239,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2016-06-16,280,D,0,1,3I0411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Sample size was 22 residents. Based on observation, record review, and interviews, the facility failed to revise the care plan for one resident (#49). Findings included: Resident #49 was admitted on [DATE] and the [DIAGNOSES REDACTED]. The 4/29/16 significant change Minimum Data Set (MDS) revealed the resident had a Brief Interview for Mental Status score of 9, moderate cognitive impairment. The MDS also revealed the resident required limited assistance with eating, received a therapeutic diet and had no natural teeth. The Care Area Assessment for dental dated 5/12/16, revealed the resident had no natural teeth and had upper and lower dentures. The up-dated care plan dated 6/10/16 revealed the resident had upper and lower dentures, required assistance with oral hygiene, received a regular pureed diet, staff would assist with the insertion of dentures as needed, staff would monitor for chewing and swallowing issues during meals and report to appropriate staff/discipline as indicated, staff would provide/assist with mouth care every shift and as needed, and referral to oral health professional as needed. Observation and interview with direct care staff # 3 on 6/15/16 at 12:07 PM revealed the staff was feeding the resident her pureed diet. The resident did not have dentures in place. Direct care staff #3 at that time stated he/she thought they lost the resident's teeth at the hospital. Interview with administrative staff #4 on 6/16/16 at 8:48 am in her office, revealed, the spouse and the resident visited with this staff and reported the resident's dentures were missing the week of 5/23/16. Administrative staff #4 stated she had sent an email to the resident's unit manager, nurse manager on the resident's unit, and the housekeeping and dietary manager so they could each begin looking for the dentures. The dentures had not been found. Interview with licensed Nurse #6, 6/16/16 at 9:37 am on the unit revealed the nurses completing the MDSs revised the care plan as needed. Interview with Licensed Nurse #5 in her office on 6/16/16 at 11:28 am revealed the floor nurses revise the care plan or they can notify the MDS nurse and he/she can update the care plan. The facility's policy for Care Plan dated 5/16/11 documented, revisions to the care plan are made by adding to the plan using black ink and including a signature and date and discontinued areas with the use of a yellow highlighted with date and initials of the discipline/person making the changes. The policy did not direct which staff was responsible for revising the care plan. The facility failed to revise the care plan after this resident lost his/her dentures.",2020-05-01
4240,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2016-06-16,309,D,0,1,3I0411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Sample size included 22 residents of which 1 was reviewed for [MEDICAL TREATMENT] services. Based on observation, record review, and interviews, the facility failed to monitor the fluid intake for 1 (#393) resident of the sample who was on a fluid restriction. Findings included: Resident #393 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 15, cognitively intact. The resident received a therapeutic diet and required set-up assistance with eating. The 4/22/16 care plan included the interventions: set-up assistance with meals, current diet of high protein renal/diabetic with thin liquids, 1000 millimeters (ml), fluid restriction in 24 hours, 600 ml with meal trays, and 400 ml with nursing, and [MEDICAL TREATMENT] every Tuesday, Thursday, and Saturday. The physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Further review of the clinical record lacked evidence of any other fluid intake documentation. Review of a progress note dated 5/17/16 and timed 4:19 PM revealed the resident was drinking a 20 ounce bottle of soda. Review of the MAR for that date revealed staff documented the resident consumed 400 ml of fluid for the 24 hour period. Observation on 6/15/16 at 12:09 PM revealed the resident was served her lunch tray including a 240 ml coffee mug of liquid. Interview with Licensed Nurse # 5 on 6/16/16 at 11:10 am revealed the nurses should document on the MAR indicated [REDACTED]. This nurse was unable to find documentation regarding the fluid intake of this resident at meals. The policy for Measuring Intake and Output dated 11/24/97 revealed fluid intake means the amount of any liquid taken into the body. The amount must be accurate. The purpose is to provide accurate records of fluids taken and eliminated by the resident to aide the doctor in determining the resident's fluid balance. Staff should write down exactly what the resident has taken. The facility failed to monitor the fluid intake for this resident receiving [MEDICAL TREATMENT] and on a fluid restriction.",2020-05-01
5733,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2015-02-26,241,D,0,1,HJ6E11,"Based on observations and interviews, the facility failed to obtain permission from residents prior to placing clothing protectors on them at meal time in 1 of 8 dining rooms observed on one of four days of the survey. In one dining room, two Certified Nursing Assistants placed clothing protectors on at least five residents without first asking the residents' permission. The findings included: During observation of the noon meal in the(NAME)Place dining room on 2/23/2015 at approximately 12:53 PM, Certified Nursing Assistant (CNA) #1 was observed placing clothing protectors on residents without asking permission prior to placement. CNA #1 placed clothing protectors on 4 residents without asking if they would like one. S/he did not let the residents know what s/he was doing. During an interview on 2/23/2015 at 1:04 PM, CNA #1 confirmed that s/he did not ask the residents if they would like a clothing protector prior to placing them on the residents. Observation on 2/23/15 at approximately 12:56 PM in the(NAME)Place dining room revealed a Certified Nursing Assistant (CNA) #7 placing a clothing protector over a resident's head without informing him/her or asking for permission. The resident snatched the clothing protector off and refused to wear it. During an interview on 2/23/15 at approximately 1:06 PM, CNA #7 confirmed they did not obtain permission or inform the resident that they were placing the clothing protector.",2018-10-01
5734,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2015-02-26,279,D,0,1,HJ6E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop a dental care plan for 1 of 3 sampled residents (#367) reviewed for dental services. The findings included: Resident #367 was observed on 02/23/2015 at 01:28 PM with no natural teeth or broken natural teeth. The surveyor asked Resident #367 if s/he was experiencing any eating or chewing problems since s/he didn't have any teeth. S/he stated, I can't eat hard stuff. Resident #367 was asked if s/he had seen a dentist. S/he stated, I haven't been to a dentist in a long time. Review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed s/he was assessed as having no natural teeth. Resident #367 was scored as having a cognitive ability of 04, indicating s/he had some cognitive impairment. On 2/26/15 at 8:30 AM, the surveyor asked Resident #367 again if s/he wanted to see a dentist. Resident #367 stated, Yes, I need to see someone. Review of the care plans did not reveal a care plan addressing the resident's dental status of having no natural teeth or experiencing chewing problems. Review of a dietary assessment dated [DATE] revealed No chewing problems was noted on the assessment. The surveyor asked the MDS Coordinators if they were responsible for creating care plans and making dental referrals on 2/25/15 beginning at 4:12 PM. MDS Coordinator #3 stated, Yes. When asked about lack of a dental care plan for Resident #367, MDS Coordinator #3 stated it will trigger a CAA (Care Area Assessment) summary and advised Resident #367 was noted without any natural teeth and top dentures only. Her (His) mouth is pink and intact to exam with no complaints of oral pain or discomfort. During the same interview on 2/25/15 at 4:12 PM, MDS Coordinator #2 stated, When s/he (Resident #367) came in s/he and her (his) sister stated s/he didn't like to wear her (his) bottom dentures. S/he continued, When Resident #367 was admitted , s/he was receiving tube feedings in conjunction with a pureed diet. I documented on 7/14 Resident #367 is noted without natural teeth or dentures present. S/he continued, S/he had an upper denture but s/he does not wear it. S/he is assisted with oral care by staff routinely so I care planned it under ADLs (activities of daily living). S/he acknowledged a care plan specifically addressing her/his dental status had not been created.",2018-10-01
5735,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2015-02-26,280,D,0,1,HJ6E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the care plan for 1 of 3 residents (#101) whose care plans were reviewed for weight loss. The findings included: Review of a Significant Change Minimum Data Set ((MDS) dated [DATE] for Resident #101 revealed the resident was marked as having weight loss. S/he was also marked as having a therapeutic and mechanical altered diet. Further review of the clinical record revealed Resident #101 was at risk for aspiration related [MEDICAL CONDITION] with Dysphasia. Other pertinent [DIAGNOSES REDACTED]. Review of the resident's care plan dated 1/14/15 revealed s/he was planned as being at risk for altered nutritional status and hydration due to ICH and [MEDICAL CONDITIONS]. Significant weight loss was noted 10/17/14. The approaches were listed as: *assess for dehydration and malnutrition document/report Diet/supplements as ordered *Labs as ordered *nutritional consult as needed There was no evidence on the nutritional care plan that the resident was receiving comfort care measures. There was, however, an additional care plan for comfort care measures. The care plan addressed: No labs, no hospitalization s, no IV hydration but the care plan did not address nutritional interventions. The Unit Manager (Registered Nurse #3) was interviewed on 02/26/2015 8:35 AM. S/he stated Resident #101 just quit eating. The Unit Manager continued, On 8/18/14, the facility began discussions of Hospice. Review of the clinical record revealed on 8/25/14 Nurse's Notes documented Resident #101's decline and the decision by the family for comfort care measures only. The Unit Manager stated, It would be care planned as a significant change for expected weight loss due to declining medical condition. MDS Coordinator #1 was interviewed on 02/26/2015 at 9:06 AM. S/he stated, Yes we are responsible for updating the care plans but dietary is responsible for advising us of significant changes. During an interview with the supervisor for the Registered Dietitians on 2/26/15 at approximately 12:45 PM, s/he stated, We could do a better job with care planning anticipated weight loss due to comfort care. We are trying to provide her (him) with what she (he) wants (to eat) now.",2018-10-01
5736,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2015-02-26,329,D,0,1,HJ6E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure appropriate documentation was maintained for a specific clinical condition to warrant the use of an anti-anxiety medication for 1 of 6 residents reviewed for unnecessary medications. Resident #429 received an anti-anxiety medication ([MEDICATION NAME]) on an as-needed basis without an appropriate diagnosis. The findings included: The facility admitted Resident #429 with [DIAGNOSES REDACTED]. Record review revealed 2/4/15 physician's orders [REDACTED]. Continue IM (intramuscular) prn. On 2/5/15, the [MEDICATION NAME] gel was increased to three times daily. On 2/6/15, an order was written to D/C (Discontinue) PO (by mouth) [MEDICATION NAME]-Replaced with PLO gel. Review of the Resident's Medication Administration Record [REDACTED]. No specific behaviors were noted. Review of the Nurse's Notes on 2/25/15 at approximately 10:46 AM revealed Resident #429 had episodes of increased agitation and confusion. 1/25/15 Behavior note: Resident was climbing out of bed this morning saying (s/he) had to go home .scheduled [MEDICATION NAME] given. 1/30/15 Resident continues to show agitation with care yelling at staff and swinging. [MEDICATION NAME] 0.5 mililiter given. 1/30/15 Increased agitation this AM fighting with staff refusing care difficult taking meds this shift. 1/30/15 9:48 PM increase agitation at the beginning of shift IM [MEDICATION NAME] given with effective results. 2/1/15 Increase agitation this am fighting with staff refusing care difficult taking meds this shift. Further review of Resident #429's medical record revealed a 2/17/15 Note to Attending Physician/Prescriber from the Pharmacy Consultant: Please consider updating the [DIAGNOSES REDACTED]. The Physician agreed and wrote agitation as the [DIAGNOSES REDACTED]. During an interview on 2/25/15 at approximately 1:41 PM, Licensed Practical Nurse (LPN) #2 stated that Resident #429 received [MEDICATION NAME] for agitation. LPN #2 stated that the resident was combative, yelled and cursed at staff. LPN #4 stated that resident behaviors were documented in progress notes and that a behavior monitoring form was only used for residents on antipsychotics. During an interview on 2/25/15 at approximately 2:19 PM, the Consultant Pharmacist confirmed the resident did not have a clinical indication for the use of an anti-anxiety medication. S/he stated that the doctor had been made aware, but no changes had been made to the resident's diagnoses.",2018-10-01
5737,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2015-02-26,371,E,0,1,HJ6E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the Food Code U.S. Public Health Service FDA 2013, the facility failed to distribute food under sanitary conditions as evidenced by staff touching ready-to-eat foods with bare hands in 3 of 8 dining rooms during two observations of meal service during the four days of the survey. Six Certified Nursing Assistants were observed handling residents' bread products with bare hands. The findings included: On 02-23-15 at approximately 12:17 PM, observation of the lunch meal service in the Lexington Unit Dining Room revealed Certified Nursing Assistant (CNA) #2 removed bread from packaging with his/her bare hands for 2 residents. CNA #6 was observed touching a resident's bread with his/her bare hands. Observation of the [MEDICATION NAME] Unit lunch meal distribution on 02-23-15 at approximately 12:58 PM revealed CNA #4 touched 2 residents' bread with his/her bare hands. Additional observation of the lunch meal distribution in the Lexington Unit Dining Room on 02-25-14 at approximately 12:22 PM revealed CNA #4 and CNA #5 removed residents' muffins from the muffin wrapping with their bare hands. During an interview on 02-25-15 at approximately 12:22 PM, the Food Service Manager stated the dietary department followed state regulations related to staff not touching ready-to-eat food with bare hands. During interviews on 02-26-15 at approximately 1:45 PM, CNA's #2, #4 and #5 confirmed the surveyor's observations. Review of the Food Code U.S. Public Health Service FDA 2013 revealed in Chapter 3, Part 3-3: Protection from contamination after receiving food, Subpart 3-301.11, Preventing Contamination from Hands, the following, (B) Except when washing fruits and vegetables .food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatula, tongs, single-use gloves or dispensing equipment. During the noon meal observation on 2/23/15 on the(NAME)Unit, multiple Certified Nursing Assistants (CNA's) were handling ready-to-eat foods with their bare hands. The surveyor observed CNA #7 touching a resident's bread while taking it out of the plastic packaging. Further observation of dining on the(NAME)Unit revealed CNA #9 serving resident room trays on the hall. On 2/23/15 at approximately 1:12 PM, CNA #9 was observed touching the resident's bread while taking it out of the packaging. CNA #8 was observed touching the resident's bread on 2/23/15 at approximately 1:20 PM. S/he was also observed picking up the bread with bare hands and holding it while putting butter on it for the resident. During an interview on 2/23/15 at approximately 1:35 PM, the CNA's confirmed that they had touched the residents' bread with their bare hands. The CNA's stated they thought they were able to touch the bread after washing their hands or using hand sanitizer.",2018-10-01
5738,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2015-02-26,412,D,0,1,HJ6E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide dental services for 1 of 3 sampled residents (#367) reviewed for dental services. The findings included: Resident #367 was observed on 02/23/2015 at 1:28 PM with no natural teeth or broken natural teeth. Resident #367 was asked if s/he had seen a dentist. S/he stated, I haven't been to a dentist in a long time. The surveyor asked Resident #367 if s/he was experiencing any eating or chewing problems. S/he stated, I can't eat hard stuff. Review of a Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed as having no natural teeth. Resident #367 was scored as having a cognitive ability of 04, indicating s/he had some cognitive impairment. On 2/26/15 at 8:30 AM, the surveyor asked Resident #367 again if s/he wanted to see a dentist. Resident #367 stated, Yes, I need to see someone. Review of the care plans did not reveal a care plan addressing the resident's dental status of having no natural teeth or experiencing chewing problems. Further review of the clinical record did not reveal a dental consultation. Review of a dietary assessment dated [DATE] revealed, No chewing problems was noted on the assessment. A nurse (#4) responsible for the care of Resident #367 stated on 2/25/15 at 3:51 PM, We assess if they have dentures, etc. on admission, then the MDS Coordinators assess quarterly thereafter. The nurse was aware the resident did not have any teeth, however was not aware s/he had chewing problems. The surveyor asked the MDS Coordinators if they were responsible for creating care plans and making dental referrals on 2/25/15 beginning at 4:12 PM. The MDS Coordinator stated, Yes. When asked about lack of a dental care plan for Resident #367, MDS Coordinator #3 stated it will trigger a CAA (Care Area Assessment) summary and advised Resident #367 was noted without any natural teeth and top dentures only. Her (his) mouth is pink and intact to exam with no complaints of oral pain or discomfort. Staff assist her (him) with oral care. During the same interview on 2/25/15 at 4:12 PM, MDS Coordinator #2 stated, When s/he (Resident #367) came in, s/he and her (his) sister stated s/he didn't like to wear her (his) bottom dentures. S/he continued when Resident #367 was admitted , s/he was receiving tube feedings in conjunction with a pureed diet. I documented on 7/14 Resident #367 is noted without natural teeth or dentures present. S/he continued, S/he had an upper denture but s/he does not wear it. S/he is assisted with oral care by staff routinely so I care planned it under ADLs (activities of daily living). The MDS Coordinator acknowledged a care plan specifically addressing her/his dental status had not been created. The surveyor asked if a resident came in without teeth would they address the resident's lack of teeth, and chewing problems. MDS Coordinator #2 stated, If someone came in edentulous, I would ask if they need dentures or want dentures. If they want them, we do a referral to social services. S/he acknowledged a referral to social services was not done. This is the first time we have heard s/he might want them. The Director of Nursing was interviewed on 2/26/14 at approximately 2:00 PM. S/he stated they would make certain Resident #367 saw a dentist.",2018-10-01
5739,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2015-02-26,431,D,0,1,HJ6E11,"Based on observation, record review and interview, the facility failed to ensure that drugs and biologicals were properly labeled in 3 of 8 medication carts reviewed. The facility failed to ensure that procedures were in place to ensure that expired medications were not stored with current medications in 4 of 8 medication carts reviewed. Magic Mouthwash was expired in one cart on Lexington Trace. Magic Mouthwash had no expiration date on Palmetto Lane. UTI Stat, Prostat, and Prostat Sugar Free were opened and undated on 2 carts on Ivey Unit. In addition, one medication cart was randomly observed unlocked and unattended on one evening shift on the four days of the survey. The findings included: Observation of a medication cart on Lexington Trace on 2/24/2015 at 4:20 PM revealed a bottle of Magic Mouthwash with an expiration date of 1/29/2015. Review of the resident's Medication Administration Record [REDACTED]. During an interview on 2/24/2015 at approximately 4:20 PM, Licensed Practical Nurse (LPN) #1 confirmed that the Magic Mouthwash had an expiration date of 1/29/2015 and that the resident received a dose of Magic Mouthwash on 2/5/2015. Observation of a Medication Cart on Palmetto Lane on 2/24/2015 at 4:51 PM revealed a resident's bottle of Magic Mouthwash that was not labeled with an expiration date. During an interview on 2/24/2015 at approximately 4:51 PM, the Consultant Pharmacist confirmed the Magic Mouthwash did not have an expiration date and stated the Magic Mouthwash should be labeled with an expiration date. Observation on 02-25-15 at approximately 6:45 PM revealed that the Ivy Medication Cart had been left unsecured/unlocked and unattended. During an interview on 02-25-15 at approximately 6:47 PM, Licensed Practical Nurse (LPN) #3 confirmed that s/he had left the medication cart unlocked. S/he verified that the medication cart should be locked when not in use. During an interview on 02-25-15 at approximately 7:00 PM, the Director of Nursing (DON) confirmed the medication cart should have been locked when not in use. On 02-26-15 at approximately 11:30 AM, review of LPN #3's New Employee Medication Pass Audit (dated 02-17-14) revealed s/he had been checked Yes for Competence Skill: Maintained security of cart at all times. Review of the facility policy entitled Medication Guidelines revealed the following: The nurse is responsible for all drugs in the med cart. She/he is not to leave this cart unlocked or unattended unless in the presence of another nurse or pharmacist. Observation of the Hall 1 Medication Cart on the Ivey Unit on 2/24/15 at approximately 4:31 PM revealed an open undated 30 fluid ounce bottle of UTI Stat and an open undated 30 fluid ounce bottle of Prostat Sugar Free. The directions on the bottles specifed: Discard 3 months after opening, record date opened on bottom of container. During an interview on 2/24/15 at approximately 4:46 PM, Licensed Practical Nurse #4 confirmed the surveyor findings and stated that it should have been dated after opening. Observation of the Hall 2 Medication Cart on the Ivey Unit on 2/24/15 at approximately 4:49 PM revealed an open undated 30 fluid ounce bottle of Prostat. The bottle of Prostat had directions to Discard 3 months after opening, record date opened on bottom of container.",2018-10-01
5740,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2015-02-26,505,D,0,1,HJ6E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the physician had been notified of laboratory findings for 2 of 13 residents reviewed. There was no evidence that the facility notified the physician of abnormal laboratory findings for Resident #148 and Resident #429. The findings included: The facility admitted Resident #148 with [DIAGNOSES REDACTED]. Review of Resident #148's medical record on 2/26/15 at approximately 8:00 AM revealed a 1/22/15 wound care note that stated: In to see resident this am for dressing change to sacral pressure ulcer. Upon removal of the dressing noted that the wound bed is covered with slough and necrotic tissue .Also noted new area Suspected Deep Tissue Injury (SDTI) pressure ulcer to right heel. Review of the 1/22/15 Skin Integrity Conditions Observations Report revealed the resident had acquired a pressure ulcer to the right heel. The wound was noted as a SDTI pressure ulcer. The plan of care section stated: Continue current Plan of Care. Also ordered [MEDICATION NAME] to check nutritional status. Review of physician's orders [REDACTED]. Further review on 2/26/15 at approximately 11:47 AM revealed no result for the Pre-[MEDICATION NAME] lab in the resident's medical record. Review of the Resident's Medication Administration Record [REDACTED]. The facility staff was able to print a computerized report upon request. Review of the laboratory report for 1/23/15 revealed a Pre-[MEDICATION NAME] of 8.90 (L(ow)) with a reference range of 20.0-40.0 mg/dl. Further review of the medical record revealed no evidence that the results had been conveyed to the attending medical practitioner and/or wound care nurse. During an interview on 2/26/15 at approximately 1:30 PM, Registered Nurse (RN) #1 confirmed that there was no evidence in the resident's medical record that the physician had been notified of the abnormal Pre-[MEDICATION NAME] level. The facility admitted Resident #429 with [DIAGNOSES REDACTED]. Review of the resident's care plan on 2/25/15 at approximately 9:21 AM revealed a problem that noted Resident is at risk for altered nutrition and hydration status d/t (due to) variable po (by mouth) intake of meals. Approaches included diet and supplements as ordered, labs/diagnostic studies as ordered, alert MD of abnormal values, .and obtain nutrition consult. Record review on 2/25/15 at approximately 9:09 AM revealed a 1/13/15 physician's orders [REDACTED]. Further review on 2/25/15 at approximately 10:46 AM revealed no BMET lab results in the resident's medical record. The Unit Manager later provided Resident #429's lab results when they printed the computerized report. Review of the resident's 1/16/15 BMET results revealed an elevated BUN of 25 with a reference range of 7-18mg/dL. Review of the resident's 1/27/15 BMET revealed a BUN of 49, a low sodium level of 135 (reference range = 136-145meq/L) and an elevated Creatinine of 1.8 (reference range = 0.6 - 1.3 mg/dL). Further review of Resident #429's medical record revealed no evidence that the physician had been notified of the abnormal laboratory results. During an interview on 2/25/15 at approximately 2:19 PM, RN #2 confirmed there was no documentation in the record that the medical practitioner requesting the labs had been notified. S/he stated that the lab was not placed on the chart for the physician to access it for review and further stated that the result was very high and the physician should have been made aware. During an interview on 2/26/15 at approximately 9:50 AM, the attending physician stated that the labs should be faxed to the office if abnormal. The physician stated that an elevated BUN and Creatinine level raises concerns with the resident's kidney function and s/he should have been made aware.",2018-10-01
6980,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2013-08-29,280,E,0,1,6QMD11,"**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 update the Care Plan for 1 of 3 sampled residents with a [MEDICAL CONDITION]. Resident #11's Care Plan was not updated to include an incident [MEDICAL CONDITION] and/or behaviors of fidgeting with his/her trach. Interventions were not added to prevent [MEDICAL CONDITION] related to these behaviors and for the treatment of [REDACTED]. Cross Refer to F-328 related to the failure of the staff to provide prompt treatment for [REDACTED]. The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Review of Nurses Notes on 8/27/13 revealed a Nurses' Note dated 6/7/13 which stated, 0500, Resident pulled out inner cannula, was in some distress grunting. Gave Alb ([MEDICATION NAME]) Neb(ulizer) tx (Treatment) with (no) effective(ness). Changed out inner cannula but had trouble getting it all the way in. Placed Pt. (Patient) on 3L(iters) O2 (Oxygen) and s/he calmed down some but sats (Oxygen saturation levels) slowly dropping from 100% on 3L O2 to 94(%). Remained alert and responsive. Nursing Supervisor notified. The next Nurses' Note dated 6/7/13 documented, 0800 Went in with Resp(iratory) Therapist (RT) to check resident. Unable to suction resident. Assisted RT in changing out [MEDICAL CONDITION] had blockage. Resident breathing back to normal, still alert and responsive. An RT note dated 6/7/13 at 7:30 AM documented, Called by RN (Registered Nurse) manager to come check (Resident #11)- Having hard time breathing and his/her nurse was having a hard time inserting IC (inner cannula) into trach- I used several vials of 3 cc (cubic centimeters) normal saline to try to loosen up plug- to no avail. Res(ident) had a huge plug @ end of trach. It was necessary to change out [MEDICAL CONDITION] immediately s/he was able to breath(e) w/o (without) a [MEDICATION NAME] and a struggle- O2 sats after 5 min(utes) [MEDICAL CONDITION]% on RA (Room Air). Review of the Care Plan for Resident #11 on 8/27/13 at 12:30 PM revealed an entry dated 4/18/13 which stated, [MEDICAL CONDITION] with Potential for Complications, (Resident #11) will have complications of [MEDICAL CONDITION] detected and Tx'd (Treated) promptly through next review. The Care Plan failed to include documented interventions that should be implemented related to a mucus plug or what should be done if suctioning or other measures failed to resolve the issue. Further review of Nurses' Notes on 8/27/13 revealed a note dated 6/11/13 at 10:40 PM which stated, Resident found [MEDICAL CONDITION] of throat. Placed back in and tolerated well by staff RN (Registered Nurse). O2 sats 98%. Tube feeding started and meds given by peg. Will con't to monitor resident . During an interview on 8/27/13 at 12:55 PM, RT #1 was asked if s/he knew about the incident on 6/11/13 where the resident pulled out his/her trach. According to RT #1, it had been reported to her/him by another nurse (not the actual nurse that worked that night), that [MEDICAL CONDITION] about to come out of the stoma and that the nurse had just popped it back in, both the inner and outer cannula. All but the tip of the end of [MEDICAL CONDITION] out. During an interview on 8/27/13 at 1:05 PM, RN #6 stated that Resident #11 does try to pull out his/her inner cannula. According to the nurse, the resident have limitations and can't use one side of his/her body, but can pull it out. According to RN #6, Resident #11 will point at the Passey Muir valve when s/he wants to take it off; and s/he has seen the resident try to pull it off. RN #6 stated that s/he has seen the resident trying to pull the Passy Muir valve off about 3 times when s/he was passing the resident's room. According to the nurse, [MEDICAL CONDITION] never come out. When asked if s/he had documented this behavior, the nurse stated s/he hadn't. During an interview on 8/28/13 at approximately 7:10 AM, License Practical Nurse (LPN) #1 stated that s/he had seen Resident #11 fidget with his/her inner cannula, but hadn't seen the resident pull it out. According to LPN #1, s/he had reminded the resident to leave it alone. Resident #11 wrote the nurse a note; and what the nurse got from it was that the cannula was poking into his/her neck. LPN #1 asked the resident what was poking and the resident pointed at his/her trach. LPN #1 stated s/he guessed it was uncomfortable. Review of the Care Plan for Resident #11 revealed these behaviors had not been care planned and interventions had not been developed to prevent possible dislodgement of the [MEDICAL CONDITION]. There were no interventions that included information about what action staff were to take in the event [MEDICAL CONDITION].",2017-07-01
6981,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2013-08-29,328,E,0,1,6QMD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based record review, interviews, and review of the policy provided by the facility entitled Changing a [MEDICAL CONDITION], the facility staff failed to provide prompt respiratory care for one of three sampled residents reviewed with a [MEDICAL CONDITION] (trach). Resident #11 did not receive prompt treatment to relieve a mucus plug in his/her trach. There was a delay of approximately 2 hours from when symptoms of a mucus plug were first documented until [MEDICAL CONDITION] been changed out. Observations and interview revealed obturators were not taped to bed of [MEDICAL CONDITION] as per policy. The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set Assessment with an Assessment Reference Date of 7/7/13 revealed the resident had been coded as having no speech, understands, and is usually understood. The resident's Brief Interview for Mental Status score was 15, indicating the resident was cognitively intact at the time of the assessment. The resident was not coded as having any behavioral symptoms or rejection of care. Resident #11 had impairment in range of motion in the upper and lower extremities on one side and required the extensive assistance of one person physical assist for dressing, personal hygiene, and bathing. Record review on 8/27/13 at approximately 12:00 Noon revealed the following Nurses' Notes/Respiratory Therapy Notes: A Nurses' Note dated 6/7/13 documented, 0500, Resident pulled out inner cannula, was in some distress grunting. Gave Alb ([MEDICATION NAME]) Neb(ulizer) tx (Treatment) with (no) effective(ness). Changed out inner cannula but had trouble getting it all the way in. Placed Pt. (Patient) on 3L(iters) O2 (Oxygen) and s/he calmed down some but sats (Oxygen saturation levels) slowly dropping from 100% on 3L O2 to 94(%). Remained alert and responsive. Nursing Supervisor notified. The next Nurses' Note dated 6/7/13 documented, 0800 Went in with Resp(iratory) Therapist (RT) to check resident. Unable to suction resident. Assisted RT in changing out [MEDICAL CONDITION] had blockage. Resident breathing back to normal, still alert and responsive. An RT note dated 6/7/13 at 7:30 AM documented, Called by RN (Registered Nurse) manager to come check (Resident #11)- Having hard time breathing and his/her nurse was having a hard time inserting IC (inner cannula) into trach- I used several vials of 3 cc (cubic centimeters) normal saline to try to loosen up plug- to no avail. Res(ident) had a huge plug @ end of trach. It was necessary to change out [MEDICAL CONDITION] immediately s/he was able to breath(e) w/o (without) a [MEDICATION NAME] and a struggle- O2 sats after 5 min(utes) [MEDICAL CONDITION]% on RA (Room Air). During an interview on 8/27/13 at 12:42 PM, RN #4 (the Unit Manager), verified the above entries and later stated that an occurrence report had not been completed related to the incident. During an interview on 8/27/13 at 12:55 PM, the Respiratory Therapist (RT #1) verified s/he had worked the morning of the incident on 6/7/13 and had documented the RT note. The RT verified the ENT (Ear Nose and Throat) Physician's documentation which indicated the resident still needed [MEDICAL CONDITION] to vocal cord paralysis and had not tolerated [MEDICAL CONDITION] plugged. After reviewing the above nursing and respiratory notes, RT #1 stated the resident had a mucus plug in [MEDICAL CONDITION] it was necessary to change out the entire trach. According to RT #1, s/he had noticed that Resident #11 was turning blue across the mouth and nailbeds. When asked about what s/he had meant when s/he had documented that (after [MEDICAL CONDITION] changed), the resident was able to breathe without a [MEDICATION NAME]; RT #1 stated that it sounded like (the resident) only had a tiny air hole and the breathing sounded like a [MEDICATION NAME]. According to RT #1, the resident's saturations had not dropped too low. The RT verified s/he had not documented what the resident's O2 saturation was prior to changing out the whole trach. The RT stated that s/he thought s/he could find the sheet where s/he had documented the resident's O2 sat prior to changing out the trach. When asked again about the resident turning blue, the RT stated that it was just around the resident's mouth and nailbed and stated that s/he was sure the O2 sats had dropped. According to RT #1, s/he had arrived at the facility around 6:30 AM and got to the resident's room around 7:30 AM. According to RT #1, s/he had come immediately when s/he had been told Resident #11 was having trouble breathing. RT #1 later stated that s/he had added a late entry to the respiratory note 6/7/13. Review of the note revealed a Late entry 8/27/13, O2 sats on R(oom) Air (before)[MEDICAL CONDITION](change) (decreased) to 88%. During an interview on 8/28/13 at 6:45 AM, Licensed Practical Nurse (LPN) #1 reviewed the Nurses' Notes above for the morning of 6/7/13 and verified s/he had made the entries. LPN #1 stated Resident #11 had been fine most of that night and had required suctioning only about once or twice. During the medpass the morning of 6/7/13 between 5:00 AM and 5:30 AM, s/he noticed the resident was grunting more. LPN #1 stated s/he tried to suction the resident'[MEDICAL CONDITION] it was difficult to get the suction catheter down and there was nothing in the suction tubing (no secretions or mucus obtained). So, s/he tried a breathing treatment. After the breathing treatment, Resident #11 was not grunting so bad and had calmed down some. LPN #1 stated s/he had kept an eye out for the resident because s/he had never seen the resident like that. LPN #1 stated s/he kept checking on the resident by peeking in on him/her between medications. LPN #1 stated that s/he had gone a couple of rooms down when s/he heard the resident again. Resident #11 was grunting again and had pulled out the inner cannula of his/her trach. Sometime between 6:00 AM and 6:30 AM, s/he tried to suction Resident #11 again, and at that time, the resident's O2 saturation was about 94% (on 3L of O2). LPN #1 stated that s/he knew something was going on. The suction catheter could only be advanced about 6 inches down [MEDICAL CONDITION] s/he wasn't getting anything out. According to LPN #1, s/he asked Registered Nurse (RN) #5 (the nursing supervisor) to come. LPN #1 believed s/he told the supervisor that when s/he had heard the resident grunting, that it scared her/him (LPN #1) half to death. LPN#1 was asked to demonstrate the grunting noise and stated, It was a Hmm Hmm sound. That grunt ain't good. I used to work in the emergency room (ER) as a tech. There was not a whole lot of air going through. According to LPN #1, the nursing supervisor first came at 5:30 AM and told her/him to keep an eye on Resident #11 since the sats were good. The resident was grunting a little at that time. The 2nd time s/he had called the nursing supervisor was about 6:00 AM. No other staff had come in yet for the morning. According to LPN #1, the nursing supervisor stood there for about 15 minutes watching the resident. The resident's Oxygen saturation at that time was around 94% (on 3 Liters of Oxygen). LPN #1 stated that at 6:30 AM when everyone (the morning shift staff) came in, the nursing supervisor went to her/his office. LPN #1 stated that s/he had kept checking on Resident #11 and the resident had a little bit of a grunt, so for the third time s/he attempted to suction [MEDICAL CONDITION] didn't get anything in the tubing. According to LPN #1, s/he then went and finished passing out medications. LPN #1 stated that at approximately 6:45 AM s/he let the nurse manager know about Resident #11. The nurse manager said that s/he would call respiratory to come (assess the resident). LPN #1 stated that when s/he saw the Respiratory Therapist go in to Resident #11's room at about 7:00 AM, s/he stopped everything s/he was doing and followed the RT into the resident's room. LPN #1 stated that maybe it was the way the resident was holding his/her neck that s/he could still get some air. According to LPN #1, the RT pulled the [MEDICAL CONDITION] the tip of [MEDICAL CONDITION] occluded. When asked if the whole tip of [MEDICAL CONDITION] occluded, LPN #1 said Yes. When asked how big the occlusion was, LPN #1 stated that it was a thick greenish mucus plug, enough to cover the opening. According to LPN #1, this was not any mucus that you would have been able to push through with a suction catheter; this mucus was hard. LPN #1 could not recall any bluish discoloration to the resident's nails or mouth. According to LPN #1, there were no RT services available at night. When asked if the nursing supervisor had said anything about changing out the trach, LPN #1 stated that the nursing supervisor had just said to keep an eye on the resident and didn't know what was wrong. When asked if s/he had obtained a set of Vital Signs on Resident #11 during this time frame, LPN #1 stated that s/he hadn't and that s/he had just gotten an Oxygen saturation and had kept a check on the resident. Review of the Nurses' Notes documentation with LPN #1 revealed a set of Vital Signs documented for the day shift on 6/7/13. LPN #1 stated these were taken after the incident. When asked if s/he had spoken to the nursing supervisor about changing out [MEDICAL CONDITION] time during the incident, LPN #1 believed that s/he had asked the nursing supervisor (sometime between 5:00 AM and 7:00 AM) about the possibility of changing out the whole trach. The surveyor asked LPN #1 if this was because s/he thought it may need to be changed, and LPN #1 answered, Yes. When asked what the nursing supervisor had said, LPN #1 stated the supervisor said to watch the resident. The resident didn't appear to be in a great deal of distress, one minute grunting and the next resting. During an interview on 8/28/13 at 7:18 AM, RN #5 (the nursing supervisor) reviewed the above nursing notes and stated s/he couldn't remember any particulars related to the incident. Interviews with both nurses involved in the incident revealed they were unsure of what the obturator was used for. During an interview on 8/28/13 at approximately 7:00 AM, LPN #1 was asked if s/he knew how to change out a whole [MEDICAL CONDITION] (not just the inner cannula) and if s/he were comfortable doing this. LPN #1 stated that s/he could if s/he needed to. LPN #1 stated s/he would pop one out and put a [MEDICAL CONDITION] and then put the inner cannula in. When asked how s/he would pop a new [MEDICAL CONDITION] in, LPN #1 stated that s/he had never replaced a whole trach, but from what s/he had seen, s/he would open the [MEDICAL CONDITION] slowly insert it (into the ostomy site). Immediately s/he would get air back and put the inner cannula back in and place the collar straps. LPN #1 had to be prompted by the surveyor about what needed to go into [MEDICAL CONDITION] inserting it back into the resident, but after prompting, LPN #1 stated a thin long piece, a guide. When asked what the guide was used for, LPN #1 said, I don't know, I guess it's to make sure the space doesn't close up before getting the inner cannula in. LPN #1 stated that s/he had received training in changing out the inner cannula [MEDICAL CONDITION], both of which s/he had hands on training. However, s/he had only observed while a [MEDICAL CONDITION] changed out and did not have any hands on except for opening the supplies while someone else did [MEDICAL CONDITION]. This was around July of last year in orientation when s/he first started working at the facility. When asked if s/he knew what an obturator was, LPN #1 said it was the thin piece. During an interview on 8/28/13 at 7:18 AM, RN #5 was asked if s/he knew how to change out the [MEDICAL CONDITION]. RN #5 stated that to put a [MEDICAL CONDITION] you would position the patient and put the [MEDICAL CONDITION] inner cannula in. When asked if you would do anything to the [MEDICAL CONDITION] inserting it into the resident, RN #5 stated s/he would put saline on it. The surveyor and RN #5 went to Resident #11's room and the nurse removed a [MEDICAL CONDITION] (still boxed in the original wrapping) from the resident's drawer. The surveyor pointed to the obturator and asked the nurse what it was used for. RN #5 stated that s/he couldn't remember; but thought it was used to get a mucus plug out. When asked if s/he would insert the obturator down [MEDICAL CONDITION] loosen a mucus plug, RN #5 stated, Yes. When asked what this was called (the obturator), the nurse stated it was called a plug. When asked if s/he would feel comfortable changing out the entire trach, RN #5 said Yes, then added that s/he didn't do this much and had changed out [MEDICAL CONDITION] another state where s/he had worked. When asked about any training provided by the facility in changing out the trach, RN #5 stated that the facility had instructed her/him in the class room where s/he had observed another staff member changing out [MEDICAL CONDITION] a mannequin. According to RN #5 there was no hands on training with a repeat demonstration; s/he had just watched. Review of the policy provided by the facility on 8/29/13 entitled Changing a [MEDICAL CONDITION] dated 5/12/11 revealed guidelines for changing of a [MEDICAL CONDITION]. According to the policy, the procedure required two licensed personnel, one of whom needs to be competent in changing [MEDICAL CONDITION]. Under Procedure, #9 stated to place the obturator in the new [MEDICAL CONDITION], #10- to apply a small amount of water soluble lubricant, #16- to gently place the [MEDICAL CONDITION] into the stoma following the natural contour of the trachea: If unable to replace tube, keep stoma open with obturator and call for assistance, #17- remove obturator. If applicable, insert cannula and snap or lock into place . The facility was unable to provide any documentation that LPN #1 or RN #5 had undergone training on changing out a whole [MEDICAL CONDITION] appliance or that they had been trained on what to do for emergent dislodgement of a trach. During an interview on 8/29/13 at 8:45 AM, the Director of Nursing (DON) reviewed the respiratory/nursing notes and stated that s/he thought RN #5 and LPN #1 acted appropriately relative to the treatment of [REDACTED]. The surveyor expressed concerns that nursing staff left Resident #11 alone after identifying there was a problem with the resident's airway, that the nurses did not get a set of Vital Signs during the incident, and just watched the resident instead of ensuring that appropriate treatment was provided to maintain the resident's airway. The surveyor also expressed concern that possibly the nursing staff were unsure about what exactly the problem was and what to do. In addition, the two nurses were unsure of what the obturator was to be used for. According to the DON, LPNs are not supposed to change out the trach,and the nursing supervisor could have sent the resident to the emergency room (ER). Further interview with the DON on 8/29/13 at 9:32 AM revealed the facility did not have a policy on [MEDICAL CONDITION], and [MEDICAL CONDITION] out policy did not specifically state who could or could not change out a [MEDICAL CONDITION] (other than 2 licensed staff, one of whom must be competent in changing them out). During an interview on 8/29/13 at 9:15 AM, RT #2 stated that there are 3 RTs on staff and there is at least one RT scheduled from 6:30 AM- 7:00 PM, 7 days a week to include holidays. After hours the nurses on the floor take care of the patients' respiratory needs. After reviewing the nursing and respiratory notes from 6/7/13 for Resident #11, RT #2 stated that s/he believed the nurses had acted appropriately since the resident's O2 sats were okay. When asked if the RT would leave a resident alone after identifying a mucus plug, the RT stated that s/he wouldn't have left the resident, but thought the nursing staff did a good job of monitoring the patient. When asked about the treatment for [REDACTED].#2 stated that if s/he were not getting anything out of the suction catheter, that at some point s/he would change out the trach. According to RT #2, if the staff were not comfortable with changing the trach, they could send the resident out. RT #2 agreed that the signs/symptoms exhibited by Resident #11 indicated a blockage (in the trach). When asked if an obturator was used to remove mucus plugs, RT #2 said no, that a suction catheter was used to remove mucus plugs. Observations on 3 days of the survey revealed an obturator was not taped to the head of the bed, but located in Resident #11's drawer next to the bed. Review on 8/28/13 at 2:35 PM of the policy provided by the facility entitled [MEDICAL CONDITION] Care dated 9/22/09 revealed information that an obturator was to be taped at the head of the bed at all times ([MEDICAL CONDITION]). During an interview on 8/29/13 at 9:40 AM, RT #2 was asked to review the policy and told that the obturator was not observed taped to the head of the bed. RT #2 stated (when asked) that all [MEDICAL CONDITION] in the facility did not have obturators taped to their beds that morning when s/he had come to [MEDICAL CONDITION]. RT #2 stated s/he knew where the obturators were located and that s/he would take care of that now.",2017-07-01
6982,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2013-08-29,371,E,0,1,6QMD11,"On the days of the survey, based on observation, record review, and interview, the facility failed to prepare, distribute, and serve food under sanitary conditions. Dietary staff failed to maintain the ceiling vents in the kitchen free from dust and residue, remove food and debris from the floor, and date unboxed bagged food in the walk-in freezer. The findings included: During initial tour of the kitchen on 8-26-13 at 11:15 AM with the Director of Food Services, a heavy dust build-up and a black substance was observed on 7 ceiling vents in the food service area. Also, in the walk-in freezer (7) 4 ounce magic cups were under the storage racks along with 3 bags of mixed vegetables. On the freezer storage racks, 8 bags of buns, 1 bag of hash browns, and 1 package of hotdog's were undated. Furthermore, under the stand-up refrigerators, beverage counter, and stoves, a large amount of food and debris, dust, and a dark brown build-up of residue was observed. On 8-28-13 at 11:00 AM observations were made with the Director of Food Services of (1) 32 ounce carton of liquid eggs and food debris under the stand-up refrigerators. Also, food, debris, and a build-up of dust and residue under the beverage station, along with a large amount of dust and a black substance on (7) ceiling vents throughout the kitchen/food service area. On 8-29-13 at 11:10 AM during an interview with the Director of Food Services and the Food Services Supervisor, a review of the kitchen/food service areas cleaning schedule revealed that staff was assigned cleaning duties and had signed off as being completed. The Director of Food Services stated that the cleaning is not being done. The Food Services Supervisor then stated that is was his job to check after the cleaning schedule, but s/he has not done so lately.",2017-07-01
8163,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2012-10-24,156,C,0,1,UOMZ11,"On the days of the survey, based on review of the residents' funds and interview, the facility failed to provide the mandated Liability Notices: Skilled Nursing Facility Advanced Beneficiary Notices (SNFABN) Denial Letters for 2 of 3 residents. The findings included: Review of the residents' funds on 10/24/12 revealed that the mandated Liability Notices: SNFABN Denial Letters were not provided for 2 of 3 sampled residents. During an interview with the Business Office Personnel #1 at the time of review, he/she verified that the SNFABN Denial Letters had not been done as required.",2016-07-01
8164,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2012-10-24,281,E,0,1,UOMZ11,"**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 physician orders [REDACTED].(Resident #6 & #8) The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 10/23/12 revealed transfer orders dated 10/12/12 from the hospital which included [MEDICATION NAME] 40 mg(milligrams) in the h.s.(hour of sleep) and 20 mg t.i.d.(three times a day). Further review of the record revealed [MEDICATION NAME] was transcribed on the readmission orders [REDACTED]. Review of the MAR(Medication Administration Record) revealed Resident #6 did not start receiving the three times a day dose until 10/15/12 at 1:00 PM. On 10/23/12, Registered Nurse(RN) #1 confirmed that the orders had not been transcribed properly. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Record review on 10/22/12 revealed Resident #8 was receiving [MEDICATION NAME] BID (twice a day) Further review of the MAR indicated [REDACTED]. Review of the MAR's for the months of 8/2012, 9/2012, and 10/2012 revealed the following: Pulse checks were done prior to administration 15 out of 62 times of administration for 8/2012; 2 out of 60 times of administration for 9/2012; and 3 out of 47 times for 10/2012. There was documentation throughout the chart related to vital signs although they did not correspond with the times of the medication administration. On 10/23/12, RN #1 confirmed that the pulse checks were not done prior to each administration of [MEDICATION NAME].",2016-07-01
8165,L.M.C.- EXTENDED CARE,425321,815 OLD CHEROKEE ROAD,LEXINGTON,SC,29072,2012-10-24,371,F,0,1,UOMZ11,"**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 food was prepared, stored, and served under sanitary conditions related to proper use of hair restraints, appropriate handwashing environment and technique, use of insulated lunch bags for meals leaving the facility, and general cleanliness of the kitchen. The findings included: During the orientation tour, on 10/22/12 at 11:15 AM, the handwashing sink in the middle of the kitchen area did not have an appropriate trash receptacle next to the sink. A large trash barrel with a flat lid, requiring the user to use their hands to lift the lid, was by the sink. Three of five male kitchen staff, who had facial hair, were observed without beard restraints. The Buffalo Chopper, which appeared clean and was covered, contained a small amount of dried crumbs/debris in the bottom of the bowl. A wall mounted knife holder showed a buildup of sticky dust on the top of the slotted container where the knives were inserted. Saute pans hanging from the pot rack were observed to have heavy carbon buildup on the inside walls of the pans. A wire shelf unit used for drying pots, pans, cooking sheets, and utensils was observed to have sticky dust buildup on the shelves and side supports. Observations of the wall behind the dishwasher revealed a heavy buildup of dust from ceiling to floor in an area about nine feet in length. A floor fan was stationed by the drying shelves blowing air by the shelves, and toward the back dusty wall. Between the fan and the wall was the area of the dishwasher where the clean dishes emerged from the machine. Another kitchen observation done on 10/23/12 revealed the same general appearance of inadequate cleaning. Two additional saute pans were observed with the non-stick coating showing scratches and flaking. The buffalo chopper still contained dried crumbs/debris. A green cutting board showed heavy staining. The fire alarm positioned on the ceiling over the ice cream freezer had a heavy buildup of dust on the back. Conditions in the dishwashing area remained. The drying shelves, now empty of utensils and pans showed a heavy buildup of sticky dust, and the wall behind the dishwasher still showed heavy dust buildup. The fan by the shelves continued to blow air toward the clean dish area. As the second shift of dietary worked entered the kitchen at approximately 11:25 AM, they were observed going directly to the hand washing sink in the middle of the kitchen. A swing top kitchen trash can was next to the sink. The large round trash barrel was also next to the sink. Two staff member were observed lifting the trash barrel's cover to dispose of the paper towels used to dry their hands; one staff member walked away while drying his hands; and another staff member used bare hands to turn off the faucet after washing her hands. The Certified Dietary Manager (CDM) was present during both tours of the kitchen. He verified the concerns on 10/23/12 when they were reviewed with him. During the kitchen tour and interview with the CDM, he revealed that lunches leaving the facility were packed the night before in a zip-top plastic bag and kept in the cooler. The next morning, the lunch was delivered to the appropriate unit for the resident. There it was stored in the unit refrigerator and given to the resident on leaving the facility. The CDM stated the facility did not use insulated lunch bags with ice packs for lunches leaving the facility. Three facility residents took lunches to [MEDICAL TREATMENT], and one other resident took a lunch out on personal leave trips. The lunch menus included chicken salad sandwich, turkey or chicken sandwich, and ham and cheese. One resident did not take any type of sandwich but his lunch contained two puddings and one container of thickened milk.",2016-07-01
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
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
8994,"OMEGA HEALTH & REHAB OF GREENVILLE, LLC",425060,809 LAURENS ROAD,GREENVILLE,SC,29607,2011-05-24,371,F,0,1,ZFEO11,"On the days of the survey, based on observation, interview, and review of the facility policy entitled ""Use of Plastic Gloves"" and ""Handwashing (HAACP)"", the facility failed to prepare, distribute, and serve food under sanitary conditions based on not using proper hand hygiene, prep table containing holes, and staff member chewing gum while serving food. The findings included: On 5/23/11 at 10:00 AM, initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM). A prep table was observed with three holes in the top. The holes were visibly dirty. On 5/24/11 at 12:00 PM, trayline observations were made. The cook was observed, with gloved hands, leaving from behind the steam tables and exiting the kitchen to retreive tray cards. The cook entered the kitchen still wearing the same gloves, grabbed paper towels and wiped down the steam table and the prep table. She then removed gloves. At 12:10 PM, the cook was observed removing a pair of soiled gloves from her hand and placing a new pair of gloves on without washing her hands between glove changes. Two serving scoops were observed with their handles in the food touching the food during trayline. A Dietary Staff member in the dishroom was observed touching dirty trays and then immediately going to the clean side and touching clean trays without sanitizing his hands. At 12:45 PM, the Assistant Director of Nursing was observed chewing gum while serving residents in the dining room. On 5/24/11 at 3:30 PM, an interview with the CDM was conducted. She stated that the dietary staff in the dishroom was new. She confirmed that the prep table did have holes in the top that were visibly dirty. Per review of the policy entitled ""Use of Plastic Gloves"" from the Policy and Procedure Manual from 2000, which states ""Hands are to be washed when entering the kitchen and before putting on the plastic gloves"". Per review of the policy entitled ""Handwashing (HAACP)"" which stated hands should be washed ""before handling food or clean utensils/dishes"".",2015-08-01
8995,"OMEGA HEALTH & REHAB OF GREENVILLE, LLC",425060,809 LAURENS ROAD,GREENVILLE,SC,29607,2011-05-24,160,B,0,1,ZFEO11,"On the days of the survey, based on record reviews and interview, the facility failed to convey resident's funds and final accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate for 2 of 5 random sampled residents. Two residents' funds were conveyed to funeral homes. The findings included: An interview on 5/29/11 at approximately 8:20 AM with the Business Office Manager revealed that 2 of 5 random sampled residents' funds reviewed were conveyed to funeral homes. The Business Office Manager confirmed the findings and further stated the facility did not obtained a signed document/authorization from individual or probate jurisdiction administering the resident's estate to send the funds directly to the funeral home.",2015-08-01
8996,"OMEGA HEALTH & REHAB OF GREENVILLE, LLC",425060,809 LAURENS ROAD,GREENVILLE,SC,29607,2011-05-24,164,D,0,1,ZFEO11,"**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 one of one sampled residents observed for incontinent care. Resident #3 was not draped appropriately during incontinent care. The findings included: The facility admitted Resident #3 on 4/9/03 with [DIAGNOSES REDACTED]. Observation of incontinent care on 5/24/11 at 9:47 AM revealed Registered Nurse (RN) #3 performing incontinent care while Certified Nursing Assistant (CNA) #1 assisted. Resident #3 was lying on his back exposed from his waist to his knees while CNA #1 left the room to get some washcloths and towels for RN #3. CNA #1 returned to the room with the linen and handed them to the nurse, then went into the bathroom to put on gloves while RN #3 stood at the bedside. Resident #3 was left exposed and not draped during this time frame. CNA #1 assisted the nurse to roll the resident to his side so she could finish incontinent care. While the nurse was cleaning the resident's backside, a second CNA (not involved in the incontinent care) knocked and entered the room. The privacy curtain had not been pulled all the way leaving a gap which exposed the resident to the CNA. During an interview on 5/24/11 at 9:58 AM, RN #3 and CNA #1 verified Resident #3 had not been draped while CNA #1 left the room to get linen leaving the resident exposed. They also verified the curtain had not been pulled all the way when CNA #1 returned with the linen allowing the resident to be exposed to the CNA who entered the room.",2015-08-01
8997,"OMEGA HEALTH & REHAB OF GREENVILLE, LLC",425060,809 LAURENS ROAD,GREENVILLE,SC,29607,2011-05-24,281,D,0,1,ZFEO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and record review, the nurse failed to thicken liquids to the appropriate consistency for one of one sampled residents observed with thickened liquids during medication administration. Liquids provided during medpass for Resident #4 were not honey thick in consistency as ordered. The findings included: Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation of medication administration on 5/24/11 at 10:25 AM revealed Registered Nurse (RN) #1 preparing medications for Resident #4. She stated the resident received honey thick liquids. After preparing the medications, she poured 30 ml (milliliters) of ""ProMod"" (liquid protein supplement) in a medicine cup. After reviewing the directions on the back of the ""Thick & Easy"" container, she added 15 ml of ""Thick & Easy"" powder thickener to 8 ounces of water and stirred it with a spoon. Upon review of the back of the ""Thick & Easy"" container, the surveyor noted instructions to obtain honey consistency which stated for 8 ounces of clear liquids, 3 tablespoons (tbsp) of the thickener were required. The nurse picked up the medications, the 8 ounce cup of water, and the 30 ml of ProMod and carried them into the room and set them on the bedside table. The surveyor asked the nurse how she checked to make sure the water and the ProMod were of honey thick consistency. After stirring the water with the spoon, the nurse stated it didn't look like it was honey thick consistency. She was unable to tell the surveyor how the liquids could be checked to determine honey consistency. The surveyor asked the nurse to verify the consistency of the water and ProMod before giving it, and the nurse returned to the medication cart. After reviewing the instructions on the back of the ""Thick & Easy"" container again, she tried to figure out how many teaspoons were in a tablespoon and how many milliliters that would be. Two other nurses were summoned, (RN #3 and Licensed Practical Nurse (LPN) #1) to help figure out how much thickener should have been added to 8 ounces of water. RN #1 verified that 45 ml of the powder thickener should have been added to the 8 ounces of water. One of the nurses summoned was aware of the spoon test pictured on the back of the ""Thick & Easy"" container to aid in determining honey thick consistency. Review of admission orders [REDACTED]"".",2015-08-01
8998,"OMEGA HEALTH & REHAB OF GREENVILLE, LLC",425060,809 LAURENS ROAD,GREENVILLE,SC,29607,2012-05-03,250,D,1,0,HHOW11,"**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 provide medically related social services to one of three residents reviewed. Resident #1's Responsible Party (RP) refused to allow the facility to appropriately treat the resident resulting in a delay in treatment for [REDACTED]. The Social Services Department (SSD) failed to contact the Department of Social Services (DSS), Adult Protective Services (APS) or the Court System regarding the Responsible Party's refusal of treatment and SSD had knowledge that the RP was not acting in the resident's best interest. The findings included: Cross Refers to F-309 as it relates to the facility's failure to provide the necessary care and services to Resident #1 to attain or maintain the highest practicable well being. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1 was treated for [REDACTED]. A Urology Consult was requested, however the resident's responsible party refused treatment for [REDACTED]. The resident was noted to continuously yell and scream at night disrupting other residents. In addition, the resident would be sleepy during the day due to his yelling and screaming at night. The resident's RP refused medications that would help the resident rest at night and control his disruptive behaviors. The RP also refused to allow the facility to administer anything other than Advil to the resident for pain. Multiple progress notes were noted that indicated the RP was not acting in the resident's best interest and DSS should be contacted. During an interview on 5/2/12 at 11:30 AM, the Social Services Director stated that she had several meeting with Resident #1's RP and had followed up on all of her concerns. She stated that Ombudsman did visit with the resident regarding the conflict within the facility. The SSD stated that she had attempted to seek alternate placement when the RP would request, however no other facility would admit the resident. The SSD also stated that the RP only wanted the resident to be in the Greenville area. The SSD stated that she did not feel the resident's RP was acting in the best interest of the resident; however, DSS or APS had not been contacted as of 5/2/12.",2015-08-01
8999,"OMEGA HEALTH & REHAB OF GREENVILLE, LLC",425060,809 LAURENS ROAD,GREENVILLE,SC,29607,2012-05-03,309,D,1,0,HHOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on observation, record review and interview the facility failed to provide the necessary care and services to one of three residents reviewed. Resident #1 had a delay in obtaining appropriate treatment for [REDACTED]. The resident's providers and the facility's administration noted that the responsible party (RP) was not acting in the resident's best interest, however, failed to act upon that knowledge. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed the resident had both short term and long term memory problems and was moderately impaired with daily decision making abilities. No behaviors were coded during the assessment period. The resident was noted to require total dependence for activities of daily living. Review of the Nurse's Notes from February 2012 revealed the resident was noted to continuously yell out at night and have hallucinations. The resident was also noted to have blood in his urine from 1/23/2012 and again on 2/5/12. He was treated with antibiotics for a Urinary Tract Infection [MEDICAL CONDITION]. On 2/8/12 at 12:30 PM, ""Notified sister (RP) of Urology consult r/t hematuria. Sister stated she didn't believe he needed this appointment. This writer explained to family member that this was second time for hematuria and the MD felt best he see urology r/t this since the antibiotics have not cleared the problem; also explained to sister that he could have a kidney stone that there will be bleeding when they are trying to move down and out. She stated she did not believe that. We only wanted to get (Resident #1) out of here. I explained to her we were trying to take care of him-not get rid of him."" On 2/18/12, ""POA for (Resident #1) refused to sign papers to allow (Resident #1) to go to Urology Clinic."" On 2/22/12 ""MD present, spoke with RP regarding medications. MD explained what meds he's on and why. However, RP still upset. MD assessed resident r/t cough and congestion will start [MEDICATION NAME] 500 mg po q day x 3 days r/t URI. RP resistant but finally agreed to ABT for 3 days but still refuses to sign papers for urology consult r/t resident having hematuria. He's been treated twice for UTI but continues to pass blood intermittently, explain to RP but still refuses to sign consult for tx and eval..."" Resident #1 had the Urology consult on 2/24/12. He also was scheduled for a Cystogram on 3/5/12. On 3/22 the resident's urine noted to be ""dark greyish, very cloudy, (with) lumpy white sediment and flecks of blood. Cath very painful for resident..."" On 3/29/12 the resident was scheduled to have urological surgery. The resident was readmitted to the facility on [DATE]. The resident continued to ""scream and yell most of shift, louder than usual"" and continued to ""yell out at night"" was documented through 4/19/12 (the last documented nurses note). Review of the physician's orders [REDACTED].#1's readmission on 4/5/12, the resident was [MEDICATION NAME] mg for pain. No other as needed pain medication was available to the resident due to the RP's refusal. Review of the Progress Notes dated 2/22/12 revealed, ""The patient's primary caregiver is (Resident #1's sister) and she has expressed her discontent with his current medication regimen and his treatment at this facility. She has done this chronically to the point at this time where she is refusing for (Resident #1) to be evaluated for an outpatient consult regarding him having hematuria. I do not feel like his sister is acting in his best interest; therefore, I spoke to the medical director of this facility as well as the administrator and we feel like the best course from this time forward would be for the department of Social Services to become involved as well as the state Ombudsman so that we could evaluate the current relationship with his sister and ensure that (Resident #1) gets the appropriate amount of care in the future."" On 2/27/12 the provider documented ""Of note, we had determined last week that due to conflicting situation with the patient's caregiver and the facility that the Department of Social Services should be involved. The DSS is not being contacted at this time; however, the facility did contact the Ombudsman."" Review of the Social Services Notes from September 2011 through April 2012 revealed the Social Service Director (SSD) noted that the resident's behaviors of yelling out at night were disruptive to other residents. Several roommates were moved to other rooms due to the disruptions at night. The SSD also noted that the resident's RP refused changes in medication and treatment for [REDACTED]. The Ombudsman did make a visit to the facility on [DATE]. No documentation of recommendation was found. An investigation was conducted related to the resident's RP's complaints that was unsubstantiated. There was also no evidence that Department of Social Services (DSS) had been contacted or evidence that attempts were made to establish a Guardian Ad Litem for the resident. During an interview on 5/2/12 at 10:45 AM, the Director of Nurses (DON) stated that the resident's RP did not allow the facility to treat the resident appropriately. She stated that when the providers would prescribe medications, the RP would call the next day and demand the medication be discontinued. The DON stated that the RP refused psychiatric consults for the resident's behavior and would not allow [MEDICAL CONDITION] medications to be initiated. She also stated that the RP refused to allow the facility to treat the resident's pain with anything other than Advil. She also refused the Urology consult and refused alternate placement after a facility was found in an adjacent state. The DON also stated that the RP called the facility while the resident was admitted to the hospital complaining about the staff at the hospital and the treatment the resident was receiving. The DON stated that she had though about DSS or Adult Protective Services (APS) but had not done anything as of the time of the survey. The DON stated that she did not think the RP was acting in the best interest of the resident. During an interview on 5/2/12 at 11:30 AM, the Social Services Director (SSD) stated that she had several meeting with Resident #1's RP and had followed up on all of her concerns. She stated that Ombudsman did visit with the resident regarding the conflict within the facility. The SSD stated that she had attempted to seek alternate placement when the RP would request, however no other facility would admit the resident. The SSD also stated that the RP only wanted the resident to be in the Greenville area. The SSD stated that she did not feel the resident's RP was acting in the best interest of the resident; however, DSS or APS had not been contacted at the time of the survey. During an interview on 5/2/12 at 1:40 PM, the Nurse Practitioner (NP) confirmed her notes regarding the resident's RP and refusal of necessary medical treatment. The NP stated that the RP was not acting in the best interest of the resident. She stated that the RP would not allow the facility to administer medications to help the resident rest at night and not disturb other residents. She stated that the RP ""refused everything."" The NP confirmed that she spoke with the DON and the Administrator regarding her opinion of contacting DSS.",2015-08-01
9000,"OMEGA HEALTH & REHAB OF GREENVILLE, LLC",425060,809 LAURENS ROAD,GREENVILLE,SC,29607,2012-05-03,490,D,1,0,HHOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on observations, record review and interview, the facility's Administration failed to adequately utilize it's resources for one of three resident's reviewed. The facility's Administration failed to act upon the knowledge that Resident #1's responsible party (RP) was not acting in the resident's best interest resulting in a delay in treatment for [REDACTED]. The findings included: Cross Refers to F-250 as it relates to the facility's failure to provide the medically related social services to Resident #1 related to his disruptive behaviors and Department of Social Services (DSS)/Adult Protective Services (APS) involvement. Cross Refers to F-309 as it relates to the facility's failure to provide the necessary care and services to Resident #1 to attain or maintain the highest practicable well being related to the Responsible Party's (RP) refusal of treatment, pain management and behavior management. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Resident #1 was treated for [REDACTED]. A Urology Consult was requested, however the resident's responsible party refused treatment for [REDACTED]. The resident was noted to continuously yell and scream at night disrupting other residents. In addition, the resident would be sleepy during the day due to his yelling and screaming at night. The resident's RP refused medications that would help the resident rest at night and control his disruptive behaviors. The RP also refused to allow the facility to administer anything other [MEDICATION NAME] the resident for pain. Multiple progress notes were noted that indicated the RP was not acting in the resident's best interest and DSS should be contacted. As of the survey, DSS or APS had not been contacted. The Ombudsman did make a visit to the facility on [DATE]. No documentation of recommendation was found. An investigation was conducted related to the resident's RP's complaints that was unsubstantiated. There was also no evidence that DSS had been contacted or evidence that attempts were made to establish a Guardian Ad Litem for the resident. During an interview on 5/2/12 at 10:45 AM, the Director of Nurses (DON) stated that the resident's RP did not allow the facility to treat the resident appropriately. She stated that when the providers would prescribe medications, the RP would call the next day and demand the medication be discontinued. The DON stated that the RP refused psychiatric consults for the resident's behavior and would not allow [MEDICAL CONDITION] medications to be initiated. She also stated that the RP refused to allow the facility to treat the resident's pain with anything other than Advil. She also refused the Urology consult and refused alternate placement after a facility was found in an adjacent state. The DON also stated that the RP called the facility while the resident was admitted to the hospital complaining about the staff at the hospital and the treatment the resident was receiving. The DON stated that she had though about DSS or Adult Protective Services but had not done anything as of the time of the survey. The DON stated that she did not think the RP was acting in the best interest of the resident. During an interview on 5/2/12 at 11:30 AM, the Social Services Director (SSD) stated that she had several meeting with Resident #1's RP and had followed up on all of her concerns. She stated that Ombudsman did visit with the resident regarding the conflict within the facility. The SSD stated that she had attempted to seek alternate placement when the RP would request, however no other facility would admit the resident. The SSD also stated that the RP only wanted the resident to be in the Greenville area. The SSD stated that she did not feel the resident's RP was acting in the best interest of the resident; however, DSS or APS had not been contacted at the time of the survey. During an interview on 5/2/12 at 1:40 PM, the Nurse Practitioner (FP) confirmed her notes regarding the resident's RP and refusal of necessary medical treatment. The NP stated that the RP was not acting in the best interest of the resident. She stated that the RP would not allow the facility to administer medications to help the resident rest at night and not disturb other residents. She stated that the RP ""refused everything."" The NP confirmed that she spoke with the DON and the Administrator regarding her opinion of contacting DSS.",2015-08-01
9001,"OMEGA HEALTH & REHAB OF GREENVILLE, LLC",425060,809 LAURENS ROAD,GREENVILLE,SC,29607,2012-07-11,281,D,0,1,BLIQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interview, review of the professional resource of Perry & Potter,Clinical Nursing Skills & Techniques, 7th Edition, the facility failed to meet professional standards of quality for 2 of 3 residents sampled receiving Potassium Chloride. Residents #4 and #9 had incorrect dosage transcriptions for the administration of Potassium Chloride. Nursing staff failed to identify the discrepancy between the medication dose ordered, transcribed on the Medication Administration Record [REDACTED] The findings included: The facility admitted Resident #4 with a [DIAGNOSES REDACTED]. on 7/9/12 at 2:00 pm, record review revealed the physician wrote an order on 6/7/12 for Potassium Chloride (KCL) 20 milliequivalents by mouth every day. On the MAR for July 2012 the order read for the administration of KCL 20 milligrams by mouth every day. The physicians orders for July had been reviewed and signed by nursing. The facility also admitted Resident #9 with a [DIAGNOSES REDACTED]. The resident was discharged from a recent hospital admission for respiratory distress with orders to receive potassium chloride 20 milliequivalents by mouth two times daily. On the MAR for July 2012 the order read for the administration of Potassium KCL 10 micrograms take two tabs by mouth twice daily. Again, the physicians orders were reviewed and signed by nursing. During an interview on 7/11/12 at 9:30 am with the Director of Nursing regarding the discrepancy between the potassium order and MARs for both Residents #4 and #9, she stated she noticed the discrepancy the previous night after the survey team had left the building. Review of the professional resource of Perry & Potter,Clinical Nursing Skills & Techniques, 7th Edition, pages 515- 518 related to safe medication administration 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.....Once you determine that the medication on the patient's MAR indicated [REDACTED]",2015-08-01
1129,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2020-01-15,561,D,1,0,62ZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that 2 of 19 sampled residents (Resident #5 and Resident #6) were allowed to make personal choices and engage in intimate behavior in the privacy of their room. Resident #5 was discovered engaging in a sexual activity with Resident #6 on 10/14/19. The facility separated the residents, called the police and prohibited the two residents from visiting privately the rest of the evening. Findings include: Review of Resident #5's face sheet in the Electronic Medical Record (EMR) revealed he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/30/19, located under the MDS tab of the EMR, revealed he/she had a Brief Interview of Mental Status (BI[CONDITION]) score of 14, indicating he/she was cognitively intact. Review of Resident #5's care plan, located under the Care Plan tab of the EMR, documented a focus area for an alteration in mood state initiated on 09/07/17. On 10/12/18 the focus area was amended to include, . resident prefers to engage in sexual activity with other residents. A new intervention of, resident will be redirected when inappropriate behavior is noted, was added on 10/12/18. Review of Resident #6's face sheet, located under the Profile tab of the EMR revealed he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS assessment with an ARD of 09/23/19, located under the MDS tab of the EHR, revealed a BI[CONDITION] score of 13, indicating he/she was cognitively intact. Further review of the MDS revealed no hallucinations, delusions, or behavioral concerns. Review of Resident #6's care plan, located under the Care Plan tab of his EMR, revealed a focus which read, I have an alteration in mood (as evidenced by) inappropriate sexual behavior, added 10/01/18. The interventions included, Divert my attention when possible and attempt to refocus me on something else. Review of Resident #5's Interdisciplinary Team (IDT) progress notes for, located under the Prog Notes tab of the EMR, revealed: 10/14/19 at 07:41 PM: . was brought to this nurses (sic} attention that this resident was being sexually inappropriate with (Resident #6) who entered (his/her) room . 10/14/19 at 7:53 PM: . (Resident #6) told to leave the room immediately, which (he/she) did . 10/14/19 at 9:08 PM: . (Resident #6) from earlier incident came down hall stating (he/she) was going to (Resident #5's) room to check on (him/her). Told was (sic) not a good idea and to return to (his/her) unit. (he/she) began swearing and yelling, entered room, told resident to leave door open, again swearing. Nurse entered room and asked (Resident #5) if it was ok for (Resident #6) to be there, (he/she) put thumb up. Staff at door for resident safety. (Resident #6) eventually left unit . nurse . in the meantime, had phoned authorities, who came and questioned both residents. (Resident #5) reported to authorities that they were friends who were watching tv (sic) and they did some kissing . During an interview on 01/14/19 at 10:45 AM the Social Services Director (SSD) stated he/she was aware of Resident #5's right to be sexually active, and that it was commonplace for Resident #5 to exercise that right. The SSD stated initially Resident #5 had a visitor from the community with whom he/she was intimate with in the facility, then later another resident (since discharged from the facility), then finally Resident # 6. The SSD stated while some staff had concern regarding Resident #5's relationship with Resident #6, the residents were both able to make their own decisions and could interact with one another as they chose. The SSD stated he/she was not sure why staff intervened the way they did when the event was discovered, based on Resident #5's known history and ability to consent. An interview with Resident #5's psychologist (Phy.D.) on 01/14/20 at 11:00 AM revealed he/she engaged in regular treatments with Resident #5 beginning in either June or July of 2019. Resident #5 had consistently shown the ability to make his/her own decisions and that Resident #5 had made his/her preference to engage in sexual activity at his/her own discretion known to the facility. The psychologist stated he/she was called in to evaluate Resident #5 the day after the event and Resident #5 was adamant that he/she had wanted the interaction to continue but Resident #6 was not allowed back in the room unattended. An interview with the Administrator on 01/14/20 at 11:45 AM revealed he/she became aware of the incident the following day. The Administrator stated that Resident #5's call light had been on, and as such it had been appropriate for the Certified Nurse Aide (CNA) to enter the room. The Administrator stated it was common knowledge amongst the staff that Resident #5 had been sexually active in the past and was uncertain as to why the CNA responded in that manner at the time of the event. During an interview on 01/14/20 at 2:00 PM, the Director of Nursing (DON) stated he/she was not in the facility but was called when the event occurred. The DON stated he/she instructed staff to interview Resident #5 to make sure he/she felt safe but gave no other direction. The DON stated Resident #6 was known to become angry at times so he/she wanted to make sure there was no anger involved. The DON stated if there was no anger involved and both residents consented to the interaction there should not have been a problem with the interaction continuing. An interview with CNA #5 on 01/14/20 at 3:00 PM revealed he/she was the staff person who discovered Resident #5 and Resident # 6's interaction. CNA #5 stated he/she had worked in the facility for [AGE] years and was aware of Resident #5's history of sexual activity. CNA #5 stated s/he did not know that Resident #5 was in an intimate relationship with Resident #6 and as such was not sure how to respond when he/she discovered the interaction. CNA #5 stated that he/she would have followed the care plan had one been in place. An interview with CNA #6 on 01/15/19 at 02:30 PM revealed s/he had been assigned as a one on one attendant for Resident #6 at the time the event was discovered with the assigned duty of keeping Resident #6 and Resident #5 apart. CNA #6 stated Resident #6 was calm that evening until he/she was told he/she could not return to visit Resident #5. CNA #6 stated at one point it was decided that Resident #6 could visit Resident #5 but the CNA was expected to keep the door open and observe the entire interaction. An interview with the Administrator on 01/15/19 at 03:00 PM confirmed the facility did not have a policy on resident visitation, but provided a copy of Resident Rights, which he/she reported each resident received upon admission. Review of the undated Resident Rights document provided by the Administrator revealed, . You have the right to spend private time with visitors at any reasonable hour.",2020-09-01
1130,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2020-01-15,656,D,1,0,62ZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, policy review, and medical record review, it was determined the facility failed to ensure that the care plan was followed for 1 of 19 sampled residents (Resident #16). On [DATE] Certified Nurse Aide (CNA) #3 and CNA #4 transported Resident #16 back to his/her room. CNA #3 and CNA #4 stated although Resident #16 was a mechanical lift for transfer, they transferred Resident #16 back to bed without using a mechanical lift by supporting Resident #16's legs and back. Findings include: The Face Sheet, located in the Electronic Medical Record (EMR) stated Resident #16 was admitted to the facility on [DATE] and his/her [DIAGNOSES REDACTED]. An The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in the EMR stated Resident #16 had significant cognitive impairment and had not been transferred out of bed. Review of the Nurse Aide's Information Sheet that was undated, located in the EMR stated Resident #16 was confused and required a mechanical lift with two persons for transfer. During an interview with the Assistant Director of Nurses (ADON) on [DATE] at 12:30 PM, he/she stated a mechanical lift was to be used for residents who were not able to weight bear. The ADON stated Resident #16 was not able to weight bear and a mechanical lift and two staff were to be used for any transfers. The ADON stated Resident #16 was rarely out of bed. The Safe Lifting and Handling of Residents policy, dated July 2019, stated that staff lifting of residents shall be eliminated when feasible. A lift assessment should be completed on admission, quarterly, and annually, or with significant change. The Nursing Lift Evaluation Form, dated 11/4/19, located in the EMR stated Resident #16 was non weight bearing and was a full lift transfer. During an interview with CNA #1 on [DATE] at 2:30 PM and with CNA #2 on [DATE] at 9:28 AM, they stated prior to [DATE], Resident #16 had not requested they transfer him/her out of bed. CNA #1 and CNA #2 stated that on [DATE], Resident #16 requested to be transferred out of bed. CNA #1 and CNA #2 stated Resident #16 required a mechanical lift for transfers. CNA #1 and CNA #2 stated that on [DATE], they used the mechanical lift and transferred Resident #16 to a recliner chair. CNA #1 and CNA #2 said they left the lift pad under Resident #16. During an interview with CNA #3 on 01/14/20 at 2:48 PM and with CNA #4 on [DATE] a 12:59 PM, they stated on [DATE], they transported Resident #16 back to his/her room. CNA #3 and CNA #4 said although Resident #16 was a mechanical lift for transfer, there was no lift pad under Resident #16. CNA #3 and CNA #4 said they did not notify the nurse and they both carefully transferred Resident #16 back to bed, supporting Resident #16's legs and back. CNA #3 and CNA #4 said the transfer was smooth, Resident #16 did not bump his/her leg, and had no signs of pain. During an interview with the Director of Nurses (DON) on [DATE] at 1:35 PM, the DON stated Resident #16's Nursing Lift Evaluation Form, dated 11/4/19, stated the staff were to use a mechanical lift when transferring Resident #16. The DON confirmed that on [DATE] during the evening shift, CNA #3 and CNA #4 transferred Resident #16 back to bed with two staff and did not use the mechanical lift.",2020-09-01
1131,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2020-01-15,657,D,1,0,62ZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and policy review it was determined the facility failed to revise care plan interventions for 1 of 19 sampled residents, (Resident #5). Resident #5 was discovered engaging in a sexual activity with Resident #6 on 10/14/19. The facility separated the residents, called the police and prohibited the two residents from visiting privately the rest of the evening. Findings include: Review of Resident #5's face sheet, located under the Profile tab of his/her Electronic Medical Record (EMR) revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/30/19, located under the MDS tab of the EMR, revealed he/she had a Brief Interview of Mental Status (BI[CONDITION]) score of 14, indicating he/she was cognitively intact. Review of Resident #5's care plan, located in the EMR, documented a focus area for an alteration in mood state initiated on 09/07/17. On 10/12/18 the focus area was amended to include, . resident prefers to engage in sexual activity with other residents. A new intervention of, resident will be redirected when inappropriate behavior is noted, was added on 10/12/18. Review of Resident #5's Interdisciplinary Team (IDT) progress notes, located under the Prog Notes tab of the EMR, revealed Resident #5 was discovered engaging in a sexual activity with another resident on 10/14/19 at 7:41 PM. Further review of the IDT notes revealed the residents were separated, the police were called, and the residents were prohibited from visiting privately the rest of the evening. Review of Resident #5's clinical record revealed a Death in Facility Tracking Record which documented she passed away on [DATE], thus was unavailable for observation or interview during the survey. An interview with the Social Services Director (SSD) on 01/14/19 at 10:45 AM revealed he/she had been informed that it was Resident #5's right to be sexually active and it was commonplace for the resident to exercise that right. The SSD stated Resident #5 initially had a visitor from the community with whom he/she was intimate in the facility, then became active with other residents. The SSD stated he/she was not sure why staff intervened the way they did when the event was discovered, based on Resident #5's known history. The SSD agreed Resident #5's preference to engage in sexual activity should have been included on his/her care plan. An interview with the psychologist (Phy. D.) on 01/14/20 at 11:00 AM revealed he/she engaged in regular treatments with Resident #5 beginning in either June or July of 2019. The psychologist stated Resident #5 had consistently shown the ability to make his/her own decisions and that he/she had made his/her preference to engage in sexual activity known to the facility. The psychologist stated he/she would have expected Resident #5's preference to be documented on his/her care plan. An interview with the Administrator on 01/14/20 at 11:45 AM revealed he/she became aware of the incident the following day. The Administrator stated that Resident #5's call light had been on, and as such it had been appropriate for the Certified Nurse Aide (CNA) to enter the room. The Administrator stated it was common knowledge amongst the staff that Resident #5 had been sexually active in the past so he/she was not sure why the CNA responded the way he/she did at the time of the event. The Administrator stated Resident #5's care plan should have directed staff how to respond. An interview with the Director of Nursing (DON) on 01/14/20 revealed that he/she was not in the facility but was called when the event occurred. The DON stated if the interaction was consensual there should not have been a problem with the interaction continuing. The DON stated a care plan would have given staff direction in this instance. Review of the facility's Care Planning IDT policy, dated November 2019, revealed, . the facility must develop . a comprehensive person-centered care plan . consistent with resident rights .",2020-09-01
1132,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-01-18,607,E,1,0,3V6D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect. The facility failed to thoroughly investigate and report allegations of abuse. Resident #2 was noted to suffer fractures. The facility failed to complete a thorough investigation. The family made an allegation of neglect related to Resident #2's fractures on 8/29/18 and the facility did not report the allegation to the State Agency until 8/30/18. The facility reported an injury of unknown source for Resident #1. The facility reported an allegation of neglect for Resident #2. The facility reported an allegation of resident to resident abuse involving Resident #6 and Resident #7. The facility reported an allegation of verbal abuse of Resident #4 by CNA #3. The facility failed to have evidence that all alleged violations were thoroughly investigated. 5 of 14 residents reviewed for abuse. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #2 on 8/30/18. Review of the facility investigation revealed an Initial 24-Hour Report was submitted to the State Agency on 8/30/18. The report indicated the date/time of reportable incident was reported at 7:45 AM on 8/30/18. The reportable incident was noted as an allegation of neglect. Review of the fax confirmation form revealed the Initial 24-Hour Report was sent on 8/30/18 at 8:31 AM. Further review of the facility's investigation revealed statements were obtained from staff who were present on 8/22/18 on 1st shift. There were no statements from staff who were present on 8/21/18 3rd shift, when the resident fall occurred. Review of the Customer Service Quality Assurance Form dated 8/29/18 indicated Resident #2's niece/nephew (Power of Attorney) did not understand how the resident fell out of bed and fractured both legs when s/he cannot even move. Response was that the resident has the tendency to move or slide his/her leg in the bed and has been noted by staff with leg over edge of the bed, which may have caused him/her to slide off the bed. The niece/nephew felt that the resident was really left in a wheelchair all night (never put to bed) and slid out of the wheelchair considering s/he was still dressed in his/her day clothes. Response indicated Resident #2 was put in his/her night clothes and was put to bed. Resident was then found on the floor next to his/her bed at approximately 3:00 AM. Resident was assessed and evaluated and was put back to bed. Certified Nursing Assistant (CNA) #1 then provided AM care and changed the resident to day clothes prior to the resident being sent to the hospital. CNA #1's facility-obtained statement dated 8/30/18 indicated on the day in question s/he heard Resident #2 calling out a name. CNA #1 told the resident that nobody was here by that name. Resident #2 stated s/he was hurting. CNA #1 asked the resident where and s/he said all over. CNA #1 pulled the covers back and saw Resident #2's legs were swollen. Review of the facility investigation for the incident related to Resident #2 revealed staff statements from 1st shift when the resident was noted with swelling to his/her legs. There were no staff statements completed by staff who worked 3rd shift during the time the resident fell , and the allegation of neglect pertained to. In an interview with the surveyor on 1/17/19 at approximately 1:20 PM, the Risk Manager stated Resident #2 fell on [DATE] at 3:10 AM. The Risk Manager stated the Director of Nursing communicates with the clinical liaison at the hospital. The Director of Nursing was told about the fracture on 8/22/18. The resident's family voiced concerns about neglect to the facility on [DATE]. The Risk Manager stated s/he got statements from staff on 1st shift when Resident #2 was sent out to the hospital. The Risk Manager stated s/he did not get statements from 3rd shift. The facility reported an injury of unknown source to the State Agency on 8/23/18 for Resident #1 for a compression fracture of back. Review of the facility's Five-Day Follow-Up Report dated 8/27/18 revealed upon completion of investigation including staff interviews and review of medical record, resident has had no falls. Resident has a [DIAGNOSES REDACTED]. The surveyor requested a copy of the facility's complete investigation into the incident involving Resident #1. Review of the facility's investigation revealed only one witness statement. License Practical Nurse (LPN) #2's facility-obtained statement dated 8/23/18 indicated s/he received an x-ray report that showed suspicion of possible compression fracture in spine. A Computerized tomography (CT) Scan was ordered. Review of Resident #1's Radiology Report revealed the date of service as 8/21/18 and signed by the radiologist on 8/21/18 at 12:31 PM. The Radiology Report had alert results of poorly seen but suspected T 11 vertebral compression fracture with anterior wedging deformity of unknown age. CT scan was advised. The fax stamp across the top of the Radiology Report indicated 8/21/18 at 12:36 PM. Review of the Daily Assignment Sheet revealed LPN #2 was assigned to Resident #1 on day shift on 8/23/18. Review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] and Quarterly MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15. During an interview on 1/18/19 at approximately 10:45 the Risk Manager stated the results of the x-ray were a compression fracture. The Risk Manager stated s/he only got a statement from LPN #2 because that is who the resident complained to about pain. The Risk Manager stated there was no Incident Report completed related to the incident. Review of Resident #1's Medication Administration Record [REDACTED]. Resident #1 was administered [MEDICATION NAME] 5-325 mg as needed for pain at 4:45 PM. Review of the Medication Administration Record [REDACTED]. There was no witness statement completed by the nurse who assessed the resident's pain and administered the pain medication. The facility reported an allegation of resident to resident abuse involving Resident #6 and Resident #7 on 9/27/18. Review of the facility's Five-Day Follow-Up Report dated 10/1/18 revealed upon completion of investigation including staff interviews and review of medical record, Resident #7 threw water on Resident #6. Resident #6 made contact with Resident #7 with no injuries noted. Resident #7's medications were reviewed by the nurse practitioner and the two residents are to be kept separated at all times. Resident #15's facility-obtained statement dated 9/27/18 indicated at 12:15 PM Resident #7 and Resident #6 exchanged words between each other. Resident #7 threw water at Resident #6 and Resident #6 punched Resident #7. Nurses tried to diffuse the situation, but Resident #7 was very belligerent and could not be calmed down. Registered Nurse (RN) #1's facility-obtained statement dated 9/27/18 indicated Resident #6 was sitting at the medication cart taking medication. Resident #7 wanted Resident #6 to move so s/he could get by. Resident #6 wanted Resident #7 to wait until s/he finished taking medication. Resident #7 said something about Resident #6 is fat, Resident #6 said something (most likely not nice) in response and then said, don't throw water on me. Resident #6 then hit Resident #7 (nurse did not see it but both parties said it happened). Resident #7 began yelling and cursing at staff. Social worker was called and spoke with both residents. CNA #1's facility-obtained statement dated 9/27/18 indicated as s/he was walking down the hall s/he witnessed Resident #7 pour water on Resident #6. Then Resident #6 had his/her hands around Resident #7's neck. Resident #7 went into a rage with profanity. During an interview on 1/18/19 at approximately 10:35 AM the Risk Manager stated Resident #6 was in the hallway with the nurse getting ready to take his/her medicine administered by RN #1. Resident #7 came up behind Resident #6 to go through the hallway to get past him/her. Resident #6 said give me a minute, I am taking my medicine. Resident #7 got impatient and splashed water on Resident #6, and Resident #6 pushed Resident #7. RN #1 told the Risk Manager s/he was getting the medicine ready and did not witness the event. There was an exchange of words when Resident #7 was trying to get past Resident #6. There had been no previous concerns between the two residents. The Risk Manager stated s/he talked with both residents. Resident #6 told him/her the above information. Resident #7 said s/he was trying to go through the hallway and Resident #6 was taking his/her time. Resident #7 said s/he splashed water on the resident and then Resident #6 pushed him/her. The nurse would not document the incident in the Progress Notes because the Risk Manager wanted to do the investigation and not make an assumption. The DON was interviewed and stated the behavior should be documented in the Progress Notes labeled behavior note if there were any other behaviors. The DON stated s/he would not expect the nurses to have documented the behavior of the incident, even though the residents admitted to the incident. The Risk Manager stated an Incident Report was not completed since it was a reportable incident. The facility reported an allegation of verbal abuse of Resident #4 by CNA #3 on 9/13/18. Review of the facility's Five-Day Follow-Up Report dated 9/14/18 revealed upon completion of staff interviews and review of medical record unable to substantiate allegation of abuse. Staff will be educated related to customer service. The surveyor requested a copy of the facility's complete investigation of the allegation. Review of the investigation revealed a statement by CNA #3, CNA #2, and LPN #3. There was one other CNA and one other nurse on duty on the unit at the time of the alleged incident who did not complete statements. Review of the investigation revealed there was no statement from RN Unit Manager #1 who received report of the allegation from another staff member. There was no statement that indicated what staff member Resident #4 initially made the allegation of verbal abuse to and what the resident stated. Review of Resident #4's Progress Notes revealed there was no entry between 9/11/18 and 9/19/18. Review of Resident #4's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 12. There was no documentation in the facility's investigation that the resident was interviewed or completed a statement related to the allegation. During an interview with the surveyor on 1/17/19 at approximately 4:15 PM, Risk Manager stated when s/he interviewed Resident #4 s/he felt CNA #3 was unprofessional and rude with the tone of his/her voice. The Risk Manager asked for any specifics and the resident could not say. The Risk Manager stated s/he did not document the conversation with the resident. The Risk Manager stated RN Unit Manager #1 reported Resident #4's allegation of verbal abuse to him/her. The Risk Manager stated RN Unit Manager #1 did not complete a statement. During an interview with the surveyor on 1/17/19 at approximately 4:55 PM, RN Unit Manager #1 stated a staff member reported Resident #4's allegation to him/her. RN Unit Manager #1 could not remember who the staff member was who told him/her about the allegation. S/he thinks it was something to the effect that Resident #4 said someone spoke to harshly to him/her. RN Unit Manager #1 could not remember exactly what they said Resident #4 told them. RN Unit Manager #1 stated s/he could not remember if s/he completed a witness statement. RN Unit Manager #1 stated s/he does not recall talking to Resident #4 about the incident.",2020-09-01
1133,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-01-18,609,D,1,0,3V6D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse and neglect, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Agency. One of 14 residents reviewed for abuse. (Resident #2) The findings included: The facility reported an allegation of neglect to the State Agency for Resident #2 on 8/30/18. Review of facility investigation revealed an Initial 24-Hour Report was submitted to the State Agency on 8/30/18. The report indicated the date/time of reportable incident indicated reported at 7:45 AM on 8/30/18. The reportable incident was noted as an allegation of neglect. Review of the fax confirmation form revealed the Initial 24-Hour Report was sent on 8/30/18 at 8:31 AM. Review of the Customer Service Quality Assurance Form dated 8/29/18 indicated Resident #2's niece/nephew (Power of Attorney) did not understand how the resident fell out of bed and fractured both legs when s/he cannot even move. Response was that the resident has the tendency to move or slide his/her leg in the bed and has been noted by staff with leg over edge of the bed, which may have caused him/her to slide off the bed. The niece/nephew felt that the resident was really left in a wheelchair all night (never put to bed) and slid out of the wheelchair considering s/he was still dressed in his/her day clothes. Response indicated Resident #2 was put in his/her night clothes and was put to bed. Resident was then found on the floor next to his/her bed at approximately 3:00 AM. Resident was assessed and evaluated and was put back to bed. Certified Nursing Assistant (CNA) #1 then provided AM care and changed the resident to day clothes prior to the resident being sent to the hospital. CNA #1's facility-obtained statement dated 8/30/18 indicated on the day in question s/he heard Resident #2 calling out a name. CNA #1 told the resident that nobody was here by that name. Resident #2 stated s/he was hurting. CNA #1 asked the resident where and s/he said all over. CNA #1 pulled the covers back and saw Resident #2's legs were swollen. In an interview with the surveyor on 1/17/19 at approximately 1:20 PM, the Risk Manager stated Resident #2 fell on [DATE] at 3:10 AM. The Risk Manager stated the Director of Nursing communicates with the clinical liaison at the hospital. The Director of Nursing was told about the fracture on 8/22/18. The resident's family voiced concerns about neglect to the facility on [DATE].",2020-09-01
1134,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-01-18,610,E,1,0,3V6D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to have evidence that all alleged violations were thoroughly investigated. The facility reported an injury of unknown source for Resident #1. Review of the facility's investigation revealed an x-ray was obtained on 8/21/18. The x-ray report was reported to the nurse practitioner on 8/23/18 related to results of suspected fracture. The facility investigation contained only one staff statement from the nurse who reported the x-ray results on 8/23/18. Resident #1 was noted to be alert and oriented and there was no documentation the resident was interviewed related to the suspected fracture. The facility reported an allegation of neglect for Resident #2 on 8/30/18. Resident #2 was found to have fractures on day shift 8/22/18. The facility failed to obtain statements from staff who worked on night shift on 8/21/18 when the resident fell . The facility reported an allegation of resident to resident abuse involving Resident #6 and Resident #7. The facility reported an allegation of verbal abuse of Resident #4 by CNA #3. The facility failed to have evidence that all alleged violations were thoroughly investigated. 5 of 14 residents reviewed for abuse. The findings included: The facility reported an injury of unknown source to the State Agency on 8/23/18 for Resident #1 for a compression fracture of back. Review of the facility's Five-Day Follow-Up Report dated 8/27/18 revealed upon completion of investigation including staff interviews and review of medical record, resident has had no falls. Resident has a [DIAGNOSES REDACTED]. The surveyor requested a copy of the facility's complete investigation into the incident involving Resident #1. Review of the facility's investigation revealed only one witness statement. License Practical Nurse (LPN) #2's facility-obtained statement dated 8/23/18 indicated s/he received an x-ray report that showed suspicion of possible compression fracture in spine. A Computerized tomography (CT) Scan was ordered. Review of Resident #1's Radiology Report revealed the date of service as 8/21/18 and signed by the radiologist on 8/21/18 at 12:31 PM. The Radiology Report had alert results of poorly seen but suspected T 11 vertebral compression fracture with anterior wedging deformity of unknown age. CT scan was advised. The fax stamp across the top of the Radiology Report indicated 8/21/18 at 12:36 PM. Review of the Daily Assignment Sheet revealed LPN #2 was assigned to Resident #1 on day shift on 8/23/18. Review of Resident #1's Annual Minimum Data Set ((MDS) dated [DATE] and Quarterly MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15. During an interview on 1/18/19 at approximately 10:45 the Risk Manager stated the results of the x-ray were a compression fracture. The Risk Manager stated s/he only got a statement from LPN #2 because that is who the resident complained to about pain. The Risk Manager stated there was no Incident Report completed related to the incident. Review of Resident #1's Medication Administration Record [REDACTED]. Resident #1 was administered [MEDICATION NAME] 5-325 mg as needed for pain at 4:45 PM. Review of the Medication Administration Record [REDACTED]. There was no witness statement completed by the nurse who assessed the resident's pain and administered the pain medication. The facility reported an allegation of neglect to the State Agency for Resident #2 on 8/30/18. Review of facility investigation revealed an Initial 24-Hour Report was submitted to the State Agency on 8/30/18. The report indicated the date/time of reportable incident indicated reported at 7:45 AM on 8/30/18. The reportable incident was noted as an allegation of neglect. Review of the fax confirmation form revealed the Initial 24-Hour Report was sent on 8/30/18 at 8:31 AM. Further review of the facility's investigation revealed statements were obtained from staff who were present on 8/22/18 on 1st shift. There were no statements from staff who were present on 8/21/18 3rd shift, when the resident fall occurred. Review of the Customer Service Quality Assurance Form dated 8/29/18 indicated Resident #2's niece/nephew (Power of Attorney) did not understand how the resident fell out of bed and fractured both legs when s/he cannot even move. Response was that the resident has the tendency to move or slide his/her leg in the bed and has been noted by staff with leg over edge of the bed, which may have caused him/her to slide off the bed. The niece/nephew felt that the resident was really left in a wheelchair all night (never put to bed) and slid out of the wheelchair considering s/he was still dressed in his/her day clothes. Response indicated Resident #2 was put in his/her night clothes and was put to bed. Resident was then found on the floor next to his/her bed at approximately 3:00 AM. Resident was assessed and evaluated and was put back to bed. Certified Nursing Assistant (CNA) #1 then provided AM care and changed the resident to day clothes prior to the resident being sent to the hospital. CNA #1's facility-obtained statement dated 8/30/18 indicated on the day in question s/he heard Resident #2 calling out a name. CNA #1 told the resident that nobody was here by that name. Resident #2 stated s/he was hurting. CNA #1 asked the resident where and s/he said all over. CNA #1 pulled the covers back and saw Resident #2's legs were swollen. Review of the facility investigation for the incident related to Resident #2 revealed staff statements from 1st shift when the resident was noted with swelling to his/her legs. There were no staff statements completed by staff who worked 3rd shift during the time the resident fell , and the allegation of neglect pertained to. During an interview with the surveyor on 1/17/19 at approximately 1:20 PM, the Risk Manager stated Resident #2 fell on [DATE] at 3:10 AM. The Risk Manager stated the Director of Nursing communicates with the clinical liaison at the hospital. The Director of Nursing was told about the fracture on 8/22/18. The resident's family voiced concerns about neglect to the facility on [DATE]. The Risk Manager stated s/he got statements from staff on 1st shift when Resident #2 was sent out to the hospital. The Risk Manager stated s/he did not get statements from 3rd shift. The facility reported an allegation of resident to resident abuse involving Resident #6 and Resident #7 on 9/27/18. Review of the facility's Five-Day Follow-Up Report dated 10/1/18 revealed upon completion of investigation including staff interviews and review of medical record, Resident #7 threw water on Resident #6. Resident #6 made contact with Resident #7 with no injuries noted. Resident #7's medications were reviewed by the nurse practitioner and the two residents are to be kept separated at all times. Resident #15's facility-obtained statement dated 9/27/18 indicated at 12:15 PM Resident #7 and Resident #6 exchanged words between each other. Resident #7 threw water at Resident #6 and Resident #6 punched Resident #7. Nurses tried to diffuse the situation, but Resident #7 was very belligerent and could not be calmed down. Registered Nurse (RN) #1's facility-obtained statement dated 9/27/18 indicated Resident #6 was sitting at the medication cart taking medication. Resident #7 wanted Resident #6 to move so s/he could get by. Resident #6 wanted Resident #7 to wait until s/he finished taking medication. Resident #7 said something about Resident #6 is fat, Resident #6 said something (most likely not nice) in response and then said, don't throw water on me. Resident #6 then hit Resident #7 (nurse did not see it but both parties said it happened). Resident #7 began yelling and cursing at staff. Social worker was called and spoke with both residents. CNA #1's facility-obtained statement dated 9/27/18 indicated as s/he was walking down the hall s/he witnessed Resident #7 pour water on Resident #6. Then Resident #6 had his/her hands around Resident #7's neck. Resident #7 went into a rage with profanity. During an interview on 1/18/19 at approximately 10:35 AM the Risk Manager stated Resident #6 was in the hallway with the nurse getting ready to take his/her medicine administered by RN #1. Resident #7 came up behind Resident #6 to go through the hallway to get past him/her. Resident #6 said give me a minute, I am taking my medicine. Resident #7 got impatient and splashed water on Resident #6, and Resident #6 pushed Resident #7. RN #1 told the Risk Manager s/he was getting the medicine ready and did not witness the event. There was an exchange of words when Resident #7 was trying to get past Resident #6. There had been no previous concerns between the two residents. The Risk Manager stated s/he talked with both residents. Resident #6 told him/her the above information. Resident #7 said s/he was trying to go through the hallway and Resident #6 was taking his/her time. Resident #7 said s/he splashed water on the resident and then Resident #6 pushed him/her. The nurse would not document the incident in the Progress Notes because the Risk Manager wanted to do the investigation and not make an assumption. The DON was interviewed and stated the behavior should be documented in the Progress Notes labeled behavior note if there were any other behaviors. The DON stated s/he would not expect the nurses to have documented the behavior of the incident, even though the residents admitted to the incident. The Risk Manager stated an Incident Report was not completed since it was a reportable incident. The facility reported an allegation of verbal abuse of Resident #4 by CNA #3 on 9/13/18. Review of the facility's Five-Day Follow-Up Report dated 9/14/18 revealed upon completion of staff interviews and review of medical record unable to substantiate allegation of abuse. Staff will be educated related to customer service. The surveyor requested a copy of the facility's complete investigation of the allegation. Review of the investigation revealed a statement by CNA #3, CNA #2, and LPN #3. There was one other CNA and one other nurse on duty on the unit at the time of the alleged incident who did not complete statements. Review of the investigation revealed there was no statement from RN Unit Manager #1 who received report of the allegation from another staff member. There was no statement that indicated what staff member Resident #4 initially made the allegation of verbal abuse to and what the resident stated. Review of Resident #4's Progress Notes revealed there was no entry between 9/11/18 and 9/19/18. Review of Resident #4's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 12. There was no documentation in the facility's investigation that the resident was interviewed or completed a statement related to the allegation. During an interview with the surveyor on 1/17/19 at approximately 4:15 PM, Risk Manager stated when s/he interviewed Resident #4 s/he felt CNA #3 was unprofessional and rude with the tone of his/her voice. The Risk Manager asked for any specifics and the resident could not say. The Risk Manager stated s/he did not document the conversation with the resident. The Risk Manager stated RN Unit Manager #1 reported Resident #4's allegation of verbal abuse to him/her. The Risk Manager stated RN Unit Manager #1 did not complete a statement. During an interview with the surveyor on 1/17/19 at approximately 4:55 PM, RN Unit Manager #1 stated a staff member reported Resident #4's allegation to him/her. RN Unit Manager #1 could not remember who the staff member was who told him/her about the allegation. S/he thinks it was something to the effect that Resident #4 said someone spoke to harshly to him/her. RN Unit Manager #1 could not remember exactly what they said Resident #4 told them. RN Unit Manager #1 stated s/he could not remember if s/he completed a witness statement. RN Unit Manager #1 stated s/he does not recall talking to Resident #4 about the incident.",2020-09-01
1135,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-01-18,635,D,1,0,3V6D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to have physician orders [REDACTED]. Resident #13 was noted to be on oxygen on admission to the facility on [DATE]. Review of the resident's Physician order [REDACTED]. One of one resident reviewed for admission orders [REDACTED] The findings included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's Progress Notes revealed an entry on 12/15/18 at 5:10 indicated nurse heard resident calling out for help. Resident was noted at entry way of door with cane at side. No non-skid footwear worn. Oxygen (O 2) tubing at feet. N/c (nasal cannula) in place. Resident noted to be bleeding from right forehead with hematoma. Resident unable to explain what s/he was doing prior to the fall and what caused her/him to fall. At time of fall residents only complaint was headache. Resident O 2 Review of Resident #13's Admission/Readmission Evaluation dated 12/10/18 revealed the resident was on O 2 at 2 L/min via NC (chronic). Review of the Resident #13's Physician order [REDACTED]. There were no additional oxygen orders noted. Review of Resident #13's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed O 2 at 2 Liters Per Minute ordered 12/23/18 upon return from hospital to maintain O 2 sats greater than 90% every shift. Review of the resident's MAR revealed no orders for O 2 from admission on 12/10/18-12/23/18. Further review of the MAR revealed O 2 sats were recorded on day shift, evening shift, and night shift. Change O 2 tubing every night shift every Wednesday and clean O 2 filter every night shift was ordered 12/23/18. Licensed Practical Nurse (LPN) #1's facility-obtained statement dated 12/15/18 indicated s/he heard Resident #13 yelling for help. Resident #13 was found at the doorway of room, bleeding from right side forehead with hematoma. Resident noted to be sitting on buttocks. Oxygen tubing at feet and cane noted at resident's side. Resident complained of headache. Resident denied hip pain/leg pain. Resident was transferred back to bed. Resident O 2 sat noted 90%. Notified physician and received an order to send to emergency room . Once EMS arrived resident complained of right mid-thigh pain. Resident transferred to emergency room for evaluation. During an interview with the surveyor on 1/17/19 at approximately 11:50 AM, the Director of Nursing (DON) stated O 2 sats are documented on the MAR/TAR. They are monitored based on what is ordered. The first O 2 documentation for Resident #13 is on 12/15/18 at 88% documented by LPN #1 and documented in the vitals area. If the resident is admitted with oxygen they should have an order for [REDACTED]. During an interview with the surveyor on 1/17/19 at approximately 1:02 PM, the DON stated s/he reviewed Resident #13's medical record and did not see an order for [REDACTED]. The nurse should have called and gotten an order to clarify and put the order for oxygen in the system. If the resident was admitted to the facility on oxygen and there was no order from the hospital, the nurse should have called and gotten an order. The nursing admission assessment noted the resident was on oxygen.",2020-09-01
1136,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-01-18,655,D,1,0,3V6D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Resident #13 was admitted to the facility receiving oxygen (O2). Review of the resident's baseline care plan revealed there was no care plan completed for oxygen use. One of one resident reviewed for baseline care plan. The findings included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's Progress Note dated 12/15/18 at 5:10 AM indicated nurse heard resident calling out for help. Resident was noted at entry way of door with cane at side. No non-skid footwear worn. Oxygen tubing at feet. N/c (nasal cannula) in place. Resident noted to be bleeding from right forehead with hematoma. Resident unable to explain what she was doing prior to the fall and what caused her to fall. At time of fall resident only complaint was headache. Resident O2 Review of resident's Baseline Care Plan for admitted [DATE] revealed an area for special treatments/procedures that included oxygen. The section was not marked as the resident requiring oxygen. Review of the Admission/Readmission Evaluation dated 12/10/18 revealed the resident was on O2 at 2L/min via NC (chronic). During an interview with the surveyor on 1/17/19 at approximately 1:02 PM, the Director of Nursing confirmed the oxygen was not noted on the resident's initial care plan.",2020-09-01
1137,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-01-18,656,E,1,0,3V6D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical and nursing needs as identified in the comprehensive assessment. Resident #13 was noted to be receiving oxygen and there was no care plan in place. The facility reported an allegation of resident to resident abuse involving Resident #5 and Resident #7 and resident to resident abuse involving Resident #6 and Resident #7. The facility failed to update the residents care plans related to resident to resident altercations and resident behaviors. Three of thirteen residents reviewed for comprehensive care plans. The findings included: Resident #13 was noted Review of the resident's Physician order [REDACTED]. Review of Resident #13's Medication Administration Record [REDACTED]. Review of the resident's MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Change O 2 tubing every night shift every Wednesday and clean O 2 filter every night shift was ordered 12/23/18. Review of Resident #13's Admission/Readmission Evaluation dated 12/10/18 revealed the resident was on O 2 at 2L/min via NC (nasal cannula) (chronic). Review of Resident #13's Comprehensive Care Plan revealed no care plan for oxygen use. During an interview with the surveyor on 1/17/19 at approximately 1:02 PM, the Director of Nursing (DON) reviewed the resident's care plan the surveyor was provided and confirmed there was no care plan for oxygen. During an interview with the surveyor on 1/17/19 at approximately 3:05 PM, the DON stated the Minimum Data Set nurse was still working on Resident #13's care plan for return from the hospital on [DATE]. The DON stated the printed care plan provided was from what had triggered from the nursing assessment. Review of Resident #13's Admission/Readmission Evaluation dated 12/23/18 revealed oxygen at 2 L/minute by NC (chronic) was documented. The facility reported an allegation of resident to resident abuse involving Resident #5 and Resident #7 on 12/18/18. Review of the facility's Five-Day Follow-Up Report dated 12/20/18 revealed upon completion of investigation including staff interviews and review of medical record, unable to substantiate allegation of abuse. Resident #5 approached Resident #7 and poured tea on him/her. Resident #7 then made contact with Resident #5. Residents were immediately separated. Staff are to redirect Resident #5 away from Resident #7 frequently and as needed. Certified Nursing Assistant (CNA) #2's facility-obtained statement dated 12/18/18 indicated s/he was standing in the dining room door when Resident #7 pushed Resident #5 down and s/he fell . In an interview with the surveyor on 1/18/19 at approximately 3:45 PM, CNA #2 stated Resident #5 and Resident #7 were in the dining room eating. CNA #2 saw Resident #5 hit the floor, CNA #2 saw Resident #7 push Resident #5 down. CNA #2 was in the doorway when s/he witnessed the incident. CNA #2 did not see what happened immediately prior to the push and fall. CNA #2 stated s/he is not sure if Resident #5 threw a drink on Resident #7. During an interview with the surveyor on 1/18/19 at approximately 10:25 AM, the Risk Manager and DON were interviewed related to the incident. The Risk Manager stated during the investigation s/he found that Resident #5 poured tea on Resident #7. Resident #7 reported that Resident #5 had walked up and poured tea on him/her. As a reaction, s/he pushed Resident #5 and s/he fell . The Risk Manager stated there was no incident report completed because the information is in the reportable. Review of Resident #7's care plan revealed there was no care plan related to resident to resident altercations and resident behaviors. The facility reported an allegation of resident to resident abuse involving Resident #6 and Resident #7 on 9/27/18. Review of the facility's Five-Day Follow-Up Report dated 10/1/18 revealed upon completion of investigation including staff interviews and review of medical record, Resident #7 threw water on Resident #6. Resident #6 made contact with Resident #7 with no injuries noted. Resident #7's medications were reviewed by the nurse practitioner and the two residents are to be kept separated at all times. Resident #15's facility-obtained statement dated 9/27/18 indicated at 12:15 PM Resident #7 and Resident #6 exchanged words between each other. Resident #7 threw water at Resident #6 and Resident #6 punched Resident #7. Nurses tried to diffuse the situation, but Resident #7 was very belligerent and could not be calmed down. Registered Nurse (RN) #1's facility-obtained statement dated 9/27/18 indicated Resident #6 was sitting at the medication cart taking medication. Resident #7 wanted Resident #6 to move so s/he could get by. Resident #6 wanted Resident #7 to wait until s/he finished taking medication. Resident #7 said something about Resident #6 is fat, Resident #6 said something (most likely not nice) in response and then said, don't throw water on me. Resident #6 then hit Resident #7 (nurse did not see it but both parties said it happened). Resident #7 began yelling and cursing at staff. Social worker was called and spoke with both residents. CNA #1's facility-obtained statement dated 9/27/18 indicated as s/he was walking down the hall s/he witnessed Resident #7 pour water on Resident #6. Then Resident #6 had his/her hands around Resident #7's neck. Resident #7 went into a rage with profanity. Review of Resident #6's care plan revealed there was no care plan related to resident to resident altercations and resident behaviors. Review of Resident #7's care plan revealed there was no care plan related to resident to resident altercations and resident behaviors.",2020-09-01
1138,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-01-18,658,G,1,0,3V6D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that the services provided by the facility meet professional standards of quality. Review of Resident #1's medical record revealed an x-ray result dated 8/21/18. Review of Resident #1's medical record revealed no documentation related to the x-ray until 8/23/18. There was no documentation in the resident's medical record related to why the x-ray was obtained. The facility reported an injury of unknown source to the State Agency for Resident #8, the CNAs failed to inform the nurse of the incident involving Resident #8. Two of fourteen residents reviewed for professional standards. The findings included: The facility reported an injury of unknown source to the State Agency on 8/23/18 for Resident #1 for a compression fracture of back. The Initial 23-Hour Report indicated the reportable incident was reported at 1:00 PM on 8/23/18. Review of the facility's Five-Day Follow-Up Report dated 8/27/18 revealed upon completion of investigation including staff interviews and review of medical record, resident has had no falls. Resident has a [DIAGNOSES REDACTED]. The surveyor requested a copy of the facility's complete investigation into the incident involving Resident #1. Review of the facility's investigation revealed only one witness statement. License Practical Nurse (LPN) #2's facility-obtained statement dated 8/23/18 indicated s/he received an x-ray report that showed suspicion of possible compression fracture in spine. A Computerized tomography (CT) Scan was ordered. Review of Resident #1's Radiology Report revealed the date of service as 8/21/18 and signed by the radiologist on 8/21/18 at 12:31 PM. The Radiology Report had alert results of poorly seen but suspected T 11 vertebral compression fracture with anterior wedging deformity of unknown age. CT scan was advised. The fax stamp across the top of the Radiology Report indicated 8/21/18 at 12:36 PM. Review of Resident #1's Progress Notes revealed an entry on 8/23/18 at 12:54 that indicated x-ray right hip and pelvis done with findings of suspected T 11 vertebral compression fracture with anterior wedging deformity of unknown age. Resident #1 seen by nurse practitioner and an order for [REDACTED]. The previous entry was dated 8/20/18 at 6:30 PM and indicated resident returned from [MEDICAL TREATMENT] with no distress noted. Appears stable and no distress. Review of Resident #1's medical record revealed no documentation related to the resident having a change in condition that would indicate why an x-ray was done. Review of the Daily Assignment Sheet revealed LPN #2 was assigned to Resident #1 on day shift on 8/23/18. Review of Resident #1's Medication Administration Record [REDACTED]. Resident #1 was administered [MEDICATION NAME] 5-325 mg 1 tablet as needed for pain on 4:45 PM on 8/21/18. During an interview on 1/18/19 at approximately 10:45 AM the Risk Manager stated Resident #1 complained of discomfort in his/her back to LPN #2 on 8/23/18. The nurse completed an x-ray and the result was a compression fracture. The Risk Manager stated s/he had no knowledge of the resident having prior complaints of back pain. The Risk Manager stated s/he spoke with LPN #2 and s/he said it was the first time the resident had complained of back discomfort. The Risk Manager stated s/he only got a statement from LPN #2, who the resident complained to. The surveyor reviewed the medical record with the Risk Manager related to the Radiology Report being dated 8/21/18 and no documentation of follow-up with the results until 8/23/18. The Risk Manager stated s/he would double check and make sure. The Risk Manager returned and stated s/he does not know why the Radiology Report was dated 8/21/18 but not reported or documented in the resident's Progress Notes until 8/23/18. The Risk Manager stated no incident report was completed for Resident #1. During an interview on 1/18/19 at approximately 2:05 PM the DON stated s/he could not locate anything on why the x-ray was done on 8/21/18 and not documented in Resident #1's Progress Notes until 8/23/18. The facility reported an injury of unknown source to the State Agency for Resident #8 on 10/15/18. Review of the facility's Five-Day Follow-Up Report dated 10/18/18 revealed upon completion of investigation including staff interviews and review of medical record, staff that was in the bathroom with resident did not witness her fall. Resident #8 has not had a fall in several months. Review of CNA #4's facility-obtained statement dated 10/16/18 revealed s/he and another CNA were getting Resident #8 out of the restroom. When they went to stand the resident up s/he tried to sit down to early and the chair was not behind him/her. Resident #8's legs then buckled, but s/he did not hit the floor. Review of CNA #5's facility-obtained statement dated 10/15/18 revealed on 10/11/8 Resident #8 was placed on the toilet using 2 person assist. CNA #4 and CNA #5stepped out of the room so the resident could use the bathroom. Resident #8's daughter/son-in-law and resident were arguing and s/he came out and asked CNA #4 and CNA #5 to get the resident off the toilet. CNA #4 and CNA #5 went in and asked Resident #8 to stand, as they stood the resident up his/her daughter/son-in-law began to talk with him/her. They were having words as the CNAs were cleaning the resident. Resident #8 thought the chair was behind him/her, s/he went down and CNA #4 and CNA #5 grabbed him/her and put them in the chair. Resident #8 never hit the floor. Review of LPN #2's facility-obtained statement dated 10/15/18 indicated s/he had no knowledge of Resident #8 having any falls. Review of RN #2's facility-obtained statement dated 10/15/18 indicated s/he did not know of any incidents with Resident #8. Review of RN #1's facility-obtained statement dated 10/16/18 indicated Resident #8 did not fall during shower. Resident's daughter/son-in-law was at the facility and made no report regarding a fall on 10/11/18. Review of Resident #8's Progress Notes revealed on 10/11/18 at 11:47 AM resident combative with care. Taken into shower room by nurse and CN[NAME] When attempting to undress resident s/he punched the CN[NAME] Daughter/son in law present and asked to come into the shower room. Eventually able to undress resident and begin bathing. On 10/11/18 at 9:50 PM resident pointing to right leg and wincing. Resident fighting staff and refused care at 9:30 PM. On 10/11/18 at 11:02 PM resident complained of nausea and complained of pain in right knee when s/he moves. Grandson/Granddaughter here and demands s/he has an injection for his/her nausea. Wants resident seen in AM by MD (Medical Doctor) or NP (Nurse Practitioner). Check both knees. Call placed to NP and received order for [MEDICATION NAME]. On 10/12/18 at 10:51 AM resident with swelling and pain noted to bilateral knees. Nurse practitioner in to examine with order to send resident to rheumatology. On 10/13/18 at 6:30 PM resident continues to refuse care. The nurse attempted to provide care but resident displayed signs of pain to right knee and would not allow peri care. Scheduled [MEDICATION NAME] was given. Responsible party notified of refusal of care at approximately 6:00 PM. On 10/13/18 at 9:36 PM responsible party requesting resident be sent to emergency room for evaluation to right knee due to increased pain related to swelling. On call clinician notified at 9:35 PM and order given to send to emergency room . Review of the Transfer to Hospital Form dated 10/13/18 revealed resident complained of increased pain to right knee with swelling noted to area. Resident stated pain started on 10/11/18. Review of the SBAR (Situation, Background, Assessment, Recommendation) Communication Form revealed resident with increased right knee pain and swelling that started on 10/11/18. Indicated resident's family requested ER (emergency room ) intervention. Review of the resident's (MONTH) MAR (Medication Administration Record) revealed the resident was monitored for pain TID (Three Times a Day). The resident had no pain noted from 10/1/18-10/11/18. On 10/11/18 on second shift the resident was coded as having mild pain. On 10/12/18 the resident was coded as having mild pain on all three shifts. On 10/13/18 the resident was coded as having severe pain on first shift. Resident had an order for [REDACTED].>Review of the Hospital History and Physical dated 10/14/18 revealed the resident presented with right knee pain. Resident stays at a SNF (Skilled Nursing Facility) and apparently had a fall 2 days ago (per reports) but was found today by family complaining of right leg pain. Resident was brought to ER and found to have a distal right femoral fracture. Review of the NP Progress Note dated 10/22/18 resident was being seen s/p hospitalization for right knee pain. Note resident reported falling 2 days prior to hospitalization . Resident was found to have a right femoral fracture. During an interview on 1/18/19 at approximately 11:10 AM, the Risk Manager stated on 10/15/18 s/he received a report the resident had a right femur fracture. LPN #2 reported the fracture to him/her at 9:45 AM. The Risk Manager was trying to investigate how the injury came about. Resident #8 stated s/he had a fall in the bathroom, that is what s/he told the grandson/granddaughter. The Risk Manager interviewed several staff and found two CNAs reported that while s/he was in the bathroom they had him/her up standing with 2 CNAs trying to clean the resident. Resident #8 buckled but did not touch the ground. There were two CNAs holding the resident up, and one of the CNAs were trying to clean the resident. The resident could bear weight at that time. The resident's daughter/son-in-law was behind the wheelchair at the time of the incident. When the resident buckled they transferred him/her back to the wheelchair. The incident occurred on 10/11/18. The Risk Managers stated the CNAs reported the incident to the nurse. The DON stated they did not do an incident report because the resident did not fall. The DON stated if the nurses knew about the resident buckling then they should have done an assessment. The DON stated s/he is not sure when the CNAs told the nurses about the incident. The DON said s/he is not sure what happened at the time of the incident when the resident buckled so s/he can't say if the CNAs should have reported it to the nurses. The Risk Manager stated Resident #8 was evaluated by the nurse practitioner and if s/he feels like the resident needs to be sent out then the resident will be sent out. Neither the DON nor Risk Manager know if the nurse practitioner was aware the resident buckled prior to complaining of knee pain.",2020-09-01
1139,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-01-18,695,D,1,0,3V6D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences. Resident #13 was admitted with oxygen (O 2), but the facility failed to obtain orders for the oxygen. Review of the resident's baseline care plan revealed there was no care plan developed for oxygen use. Review of the resident's comprehensive care plan revealed there was no care plan for oxygen use. One of one resident reviewed for oxygen. The findings included: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility reported an injury of unknown source to the State Agency on 12/15/18 related to a right [MEDICAL CONDITION]. Review of the facility's Five-Day Follow-Up Report dated 12/18/18 indicated upon completion of investigation, including staff interviews and review of medical record, resident got up from his/her bed and ended up falling. Resident complained of right mid-thigh pain and was transferred to the emergency room . Resident #13 was found to have a right [MEDICAL CONDITION]. Review of Resident #13's Progress Note dated 12/15/18 at 5:10 AM indicated nurse heard resident calling out for help. Resident was noted at entry way of door with cane at side. No non-skid footwear worn. Oxygen tubing at feet with nasal cannula (NC) in place. Resident noted to be bleeding from right forehead with hematoma. Resident unable to explain what s/he was doing prior to the fall and what caused him/her to fall. At time of fall resident's only complaint was headache. Resident O 2 Review of Resident #13's SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 12/15/18 noted resident on O 2 via NC, pulse oximetry 88%. Respiratory evaluation indicated abnormal lung sounds, labored or rapid breathing, and shortness of breath. Review of resident's Vitals Summary revealed O 2 Sats (saturation) documented daily 12/23/18-1/11/19. There was one other entry on 12/15/18 at 4:54 AM that noted 88%. There were no entries between 12/10/18-12/15/18. Review of Resident #13's Medication Administration Record (MAR)/Treatment Administration Record (TAR) revealed O 2 at 2 LPM was ordered 12/23/18 upon return from hospital to maintain O 2 sats greater than 90% every shift. Review of the resident's MAR revealed no orders for O 2 from admission on 12/10/18-12/23/18. Further review of the MAR revealed O 2 sats were recorded on day shift, evening shift, and night shift. Change O 2 tubing every night shift every Wednesday and clean O 2 filter every night shift was ordered 12/23/18. Review of Resident #13's (MONTH) (YEAR) MAR revealed the resident's O 2 sats were not recorded prior to 12/23/18. Review of Resident #13's Baseline Care Plan for admitted [DATE] revealed an area for special treatments/procedures that included oxygen. The section was not marked as the resident requiring oxygen. Review of the Admission/Readmission Evaluation dated 12/10/18 and Readmission Evaluation dated 12/23/18 revealed the resident was on O 2 at 2L/min via NC (chronic). Review of the resident's Physician order [REDACTED]. There were no additional oxygen orders noted. Review of the resident's Comprehensive Care Plan revealed no care plan for oxygen use. Licensed Practical Nurse (LPN) #1's facility-obtained statement dated 12/15/18 indicated s/he heard resident yelling for help. Resident was found at doorway of room, bleeding from right side forehead with hematoma. Resident noted to be sitting on buttocks. Oxygen tubing at feet and cane noted at resident's side. Resident O 2 sat noted 90%. Notified physician and received an order to send to ER. Once EMS arrive resident complained of right mid-thigh pain. Resident transferred to emergency room for evaluation. During an interview with the surveyor on 1/17/19 at approximately 11:50 AM, the DON stated O 2 sats are documented on the MAR/TAR and are monitored based on what is ordered. The first O 2 documentation for Resident #13 is on 12/15/18 at 88% documented by LPN #1 and documented in the vitals area. The DON stated if a resident is admitted with oxygen they should have an order for [REDACTED]. During an interview with the surveyor on 1/17/19 at approximately 12:22 PM, the DON stated they initiated O 2 on the night Resident #13 fell from what s/he sees in the chart. They ordered it when Resident #13 returned to the facility after the fracture on 12/23/18. When reviewed Progress Notes the DON stated the admission note that referred to the resident being on O 2 at 1 LPM was when s/he was in the hospital and they received report. The surveyor asked if the nurse should have followed up on the orders and the DON stated they should have assessed the resident when s/he arrived and would base the decision on that assessment. When asked about the resident having O 2 tubing around his/her feet during fall on 12/15/18, the DON stated the nurse had documented the O 2 sat at 88% at 4:54 AM and the fall occurred at 5:00 AM, so s/he had just placed the oxygen on prior to the resident falling. The surveyor reviewed Progress Notes with the DON and noted there was no Progress Note related to resident having a change in condition prior to the fall. The surveyor also asked the DON about the Progress Note on 12/11/18 that indicated Resident #13 was receiving O 2 at 2 LPM via N/C. The DON was unable to report if Resident #13 was receiving oxygen or not prior to 12/15/18. During an interview with the surveyor on 1/17/19 at approximately 1:02 PM, the DON stated s/he did not see an order for [REDACTED]. The DON reviewed Resident #13's medical record and it looks like they had oxygen on the resident from admission. The DON stated the nurse should have called and gotten an order to clarify and put the order for oxygen in the system on admission. The DON stated if a resident was admitted on oxygen and there was no order from the hospital, the nurse should call and get an order. The DON confirmed the nursing admission assessment noted the resident was on oxygen. The DON confirmed the oxygen was not noted on the resident's initial care plan. The DON confirmed O 2 sats were to be checked every shift when it was ordered on [DATE] and there was no documentation that O 2 sats were checked prior to the order on 12/23/18. The DON stated s/he thought oxygen was care planned on the resident's comprehensive care plan. The DON reviewed the copy the surveyor was provided and confirmed there was no care plan for oxygen.",2020-09-01
1140,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-01-18,740,E,1,0,3V6D11,"> Based on review of facility files and interview, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident to resident abuse involving Resident #5 and Resident #7. Resident to resident abuse involving Resident #6 and Resident #7. Three of 14 residents reviewed for abuse The findings included: The facility reported an allegation of resident to resident abuse involving Resident #5 and Resident #7 on 12/18/18. Review of the facility's Five-Day Follow-Up Report dated 12/20/18 revealed upon completion of investigation including staff interviews and review of medical record, unable to substantiate allegation of abuse. Resident #5 approached Resident #7 and poured tea on him/her. Resident #7 then made contact with Resident #5. Residents were immediately separated. Staff are to redirect Resident #5 away from Resident #7 frequently and as needed. Review of Resident #5's Progress Notes revealed an entry on 12/18/18 that indicated resident fell in dayroom causing skin tear to back of left back of hand. Fall was witnessed by staff member. Review of the Progress Notes revealed there was no documentation about the resident to resident altercation with Resident #7 prior to the resident's fall. The facility provided an Incident Report for Resident #5 on 12/18/18 that indicated resident had a witnessed fall in the dayroom. There was no documentation on the Incident Report related to the resident to resident altercation. Review of Certified Nursing Assistant (CAN) #2's facility-obtained statement dated 12/18/18 indicated s/he was standing in the dining room door when Resident #7 pushed Resident #5 down and s/he fell . During an interview with the surveyor on 1/18/19 at approximately 3:45 PM, CNA #2 stated Resident #5 and Resident #7 were in the dining room eating. CNA #2 saw Resident #5 hit the floor, CNA #2 saw Resident #7 push Resident #5 down. CNA #2 was in the doorway when s/he witnessed the incident. CNA #2 did not see what happened immediately prior to the push and fall. CNA #2 stated s/he is not sure if Resident #5 threw a drink on Resident #7. During an interview with the surveyor on 1/18/19 at approximately 10:25 AM, the Risk Manager and DON were interviewed related to the incident. The Risk Manager stated during the investigation s/he found that Resident #5 poured tea on Resident #7. Resident #7 reported that Resident #5 had walked up and poured tea on him/her. As a reaction, s/he pushed Resident #5 and s/he fell . The Risk Manager stated there was no incident report completed because the information is in the reportable. The facility reported an allegation of resident to resident abuse involving Resident #6 and Resident #7 on 9/27/18. Review of the facility's Five-Day Follow-Up Report dated 10/1/18 revealed upon completion of investigation including staff interviews and review of medical record, Resident #7 threw water on Resident #6. Resident #6 made contact with Resident #7 with no injuries noted. Resident #7's medications were reviewed by the nurse practitioner and the two residents are to be kept separated at all times. Review of Resident #6's Progress Notes revealed there was no entry on 9/27/18 and no documentation related to the resident to resident altercation with Resident #7. Review of Resident #7's Progress Notes dated 9/27/18 revealed there was no documentation related to the resident to resident altercation with Resident #6. Review of Resident #6's care plan revealed there was no care plan related to resident to resident altercations and resident behaviors. Review of Resident #7's care plan revealed there was no care plan related to resident to resident altercations and resident behaviors. Review of Resident #15's facility-obtained statement dated 9/27/18 indicated at 12:15 PM Resident #7 and Resident #6 exchanged words between each other. Resident #7 threw water at Resident #6 and Resident #6 punched Resident #7. Nurses tried to diffuse the situation, but Resident #7 was very belligerent and could not be calmed down. Review of RN #1's facility-obtained statement dated 9/27/18 indicated Resident #6 was sitting at the medication cart taking medication. Resident #7 wanted Resident #6 to move so s/he could get by. Resident #6 wanted Resident #7 to wait until s/he finished taking medication. Resident #7 said something about Resident #6 is fat, Resident #6 said something (most likely not nice) in response and then said, don't throw water on me. Resident #6 then hit Resident #7 (nurse did not see it but both parties said it happened). Resident #7 began yelling and cursing at staff. Social worker was called and spoke with both residents. Review of CNA #1's facility-obtained statement dated 9/27/18 indicated as s/he was walking down the hall s/he witnessed Resident #7 pour water on Resident #6. Then Resident #6 had his/her hands around Resident #7's neck. Resident #7 went into a rage with profanity. During an interview on 1/18/19 at approximately 10:35 AM the Risk Manager stated Resident #6 was in the hallway with the nurse getting ready to take his/her medicine administered by RN #1. Resident #7 came up behind Resident #6 to go through the hallway to get past him/her. Resident #6 said give me a minute, I am taking my medicine. Resident #7 got impatient and splashed water on Resident #6, and Resident #6 pushed Resident #7. RN #1 told the Risk Manager s/he was getting the medicine ready and did not witness the event. There was an exchange of words when Resident #7 was trying to get past Resident #6. There had been no previous concerns between the two residents. The Risk Manager stated s/he talked with both residents. Resident #6 told him/her the above information. Resident #7 said s/he was trying to go through the hallway and Resident #6 was taking his/her time. Resident #7 said s/he splashed water on the resident and then Resident #6 pushed him/her. The nurse would not document the incident in the Progress Notes because the Risk Manager wanted to do the investigation and not make an assumption. The DON was interviewed and stated the behavior should be documented in the Progress Notes labeled behavior note if there were any other behaviors. The DON stated s/he would not expect the nurses to have documented the behavior of the incident, even though the residents admitted to the incident. The Risk Manager stated an Incident Report was not completed since it was a reportable incident. During an interview on 1/18/19 at approximately 2:57 PM the Risk Manger stated that Behavior monitoring is on the MARs related to medication orders. The nurses will document resident behaviors on Progress Notes. They discuss resident behaviors in morning meeting for anything that happened the day before. There is no tracking of resident behaviors.",2020-09-01
1141,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-01-18,842,E,1,0,3V6D11,"> Based on record review and interview, the facility failed to maintain medical records on each resident that were complete and accurately documented. The facility failed to document resident to resident altercation with Resident #5 and Resident #7. The facility failed to document resident to resident altercation with Resident #6 and Resident #7. Three of 14 residents reviewed for abuse. The findings included: The facility reported an allegation of resident to resident abuse involving Resident #5 and Resident #7 on 12/18/18. Review of the facility's Five-Day Follow-Up Report dated 12/20/18 revealed upon completion of investigation including staff interviews and review of medical record, unable to substantiate allegation of abuse. Resident #5 approached Resident #7 and poured tea on him/her. Resident #7 then made contact with Resident #5. Residents were immediately separated. Staff are to redirect Resident #5 away from Resident #7 frequently and as needed. Review of Resident #5's Progress Notes revealed an entry on 12/18/18 that indicated resident fell in dayroom causing skin tear to back of left back of hand. Fall was witnessed by staff member. Review of the Progress Notes revealed there was no documentation about the resident to resident altercation with Resident #7 prior to the resident's fall. During an interview with the surveyor on 1/18/19 at approximately 10:25 AM, the Risk Manager and DON were interviewed related to the incident. The Risk Manager stated during the investigation s/he found that Resident #5 poured tea on Resident #7. Resident #7 reported that Resident #5 had walked up and poured tea on him/her. As a reaction, s/he pushed Resident #5 and s/he fell . The Risk Manager stated there was no incident report completed because the information is in the reportable. The facility reported an allegation of resident to resident abuse involving Resident #6 and Resident #7 on 9/27/18. Review of the facility's Five-Day Follow-Up Report dated 10/1/18 revealed upon completion of investigation including staff interviews and review of medical record, Resident #7 threw water on Resident #6. Resident #6 made contact with Resident #7 with no injuries noted. Resident #7's medications were reviewed by the nurse practitioner and the two residents are to be kept separated at all times. Review of Resident #6's Progress Notes revealed there was no entry on 9/27/18 and no documentation related to the resident to resident altercation with Resident #7. Review of Resident #7's Progress Notes dated 9/27/18 revealed there was no documentation related to the resident to resident altercation with Resident #6. Resident #15's facility-obtained statement dated 9/27/18 indicated at 12:15 PM Resident #7 and Resident #6 exchanged words between each other. Resident #7 threw water at Resident #6 and Resident #6 punched Resident #7. Nurses tried to diffuse the situation, but Resident #7 was very belligerent and could not be calmed down. Review of RN #1's facility-obtained statement dated 9/27/18 indicated Resident #6 was sitting at the medication cart taking medication. Resident #7 wanted Resident #6 to move so s/he could get by. Resident #6 wanted Resident #7 to wait until s/he finished taking medication. Resident #7 said something about Resident #6 is fat, Resident #6 said something (most likely not nice) in response and then said, don't throw water on me. Resident #6 then hit Resident #7 (nurse did not see it but both parties said it happened). Resident #7 began yelling and cursing at staff. Social worker was called and spoke with both residents. Review of CNA #1's facility-obtained statement dated 9/27/18 indicated as s/he was walking down the hall s/he witnessed Resident #7 pour water on Resident #6. Then Resident #6 had his/her hands around Resident #7's neck. Resident #7 went into a rage with profanity. During an interview on 1/18/19 at approximately 10:35 AM the Risk Manager stated Resident #6 was in the hallway with the nurse getting ready to take his/her medicine administered by RN #1. Resident #7 came up behind Resident #6 to go through the hallway to get past him/her. Resident #6 said give me a minute, I am taking my medicine. Resident #7 got impatient and splashed water on Resident #6, and Resident #6 pushed Resident #7. RN #1 told the Risk Manager s/he was getting the medicine ready and did not witness the event. There was an exchange of words when Resident #7 was trying to get past Resident #6. There had been no previous concerns between the two residents. The Risk Manager stated s/he talked with both residents. Resident #6 told him/her the above information. Resident #7 said s/he was trying to go through the hallway and Resident #6 was taking his/her time. Resident #7 said s/he splashed water on the resident and then Resident #6 pushed him/her. The nurse would not document the incident in the Progress Notes because the Risk Manager wanted to do the investigation and not make an assumption. The DON was interviewed and stated the behavior should be documented in the Progress Notes labeled behavior note if there were any other behaviors. The DON stated s/he would not expect the nurses to have documented the behavior of the incident, even though the residents admitted to the incident. The Risk Manager stated an Incident Report was not completed since it was a reportable incident.",2020-09-01
1142,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2017-01-19,282,D,0,1,I7S511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with Licensed [MEDICATION NAME] Nurses (LPNs) # 2 and 4, and observations of Resident #119, the facility failed to implement the care plan for 1 fo 3 residents reviewed for accidents. Resident #119 was care planned to have fall mats while in bed, but on two observations the resident did not have fall mats while in bed. The findings included: Resident #119 was admitted to the facility for dementia with behavioral disturbance, heart failure, [MEDICAL CONDITION], delusional disorder, [MEDICAL CONDITION], muscle weakness, pain, difficulty walking, and malaise. Interview with LPN #4 on 1/17/17 at approximately 12:30 PM revealed that Resident #4 had fallen twice in the previous 30 days. Review of the Resident #119's care plan on 1/18/17 at approximately 2 PM revealed that Resident #119 was care planned to have floor mats while in bed. Observation of Resident #119 on 1/18/17 at approximately 12:35 PM revealed that the resident was eating lunch in his bed. No fall mats were present. Review of Resident #119's orders on 1/18/17 at approximately 2:15 PM revealed that there were no orders for floor mats per the care plan. Observation of Resident #119 on 1/19/17 at approximately 8:40 AM revealed that the resident was lying in bed but no fall mats were in use. Interview with LPN #2 on 1/18/17 at approximately 8:50 AM confirmed no fall mats were in use, and s/he called to have fall mats placed per care plan.",2020-09-01
1143,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2017-01-19,312,D,0,1,I7S511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with Certified Nursing Assistant (CNA) #1 and Licensed [MEDICATION NAME] Nurse (LPN) #1 the facility failed to provide Activities of Daily Living (ADL) care for 1 of 3 residents reviewed for ADLs. Resident #142 was observed with facial hair for two days of the survey. The findings included: Observation of Resident #142 on 1/17/17 at approximately 3:15 PM revealed that the resident had noticeable chin hairs of 1-2 cm length. Observation of Resident #142 on 1/18/17 at approximately 9:15 AM revealed that the resident still had at least three 1-2 cm length hairs that were noticeable. Review of Resident #142's care plan on 1/18/17 at approximately 1:10 PM revealed that the resident was care planned to have assistance with ADLs. Observation of Resident #142 on 1/18/17 at approximately 2:07 PM revealed that the resident still had hairs on her chin. Interview with LPN #1 on 1/18/17 at approximately 2:08 PM revealed that the resident has morning care with all ADLs. Nails and other grooming are on an as-needed basis. If she has any chin hairs growing the CNA will shave her immediately. Interview with LPN #1 on 1/18/17 at approximately 2:08 PM revealed that the resident still had noticeable chin hairs despite it being practiced they be shaved on an as-needed basis. Review of Shaving policy provided by the facility on 1/19/17 at approximately 11:52 PM revealed that the facility is to use a disposable or electric razor to shave residents. Interview with CNA #1 on 1/19/17 at approximately 12:06 PM revealed that the CNA shaves Resident #142 when she sees hairs which is usually once a week. S/he stated Resident #142 is combative and it is difficult to shave her with a disposable razor. S/he then stated that there is no electric razor to shave the resident, though facility policy states an electric or disposable razor is to be used to shave residents.",2020-09-01
1144,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2017-01-19,323,D,0,1,I7S511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with Licensed Practicing Nurses (LPNs) # 2 and 4, and observations of Resident #119, the facility failed to implement the care plan for 1 to 3 residents reviewed for accidents. Resident #119 was care planned to have fall mats while in bed, but on two observations the resident did not have fall mats while in bed. The findings included: Resident #119 was admitted to the facility for dementia with behavioral disturbance, heart failure, Alzheimer's disease, delusional disorder, [DIAGNOSES REDACTED], muscle weakness, pain, difficulty walking, and malaise. Interview with LPN #4 on 1/17/17 at approximately 12:30 PM revealed that Resident #4 had fallen twice in the previous 30 days. Review of the Resident #119's care plan on 1/18/17 at approximately 2 PM revealed that Resident #119 was care planned to have floor mats while in bed. Observation of Resident #119 on 1/18/17 at approximately 12:35 PM revealed that the resident was eating lunch in his bed. No fall mats were present. Review of Resident #119's orders on 1/18/17 at approximately 2:15 PM revealed that there were no orders for floor mats per the care plan. Observation of Resident #119 on 1/19/17 at approximately 8:40 AM revealed that the resident was lying in bed but no fall mats were in use. Interview with LPN #2 on 1/18/17 at approximately 8:50 AM confirmed no fall mats were in use, and s/he called to have fall mats placed per care plan.",2020-09-01
1145,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2017-01-19,371,E,0,1,I7S511,"Based on observations and interviews, the facility failed to ensure food prepared and served in a sanitary manner due to staff touching resident's bread with bare hands in the main dining room. Two frying pans used in the main kitchen was noted with a heavy build up of a thickened crusty black substance inside the pans. A microwave in the nutrition kitchen on Unit 100-300 for residents was noted with food particles on top and sides of the microwave. The findings included: During a random lunch observation in the main dining room on 1/17/17 at approximately 11:48 AM two residents were seated at a table near a hand sanitizer dispenser. The facility staff was observed multiple times reaching over the residents while they had their food tray to get to the sanitizer dispenser. At various times during the food delivery in the main dining room, staff was observed removing residents' bread (roll) from a small white wax bag with their bare hands. Staff was observed picking up residents' roll with bare hands to put butter on the rolls. During a random lunch observation in the main dining room on 1/18/17 at approximately 11:50 AM the facility staff was observed removing residents' corn bread muffin from white wax bag with their bare hands. An interview on 1/18/17 at approximately with facility staff (Activity) confirmed he/she had been touching residents' bread with bare hands. The facility staff further stated he/she touched the bread with his/her bare hand because it was hard the get the bread out of the paper wrapping. A random observation on 1/18/17 at approximately 3:17 PM of the nutrition kitchen for residents on Unit 100-300 revealed a microwave oven with a heavy deposit of dried food particles on inside top and sides of the microwave. A random observation of the main kitchen on 1/19/17 at approximately 8:35 AM revealed two (2) frying pans noted with a heavy build up of a heavy black crusty substance on the inside. One frying pan on top of the stove and empty and the other frying pan was hanging on a cookware rack. When the Dietary Manager (DM) was asked if the frying pans were used by the kitchen staff, the DM stated the frying pans were used to make grill cheese sandwiches for the residents. Further review of the frying pans revealed they were Teflon coated at some point but the Teflon coating was not visible due to the burnt crusty coating inside the pans. The DM confirmed the findings and removed the frying pan from the cookware rack. A random observation and interview on 1/19/17 at approximately 11:05 AM of the nutrition kitchen on Unit 100-300 revealed the microwave had food particles on the inside top and stains on the sides of the microwave. An interview with the housekeeping staff who was reportedly responsible for keeping the microwave clean confirmed the findings.",2020-09-01
1146,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2018-01-19,580,G,1,0,759411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to notify the physician for continued vomiting and pain for 1 of 3 residents reviewed for change in condition. Resident #3's physician was not notified of residents continued vomiting/spitting up and pain after an initial notification on the day shift. The findings included: On 12/22/17 resident #3 was vomiting/spitting up and complained of abdominal pain on the 7 AM - 3 PM shift, sometime after lunch. The resident continued to have vomiting/spitting up and abdominal pain throughout the day. The physician was not notified the resident continued with vomiting/spitting up and pain into the evening shift. The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nurse's Progress Note dated 12/22/17 at 2:54 PM, Family in to visit at lunch and fed resident. Resident has been coughing up phlegm and c/o (complained of) stomach pain. Dr. (Doctor) (name of physician) informed and new orders received. RP (responsible party) aware. Further review of the medical record revealed a Radiology Report for a Chest X-ray (CXR) was available for 12/22/17, with a faxed time of 5:44 PM. The chest x-ray conclusion was, No acute cardiopulmonary disease process. No documentation that the physician was notified of the CXR results. On 12/22/17 at 8:26 PM a SBAR (Situation-Background-Assessment/Appearance- Request) Report was completed for physician notification. Situation: Pain (uncontrolled) Since this started it has gotten worse. Vital signs: B/P (blood pressure): 124/72, Pulse: 72, Respirations: 14, Temp 98.8, Oximetry%: 97%. Abdominal/Gastro-intestinal (GI) Evaluation: Vomiting, abdominal pain, abdominal tenderness. Describe vomiting: Description checked was Persistent or recurrent (two or more episodes within 12 hours) vomiting, with or without abdominal pain, bleeding, distention, or fever. Describe abdominal pain: Description checked: Associated with fever, continuous GI bleeding, or other acute symptoms. Describe GI signs and symptoms: brown, then pink, then darker pink vomitous. Pain Evaluation: Facial grimacing, occasional moan or groan. New orders to send to emergency room (ER) for evaluation. On 1/18/18 Licensed Practical Nurse #1 was interviewed by the surveyor. I got in report that s/he had been sick and the doctor had ordered x-rays. I went first to check on her/him. It was clear phlegm. I told them we could not lay her/him down while s/he was vomiting and I could watch her/him in the day room. It took a while for the x-ray report to come back. When it did I called the on call and s/he said to send her/him out. The family wanted to give her/him some pain medicine, but the doctor didn't want to give her/him anything while s/he was vomiting to see what was wrong. The nurse stated the family remained with the resident the entire time.",2020-09-01
1147,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2018-01-19,657,D,1,0,759411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to revise care plan for 1 of 2 residents reviewed for a trach. Resident #1 coughed out her/his trach. The care plan was not revised to include potential/actual tracheal displacement. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurses' Notes dated 12/11/17 at 3:21 PM and 12/20/17: emergency room called facility to notify them resident was returning to facility with a new trach. Review of the care plan revealed a care plan on 11/30/17 for [MEDICAL CONDITION] related to [DIAGNOSES REDACTED]. Review of the care plan revealed there was no revision for the dislodgement of the trach. The care plan did not include the emergency equipment that was at the bedside. The care plan did not include the size of [MEDICAL CONDITION] resident had in place. The care plan did not include the resident's need to go to the emergency room for placement related to tracheal stenosis or polyp. On 1/18/18 at approximately 3:15 PM, Licensed Practical Nurse #2 was interviewed by the surveyor and asked what had occurred for the resident to be sent out. [MEDICAL CONDITION] only come out twice. Both times, s/he had a coughing spell and it came out. S/he went to the hospital both times. We kept a pulse ox on her/him the whole time until EMS (Emergency Medical Services) arrived. We notified the physician as well. We kept her/him upright, we stayed with her/him and assessed the whole time. S/he has the ambu bag, we had oxygen at the bedside in case her/his sats dropped, but they did not. S/he maintained. The Nurse Practitioner was in the building and stayed with the resident as well, s/he maintained sats at 96%. S/he maintained above 90% both times. I was here both times it occurred. S/he has to go to the hospital to change the trach. S/he can breathe. Originally s/he had a size 6 and now has a 4. They were going to remove [MEDICAL CONDITION] s/he has a polyp right behind the trach. The physician wants to remove the polyp, but not right now, then remove the trach.",2020-09-01
1148,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2018-01-19,658,G,1,0,759411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to maintain professional standards for treating residents in pain and for documentation of resident's condition for 2 of 3 residents reviewed for change in condition. Resident #1, and #3 with changes in their condition that required hospital transfer did not have documentation in their medical records to depict the changes. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurses' Notes of 12/11/17 at 3:21 PM: Nurse from emergency room (ER) called and stated resident will be coming back with new #4 trach. 12/20/17: ER called stated resident was on her way back.[MEDICAL CONDITION]#4 was replaced. Resident is in no respiratory distress. There was no documentation as to what had occurred to send the resident to the ER. On 1/18/18 at approximately 3:15 PM, Licensed Practical Nurse #2 was interviewed by the surveyor and asked what had occurred for the resident to be sent out. [MEDICAL CONDITION] only come out twice. Both times, s/he had a coughing spell and it came out. S/he went to the hospital both times. We kept a pulse ox on her/him the whole time until EMS (Emergency Medical Services) arrived. We notified the physician as well. We kept her/him upright, we stayed with her/him and assessed the whole time. S/he has the ambu bag, we had oxygen at the bedside in case her/his sats dropped, but they did not. S/he maintained. The Nurse Practitioner was in the building and stayed with the resident as well, s/he maintained sats at 96%. S/he maintained above 90% both times. I was here both times it occurred. S/he has to go to the hospital to change the trach. S/he can breathe. Originally s/he had a size 6 and now has a 4. They were going to remove [MEDICAL CONDITION] s/he has a polyp right behind the trach. The physician wants to remove the polyp, but not right now, then remove the trach. The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nurse's Progress Note of 12/22/17 at 2:54 PM, Family in to visit at lunch and fed resident. Resident has been coughing up phlegm and c/o (complained of) stomach pain. Dr. (Doctor) (name of physician) informed and new orders received. RP (responsible party) aware. There was no other documentation as to the monitoring, assessing or how resident's condition progressed. There was no documentation as to when the resident began vomiting or complained of abdominal pain. There was no assessment of the resident for the abdominal pain. The nurse failed to document the resident was not given any medication for pain or vomiting. There was a pain score noted on the Medication Administration Record [REDACTED]. Further review of the medical record revealed a Radiology Report for a Chest X-ray (CXR) was available for 12/22/17, with a faxed time of 5:44 PM. The chest x-ray conclusion was, No acute cardiopulmonary disease process. No documentation that the physician was notified of the CXR results. On 12/22/17 at 8:26 PM a SBAR Report was completed for physician notification. Situation: Pain (uncontrolled) Since this started it has gotten worse. Vital signs: B/P (blood pressure): 124/72, Pulse: 72, Respirations: 14. Temp 98.8, Oximetry%: 97%. Abdominal/Gastro-intestinal (GI) Evaluation: Vomiting, abdominal pain, abdominal tenderness. Describe vomiting: Description checked was Persistent or recurrent (two or more episodes within 12 hours) vomiting, with or without abdominal pain, bleeding, distention, or fever. Describe abdominal pain: Description checked: Associated with fever, continuous GI bleeding, or other acute symptoms. Describe GI signs and symptoms: brown, then pink, then darker pink vomitus. Pain Evaluation: Facial grimacing, occasional moan or groan. New orders to send to ER emergency room for evaluation. The surveyor interviewed Licensed Practical Nurse (LPN) #1 by phone on 1/18/2018 at approximately 4:50 PM. The LPN stated, I got in report that s/he had been sick and the doctor had ordered x-rays. I went first to check on her/him. It was clear phlegm. I told them we could not lay her/him down while s/he was vomiting and I could watch her/him in the day room. It took a while for the x-ray report to come back. When it did I called the on call and s/he said to send the resident out. I was checking on her/him. The family wanted to give her/him some pain medicine, but the doctor didn't want to give anything while s/he was vomiting to see what was wrong. I came on at 3:00 PM. S/He sat up in the geri chair so I could keep an eye on her/him. We couldn't put her/him in the bed. The girls (Certified Nursing Assistants (CNA's)) changed her/him. I was checking on her/him and they were checking her/him every 2 hours. I did vitals and listened to her/his lungs. S/He did tell me s/he was in pain, s/he was not yelling out. S/He was a little restless, no more than usual. More like spitting up than vomiting. You know like mucus you get in your mouth when you are getting nauseated. It (vomitus) was clear at first. No stomach contents. Around the time the tech got there to do the x-ray it (phlegm) was a pink color. I was keeping the sisters and the niece apprised of what was going on. The daughter came in and I talked with her. On 1/19/18 the surveyor attempted a phone interview with the physician named in the nurses' note. The physician stated s/he was not the physician on call on 12/22/2017 and was not able to say if the nurses should have called the physician to let her/him know the resident continued to complain of pain and vomiting.",2020-09-01
1149,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2018-01-19,684,G,1,0,759411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide interventions for pain and vomiting/spitting up which persisted from sometime after lunch until evening. Resident #3 was vomiting/spitting up and complained of abdominal pain with no treatment. 1 of 3 residents reviewed for change in condition. The findings included: The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nurse's Progress Note of 12/22/17 at 2:54 PM, Family in to visit at lunch and fed resident. Resident has been coughing up phlegm and c/o (complained of) stomach pain. Dr. (Doctor) (name of physician) informed and new orders received. RP (responsible party) aware. No documentation of physician's orders [REDACTED]. Further review of the medical record revealed a Radiology Report for a Chest X-ray (CXR) was available for 12/22/17, with a faxed time of 5:44 PM. The chest x-ray conclusion was, No acute cardiopulmonary disease process. No documentation that the physician was notified of the CXR results. On 12/22/17 at 8:26 PM a SBAR (Situation-Background-Assessment/Appearance- Request) Report was completed for physician notification. Situation: Pain (uncontrolled) Since this started it has gotten worse. Vital signs: B/P (blood pressure): 124/72, Pulse: 72, Respirations: 14. Temp 98.8, Oximetry%: 97%. Abdominal/Gastro-intestinal (GI) Evaluation: Vomiting, abdominal pain, abdominal tenderness. Describe vomiting: Description checked was Persistent or recurrent (two or more episodes within 12 hours) vomiting, with or without abdominal pain, bleeding, distention, or fever. Describe abdominal pain: Description checked: Associated with fever, continuous GI bleeding, or other acute symptoms. Describe GI signs and symptoms: brown, then pink, then darker pink vomitous. Pain Evaluation: Facial grimacing, occasional moan or groan. New orders to send to ER emergency room for evaluation. The surveyor interviewed Licensed Practical Nurse (LPN) #1 by phone on 1/18/2018 at approximately 4:50 PM. The LPN stated, I got in report that s/he had been sick and the doctor had ordered x-rays. I went first to check on her/him. It was clear phlegm. I told them we could not lay her/him down while s/he was vomiting and I could watch her/him in the day room. It took a while for the x-ray report to come back. When it did I called the on call and s/he said to send the resident out. I was checking on her/him. The family wanted to give her/him some pain medicine, but the doctor didn't want to give anything while s/he was vomiting to see what was wrong. I came on at 3:00 PM. S/He sat up in the geri chair so I could keep an eye on her/him. We couldn't put her/him in the bed. The girls (Certified Nursing Assistants (CNA's)) changed her/him. I was checking on her/him and they were checking him every 2 hours. I did vitals and listened to her/his lungs. S/He did tell me s/he was in pain, s/he was not yelling out. He was a little restless, no more than usual. More like spitting up than vomiting. You know like mucus you get in your mouth when you are getting nauseated. It (vomitus) was clear at first. No stomach contents. Around the time the tech got there to do the x-ray it was a pink color. I was keeping the sisters and the niece apprised of what was going on. The daughter came in and I talked with her. Review of the Emergency Medical Services report stated the resident was in the day room sitting up when they arrived. On 1/19/18 the surveyor attempted a phone interview with the physician named in the nurses' note. The physician stated s/he was not the physician on call on 12/22/2017 and was not able to say if the nurses should have called the physician to let her/him know the resident continued to complain of pain and vomiting.",2020-09-01
1150,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2018-01-19,842,E,1,0,759411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to maintain medical records that were complete and accurately documented for 3 of 3 residents reviewed for change in condition. Resident #1, #2, and #3 did not have complete and or accurate documentation. The findings included: Cross refer to F657 Care plan revision, F658 Professional Standards The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurses' Notes dated 12/11/17 at 3:21 PM and 12/20/17: emergency room called facility to notify them resident was returning to facility with a new trach. There was no documentation of what had occurred that the resident needed to go to the hospital. The care plan was not revised to include the resident's dislodgment of [MEDICAL CONDITION] emergency care of the resident in the event [MEDICAL CONDITION]. The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Nurse's Progress Note dated 12/22/17 at 2:54 PM, Family in to visit at lunch and fed resident. Resident has been coughing up phlegm and c/o (complained of) stomach pain. Dr. (Doctor) (name of physician) informed and new orders received. RP (responsible party) aware. There was no documentation as to when the resident began to vomit/cough up, or complain of abdominal pain. There was no further documentation as to how the acute condition progressed until approximately 8:30 PM. There was no documentation of vital signs, oxygen saturations, and physician's orders [REDACTED]. The facility admitted resident # 2 with [DIAGNOSES REDACTED]. The resident was at the facility less than 24 hours. Review of the Medication Administration Record [REDACTED]. There was no description of the resident's respiratory status until s/he began with respiratory issues. The Risk Manager and the Assistant Director of Nursing reviewed the documentation with the surveyor. They were unable to produce any further documentation regarding the events. The Risk Manager stated s/he understood.",2020-09-01
1151,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2018-04-13,623,E,0,1,9HE711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide a written notice of transfer to the resident/resident's representative at the time of two hospitalization s for Residents #37 and #27. Two of 2 residents reviewed for transfers out of the facility. The findings included: The facility admitted resident #37 on 08/12/14 with [DIAGNOSES REDACTED]. PRESSURE ULCER OF UNSPECIFIED BUTT[NAME]K, [MEDICAL CONDITION],LACK OF COORDINATION, CONTRACTURE, LEFT WRIST, CONTRACTURE, LEFT HAND, [MEDICAL CONDITION], UNSPECIFIED, DYSPHAGIA, OROPHARYNGEAL , BLADDER DISORDER, NEUROMUSCULAR DYSFUNCTION OF BLADDER, MALAISE, MUSCLE WEAKNESS (GENERALIZED), ABNORMAL POSTURE, ANXIETY DISORDER, [MEDICAL CONDITION], MODERATE PROTEIN-CALORIE MALNUTRITION, CONSTIPATION, OSTEO[DIAGNOSES REDACTED],HEREDITARY SPASTIC [MEDICAL CONDITION], [DIAGNOSES REDACTED] IN DISEASES , SPINAL STENOSIS, CERVICAL REGION,CHRONIC [MEDICAL CONDITION],[MEDICAL CONDITIONS], MAJOR [MEDICAL CONDITION], ESSENTIAL (PRIMARY) HYPERTENSION, CAUDA EQUINA SYNDROME, [MEDICAL CONDITION] BOWEL, [MEDICAL CONDITION] and GASTRO-[MEDICAL CONDITION] REFLUX DISEASE WITHOUT ESOPHAGITIS. Review of the Nurses Progress Notes revealed documentation of the reasons for the transfers to the hospital on [DATE] and 04/03/2018. Further review revealed no documentation for the written notice required to be provided to the resident or the resident's representative. During an interview 04/12/2018 at 3:30 pm the East Wing Unit Manager confirmed that no written notice was provided to the resident or resident's representative. The facility admitted Resident #27 on 07/26/17 with [DIAGNOSES REDACTED]. On 04/10/18 at 09:08 AM, review of the MDS (Minimal Data Set) indicated Resident #27 was discharged to the hospital on [DATE] and 04/02/18. During record review on 4/12/18, no documentation of notice to resident/resident representative was located in the medical record related to the hospitalization in (MONTH) or April. During an interview on 04/12/18 at 4:40 PM, the Director of Nursing stated that the reasons for transfer was documented in the resident's clinical record but was not aware of the requirement for written notice to be provided to the resident or the resident's representative and confirmed that written notice had not been being provided for transfers to the hospital.",2020-09-01
1152,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2018-04-13,637,D,0,1,9HE711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a Significant Change in Status Assessment (SCSA) for 10 areas of decline for Resident #85, 1 of 1 resident reviewed with a significant change in condition. The findings included: The facility admitted Resident #85 12/09/15 with [DIAGNOSES REDACTED]. On 04/12/18 at 04:00 PM, review of the Annual Minimal Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed Resident #85 had a decline in cognition, bed mobility, transfers, ambulation, locomotion, dressing, toileting, hygiene, bathing, and continence. Review of the RAI (Resident Assessment Instrument) Manual revealed A SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement. Further review revealed a SCSA should be Completed by the end of the 14th calendar day after determination that a significant change has occurred. On 04/13/18 at 09:11 AM, review of the Hospital Discharge Summary revealed Resident #85 was hospitalized [DATE] to 02/17/18 with [DIAGNOSES REDACTED]. Resident #85 had not returned to baseline as documented in (MONTH) within 14 days. During the Quarterly MDS assessment dated [DATE], the significant decline was identified and a SCSA was scheduled with an Assessment Reference Date of 03/31/18. During an interview on 04/12/18 at 4:19 PM, MDS RN #1 confirmed the resident had a significant change in status identified at the time of the quarterly assessment dated [DATE]. The RN further stated that a SCSA had been opened on 3/31/18 which was the 14th day. When the RAI Manual was reviewed with the RN, s/he confirmed the SCSA should have been completed on 03/31/18.",2020-09-01
1153,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-05-23,550,D,0,1,6RM411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that residents were treated with respect and dignity during the dining experience. Residents seated at same tables were not served sequentially and staff entered residents' rooms without knocking on 1 of 4 dining rooms observed (West Wing). The finding included: A random observation on 5/20/19 at approximately 12:10 PM revealed a food cart delivered to the 400 Hall of the West Wing. At proximately 12:20 PM the staff were serving residents in the West Wing dining room. The food cart was removed from the dining room before all the residents seated in the dining room were served. At approximately 12:27 PM staff were observed taking food trays down the 600 Hall of the West Wing before all residents seated in the dining room were served. At approximately 12:30 PM staff were observed removing two residents from the dining room who had not been served while other residents in the dining room were eating. At approximately 12:52 PM on 5/20/19 another cart arrived. Staff was observed taking trays down 600 Hall on the West Wing before taking the two residents positioned outside the dining room while the other residents were eating. The residents in the dining room had finished their meals before the two residents seated outside the dining room were served. On 5/21/19 at approximately 11:57 AM, the first food cart was delivered to Hall 400 on the West Wing. Staff was observed entering residents' rooms without knocking. A CNA looked toward the surveyor and knocked on room [ROOM NUMBER] loudly. The resident was heard laughing and telling the CNA to come in the room. The resident further stated to the CNA, You had not been knocking before, there was no need to knock now. On 5/21/19 at approximately 12:15 PM staff was observed delivering food trays and not serving all residents seated at the same table prior to serving residents at other tables. During an interview and observation on 5/21/19 with LPN #1 and LPN #3 confirmed the findings. LPN #1 further stated staff was supposed to serve all residents seated at the same table before moving on to another table. Staff was observed delivering a tray to room [ROOM NUMBER] before all the residents in the dining room were served.",2020-09-01
1154,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-05-23,576,E,0,1,6RM411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, the facility failed to provide forms of communication with privacy for one of one resident observed and eight of eight residents in residents interviewed. Resident #15 was unable to make private telephone calls since the only available telephone was restricted to the nurse's station. Resident Council stated mail was not delivered on Saturdays. The findings included: During an interview with Resident Council on 5/20/19 at approximately 2:29 PM revealed the entire resident council agreed the mail is not delivered on Saturdays. During an interview with the Activities Director on 5/22/19 at approximately 2:19 PM revealed the mail was not delivered on Saturdays. Residents do not receive mail on Saturdays because nobody is there on Saturdays to pick it up from the mailbox to deliver it to activities. Additionally, the Activities Director stated residents are not able to send mail on Saturdays since the stamps are locked away over the weekend. The facility admitted Resident #15 on 10/31/18 with [DIAGNOSES REDACTED]. An Admission's Minimum Data Set ((MDS) dated [DATE] indicated the resident had a BIMS (Brief Interview of Mental Status) score of 3 (cognitively impaired) and the Quarterly MDS dated [DATE] indicated the BIMS was 00. A random observation on 5/20/19 at approximately 12:52 PM revealed Resident #15 still seated in the hallway waiting for his/her food tray to be delivered to the dining room. At approximately 12:54 PM, Licensed Practical Nurse #2 was observed removing Resident #15 from outside the dining room and taking him/her to the nurses' station to make a telephone call. Resident #15 was observed talking on the nursing station telephone while the surveyor and two staff members were present. During an interview on 5/20/19 at approximately 12:56 PM with LPN #2 s/he confirmed the observation. LPN #2 further stated there was no cordless phone on the West Wing for residents to use so they use the telephone at the nurses' station.",2020-09-01
1155,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-05-23,641,D,0,1,6RM411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform accurate assessments for 3 of 28 residents reviewed. Residents #37, #45, and #328 had fall assessments that were inaccurately completed. The findings included: Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #37's Fall Risk assessments on 5/22/19 at approximately 10:33 AM revealed a 3/20/19 assessment that stated the resident received 1-2 medications that raised risk for falls. Review of Resident #37's Medication Administration Record [REDACTED]. Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #45 Fall Risk assessments on 5/22/19 at approximately 12:56 PM revealed a 4/22/19 fall risk assessment that stated the resident received no medications raising risk for falls. Review of Resident #45 MAR indicated [REDACTED]. Resident #328 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #328 Fall Risk assessments on 5/21/19 at approximately 3:59 PM revealed a 5/21/19 fall risk assessment that checked the resident as receiving no medications raising risk for falls. Review of Resident #328 MAR indicated [REDACTED]. During an interview with the Director of Nursing (DON) on 5/22/19 at 1:43 PM s/he confirmed the inaccurate assessments for Residents #37, #45, and #328.",2020-09-01
1156,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-05-23,679,D,0,1,6RM411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interview, the facility failed to ensure that a structured ongoing program of activities were provided for 2 of 2 sampled residents reviewed. Resident #42, #15 and other random residents were observed on the West Wing with no structured program of activities. Residents were placed in the dining with a television playing. The findings included: The facility admitted Resident #42 on 11/27/17 with [DIAGNOSES REDACTED]. An Annual Minimum Data Set ((MDS) dated [DATE] indicated the resident had a BIMS (Brief Interview of Mental Status) score of 10 (some cognitive impairment) and the Quarterly MDS dated [DATE] indicated the resident's BIMS was 9. Random observation on 5/20/19 between 9:45 AM and 12:11 PM revealed Resident #42 positioned in the dining room with several other residents with no structured activity program being provided. There was a television playing in the day area with no staff interaction. Two to three residents had their head down. Resident #42 was in a gerri chair with head back and eyes closed. At 3:44 PM Resident #42 was observed in his/her room in bed with no structured program of activities being provided Random observation on 5/21/19 at approximately 11:15 AM Resident #42 was observed seated in his/her gerri chair while a Bingo activity was in progress. The resident did not have a Bingo card or staff seated near him/her to participate in the Bingo activity. Several other residents were noted during the Bingo activity with their heads down and not participating in the activity. There were no staff interaction to engage the residents that were not participating in the group activity. A review of Resident #42 monthly activity monitoring calendar for February, March, (MONTH) and (MONTH) 2019 provided by the facility revealed the resident's daily documented group activities included television and being out of room. The facility admitted Resident #15 on 10/31/18 with [DIAGNOSES REDACTED]. An Admission's Minimum Data Set ((MDS) dated [DATE] indicated the resident had a BIMS (Brief Interview of Mental Status) score of 3 (cognitively impaired) and the Quarterly MDS dated [DATE] indicated the BIMS was 00. Random observation on 5/20/19 between 9:45 AM and 12:11 PM revealed Resident #15 seated in the dining room with several other residents with no structured activity program being provided. There was a television playing in the day area. Two to three residents had their head down. Resident #15 was in a wheelchair with his/her head down and hand on forehead. On 5/21/19 at approximately 10:19 AM, Resident #15 was observed seated in the dining room with several residents. No structured activity was in progress and the television in the dining room was on low volume. Random observation on 5/21/19 at approximately 11:15 AM Resident #15 was observed seated in his/her wheelchair while a Bingo activity was in progress. The resident was at a table with another resident and staff. There was a Bingo card on the table closer to the other resident. Resident #15 was noted with his/her head down and hand on his/her forehead. The activity staff did not engage the resident in the Bingo activity. Several other residents were noted with their heads down and not participating in the activity. On 5/21/19 at approximately 1:53 PM, Resident #15 was observed in his/her room with no structured program of activities in progress. During an interview with the Activity Director (AD) on 5/22/19 at approximately 8:57 AM revealed that Resident #15's program of activities includes sitting on the porch for an hour. And that activities for Resident #42 included being out of room in the day area. The AD further stated he/she would like to have more staff such and certified nursing aides and nurses to assist with activity but there are only 2 activity staff. The AD stated he/she does provide one to one activities but has no documentation to determine the resident's response. Reportedly there was no documentation to indicate a cognitively impaired resident's response to one to one or group activities. A review of Resident #15 monthly activity monitoring calendar for February, March, (MONTH) and (MONTH) 2019 provided by the facility revealed the resident's daily documented activities included televisions, being out of room and being on the porch.",2020-09-01
1157,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2019-05-23,684,D,0,1,6RM411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility hospice agreement, the facility failed to ensure that integrated hospice services were provided for 1 of 1 residents reviewed services. Resident #327 hospice certification, hospice agency care plan and facility integrated hospice care plan was not available. The findings included: The facility readmitted Resident #327 5/09/19 with [DIAGNOSES REDACTED]. A review of the paper medical record on 5/21/19 at approximately 12:27 PM revealed Resident #327 was admitted to hospice on 5/09/19. Further review of the medical record revealed the facility failed to obtain the hospice certification documentation and hospice agency care plan. During an interview on 5/21/19 at approximately 12:38 PM with Licensed Practical Nurse (LPN) #3 who reviewed the medical record confirmed the hospice certification documentation and hospice agency care plan was not in the medical record. LPN #3 further stated he/she will check with medical records room for the hospice documentation. A review of the electronic medical record on 5/21/19 at approximately 1:45 PM revealed the facility did not develop a comprehensive care plan the included integrated hospice services. On 5/21/19 at approximately 1:50 PM the facility consultant provided a printed out copy of the hospice certification and hospice agency care plan that had been faxed to the facility on [DATE]. The facility consultant confirmed the documentation was received on 5/21/19. During an interview on 5/22/19 at approximately 8:37 AM with Registered Nurse (RN) #1 confirmed the facility did not development an integrated care plan that included hospice services. RN#1 further stated the integrated care plan related to hospice services was not developed until 5/21/19. A review of the facility's hospice agreement on 5/22/19 at 11:41 AM revealed When the resident is authorized for hospice the facility and Hospice will develop a care plan and Hospice and the facility will maintain a copy of the care plan.",2020-09-01
1158,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2018-07-10,689,G,1,0,JUZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure Resident #1 received adequate supervision and assistance to prevent accidents/hazards, 1 of 5 sampled residents reviewed for Accidents/Hazards. Resident #1 had a documented food allergy to peanuts and was served peanut butter crackers. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the Telephone Orders on 7/9/2018 at 12:01 PM revealed a dietary order, dated 4/16/2018, indicating the resident should have no nut and no chocolate. Record review of a Diet Requisition Form on 7/9/2018 at 12:30 PM, revealed the resident was to have no nuts and no chocolate. Record review of the care plan on 7/9/2018 at 3:59 PM, revealed the resident had a peanut allergy. Record review of the Nurse Aide's Information Sheet on 7/9/2018 at 12:05 PM, revealed the resident had a food allergy to peanuts. Record review of the Nurse's Notes on 7/9/2018 at 12:45 PM, revealed a note, dated 4/25/2018, indicating Resident #1 called the nurse into her/his room and stated s/he placed a cracker into her/his mouth and did not realize it was a peanut butter cracker until it was in her/his mouth. The note indicated the resident did not eat the cracker. The Nurse Practitioner (NP) was notified and instructed the nurse to monitor for any reaction. A few minutes later the resident stated she/he was having an anaphylactic reaction with difficulty breathing and needed a dose of [MEDICATION NAME]. The NP was called again and gave orders for [MEDICATION NAME] and to send the resident to the emergency room . The [MEDICATION NAME] was given and E[CONDITION] was called. The note indicated the resident was lying in bed communicating with staff while waiting for E[CONDITION]. During an interview with the Risk Manager (RM) on 7/9/2018 at 2:51 PM, the RM confirmed the resident was given peanut butter crackers by a Certified Nursing Assistant (CNA). The Risk Manager confirmed the resident care plan and the Nurse Aide's Information Sheet indicated the resident had a peanut allergy. The RM also provided a staff in-service done on 4/26/2018 related to resident allergies [REDACTED].>During an interview with Registered Nurse (RN) #1 on 7/9/2018 at 3:05 PM, RN #1 stated the resident had asked for a snack and the CNA brought her/him crackers. RN #1 was called to the resident's room and the resident told RN #1 s/he did not eat the cracker and spit it out after s/he realized it was a peanut butter cracker. A few minutes later, RN #1 was called back to the room and the resident complained of difficulty breathing and going into anaphylactic shock. RN #1 stated orders were received for [MEDICATION NAME] and to send the resident to the emergency room . RN #1 stated the resident was stable and had no difficulty talking while waiting for E[CONDITION]. During an interview with CNA #1 on 7/9/2018 at 3:11 PM, CNA #1 stated on 4/25/2018 the resident asked her/him for a snack. CNA #1 asked what kind of snack and the resident told her/him anything with peanut butter. CNA #1 stated s/he was sure this is what the resident asked for because s/he asked the resident if s/he wanted a sandwich or crackers, since the facility had peanut butter and jelly sandwiches, also. CNA #1 stated the resident replied s/he would just have the crackers. CNA #1 stated s/he brought the resident the crackers and was unaware the resident had a peanut allergy. Review of a written statement by Resident #1, dated 5/7/2018, Resident #1 indicated s/he asked for a snack and told the CNA s/he could not have anything with nuts or chocolate. Review of the hospital History and Physical from 4/25/2018 revealed the resident complained of shortness of breath on admission, but displayed no symptoms of anaphylactic shock. The resident was admitted to the hospital for an unrelated matter.",2020-09-01
1159,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2018-07-10,697,G,1,0,JUZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to provide scheduled pain medication timely for Resident #1, 1 of 4 sampled residents reviewed for pain management. Resident #1's pain medication was administered 7 hours late due to the medication being out of stock at the facility. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Medication Administration Record [REDACTED]. In addition, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Further record review on 7/9/2018 at 11:57 AM revealed a faxed prescription, dated 4/17/2018, for [MEDICATION NAME] [MED] extended release 30 mg every 12 hours. The resident's date of birth was omitted from the prescription. The prescription was faxed to the pharmacy on 4/17/2018 at 3:25 PM. Record review of the Nurse's Notes on 7/9/2018 at 12:45 PM, revealed a note from 4/19/2018 at 4:30 AM, indicating the resident was given her/his 9:00 PM dose of [MEDICATION NAME] extended release at 4:00 AM. The Nurse's Notes also indicated the resident was very upset his/her [MEDICATION NAME] took so long to arrive from the pharmacy. There was no pain evaluation done at the time of administration. During an interview with the Assistant Director of Nursing (ADON) on 7/9/2018 at 2:35 PM, the ADON confirmed that the resident's scheduled pain medication was given 7 hours late due to waiting for it to come in from the pharmacy. During an interview with the Director of Nursing (DON) on 4/10/2018 at 10:40 AM, the DON stated the resident was admitted from the hospital with enough [MEDICATION NAME] to last through the 9:00 AM dose on 4/18/2018. The DON stated the physician saw the resident on 4/17/2018 and wrote a refill prescription which was faxed timely to the pharmacy. The DON also stated that the prescription was faxed without the resident's date of birth and this caused the delay in delivery of the medication. The DON stated eventually someone from the pharmacy contacted the facility about the discrepancy and the prescription was faxed again with the date of birth. During an interview with the DON on 4/10/2018 at 1:40 PM, the DON stated the facility keeps a supply of [MEDICATION NAME] immediate release in the Stat Box. The DON stated the resident could have been given this while waiting for the medication to be delivered. The DON also stated nurses are frequently educated on the availability of medications in the Stat Box. The DON provided Vital Signs Reports from the 2nd and 3rd shifts on 4/18 and 4/19. The DON stated the reports indicate the resident's vitals signs were stable and did not appear to be affected by the lack of pain medication. The DON also stated s/he was not denying that the resident was in pain due to the lack of pain medication. During an interview with the Nurse Practitioner (NP) on 7/10/2018 at 12:37 PM, the NP stated it was reasonable to believe that the resident was having increased levels of pain due to the long delay in receiving her/his scheduled pain medication. In a written statement provided by Resident #1 on 5/7/2018, Resident #1 indicated her/his pain level was nearing a 10 out of 10 on the pain scale when her pain medication was due on 4/18/2018. The resident also indicated that by midnight s/he was in severe pain. The resident statement indicated s/he had been up all night due to pain. In addition, after the resident received the [MEDICATION NAME] [MED], s/he indicated it was an hour before s/he felt any relief.",2020-09-01
4758,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2016-02-04,371,E,0,1,MV5M11,"Based on observations and interviews, the facility failed to ensure food was prepared and served in a sanitary manner. The oven in the kitchen was observed with brown stains on the glass door, rack and sides and bottom of the oven, hair not properly restrained, gloves not used by staff when plating foods. Hand sink in the kitchen noted with black stains in the sink under the faucet. One of 1 main kitchen reviewed. The findings included: During initial tour on 2/02/16 at approximately 7:35 AM the white basin hand washing sink in the main kitchen was observed with black stain spatters inside the sink under the faucet. Multiple staff observed going back and forth to the sink to wash hands when in the kitchen. During meal temp observation on 2/03/16 at approximately 11:20 AM, the white basin hand sink in the main kitchen was observed with black stain splatters inside the sink under the faucet. Multiple staff was observed using the sink. The Dietary Manager (DM) was observed doing food temperatures with facial hair (mustache) uncovered by face cover. Staff was observed plating foods without gloved hands. A staff member was observed doing food temps with a bandage on ungloved hands. The staff member that was plating foods with ungloved hands was noted with braided hair that was not covered under a hairnet. During random observation on 2/04/16 at approximately 9:15 AM the Dietary Manager (DM) was observed with facial hair not covered in the kitchen while demonstrating the dishwasher process and oven in main kitchen. The oven was noted with dark stains on glass doors, oven racks and bottom and sides of the oven. The DM stated the facial covering keeps falling down when asked about facial covering. When asked about a cleaning schedule of the oven, the DM stated he/she did not keep written schedule of when the ovens are cleaned. The DM provided a WEEKLY DEEP CLEANING LIST 2/1/16-2/5/16 that did not indicate what day of the week the oven was reportedly cleaned. On 2/04/16 at approximately 1:57 PM the DM provided additional weekly cleaning lists that did not indicate which day of the week the oven was cleaned.",2019-08-01
6096,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2014-10-16,241,E,0,1,K3E111,"Based on observations and interviews, the facility failed to provide services that promoted the dignity of the resident's during dining in 2 of 2 dining experiences observed on the Transition Unit and 2 of 2 dining experiences observed on the East Unit. The findings included: On 10/13/2014 at 11:57 AM, during the meal service on the Transition Unit, Certified Nursing Assistant (CNA) #1 was noted to apply towels as clothing protectors to two residents without asking permission or explaining to the resident what was being done. On 10/15/2014 at 12:05 PM, the same CNA was observed to place a towel as clothing protector on a randomly observed resident without asking the resident's permission. On 10/15/2014 12:19 PM, CNA #1 stated s/he should ask oriented residents if they wanted a clothing protector and but s/he does not ask the disoriented residents their preferences. On 10/13/14 during lunch observation on the East Unit, Certified Nursing Assistants (CNA's) #4 and #5 were observed to place a towel over residents as use for a clothing protector without asking the residents' permission. On 10/15/14 at 12:50 PM on the East Unit, two randomly observed staff members were noted placing towels on residents as a clothing protector without asking permission. On 10/15/14 at 2:56 PM, during an interview with CNA #4, s/he stated did not recall not asking the resident's permission prior to placing the towel on the resident. On 10/16/14 at 1:21 PM during an interview with CNA #5, s/he verified the resident was not asked if he/she would like a towel prior to placing the towel over the resident but that s/he was aware s/he should have done so.",2018-05-01
6097,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2014-10-16,280,E,0,1,K3E111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, and review of the policy titled Falls Potential and Risk Reduction Protocol, the facility failed to show evidence the Comprehensive Plan of Care was reviewed and or updated to reflect interventions to prevent or reduce falls for 1 of 3 residents reviewed for falls. Resident #238 care plan did not include physician ordered bed alarm nor mats to the side of the bed. The findings included: The facility admitted Resident #238 with [DIAGNOSES REDACTED]. Record review on 10/16/2014 at approximately 9:04 AM revealed a physician's orders [REDACTED]. Also, the physician's orders [REDACTED]. Review of Resident# 238's Comprehensive Plan of Care on 10/16/2014 at approximately 9:42 AM revealed it did not include the ordered interventions to prevent and or reduce falls. Review of the nurses notes on 10/16/2014 at approximately 9:54 AM revealed a note dated 10/6/2014 at 5:30 PM which stated, patient was found sitting on floor at his/her bedside. Side rails up and bed is in low position. Was still screaming and crying as s/he had been doing 20 minutes ago while in dining room. Keeps saying s/he wants to leave. Another nurses note at 5:45 PM states, put in wheel chair with belt in place. Five minutes later found him/her sliding out of the chair with belt in place. Brought out to nurses station where s/he could be observed. Another nurses note dated 10/7/2014 at 8:00 PM states, Resident was observed on the floor by staff. The fall was witnessed by the floor nurse and certified nursing assistant (CNA). S/he was assisted back to bed and shortly after, [MEDICAL CONDITION] began. [MEDICATION NAME] 0.5 milligrams (mg) x 2 doses was given. An interview on 10/16/2014 at approximately 2:42 PM with the care plan coordinator confirmed that the Comprehensive Plan of Care had not been updated to reflect the falls or the ordered interventions to reduce or prevent falls. Review of the policy entitled, Falls Potential and Risk Reduction Protocol, under procedure #4 states, The care plan should be updated after a fall to address the most recent cause of the fall.",2018-05-01
6098,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2014-10-16,323,E,0,1,K3E111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to ensure ordered fall mats were in place to prevent or reduce the risk of injury from falls for 1 of 3 residents review for falls. Resident #238. Cross refer to F 280 related to failure to update the plan of care related to physician ordered devices related to falls. The findings included: The facility admitted Resident #238 with [DIAGNOSES REDACTED]. Record review on 10/16/2014 at approximately 9:04 AM revealed a physician's orders [REDACTED]. No documentation by the nursing staff could be found in Resident #238's medical record verifying that the staff had checked to make sure the falls mats were in place as ordered. During an observation and interview on 10/16/2014 at approximately 9:51 AM with the Unit Manager on the Transition unit, he/she verified that the fall mats were not in place, and could not be found in Resident #238's room.",2018-05-01
6099,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2014-10-16,371,E,0,1,K3E111,"Based on observations and interview, the facility failed to serve and distribute food under sanitary conditions. During meal observation, Certified Nursing Assistants(CNA's) were observed to handle food items with their bare hands on 2 of 3 units. The findings included: On 10/13/14 during the lunch observation on the East Unit, CNA's #4 and #5 were observed removing bread out of the individual paper bags with their bare hands and serving the residents. On 10/15/14 at 2:56 PM, during an interview with CNA #4, he/she stated could not recall touching bread with his/her bare hand. On 10/16/14 at 1:21 PM, during an interview with CNA #5, s/he confirmed touching the bread with his/her bare hand and continued by stating you should not touch food with your bare hand. During an observation of the lunch service on 10/13/2014 at approximately 11:56 AM on the West Unit, Certified Nursing Assistants (CNA) #11 and #12 were removing the dinner roll from the plastic wrapper with their bare hands, applying butter and serving the residents. During another observation of the lunch service on the West Unit on 10/15/2014 at approximately 12:17 PM CNA #13 was observed removing the dinner roll from the plastic wrapper with his/her bare hands. An interview on 10/15/2014 at approximately 12:20 PM with CNA #13, s/he confirmed the touching of the dinner roll with his/her bare hands and stated, I thought it was ok to touch the roll if I cleaned my hands. CNA #11 and CNA #12 were not available for interview. During an interview on 10/16/2014 at approximately 1:51 PM with the Certified Dietary Manager, he/she stated, I would expect staff to remove the bread from the plastic wrapper by holding the outside of the wrapper ,putting the bread on the plate, and then take a knife and fork and apply the butter. On 10/16/14 2:07 PM a facility policy could not be located related to staff touching food with bare hands that was being served to the resident's.",2018-05-01
6100,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2014-10-16,441,E,0,1,K3E111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of Policy titled, Cleaning and Disinfecting Diagnostic Equipment, the facility failed to ensure the glucometer was properly cleaned between each resident usage. The findings included: During observation of the medication pass on [DATE] at approximately 5:30 AM on the North Hall/Transition Unit , Registered Nurse (RN) #2 used alcohol wipes to clean a glucometer after performing a blood sugar test on a resident. During an interview on [DATE] at approximately 5:35 AM with RN #2, concerning the cleaning of the glucometer before and after residents, s/he stated: We clean the glucometer with the Clorox wipes that are locked in the medication storage room first thing, then we clean them with the alcohol pads here on the medication cart between residents. When RN#2 was asked if s/he was aware of what the facility policy was for cleaning the glucometers and s/he stated, I am not sure and would have to look it up. On [DATE] at approximately 6:34 AM, RN #2 stated, The policy does state that we are to use the Clorox wipes to clean the glucometers before and after each resident use. During an interview on [DATE] at approximately 7:02 AM with RN #1, s/he was aware of how to clean the glucometers and was observed doing so appropriately. Additional interviews with on [DATE] at approximately 7:25 AM with Licensed Practical Nurse #3 and #4, both stated that the Clorox wipes were to be used and verified the Clorox wipes in the medication storage rooms had not expired. During an interview on [DATE] at approximately 8:15 AM with the Director of Nursing, s/he confirmed that the glucometers were to be cleaned with the Clorox wipes and stated that the inservices for the cleaning is completed on hire, annually and as needed. S/he stated the last inservice was conducted in [DATE]. Review of the policy on [DATE] at approximately 10:15 AM, entitled, Cleaning and Disinfecting Diagnostic Equipment, revealed the Purpose - To Provide and maintain clean resident care equipment. Procedure - #1. After completing the test, wipe the blood glucose meter with a bleach wipe, especially the area where the test strip enters the machine. #2. Diagnostic machines such as glucometers are designed and developed to prevent blood specimens from entering the machine. Therefore, any blood found on a machine should be disinfected immediately with a bleach wipe. #3. The nurse will wear gloves when removing bleach wipes from the package and cleaning the machine(s). #4. Wipe machine with bleach wipe until it is completely wet. #5. Lay the machine on a clean barrier and allow it to dry at room temperature for four (4) minutes. #6. After 4 minutes, wipe dry or allow to air dry completely. #7. If streaks appear, wipe with a soft dry cloth. #8. Repeat this procedure between each resident usage and at the end of each shift. #9. Store the meter in a clean plastic bag.",2018-05-01
6101,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2015-06-03,281,G,1,0,257311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews services provided by the facility did not meet professional standards of quality. Resident #1 was administered Resident #5's 9:00 AM medications between noon and 1:00 PM and there was no documentation in the medical record of Resident #1 being monitored after the incident. Two of five residents reviewed for medication errors. The findings included: Review of Resident #1's medical record revealed the resident's [DIAGNOSES REDACTED]. Review of the Medication Error Report for Resident #1 dated 5/17/15 revealed medications were administered to the wrong resident. Resident #1 received Resident #5's medications. Factors contributing to the incident were documented and included not following policy or procedure and medication sheet not read or read incorrectly. The Medication Error Report indicated Resident #1 received in error Aspirin 81 mg (milligrams), Vitamin D3, Vitamin B12, Senna, [MEDICATION NAME] 40 mg, [MEDICATION NAME] XL 60 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 100 mg, Linsinopril 5 mg and [MEDICATION NAME] 25 mg. Review of Resident #1's SBAR Communication Form dated 5/17/15 indicated the resident received the wrong medications. Resident #1 was given salt tablets to counteract blood pressure medications. Pertinent history included Resident #1 normally has low blood pressure. Resident #1's blood pressure was documented as 98/50. Resident #1's vital signs were documented as pulse 72, respiration 18 and temperature 98.2. There was no documentation that indicated what time the vital signs were obtained or what time the SBAR Communication Form was completed. Review of Resident #1's SBAR Communication Form dated 5/18/15 indicated the resident had altered mental status and was unresponsive. The resident's vital signs were documented as pulse 67, respiration 20 and temperature 98.2. There was no blood pressure documented. Review of Resident #1's Nurse's Notes revealed an entry dated 5/15/15. The next entry was dated 5/18/15 and indicated at 2:00 AM the resident was alert and blood pressure was 90/50. At 4:30 AM the Nurse's Notes indicated This nurse observed resident being unresponsive to verbal stimuli and mid sternal rub: BS (blood sugar) - 151: notified EMS also night supervisor: night supervisor talked with (resident's daughter). The next entry was dated 5/17/15 at 6:55 as a late entry Pt (patient) was given roommates meds: [MEDICATION NAME] 60 mg XL, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 100 mg by accident. Pt B/P (blood pressure) normally was low. Supervisor notified. This happened around 12-1 P. (S/he) was also given [MEDICATION NAME] 40 mg and Linsinopril 5 mg. Dr. was notified & at first recommended Ipecac but then changed order to salt tablets & high carb foods. B/P remained normal for the rest of my shift. Pt was A(lert) & O(riented) x 3 by the end of my shift. Review of Resident #1's Physician's Telephone Orders revealed an order dated 5/17/15 to encourage fluids and give sodium tablets. Give resident shake high in carbohydrate related to low blood pressure. There was no indication of how often to administer the sodium tablets or a time frame for how long to administer the sodium tablets. Review of Resident #1's vital sign sheet revealed an entry on 5/18/15 at 2:00 AM that indicated the resident's blood pressure was 90/50. There were three additional entries after the 5/18/15 entry that indicated on 5/17/15 Resident #1's blood pressure was 98/50, 94/48 and 112/45. There were no times to indicate when the 5/17/15 blood pressures were obtained. Review of Resident #1's May 2015 Medication Administration Record [REDACTED]. There was no documentation that sodium tablets were administered to Resident #1. A Physician's Telephone Order dated 5/18/15 indicated may transport Resident #1 to the emergency department. In an interview with the surveyor on 6/3/15 at approximately 11:55 AM, the facility Administrator stated that RN #1 realized almost immediately s/he had given the wrong medications. The physician and family were notified. The physician ordered ipecac and they did not have any in the facility. Staff went to the pharmacy to look for the ipecac and could not find. The physician then ordered sodium tablets and a high carbohydrate diet. Resident #1's blood pressure was monitored and there were no changes noted. Resident #1 has a history of altered mental status related to high ammonia levels. On 6/3/15 at approximately 1:25 PM, the facility Administrator stated that RN #1 stated s/he was running late and that is why Resident #1 was given his/her roommates 9:00 AM medications between 12:00-1:00 PM. RN #1 normally worked on a different unit and picked up a shift that day. The facility Administrator was not aware of any events on the unit that would have caused the nurse to be running so far behind. On 6/3/15 at approximately 1:40 PM the facility Administrator stated that the blood pressures for 5/17/15 that were listed on Resident #1's vital sign sheet were documented on staff 's cheat sheet and then later transcribed to the vital sign sheet. S/he was not sure what time the blood pressures were taken. The facility Administrator was also asked about the lack of documentation of a blood pressure when Resident #1 was found unresponsive on 5/18/15 and did not provide any information that the blood pressure was documented anywhere. In an interview with the surveyor on 6/3/15 at approximately 1:45 PM, the Nurse Practitioner stated that s/he was familiar with Resident #1. The Nurse Practitioner stated that [MEDICATION NAME] and Linsinopril could make the residents blood pressure lower. There would be no major side effects from the other medications given in error. Low blood pressure could cause Resident #1 to become unresponsive. The Nurse Practitioner stated that s/he would expect blood pressure to be documented when the resident was found unresponsive. S/he would also expect documentation related to the resident being monitored after the medication error. The Nurse Practitioner stated that s/he could not say that receiving the medications given would affect the resident after being given one time. Resident #1 would metabolize the medications differently related to his/her decreased renal function. Review of Resident #5's May 2015 Medication Administration Record [REDACTED]. In an interview with the surveyor on 6/3/15 at approximately 12:15 PM, Resident #5 stated that the nurse brought him/her the wrong medications one Sunday. S/he noticed they were not his/her medications and told the nurse. Resident #5's roommate (Resident #1) received his/her medications. The nurse brought both resident 's medications in at the same time in different medication cups. Review of Resident #5's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 14.",2018-05-01
6102,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2015-06-03,333,G,1,0,257311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents are free of any significant medication errors. Resident #1 was administered Resident #5''s medications. Registered Nurse (RN) #1 brought Resident #1 and Resident #5's medications into the residents' room at the same time and handed each resident a medication cup. Resident #5 realized that the medications were not what s/he usually took and told RN #1. Resident #1 had already taken Resident #5's medications. Two of five residents reviewed for medication errors. The findings included: Review of Resident #1's medical record revealed the resident's [DIAGNOSES REDACTED]. Review of the Medication Error Report for Resident #1 dated 5/17/15 revealed medications were administered to the wrong resident. Resident #1 received Resident #5's medications. Factors contributing to the incident were documented and included not following policy or procedure and medication sheet not read or read incorrectly. The Medication Error Report indicated Resident #1 received Aspirin 81 mg (milligrams), Vitamin D3, Vitamin B12, Senna, [MEDICATION NAME] 40 mg, [MEDICATION NAME] XL 60 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 100 mg, Linsinopril 5 mg and [MEDICATION NAME] 25 mg. Review of Resident #1's SBAR Communication Form dated 5/17/15 indicated the resident received the wrong medications. Resident #1 was given salt tablets to counteract blood pressure medications. Pertinent history included Resident #1 normally has low blood pressure. Resident #1's blood pressure was documented as 98/50. Resident #1's vital signs were documented as pulse 72, respiration 18 and temperature 98.2. There was no documentation that indicated what time the vital signs were obtained or what time the SBAR Communication Form was completed. Review of Resident #1's SBAR Communication Form dated 5/18/15 indicated the resident had altered mental status and was unresponsive. The resident's vital signs were documented as pulse 67, respiration 20 and temperature 98.2. There was no blood pressure documented. Review of Resident #1's Nurse's Notes revealed an entry dated 5/17/15 at 6:55 as a late entry Pt (patient) was given roommates meds: [MEDICATION NAME] 60 mg XL, [MEDICATION NAME] 25 mg, [MEDICATION NAME] 100 mg by accident. Pt B/P (blood pressure) normally was low. Supervisor notified. This happened around 12-1 P. (S/he) was also given [MEDICATION NAME] 40 mg and Linsinopril 5 mg. Dr. was notified & at first recommended Ipecac but then changed order to salt tablets & high carb foods. B/P remained normal for the rest of my shift. Pt was A(lert) & O(riented) x 3 by the end of my shift. On 5/18/15 at 4:30 AM the Nurse's Notes indicated the resident was unresponsive to verbal stimuli and transferred to the emergency room . Review of Resident #1's Physician's Telephone Orders revealed an order dated 5/17/15 to encourage fluids and give sodium tablets. Give resident shake high in carbohydrate related to low blood pressure. There was no indication of how often to administer the sodium tablets or a time frame for how long to administer the sodium tablets. Review of Resident #1's May 2015 Medication Administration Record [REDACTED]. There was no documentation that sodium tablets were administered to Resident #1. A Physician's Telephone Order dated 5/18/15 indicated may transport Resident #1 to the emergency department. In an interview with the surveyor on 6/3/15 at approximately 11:55 AM, the facility Administrator stated that RN #1 realized almost immediately s/he had given the wrong medications. The physician and family were notified. The physician ordered ipecac and they did not have any in the facility. Staff went to the pharmacy to look for the ipecac and could not find. The physician then ordered sodium tablets and a high carbohydrate diet. Resident #1's blood pressure was monitored and there were no changes noted. Resident #1 has a history of altered mental status related to high ammonia levels. Review of Resident #5's May 2015 Medication Administration Record [REDACTED]. In an interview with the surveyor on 6/3/15 at approximately 12:15 PM, Resident #5 stated that the nurse brought him/her the wrong medications one Sunday. S/he noticed they were not his/her medications and told the nurse. Resident #5's roommate (Resident #1) received his/her medications. The nurse brought both resident 's medications in at the same time in different medication cups. Review of Resident #5's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 14.",2018-05-01
6277,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2015-04-08,226,D,1,0,WJCN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement written policies and procedures that prohibit mistreatment of [REDACTED].#1 was found to have multiple medication patches on by EMS at the facility. The incident was not investigated by facility staff. One of four residents reviewed for abuse. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the SBAR Communication Form dated 4/2/15 indicated Resident #1 had decreased alertness and was less responsive. The nurse called 911 and Resident #1 was transported to the hospital. Resident #1 returned to the facility on [DATE]. Review of the hospital History and Physical Report on Resident #1's medical record revealed when EMS arrived at the facility they found the resident with multiple medication patches on him/her and thought s/he might be overdosing with possible narcotics. In an interview with the surveyor on 4/8/15 at approximately 1:30 PM, the facility administrator stated that s/he did not know about the hospital note related to multiple patches on Resident #1. The facility administrator stated s/he would expect to be notified by nursing about the incident. The facility administrator stated that the Unit Manager and nurse on duty at the time of a resident's return review the hospital paperwork. The facility administrator stated s/he would have investigated the incident and to his/her knowledge no investigation was done related to the hospital report of multiple medication patches on Resident #1.",2018-04-01
6278,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2015-04-08,323,G,1,0,WJCN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility files and interviews, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Resident #1 was on 1:1 supervision related to having multiple falls. Resident #1 fell while CNA (Certified Nurse Aide) #1, who was assigned to watch the resident, was on their phone. One of four residents reviewed for falls. The findings included: The facility reported an incident to the State Agency on 3/4/15. The facility report indicated Resident #1 fell and sustained a right forehead hematoma and a laceration to the resident's right forehead reopened after falling face forward from a wheelchair to the floor. CNA #1 was distracted while providing 1:1 care for Resident #1 at the time of the fall. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Further 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 severely impaired cognitive skills for daily decision-making. Review of the care plan revealed at risk for falls and/or serious injury related to history of falls was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included nursing will observe more frequently with 1:1 on 3:00-11:00 PM shift. Review of the Nurses' Notes dated 3/3/15 at 8:45 PM indicated Resident #1 was receiving one on one with a caregiver. The resident was sitting in a wheelchair and the caregiver was sitting beside the resident. Resident #1 leaned forward with his/her whole upper body and fell on the floor. One on one caregiver is to be within arms reach, hand on resident or wheelchair while out of bed, no exceptions. Education was provided to the caregiver. CNA #1's facility-obtained statement indicated his/her job assignment was to sit with Resident #1 on 3/3/15. During the time CNA #1 was with the resident s/he seemed agitated and upset. CNA #1 was sitting in a chair approximately 5 feet away from Resident #1 when the resident fell down on the floor face first. CNA #1 was not looking at Resident #1 when the incident happened. CNA #1 was looking at his/her phone. There were two other CNAs in the dayroom at the time and one of them said look s/he is falling. By the time CNA #1 reacted it was too late. In an interview with the surveyor on 4/7/15 at approximately 5:25 PM, CNA #2 stated that s/he saw CNA #1 sitting in a chair next to Resident #1. CNA #1 was intense looking at his/her phone. CNA #1 had been on the phone earlier in the day. CNA #2 stated CNA #1 had been on the phone the majority of the time s/he saw him/her. CNA #1 and Resident #1 were in the dayroom most of the day on 3/3/15. In an interview with the surveyor on 4/7/15 at approximately 5:00 PM, CNA #3 stated s/he was in the dayroom when the incident occurred on 3/3/15. Resident #1 was leaning over trying to stand up and fell . CNA #1 was on his/her phone and was too far from the resident to reach out and touch the resident. CNA #3 stated CNA # had been on the phone texting when Resident #1 fell . In an interview with the surveyor on 4/8/15 at approximately 4:00 PM, CNA #4 stated s/he was in the dayroom across the room from Resident #1 and CNA #1 when the incident occurred. CNA #4 stated s/he had been in the dayroom approximately 5 minutes when Resident #1 fell . CNA #4 stated CNA #1 was sitting across the table from Resident #1. CNA #1 was texting on his/her phone when CNA #4 came into the dayroom. CNA #1 stayed on the phone until CNA #3 yelled his/her name because Resident #1 was standing up. CNA #1 looked up but could not get to Resident #1 before he fell . In an interview with the surveyor on 4/8/15 at approximately 11:30 AM, the facility Administrator stated that CNA #1 stated s/he was having an argument with his/her spouse and was trying to resolve it at the time of the incident on 3/3/15. At approximately 4:40 PM, the facility Administrator stated that CNAs were not inserviced on 1:1 expectations prior to the incident on 3/3/15. CNAs should know that 1:1 means they cannot take their eyes off the residents.",2018-04-01
6279,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2015-04-08,325,D,1,0,WJCN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a resident maintains acceptable parameter of nutritional status such as body weight. Resident #1 was noted to have a significant weight loss that was not addressed. One of four resident's reviewed for weight. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 weighed 141.2# on admission to the facility. Review of Resident #1's weights revealed the following: 2/19 - 105# (note- weight was taken x 2) 3/3 - 133.4# 3/10 - 134.8# 3/25 - 129.8# There was no weight documented on 2/26/15 after the significant weight loss noted on 2/19/15. The facility was unable to provide any documentation that Resident #1 was weighed between 2/19/15 and 3/3/15. Review of the Medical Nutritional Therapy Assessment form completed 2/23/15 by the RD (Registered Dietitian) revealed the Weight Tracking section had only the admission weight of 141.2 listed. Further review of the form revealed Resident #1 had a history of [REDACTED]. Review of the Nutrition Services Progress Note completed by the RD dated 3/2/15 indicated Resident #1s current body weight was 105# and that the weight was questionable. A weight was to be obtained that week. The next Nutrition Services Progress Note completed by the RD was dated 3/13/15 and indicated s/he had added sandwiches to the resident's meal trays for lunch and dinner. There was no order and no start date was given. The next Nutrition Services Progress Note completed by the RD was dated 3/18/15 and indicated Resident #1 had a significant weight loss of 3.5% x 1 week. Resident #1's weight had been 134.8 # on 3/10 and 130# on 3/18. Resident #1's diet had been downgraded to mechanical soft to provide easier to chew foods. Resident #1 was provided with snacks prn (as needed). The RD noted s/he had added sandwiches to meal trays previously. In an interview with the surveyor on 4/8/15 at approximately 3:10 PM, the Registered Dietitian stated that s/he asked the restorative aide to reweigh Resident #1 after the 105# weight result. Resident #1 was again noted to weight 105# when reweighed. The Registered Dietitian was not sure when the resident was reweighed. On 4/8/15 the facility administrator informed the surveyor there was no facility policy on weight loss.",2018-04-01
6280,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2015-04-08,333,D,1,0,WJCN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents were free of any significant medication errors. Resident #1 had an order for [REDACTED]. One of four residents reviewed for medications. The findings included: Review of Resident #1's Physician orders [REDACTED]. Review of the facility's pharmacy reports revealed 7 [MEDICATION NAME] 4.6 milligram patches were delivered for Resident #1 on 2/17/15 at 3:05 AM. Further review revealed 14 [MEDICATION NAME] 9.6 milligram patches were delivered to the facility on [DATE] at 4:01. Review of Resident #1's Medication Administration Record [REDACTED]. The [MEDICATION NAME] 9.6 milligram patch was not signed as administered on 2/26/15 or 2/27/15. In an interview with the surveyor on 4/8/15 at approximately 5:10 PM, the Interim Director of Nursing (DON) stated that s/he was not sure how the 2/24/15 [MEDICATION NAME] 9.6 milligram dose was signed as being given when the delivery logs showed the [MEDICATION NAME] 9.6 milligram patches were not delivered until 2/27/15. The Interim DON stated that s/he was not sure if the 2/25/15 dose was signed as administered or circled as not given. Review of Resident #1's February Medication Administration Record [REDACTED].",2018-04-01
6281,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2015-04-08,514,D,1,0,WJCN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 complete and accurately documented. Review of Resident #1's medical record revealed documentation that was not completed. One of four residents reviewed for medical records. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1 had a physician's orders [REDACTED]. Review of the resident's care plan revealed at high risk for elopement related to exit seeking was identified as a problem area on 2/12/15 and resolved on 4/5/15. Review of Resident #1's medical record revealed a Wander Data Collection Tool form with the resident's name that had not been completed. The instructions on the form included evaluation types as admission, annual, etc. Further review of the medical record revealed Resident #1 had Physician orders [REDACTED]. Review of the resident's care plan revealed at risk for falls and/or serious injury related to history of falls was identified as a problem area on 2/12/15. Review of Resident #1's medical record revealed a Fall Risk Assessment form with the resident's name that had not been completed. The form instructions indicated it should be completed upon admission and at a minimum quarterly thereafter. The Interim Director of Nursing provided completed Wander Data Collection Tool and Fall Risk Assessment forms on 4/8/15 at approximately 1:45 PM and stated that the forms were pulled out of the residents chart because s/he went out to the hospital. The Interim Director of Nursing was not able to answer why those forms had been removed while all other information prior to the resident's hospitalization was still on the medical record.",2018-04-01
6951,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2014-07-28,332,E,1,0,K0C311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility's policy, Administering Medications, the facility failed to ensure that the medication error rate was less than five percent. The medication error rate was 12 %. There were 3 errors out of 25 opportunities for error. The findings included: Error #1: On 7/22/14 at 9:38 AM, during observation of medication pass for Resident #8, Licensed Practical Nurse (LPN) #1 was observed to administer Vitamin D 3 100 IU (International Units) 4 tablets. At approximately 2:35 PM on 7/22/14, reconciliation of the Medication Administration Record [REDACTED]. During an interview at 2:47 PM, LPN #1 confirmed that the medication was administered at 9:00 AM and was scheduled for 9:00 PM. Error #2: On 7/22/14 at 10:00 AM, during observation of medication pass for Resident #9, LPN #2 was observed to administer Magnesium Oxide 400 mg. (milligrams) one tablet by mouth. At approximately 2:35 PM on 7/22/14, reconciliation of the Medication Administration Record [REDACTED]. by mouth. During an interview at 2:40 PM, LPN #2 confirmed that she/he had administered 400 mg and that the order was for 500 mg. Error #3: On 7/22/14 at 10:00 AM, during observation of medication pass, LPN #2 was observed to administer the 9:00 AM scheduled medications to Resident #9. Reconciliation of the Medication Administration Record [REDACTED]. During an interview on 7/22/14 at 2:40 PM, LPN #2 confirmed that [MEDICATION NAME] was not administered during the med pass but stated that she/he had discovered the error and had administered the medication after the surveyor had left the unit. LPN #2 stated she/he was not aware that the surveyor should have been notified that the error had been discovered and corrected. Review of the facility's policy entitled Administering Medications, revealed 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.",2017-07-01
6952,"SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER,",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2014-07-28,333,G,1,0,K0C311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility's policy, Administering Medications, conducted during the complaint inspection, the facility failed to ensure that residents are free of significant medication errors. Resident # 6 received 10 medications that were not ordered for Resident #6, 1 of 5 residents reviewed for administration of medications. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the closed medical record at approximately 2:50 PM on 7/21/14 revealed the following Nurse's Notes: 6/19/14 10:30 AM Res (resident) received .roommates 9 AM med's (medications). (Doctor) notified (with) orders rec'd (received) (and) processed . 6/19/14 5:00 PM Resident noted (with) low bp (blood pressure) 72/34 pulse 65 resp(irations) 20 O2 (oxygen) Sat(uration) 93% on 5 L (liters) O2. 6/19/14 5:30 PM .bp 70/30 pulse 66 resp 21 O2 Sat 92% on 5 L/O2 resident remains alert respond easily (with) stimuli. Placed call to (doctor) again (with) update of condition. (Doctor) stated to give 1 liter of NS via IV (intravenous) if ok (with) hospice. 6/19/14 6:30 PM Bolus (normal saline) complete Bp 88/46 pulse 72 resp 20 96% O2. Pt alert to stimuli. Moving around in bed. 6/19/14 7:05 PM 59/21 pulse 60 resp 20 O2 93% 6/19/14 7:10 PM Call placed to on call physician. (Doctor) returned call gave order to given (sic) [MEDICATION NAME] if approved by hospice . 6/19/14 7:25 [MEDICATION NAME] administered IM 66/45 pulse 65 respiration 20 O2 Sat 93%. Documentation of the residents vital signs and mental status every 30 minutes continued until 1:30 AM on 6/20/14 when the nurse documented the resident was noted with BBS (bilateral breath sounds) (with) pleural rub (and) (upper) lobes diminished. Clear (lower) lobes (No) urination noted . and at 2:05 AM Notified (Doctor) .of residents status inability to (increase) BP, BP 58/37 P(ulse) 73 Resp 20 T(emperature) 96.2 (degrees) Sat 93 breathing (with) depth Rt. (right) lobes adventious (sic) (and) Lt. (left) diminished (and) clear. Noted with (decreased) alertness, noted lethargic . .N/O (new order) to send resident to (hospital) . At 2:15 AM the nurse documented the arrival of emergency medical personnel, that the resident's Blood Pressure was 52/42 Pulse 72 Respirations 22, breathing irregular and the resident was lethargic. The resident left the facility at 2:40 AM. Further review of the nurse's notes revealed a Nursing Home to Hospital Transfer Form that stated the most recent pain medication administered was [MEDICATION NAME] mg. which was not ordered for resident #6. Continued review of the resident's record revealed a Nursing Focus Note by the hospice nurse that stated the resident was given 2 blood pressure medications and [MEDICATION NAME] 30 mg at 9 AM on 6/19/14. These were the roommates medication and not (the resident's). Pts. (patient's) BP has bottomed out at 67/37 even after a bolus of NS 1 liter and a dose of [MEDICATION NAME] . Review of the closed medical record revealed an un-timed Telephone Order dated 6/19/14 for neuro (neurological) checks every 15 minutes for 4 hours. A second order was noted, dated and timed 6/19/14 at 4:45 PM, for neuro checks every 15 minutes for 2 hours, every hour for 4 hours, then every 4 hours for 24 hours. Additional review revealed un-timed orders dated 6/19/14 for NS (normal saline) 1 liter now and another order for [MEDICATION NAME] (a drug that prevents or reverses the effects of opioids including respiratory depression, sedation and [MEDICAL CONDITION]) 1 milliliter IM (intramuscular) for 1 dose now. At 2:48 PM, review of the Medication Administration Record [REDACTED]. (milligrams) scheduled for 9:00 PM was held for lethargy. On 7/21/14 at 1:59 PM, review of the Social Services Notes revealed a note dated 7/2/14 that stated Res(ident) sent to hospital 6/20/14 (and) facility was informed that (the resident) passed away there 6/24/14. On 7/22/14 at 8:59 AM the Director of Nursing (DON) confirmed the resident had received the roommate's medications. The DON also stated the nurse that administered the medications was a new nurse on her/his third day of orientation. The DON also stated that the orienting nurse observed the new nurse pull the medications but did not observe her/him administer them. At approximately 10:00 AM on 7/22/14 review of the incident report provided by the facility revealed the resident received 10 medications that were not ordered for Resident #6 including, but not limited to, [MEDICATION NAME] 10 mg., [MEDICATION NAME] 6.25 mg., both used for hypertension and [MEDICATION NAME] mg., an extended release opoid pain reliever. Further review of the documentation revealed a One to One Inservice / Counselling (sic) Record for the orienting nurse. The record included a statement from the orienting nurse that stated I watched (the orientee) double check the meds. I asked if (she/he) knew which resident (and) (she/he) confirmed (she/he) did. I stood by the cart the entire time. (She/he) passed meds to the same residents the day before. Review of the facility's policy entitled Administering Medications revealed 6. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of Identifying the resident may include: A. Checking identification band B. Checking photograph attached to medical record C. Calling resident by name D. If necessary, verifying resident identification with other facility personnel. The policy further stated 27. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned.}",2017-07-01
7339,"DIAMOND HEALTH & REHAB OF SIMPSONVILLE, LLC",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2013-05-22,280,D,0,1,91VR11,"**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 evaluate and revise the comprehensive care plans for 2 of 14 resident records reviewed. The current care plan for Resident #1 included a problem that was resolved in June 2012. The current care plan for Resident #12 relating to fluid restriction was incorrect. The findings included: The care plan for Resident #1 dated 5/1/13 included the problem At risk for dehydration r/t fluid restriction per MD order. Review of the physician's orders [REDACTED]. Interview with LPN#3 (Licensed Practical Nurse) on 5/20 at 10:35 AM confirmed the resident was not on any fluid restriction and the fluid restriction had not been removed from the care plan since June 2012. The facility admitted Resident #12 with [DIAGNOSES REDACTED]. On 5/20/13 at approximately 3:50 PM, review of the Physicians Orders for the month of May 2013 revealed a order for a Regular, NAS (No Added Salt) diet and a 2l (Liter) fluid restriction. Review of the resident's care plan did not identify or reveal evidence that the resident was on a fluid restriction. During an interview with the Minimum Data Set Coordinator on 5/21/13, he/she verified that the resident care plan was not updated to reflect current status of fluid restriction.",2017-03-01
7340,"DIAMOND HEALTH & REHAB OF SIMPSONVILLE, LLC",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2013-05-22,309,D,0,1,91VR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey and Complaint Inspection, based on record review and interviews, the facility failed to implement re-admission orders [REDACTED]. Further, the facility failed to follow physician's orders [REDACTED].#3, 1 of 1 residents reviewed with orders for no straw with fluids. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. On 5/20/13 at 10:03 AM, record review of the 4/24/13 hospital Discharge Summary of Resident #14 revealed the diet order included a fluid restriction (less than) 1.5 liters (p)er day. Review of the admission orders [REDACTED]. Review of the medical record revealed no documentation of fluid restrictions being implemented; no documentation of fluids being monitored, of a calculation of fluids to be provided per shift, or of the amount of fluids to be administered by dietary and nursing could be located in the medical record or the current MAR. During an interview on 5/21/13 at 4:45 PM, the Director of Nursing (DON) confirmed the order for fluid restriction on the Discharge Summary. S/he stated that the order for fluid restriction should have been transcribed on the admission order form and fluids should have been restricted unless the order had been discontinued by the physician when the admission orders [REDACTED]. No further information was provided that the order had been discontinued. Review of the facility's policy entitled Medication Orders Section 2.1 dated 09/10 stated b. Written transfer orders (sent with a resident from a hospital or other health care facility) and instructed to Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician. In addition, the policy stated If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending prescriber before medications are administered. The nurse documents verification on the admission order record be entering the time, date, and signature. The facility admitted Resident #12 with [DIAGNOSES REDACTED]. On 5/20/13 at approximately 3:50 PM, review of the Physicians Orders for the month of May 2013 revealed an order for [REDACTED]. Throughout the days of the survey, the surveyor observed a water pitcher and other cups containing fluid on the residents tray table. Review of the resident meal card for all three meals did not equal to the 2l fluid restriction prescribed by the physician. For breakfast the resident was given a 8 ounce cup of water, 4 ounces of juice, 1 cup of coffee or hot tea and 1 cup of milk. For lunch the resident was given a 8 ounce cup of water and 1 cup of beverage of choice. For Dinner the resident was given a 8 ounce cup of sweet tea and a 8 ounce cup of water. The total calculation of fluids for meals (not including fluid given during medication pass) equaled to 2520 cc's which exceeded the resident's fluid restriction order. On 5/21/13 at approximately 10:15, during an interview with Licensed Practical Nurse (LPN) #1 she/he stated did not know resident was on a 2l fluid restriction. LPN #1 further verified the resident did not have a monitoring sheet on the Medication Administration Record [REDACTED]. Review of the facility's Dehydration Prevention Plan Policy and Procedure with the revision date of 7/07, revealed Ice and water will be placed at each resident's bedside by the nursing staff, unless medically contraindicated. Contraindicated medically refers to fluid restriction or specific fluid orders. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. On 5/20/13 at approximately 9:50 AM review of the Physician order [REDACTED]. On 5/20/13 at approximately 12 PM, the surveyor observed resident in the room eating lunch with a straw in the milk carton. On 5/21/13 at approximately 12:35 PM, the surveyor observed resident in the room with a straw in his/her milk carton. During an interview with the West wing Unit Manager on 5/21/13 at approximately 1 PM, he/she verified that the straw was given to the resident against physician orders.",2017-03-01
7540,"DIAMOND HEALTH & REHAB OF SIMPSONVILLE, LLC",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2014-01-15,152,D,1,0,CUCE11,"**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 have admission paperwork signed by the responsible party for 1 of 1 residents determined to be unable to make health care decisions. Resident #1 with limited mental capacity was asked to sign paperwork for medical treatment. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Patient Consent to Treat Authorization Release of Information Assignment of Benefits/Financial Agreement was signed on 12/3/13. The signature on the agreement was not legible. Review of Nurse's Notes from 12/3/13 through 12/11/13 revealed on 12/3/13 the facility received a report from the hospital. In the report the responsible party was identified to be the resident's, sister. The resident was stated to have the mental capacity of a 3 (three) year old. A Physician's Certification of Resident's Decision form was completed on 12/4/13. The Physician's Certification stated, I certify that I have medically examined resident (#1) and it is my opinion that s/he is unable to exercise his /her rights and make Health Care Decisions as a result of the following diagnosis (es). MR (Mental [MEDICAL CONDITION]) was listed. The Physician's Progress Note on 12/4/13 stated the resident was without decision abs (abilities). On 12/11/13 a second physician wrote, Pt (patient) is without Decisional Capacity unable to answer any questions. On 1/21/13 at approximately 12:00 PM, the Business Office Manager (BOM) was interviewed by phone by the surveyor. The BOM identified the signatures on the Patient Consent to Treat Authorization Release of Information Assignment of Benefits/Financial Agreement to belong to resident #1. The BOM stated, I do the initial forms on admission, s/he (resident #1) signed the admission agreement, arbitrary agreement and consent to treat. When I met with him/her, s/he was literally here less than an hour when I had that paperwork signed. The BOM stated the resident was his/her own responsible party. The surveyor asked the BOM if s/he was aware the resident was not capable to make health care decisions, by his/her medical record. S/he stated, I was not aware. If I know or I am told, I will review with the resident's family if I see them.",2017-01-01
8109,"DIAMOND HEALTH & REHAB OF SIMPSONVILLE, LLC",425112,807 SOUTH EAST MAIN STREET,SIMPSONVILLE,SC,29681,2013-07-31,281,F,1,0,Q9FO11,"**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 services provided meet professional standards of quality related to medication administration for all units of the facility. The findings included: On 7/29/13 at approximately 12:50 pm the surveyor reviewed the Medication Administration Records (MAR) for the two medication carts on the 400/500/600 unit. Review of the MAR revealed multiple residents on both carts with 9:00 am medications that had not been signed as administered. During interview on 7/29/13 at approximately 1:00 pm Licensed Practical Nurse (LPN) #1 stated that s/he had given the medications but had not had time to sign the MAR for the residents. LPN #1 stated that s/he needed his/her MAR so that s/he could administer 12:00 pm medications. LPN #1's medication cart included the odd rooms on the 400 hall and the 600 hall. During interview on 7/29/13 at approximately 1:22 pm LPN #2 stated that s/he had given the medications but had not had a chance to sign because s/he had a lot going on that morning. LPN #2 also stated that s/he had already administered 12:00 pm and 1:00 pm medications. LPN #2 stated that s/he had signed some of the MARs but not all. LPN #2's medication cart included the even rooms on the 400 hall and the 500 hall. Review of the MARs from LPN #2's medication cart revealed there were 19 resident's MARs. Review of the 19 MARs revealed the following blanks not signed as administered on 7/29/13 as of 1:00 pm: 2 at 6:00 am, 2 at 7:30 am, 4 at 8:00 am, 158 at 9:00 am, 3 at 11:00 AM, 4 at 11:30 am, and 4 at 12:00 pm. During interview on 7/29/13 at approximately 12:50 pm the Interim Director of Nursing confirmed the findings of multiple residents with 9:00 am medications not signed as administered on both medication carts. The Interim Director of Nursing stated that nurses should sign the Medication Administration Records as medications are given. A group interview with residents was held on 7/29/13 at approximately 1:30 pm. During the group interview Resident #1 stated that s/he was concerned about not getting medications at all. Resident #1 stated that s/he had made of list of her/his medications so s/he could keep up with medications because it was so bad. Resident #1 stated that the nurse might bring 1 pill instead of 2 or medications that s/he did not take. Resident #1 stated that s/he takes 5 [MEDICATION NAME] tablets once a week on Sunday. Resident #1 noticed that s/he did not receive his/her [MEDICATION NAME] as ordered for 3 Sundays. When s/he asked the nurse about the medication s/he acted like it wasn't important and did not order the medication. Resident #1 talked with a nurse during the week and that nurse ordered the [MEDICATION NAME] so Resident #1 would have it. During the group interview Resident #2 stated that nurses would sign and say they had given him/her medication but they had not given. Resident #2 stated that nurses had forgotten his/her blood pressure medication or brought 9:00 pm medications to him/ her at 4:00 or 5:00 pm. Resident #3 stated that s/he dumps pills out of the cup to make sure s/he has what s/he should. Resident #3 stated that s/he did not receive [MEDICATION NAME] one day and asked a nurse about it. The nurse checked and told him/ her that another nurse had noted that Resident #3 refused the [MEDICATION NAME]. Resident #3 stated s/he did not refuse because s/he knows s/he needs it. During the group interview Resident #6 stated that nurses would get an attitude if you said something to them about medications. Resident #6 stated that s/he knows what medicines s/he takes and does not always receive his/ her medications. Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Resident #1 resided on the 300 hall of the facility. Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 on s/he's most recent Quarterly Minimum Data Set ((MDS) dated [DATE]. Review of Resident #1's June 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: Fe [MEDICATION NAME] and Vitamin C at 12:00 pm on 6/23/13 [MEDICATION NAME], Nortriptylline and [MEDICATION NAME] at 9:00 pm on 6/16/13 and 6/30/13 [MEDICATION NAME] at 9:00 pm on 6/23/13 [MEDICATION NAME] at 9:00 am on 6/30/13 [MEDICATION NAME] at 9:00 pm on 6/30/13 Refresh tears at 5:00 pm on 6/29/13 and 6/30/13 [MEDICATION NAME] and [MEDICATION NAME] at 5:00 pm on 6/29/13 Review of Resident #1's July 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: [MEDICATION NAME] at 9:00 am on 7/6/13 and 7/15/13 Multivitamin at 9:00 am on 7/6/13, 7/7/13, 7/14/13 and 7/21/13 Acyclivir, [MEDICATION NAME], B-complex, [MEDICATION NAME] and [MEDICATION NAME] at 9:00 am on 7/7/13 [MEDICATION NAME] and [MEDICATION NAME] at 9:00 pm on 7/18/13 Refresh tears at 5:00 pm on 7/18/13 and 7/28/13 [MEDICATION NAME] at 5:00 pm on 7/28/13 Fe [MEDICATION NAME] and Vitamin C at 12:00 pm on 7/14/13 [MEDICATION NAME] at 9:00 am on 7/14/13 [MEDICATION NAME] at 11:00 pm on 7/18/13 During interview on 7/30/13 at approximately 1:20 pm the Interim DON stated that Resident #1's [MEDICATION NAME] administration day was changed from Sunday to Monday to give Resident #1 peace of mind about his/her medication administration. Resident #1 complained on 7/11/13 that s/he was not getting his/her medications consistently. Resident #2 admitted to the facility with [DIAGNOSES REDACTED]. Resident #2 resided on the 100 hall of the facility. Resident #2 had a BIMS score of 14 on their most recent Quarterly MDS dated [DATE]. Review of Resident #2's June 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: [MEDICATION NAME] at 9:00 am on 6/18/13, 6/27/13 and 6/28/13 [MEDICATION NAME] at 2:00 pm on 6/22/13 and at 10:00 pm on 6/11/13, 6/13/13, 6/14/13 and 6/21/13 [MEDICATION NAME] at 9:00 am on 6/18/13 and 6/22/13 Tylenol at 9:00 am on 6/9/13 and 6/15/13 at 5:00 pm on 6/19/13 and at 1:00 am on 6/23/13 Review of Resident #2's July 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: [MEDICATION NAME] at 9:00 am on 7/7/13 and at 5:00 pm on 7/27/13 [MEDICATION NAME] at 6:00 am on 7/16/13 and at 2:00 pm on 7/19/13 [MEDICATION NAME] at 9:00 pm on 7/11/13 and 7/29/13 During interview on 7/30/13 at approximately 1:20 pm the Interim DON stated that Resident #2's nurse should have a 2nd nurse check the medications against the MAR to ensure accuracy of medication and time of administration. The 2nd nurse is not signing to verify that they checked the medications. This procedure was started 7/29/13 in response to a complaint Resident #2 had related to medications on 7/28/13. Resident #2 had complained that his/her medications were not given on time and that s/he had been given pain pills s/he had not been taking. Resident #3 admitted to the facility with [DIAGNOSES REDACTED]. Resident #3 resided on the 300 hall of the facility. Resident #3 had a BIMS score of 15 on their most recent Quarterly MDS dated [DATE]. Review of Resident #3's June 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: [MEDICATION NAME] at 12:00 pm on 6/9/13 Vitamin C at 12:00 pm on 6/1/13, 6/2/13, and 6/9/13 Review of Resident #3's July 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: Calcium at 5:00 pm on 7/27/13 [MEDICATION NAME] XR at 9:00 am on 7/21/13 Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Resident #4 resided on the 200 hall of the facility. Review of Resident #4's June 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: [MEDICATION NAME] at 5:00 pm on 6/29/13 [MEDICATION NAME] at 9:00 pm on 6/9/13 Review of Resident #4's July 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: [MEDICATION NAME] at 5:00 pm on 7/6/13 and 7/27/13 (medication administered but pulse not recorded per MAR) [MEDICATION NAME] at 1:00 pm on 7/28/13 and 5:00 pm on 7/27/13 Resident #5 admitted to the facility with [DIAGNOSES REDACTED]. Resident #5 resided on the rehab unit of the facility. Review of Resident #5's June 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: [MEDICATION NAME] at 12:00 pm on 6/18/13 [MEDICATION NAME] at 11:30 am on 6/21/13 and 6/22/13 [MEDICATION NAME] at 4:30 pm on 6/14/13 Trazadone at 9:00 pm on 6/16/13 [MEDICATION NAME] at 9:00 am on 6/22/13 and 6/23/13 Review of Resident #5's July 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: [MEDICATION NAME] at 9:00 am on 7/5/13 [MEDICATION NAME] at 7:30 am on 7/1/13 [MEDICATION NAME] at 4:30 pm on 7/16/13, 7/21/13, 7/23/13 and 7/25/13 [MEDICATION NAME] at 5:00 pm on 7/16/13, 7/23/13 and 7/25/13 Trazadone at 9:00 pm on 7/16/13 and 7/23/13 [MEDICATION NAME] SSI (sliding scale insulin) FSBS (fingerstick bloodsugar) at 8:00 pm on 7/23/13 Humalog at 7:30 am on 7/1/13 and at 4:30 pm on 7/12/13 Resident #6 admitted to the facility with [DIAGNOSES REDACTED]. Resident #6 resided on the 500 hall of the facility. Resident #6 had a BIMS score of 15 on their most recent Annual MDS dated [DATE]. Review of Resident #6's June 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: No pulse taken before giving [MEDICATION NAME] on 6/20/13 at 6:30 am [MEDICATION NAME] at 12:00 pm on 6/27/13 [MEDICATION NAME] at 1:00 pm on 6/27/13 [MEDICATION NAME] and [MEDICATION NAME] at 11:30 am on 6/27/13 [MEDICATION NAME] 70/30 at 7:30 am on 6/13/13, 6/16/13, and 6/27/13 FSBS results at 11:00 am on 6/4/13 and 6/27/13 FSBS results at 4:30 pm on 6/9/13 FSBS results at 8:00 pm on 6/7/13 [MEDICATION NAME] Sliding Scale Insulin at 8:00 pm on 6/28/13 for a FSBS 197 Review of Resident #6's July 2013 Medication Administration Record revealed multiple medications that were not signed as administered. The medications included: [MEDICATION NAME] at 9:00 pm on 7/21/13 [MEDICATION NAME] at 5:00 am on 7/14/13 [MEDICATION NAME] and [MEDICATION NAME] at 6:00 am on 7/14/13 [MEDICATION NAME] at 4:30 pm on 7/13/13 [MEDICATION NAME] at 7:00 pm on 7/4/13 Midodrise at 1:00 pm on 7/26/13 [MEDICATION NAME] Sliding Scale Insulin at 8:00 pm on 7/3/13 and 7/12/13 for FSBS 200 FSBS results at 8:00 pm on 7/26/13 [MEDICATION NAME] 70/30 at 5:30 am on 7/22/13 [MEDICATION NAME] 70/30 at 7:30 am on 7/23/13 and 7/25/13 Review of the facility's Medication Administration General Guidelines revealed under documentation 1. The individual who administers the medication dose, records the administration on the resident's MAR following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. Review of the Medication Administration General Guidelines also revealed under documentation 2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time .the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified.",2016-07-01