cms_SC: 100
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 100 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 157 | D | 1 | 0 | MGP911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to inform the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. Resident #1 and Resident #3 were both noted to have a change in condition. Review of the resident's medical records revealed no documentation that the physician was notified of the residents' change in condition. Two of three residents reviewed for change in condition. The findings included: Review of Resident #1's medical record revealed Nurses' Progress Notes dated 8/2/17 indicated called to room by Certified Nursing Assistant (CNA) to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. Registered Nurse (RN) supervisor (RN #1) notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted weekly summary and body audit completed. The next note after the 8/2/17 entry was noted as a late entry for 8/1/17 and indicated the resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] was noted, daughter present. Daughter stated possible the footrest (missing) may have caused pain and [MEDICAL CONDITION]. Replaced footrest. Reported to nurse to get something for pain and monitor. The note was completed by RN #1. The Nurses' Progress Note dated 8/3/17 at 3:00 AM indicated the resident had complaints of pain and swelling to the right knee and warm to touch. Ice pack applied and elevated. As needed Tylenol given related to pain. On 8/3/17 at 5:00 AM the Nurses' Note indicated Tylenol was effective. Resident states My knee still hurts but feels a lot better since that ice. Ice appears to be effective. Swelling slightly reduced in size and less warm to touch. Resident now resting quietly. At 10:10 AM the note indicated the physician was asked to see the resident related to right knee pain. X-ray and CBC ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no documentation that the physician was notified of Resident #3's complaints of pain on 8/1/17 or 8/2/17. Review of Resident #1's (MONTH) Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his knee with some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Resident #1 was sent out to the hospital and noted to have a fracture. Review of Resident #3's medical record revealed the Nurse's Progress Note dated 6/19/17 at 9:55 AM indicated the nurse practitioner rounded and new orders were written for hospice to evaluate and treat the resident related to [MEDICAL CONDITION]. On 6/19/17 at 2:00 PM the Nurse's Note indicated Resident #3 had two bowel movements that were black, sticky and had blood clots in them. Resident resting in bed. On 6/19/17 at 6:00 PM the Nurses' Note indicated the resident was in bed with black blood and clots pouring out from rectum as quick as it can be wiped up. Still alert and awake at present. Review of the Nurses' Note dated 6/19/17 at 8:00 PM revealed the resident was constantly trying to get out of bed. Staff redirected resident with ease after attempt #4. Notified supervisor of actions. Supervisor reported to nurse practitioner who gave order for [MEDICATION NAME] 0.5 mg every 6 hours as needed related to agitation. Resident is alert with confusion. Black tarry blood still noted coming out of rectum. Review of the resident's Nurses' Notes from 6/1/17-6/19/17 revealed no prior documentation related to the resident having blood and clots coming from rectum. There was no documentation that the physician was notified related to the resident's change in condition. Review of Resident #3's medical record revealed the resident was admitted to hospice on 6/21/17. In an interview with the surveyor on 8/16/17 at approximately 1:10 PM, the Director of Nursing (DON) stated s/he would check on physician notification related to resident with blood clots from the rectum. The DON returned and had no documentation that the physician was notified of Resident #3's change in condition. The DON stated s/he thinks the nurses did not notify the physician because they were waiting on hospice, didn't want to be aggressive. | 2020-09-01 |