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Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 609 | E | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigations, the facility failed to report an allegation of abuse and injury of unknown source within the required time frame to the appropriate state agency as required for four of 14 sampled residents (Resident (R) 1, R4, R9, and R11). On 10/29/18 an allegation of verbal abuse toward R9 was made; however, the facility failed to report the allegation of verbal abuse to the state agency within the required two-hour time frame. On 12/02/18 a sewing needle was discovered in R4's wound on top of his/her right foot; however, even though the resident was not cognitively intact, and the event was unwitnessed, the facility failed to identify the occurrence as an injury of unknown source and failed to report it to the state agency. On 01/08/19 R1 who was not cognitively intact experienced what the facility identified as an injury of unknown source; however, it was not reported to the state agency until 01/10/19 two days after the fact. On 09/11/18 the facility became aware that R11's narcotic pain medication was missing; however, the facility failed to report the misappropriation of the resident's medication within the required two-hour time frame to the state agency. Findings include: Review of R4's Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R4's quarterly MDS, completed on 10/24/18, revealed the facility assessed the resident to have a BIMS score of four out of fifteen, indicating the resident was severely cognitively impaired. During an interview on 01/20/19 at approximately 2:35 PM, the facility's Risk Manager (RM) revealed the incident of the sewing needle being discovered in R4's wound on her/his foot was not reported to the state agency as an injury of unknown source. The RM stated the resident could not tell how the needle got into the wound and it was not witnessed either. During an interview on 01/21/19 at approximately 8:38 AM, the Administrator revealed s/he was not aware of the requirement that all abuse and injuries of unknown source had to be reported to the state agency no later than two hours. The Administrator stated s/he can see how R4's injury could be an injury of unknown source. During an interview on 01/21/19 at approximately 9:50 AM, the Director of Nursing (DON) revealed s/he was previously the staff training coordinator and that s/he last received abuse training in (MONTH) of (YEAR). The DON revealed s/he was not aware of the requirement to report abuse and injuries of unknown source to the state no later than two hours. Review of R9's Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R9's admission Minimum Data Set (MDS), completed on 11/05/18, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicating the resident was severely cognitively impaired. Review of the facility's Initial 24-Hour Report, dated 11/01/18, revealed the type of reportable incident was alleged abuse. Continued review revealed the date and time of the reportable incident was 10/29/18 at 7:17 PM, indicating the incident was not reported to the state agency until three days later. During an interview on 01/20/19 at approximately 6:10 PM with the RM revealed s/he was responsible for reporting all reportable incidents to the state agency. The RM revealed the allegation of verbal abuse that occurred on 10/29/18 was not reported to her/him until 11/01/18. The RM revealed after the incident was reported to her/him late, s/he sent out mass emails to nursing supervisors reeducating them about reporting requirements. Review of R11's Physician order [REDACTED]. Review of a copy of the actually script dated 09/11/18 indicated, [MEDICATION NAME] 5 mcg patch weekly on Tuesday. On the copy of the script was the notation faxes - received. Review of an email dated 09/20/18 at 7:18 AM from Registered Nurse (RN) 4 indicated, (name of Nurse Practitioner) left a prescription (dated 09/11/18) on the keypad for the [MEDICATION NAME]. I promptly faxed it and fax confirmation was received. I did not call (name of contract pharmacy) with a follow-up phone call to confirm receipt of the prescription. Review of a typed document that was part of the facility's investigation file by the facility's Risk Manager indicated 9/10/18 [MEDICATION NAME] not given by (RN4). 9/17/18 [MEDICATION NAME] not given by LPN6. On 9/17/18, LPN7 called (name of contract pharmacy) to request patches. Review of a hand-written document that was part of the facility's investigation file dated 09/19/18 indicated, on 9/11/17 (sic - the year should have been (YEAR)) I did not receive the [MEDICATION NAME] for resident (R11) in narcotic bag. The document was signed by RN5. Review of the email from the Assistant Director of Nursing (ADON) to the RM, dated Monday 09/17/18 indicated, I received a call from (LPN7) . (s/he) was unable to find the narcotic medication, '[MEDICATION NAME]es.' The medication was signed as received by RN5 on (MONTH) 11th at 11:07 pm. After searching all subacute cottages for the med (medication) to no avail, I called the pharmacy and asked for a copy of the signature page. The signature page was sent and does appear to have been signed by the said nurse at the said time. I called (RN5) . (s/he) has no recollection of receiving any narcotic patches. I informed (RN 5) I have a copy of the signature page showing (s/he) signed for the med (medication). (RN5) again stated, 'If I did sign the paper, I do not remember receiving any narcotic patches.' Review of an email from LPN 7, dated Tuesday 09/18/18 which indicated, On (MONTH) 17th, a medication on the EMAR (Electronic Medication Administration Record) was ordered for [MEDICATION NAME] Patch once a week . I was told in report that the medication was not here so I thought pharmacy had not sent it yet . I called (name of contract pharmacy) and was told that the medication was delivered and that a staff member at (name of facility) had signed for it. I believe (s/he) said it was delivered 9/10 or 9/11 . I reported this information to the nurse supervisor and (s/he) came over to look for the medication. I held the dose due to unavailabity. Review of a hand-written note that was part of the facility's investigation file dated 09/18/18 written by LPN6 indicated On 9/17/18 there was an order for [REDACTED]. I reported this to oncoming nurse to call pharmacy. Review of the Initial 24-hour Report dated 09/19/18 indicated the date and time of the incident was 09/18/18 at 2:00 PM. The description of the incident revealed, Missing Medication. Review of the Fax Call Report indicated the Initial 24-hour Report was faxed to the State Agency on 09/19/18 at 12:36 PM. Review of an email from the State Agency dated 09/19/18 at 2:53 PM indicated, It has been received and will be reviewed. During an interview with the RM on 01/20/18 at 2:50 PM, the RM confirmed that s/he was notified by the ADON on 09/17/18; however, the RM confirmed that R11's [MEDICATION NAME]es were not available at the facility on 09/11/18. The RM confirmed the State Agency should have been notified on 09/11/18 when the pharmacy indicated that the patches had been delivered and the patches were not in the facility. Review of the undated policy titled, Narcotics, Controlled Substances, and Preventing Drug Diversion indicated d. any discrepancies are immediately reported to the Administrator. Review of R1's clinical record revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R11's quarterly MDS dated [DATE] indicated that R1 was severely cognitively impaired an unable to answer the questions on the Brief Interview for Memory Status. Review of the facility's document titled Initial 24-hour Report dated 01/10/19 indicated, the type of injury of unknown source was documented, non-displaced right [MEDICATION NAME] patella fracture. The date and time of the reportable incident indicated 1/10/19 at 9:30 AM. Review of the facility's document titled, Five-Day Follow-up Report, dated 01/11/19, indicated the same injury as the initial report; however, the date and time of the Reportable Incident indicated 1/8/19 at 20:35 (8:35 PM) reported to Risk Manager 1/10/19 at 8:30 AM. The document indicated the category of Details of Reportable Incident the following, 1/8/19 Resident presented with right knee swelling and redness. Review of R1's Physician order [REDACTED]. During an interview with the RM on 01/20/18 at 2:50 PM, the RM confirmed that s/he was notified on 01/10/19 by a supervisor who no longer worked for the facility. The RM confirmed that R1's injury of unknown origin should have been reported to the State Agency on 01/08/19. Review of the facility's undated policy, Abuse Investigation and Reporting revealed all alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two hours to the state licensing/certification agency responsible for surveying/licensing the facility. | 2020-09-01 |