cms_SC: 10127

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
10127 FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC 425016 208 JAMES STREET ANDERSON SC 29625 2011-01-26 431 D     ZGHV11 On the days of the complaint inspection based on interviews, review of the facility's investigation and review of the facility's policy on Drug Storage, the facility failed to assure narcotics were securely and safely stored. A bottle of Roxanol was found at a resident's bedside with 13.5 milliliters (ml) missing. The findings included: Review of the 24 Hour Report dated 1/9/2011 revealed neglect was alleged against Licensed Practical Nurse (LPN) #2. The description of the incident was "medication left at bedside on Saturday 1/8/2011. An investigation was implemented immediately. The incident was reported to the administration at 2:08 PM. Review of the 5 Day Follow Up dated 1/13/2011 revealed the alleged perpetrator as LPN #1. The Director of Nursing (DON) was notified on 1/8/2011 at 2:08 PM. The report indicated that Resident #2 was last observed at 12:30 PM and was noted to be alert with increased congestion and thick green mucous. The Details of the Incident were "nurse in attending to resident and found liquid Morphine at bedside. Due to change in resident's respiratory status earlier in the day and the potential ingestion of medication the resident was sent to the emergency room . The hospital was notified of the potential ingestion as a precaution. The intervention in place prior to the incident were 'narcotics are counted and reconciled at shift change.' Immediate corrective action that was taken was LPN #1 was "suspended immediately and will not return to employment and license will be reported to LLR per protocol. 100% audit of narcotics in 4 of 4 medication carts was conducted. 100% of licensed staff was re-inserviced regarding securing and accounting for narcotics. Hazardous material re-inservice was done with 100% of staff." The Summary of Incident was "Nurse violated standard of practice related to securing medication." Review of the Timeline related to the incident provided by the facility revealed the resident was found lethargic and unintelligible at 1 PM per the nurse's notes. At 1:21 PM, the ambulance was called. At 1:27 PM the ambulance arrived at the facility (per the ambulance record). Per the nurse's notes the resident left at 1:30 PM. According to the ambulance record the resident did not leave the facility until 1:58 PM and arrived at the hospital at 2:03 PM. LPN #1 notified the Director of Nursing (DON) at 2:08 PM of the Morphine and incorrect narcotic count. LPN #1 also reported to the DON that Resident #2 was sent to the emergency room in respiratory distress. LPN #1 reported that 13.5 milliliters of liquid Morphine were unaccounted for. The DON arrived at the facility at 2:30 PM. Drug tests were performed on all staff with potential contact with Resident #2 including LPN #1 and 2 and on two Certified Nursing Assistants. LPN #1 and #2's drug tests were negative. CNAs #1 and #2 tested positive for drugs and were suspended. Review of the Narcotic Count sheets for Resident #3 revealed Roxanol 20 mg/ml, 30 ml bottle. Line 48 indicated that LPN #1 signed out the Roxanol on 1/8/2011 at 2 PM. It was documented that 23.5 ml should have been left in the bottle. Review of the facility obtained statement for LPN #1 revealed that she and LPN #2 "counted narcotics this am (1/8/2011). I saw three bottles of Roxanol and glanced at them for content. I did not read labels with names. At 1:30 PM, I went to get Resident #3's Roxanol and could not find the bottle on the cart. I checked each drawer, narcotic box, refrigerator and (the nurse) checked her cart. It occurred to me that some nurses administer Roxanol with the dropper so I immediately check resident room and found bottle on bedside table of roommate (Resident #2). I had been in room several times this AM and did not see bottle (or notice bottle). Bottle of Roxanol had 10 ml when I found it. When we counted meds this am, I looked at the meds and LPN #2 looked at the sheets. During an interview on 1/26/2011 at 12 PM, LPN #1 stated that during the Narcotic Count at shift change it was routine practice not to count the liquid medications because they were "always off." LPN #1 stated that she was giving Roxanol to another resident around 11:30 AM or 12 PM and noticed only three bottles of Roxanol were in the cart. She stated that she searched for the missing Roxanol in other drawers, medication room, refrigerator and the other med carts. She/he stated that it "occurred to her that nurses would use the medication dropper." She stated that she then went into Residents #2 and #3's room and found the Roxanol on Resident #2's bedside table. She stated that she immediately counted the medication and noticed it was off. She stated that the CNAs then reported to her that Resident #2 was unarousable. LPN #1 performed a sternal rub and notified the family and then the doctor. She stated that she assumed the resident consumed the medication. LPN #1 then stated that it was between 12 and 12:30 PM that she noticed the missing Roxanol and about 15-20 minutes later noticed Resident #2 was unarousable. LPN #1 stated that she did not obtain any vital signs and had administered the resident's breathing treatment. LPN #1 stated that she notified the family and then the doctor because that was the normal protocol. LPN #1 stated that she instructed the CNAs to "clean the resident up" before she was sent out. LPN #1 stated that during the narcotic counts at shift change, one nurse would look at the medication and one nurse would look at the sheets. She stated that both nurses did not visualize the medications. LPN #1 stated that it "was not an absolute necessity" for both nurses to reconcile the narcotics. LPN #1 stated that no other nurse had access to her cart that day. LPN #1 also stated that there was only one set of keys per cart. LPN #1 verified her facility obtained statement was correct as well as the statement reported to the surveyor. LPN #1 could not account for the discrepancies in the statement nor in the times of the events accounted. Review of LPN #2's facility obtained statement dated 1/8/2011 revealed that LPN #2 "counted off with first shift nurse. I stated amounts left in Roxanol bottles and she stated ok. I was looking at each narcotic sheet and did not visualize the narcotics as we were counting. I gave (Resident #3) her meds then her Roxanol, set the Roxanol on nightstand, started her breathing treatment. Went to (Resident #2) to check on her, she asked for pain medicine. I went back to med cart to get (Resident #2's) Lortab and breathing treatment. At the end of my shift I counted off with first shift nurse called amounts left in Roxanol bottles and she stated ok for each." During an interview on 1/26/2011 at 4:35 PM, LPN #2 stated that she was positive she replaced Resident #3's Roxanol back into the medication cart after she administered the Roxanol to her at 6 AM. LPN #2 stated that during the narcotic count at shift change she was calling off the medications from the narcotic sheets and LPN #1 was counting the medications. LPN #2 stated that she visualized all 4 Roxanol bottles but didn't measure the contents. LPN #2 stated that LPN #1 didn't pick up any Roxanol bottles but both visualized all 4 bottles were present at shift change. LPN #2 stated that she normally reads the narcotic sheets and counts the medications. She stated that the other nurse picks up the liquid medications and would hold them up so both could visualize the amounts. LPN #2 stated that she "always counted liquid narcotics." LPN #2 verified the accuracy of her facility obtained statement and stated that both the statement given to the facility and the statement given to the surveyor were the same and accurate. LPN #2 again stated that she visualized the Roxanol bottles at shift change. LPN #2 could not account for the discrepancy in the statements. During an interview on 1/24/2011 at 12 PM, the DON stated that both LPN #1 and #2 admitted to counting the narcotics incorrectly, the DON stated that both nurses should have visualized the narcotic as well as the narcotic sheet. The DON stated that LPN #1 reported only 3 Roxanol bottles were in the cart at shift change even though 4 were recorded as present. The DON stated that she did not know what happened to the missing 13.5 ml of Roxanol. A Narcotic Count of liquid Morphine was conducted on 1/24/2011 with the DON and the surveyor. Some of the Roxanol bottles were noted to have more than the recorded amount. The Narcotic sheets would record a number then a + sign to indicate the excess. The DON stated that the pharmacy was aware. The Pharmacy stated that the amount in the bottles was correct, however the curvature of the Roxanol bottles made it appear that there was more in the bottles. Review of the Controlled Medication Policy revealed, "there must be complete accountability of all controlled substances being stored at the facility. The nurse going off duty and the nurse coming on duty must count all controlled substances at the end of each shift. Review of the "Medication Storage in the Facility" policy revealed, "medications and biologicals are stored safely, securely and properly...." "The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications." Cross refers to F-281 as it relates to two nurses inappropriately accounting for narcotics. 2014-04-01