| 10073 |
THE COTTAGES AT BRUSHY CREEK |
425004 |
101 COTTAGE CREEK CIRCLE |
GREER |
SC |
29650 |
2011-02-14 |
225 |
E |
1 |
0 |
TWHZ11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on record review, interviews and review of the facility's reportable incidents, the facility failed to assure each reportable incident was reported within the mandated timeframes and to the appropriate agencies. Resident #1's injuries of unknown origin were not originally reported to the state certification agency until 3 days after the incident occurred (12/22/2010) and the 5 day follow up was not reported until 1/28/2011. Another injury of unknown origin occurred on 1/28/2011 that was not reported to the state certification agency. A random resident had a fracture that occurred during a transfer that was neither reported to the state certification agency nor thoroughly investigated. Another random resident with an allegation of verbal and physical abuse did not have the 5 day follow up reported to certification within the 5 days. One of three residents reviewed for injuries of unknown origin and 2 random reportable incidents. The findings included: The facility admitted Resident #1 on 1/6/2010 with diagnosed including: [DIAGNOSES REDACTED]. Review of the nursing notes revealed the following entries: "11/18 2 bruises notes to upper extremities ... ...left upper extremity with a silver dollar sized bruise, unopened and not draining, bruise is with a purplish hue ... ...second bruise noted to right upper extremity dime sized ... ...elder had been combative during am care ... ...am care performed without the aid of PRN [MEDICATION NAME]. " "12/14 CNA found quarter sized skin tear on posterior right arm this am. Origin unknown." "12/16 Bruise to left upper posterior arm and right forearm ... ...also noted bruise under chin will continue to monitor and report. " "12/19 2:43 AM, elder has bruises to right and left arms, skin tear on right posterior upper arm, no combative behavior noted today, Urine for lab obtained." "12/19 3:02 AM, 3 small circular bruises noted on elder's left anterior upper arm at about 9 PM last night. Staff reported elder has been unusually sleepy and agitated last 24 hours. " "12/22 nurse called to the cottage by companion (CNA) because resident was not responding. She was found in her wheelchair slumped over and did not respond to verbal stimuli ... ...Pearson NP (nurse practitioner) arrived, diagnosis was [MEDICAL CONDITION]." "12/24 Therapy: for safety during care it is recommended that elder be provided assist of 2 persons ... ...requires extensive assist ... ...Recommend gait belt be utilized." "1/28/2011 companions reported bruise on left elbow of elder of unknown occurrence. Called and notified supervisor and required documentation completed." Review of the incident report dated 11/18/2010 revealed the resident's bruises were identified during a body audit, the actions taken were "advised companions to not attempt am care when elder combative ... ...AM or any other care until elder settles ... ...notify nursing immediately." Review of the incident report dated 12/14/2010 revealed "resident noted to have skin tear on posterior right arm by CNA this AM. Origin unknown." The actions taken were "the skin tear cleansed with wound cleanser and a dry dressing was applied. Resident reminded to use call light for assistance." An Incident Investigation document that was not dated but appeared to reference the incident on 12/14/2010 indicated the elder sustained "skin tears of unknown origin. Staff was interviewed by Administration. Elder possibly sustained skin tear during period of agitation while in bed." An incident report dated 12/16 revealed the CNA's identified bruising to the chin and right forearm during care. The actions taken were "elder taking [MEDICATION NAME] in am before care and PRN [MEDICATION NAME] because resident has tendency to be combative." An incident report dated 12/18/2010 revealed "1 new bruises found on left anterior upper arm by primary nurse on second shift. 3 small (1 cm) bruises to left anterior upper arm. Immediate investigation to rule out abuse. Inspected room, devises, side rails, bed, tables and did not find anything that could cause that shape, size and location of elder's bruise. Full investigation in progress by DON, Administrator and SW." Review of an incident report that was not dated but appeared to reference the incident on 1/28/2011 revealed, "companion notified nurse of bruise to left elbow, 2 purplish areas found on left elbow. The actions taken were "observe elder for safety." Review of the behavior and Mood Tracking Log revealed on 11/18 Resident #1 did not exhibit any behaviors that day on any shift. On 12/14/2010 the resident did not exhibit any behaviors on any shift. On 12/16, Resident #1 was noted to resist care at 12:02 AM and 11:47 AM; she was noted to yell at 12:02 AM, made negative statements at 12:03 AM, was physically abusive at 11:47 AM and 8:54 PM and was angry at 12:03 AM, 11:48 AM and 8:56 PM. On 12/18/2010 Resident #1 was noted to by physically abusive at 11:42 AM and was negative and angry at 11:46 AM. On 1/28/2011, no behaviors were documented as occurring. Review of the Physician's Progress Notes revealed Resident #1 was seen on 12/17/2010. The provider acknowledged the resident's behaviors as a result of her dementia. On 12/21/2010 the resident was again seen by a provider and addressed the resident's combative behaviors. She documented that the resident was noted to have a skin tear to the left elbow, a bruise 2 cm x 2 cm on the right elbow, right upper arm with 3 bruises. Obtain geri-sleeves. On 12/22/2010 the physician in reference to the episode of unresponsiveness again assessed Resident #1. The differential diagnoses were "[MEDICAL CONDITION] versus bradycardic event, versus vasovagal episode... Spoke with daughter, had [MEDICAL CONDITION] and [MEDICAL CONDITION] in the past. [MEDICATION NAME] (for dementia) was discontinued." No diagnosis of [MEDICAL CONDITION] was affirmatively made nor was any treatment for [REDACTED]. Review of the physician's orders [REDACTED]. A telephone order dated 12/21/2010 indicated to "obtain Geri-sleeves." Review of the 24 hour report to the state certification agency revealed the report was sent on 12/22/2010. The date and time of the reportable incident was "12/14/2010-12/19/2010." The report was sent 3 days late. Review of the 5 day follow up revealed it was sent to certification on 1/28/2011, greater than one month after the incident. No report to the state certification agency could be located related to the bruising on 11/18/2010 or the incident that occurred on 1/28/2011. During an interview on 2/14 CNA #1 stated that she routinely cared for Resident #1. She stated that the resident required 2 people to perform care at all times. CNA #1 stated that Resident #1 did not need a lift for any transfer. CNA #1 stated that she did not always use a gait belt but would stand in front of the resident and have the resident "hug" her to assist the resident to stand. CNA #1 confirmed the use of the CNA care plan and stated she was aware the resident's mode of transfer was a stand up lift. She further stated that she did not know how the resident obtained the bruises on her arms. During an interview on 2/14/2011, CNA #2 stated that she routinely cared for Resident #1 and stated that the resident required 2 people for care. She stated that she performed a 2 person transfer for Resident #1. CNA #1 stated that she would cradle her arms under the resident's upper arm and perform a stand and pivot transfer. She stated that she sometimes used a stand up lift. CNA #1 stated that she "sometimes" used a gait belt during transfers. CNA #1 stated that she found the bruises on first shift and immediately reported them to the nurses. She stated that she was unsure of how the bruising occurred. During an interview on 2/14/2011, CNA #3 stated that she routinely assisted with Resident #1. She stated that the resident required 2 people for care. She stated that the resident transferred via a 2 person pivot transfer. CNA #3 stated that she would stand in front of the resident and grab under the resident's arms with both hands or one CNA on each side facing the resident with their arms linked in the arm pit area. During an interview on 2/14/2011, the nurse assigned to Resident #1 stated that she had recently been assigned to the resident. She stated that she began working with the resident approximately 3 weeks ago. She stated that she was not aware of how the resident transferred or if the resident needed a mechanical device. Review of the reportable incidents revealed an allegation of abuse reported on 1/7/2011 within the mandatory timeframe. However, the 5 day follow up was not sent to the state certification agency until 1/28/2011. Further review of the reportable incidents revealed a fracture that occurred during a transfer. The incident was not reported to the state certification agency. During an interview on 2/14/2011, the Administrator confirmed the 24 hour report was not sent to the state certification agency within the 24 hour mandated timeframe from the time of the incident. She also confirmed the 5 day report was not sent to the state agency until 1/18/2011. The Administrator also confirmed that the incidents on 11/18/2010 and 1/28/2011 were not reported to the state agency. The Administrator confirmed the random resident reviewed with a fracture that was caused during a transfer was not reported to the state certification agency. She also confirmed the 5 day follow up for an allegation of abuse that was initially reported on 1/7/2011 was not sent to the state certification agency until 1/28/2011. The Administrator and Director of Nursing confirmed that Resident #1 did not have an affirmative diagnosis of [MEDICAL CONDITION] and was not and has not been treated for [REDACTED]. Three interviewable residents were interviewed on 2/14/2011; no concerns were voiced related to abuse, neglect, transfers or injuries. The Resident Council Minutes and Grievance Logs were reviewed without concern. Review of the facility's policy on Abuse and Neglect stated, "All alleged violations and all substantiated incidents will be reported to the stated agency and to all other agencies required. Necessary, appropriate actions, depending upon the results of the investigation will be taken. Alleged violations involving mistreatment, neglect or abuse including injuries of unknown source are reported immediately to the Village Mentor (Administrator of the Village) or his/her designee. For Nurse Aide, abuse complaint, complaints of abuse by nurses or injuries of unknown source immediately notify the person in charge, Village Mentor, or Community Mentor (Director of Nursing). Call within 24 hours or the next working day: notify the state Ombudsman and the Division of Certification. Results of thorough investigation are sent within 5 working days in writing to the Division of Certification. Within 5 working days the following will be submitted in writing to the Bureau of Certification: All written investigative material including statements/interviews, conclusion regarding the abuse based upon the investigation as to whether allegation substantiated or not, corrective action, if any, taken as a result of the investigation." |
2014-06-01 |