cms_SC: 10133
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10133 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 309 | D | 8F5E11 | **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 care and services as ordered by the Physician for 2 of 18 sampled residents reviewed. The facility failed to ensure that Resident #13, on anticoagulant therapy, did not receive [MEDICATION NAME] after the Physician ordered the medication held due to an elevated PT/INR ([MEDICATION NAME]/International Normalization Ratio). In addition, Resident #13 did not have Ted Hose applied as ordered. Resident #7 did not have a sling applied as ordered by the physician. The findings included: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 8/24/10 at 9:36 AM revealed a laboratory (lab) report dated 5/17/10. The PT was 37.2 H(igh). The reference range was listed as 9.4-10.8 sec(onds). The INR was 3.9 H(igh). The reference range was listed as .9-1.2 with the suggested therapeutic INR range for venous [MEDICAL CONDITION] and [MEDICAL CONDITION] listed as 2.0-3.0. A handwritten note to the right of the page stated "Dr. __: Hold [MEDICATION NAME]. Redraw PT/INR Thursday 5/20/10 and call to Dr. __during business hrs (hours) Thursday". Review of the Physician's Telephone Orders on 8/24/10 at 12:42 revealed an order to "Hold [MEDICATION NAME], Check PT/INR Thursday 5/20/10, Call results to Dr. __ during business hours Thursday". The Physician's Telephone Order had been dated 5/17/10 and the time next to "Signature of Nurse Receiving Order" was 6:45 PM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 5 mg (milligrams) (1) PO (By Mouth) (at) HS (Bedtime) 9P(M)". The [MEDICATION NAME] had been initialed as having been given on 5/15/10, 5/16/10, and 5/17/10. The [MEDICATION NAME] had been held from 5/18/10 through 5/22/10 and had been discontinued on 5/23/10 according to the MAR indicated [REDACTED] During an interview on 8/24/10 at 3:45 PM, the Director of Nursing (DON) reviewed and verified the 5/17/10 PT/INR results, the Physician's Telephone Order dated 5/17/10 at 6:45 PM, and the MAR indicated [REDACTED]. Review of the laboratory reports and additional physician orders [REDACTED]. At that time the physician ordered Vitamin K to be given and a follow-up PT/INR to be drawn on 5/22/10, continue to "hold [MEDICATION NAME], d/c (discontinue [MEDICATION NAME])". The lab work on 5/22/10 was INR 3.19. Record review on 8/24/10 at 9:05 AM revealed cumulative physician's orders [REDACTED].M. OFF IN P.M. R/T (Related To) [MEDICAL CONDITION]". Review of the Care Plan on 8/24/10 at 11:24 AM revealed "TED hose as ordered" as an approach for resident being "At risk for complications r/t (related to) [MEDICAL CONDITION]". Review of the 8/9/10 "Easley Living Center" progress note (signed by the Nurse Practitioner) on 8/24/10 at 9:30 AM revealed "Her/His [MEDICATION NAME] was recently increased to 40 mg (milligrams) because she/he was having [MEDICAL CONDITION]". Review of the 8/6/10 "Easley Living Center" progress note signed by the Physician revealed "She does complain of some increased [MEDICAL CONDITION] in her left lower extremity, however. Nursing staff reports no major issues with this patient including any skin breakdown...Extremities: She does have 1+ [MEDICAL CONDITION] in that left lower extremity primarily in the dorsum of her left foot. Trace lower extremity [MEDICAL CONDITION] on the right...Regarding the lower extremity [MEDICAL CONDITION], we will increase her [MEDICATION NAME] up to 40 mg a day". Observations on 8/24/10 at 10:25 AM, 11:48 AM, 12:27 PM, 1:52 PM, 4:00 PM, and 4:38 PM revealed Resident #13 sitting in her/his wheelchair wearing socks, but no TED hose. During an interview on 8/25/10 at approximately 10:20 AM, Licensed Practical Nurse (LPN) # 3 was told that there were observations made of Resident #13 without her/his TED hose on. LPN #3 reviewed and verified the cumulative Physician"s Orders for August 2010 and the resident's Care Plan which indicated the resident was to wear the Ted Hose. She/He also verified the Physician's progress notes that indicated the resident had [MEDICAL CONDITION]. LPN #4 joined the interview and was told that the resident had been observed without the ordered TED Hose. LPN #4 verified that she/he was the nurse that documented on the Treatment Record regarding the application of the TED Hose. The surveyor, LPN #3, and LPN #4 then reviewed the Treatment Record documentation for August 2010 in which the TED Hose had been initialed as having been worn on 8/24/10 and 8/25/10 for the 7-3 shift. When asked about the discrepancy between the Treatment Record documentation and the observations of the resident without her/his TED Hose, the nurse stated that she/he reminded the Certified Nursing Assistants (CNAs) to apply the TED Hose. When asked to go to check and see if the resident was currently wearing the TED Hose, LPN #4 stated that she/he was new and didn't know the residents well. She/He went on to say that if the resident was not in her/his room, then LPN #3 would have to point the resident out to her/him. Upon entry to the room, Resident #13 was lying on her/his bed. The nurse stated the resident would not be wearing TED Hose in bed, and staff usually kept the TED Hose on her/his wheelchair. There were no TED Hose on the wheelchair, and, while checking the bedside table and closet, the nurse stated the TED Hose was probably in the laundry being washed. When asked if the resident only had one pair of TED Hose, the nurse answered "yes". Resident #7 was originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #7 had not worn a sling as ordered for all the days of the survey. Record Review on 8/23/10 at 3:48 PM revealed cumulative physician's orders [REDACTED].D. (Medical Doctor). O.K. to remove orthopedic device to left arm for ADL (Activities of Daily Living) Care". Review of the Care Plan on 8/23/10 at 4:33 PM revealed "Orthopedic device as ordered 7/13/10" as an approach to impaired mobility. The following observations were made in which Resident #7 was not wearing the ordered sling. - On 8/23/10 at 1:52 PM. Resident sitting in the doorway of the therapy office. at 2:59 PM. Resident sitting in wheelchair in her room. at 6:22 PM. Resident sitting in wheelchair in her room eating dinner. - On 8/24/10 at 8:55 AM. Resident lying in bed. at 10:00 AM. Resident lying in bed participating in interview with surveyor. at 12:32 PM. Resident eating lunch in her room. -On 8/25/10 at 9:12 AM. Resident sitting in wheelchair in room. During an interview on 8/24/10 at 10:00 AM, Resident #7 was asked about the sling and why it wasn't being worn. The resident stated that at her/his last appointment, the orthopedic doctor told her/him that she/he could take it off. She/He stated that if the doctor wanted her to wear it, she/he would. When asked if staff encourage her/him to wear the sling, the resident stated that staff members haven't instructed her/him to wear it. Review of the consult section of the chart on 8/24/10 revealed no orthopedic notes. During an interview on 8/25/10 at 10:30 AM, Licensed Practical Nurse (LPN) #3 was asked about Resident #7's last orthopedic visit. The nurse checked the appointment calendar and stated the last orthopedic visit for Resident #7 was in July. When asked about any orthopedic progress notes, the nurse stated the physician only sent a note if there were any changes and verified there were no orthopedic notes in the chart. LPN #4 joined the interview and both nurses were told that Resident #7 had been observed on all days of the survey without her/his sling having been worn. The cumulative physician's orders [REDACTED]. Upon review of the Treatment Record for Resident #7 for August 2010, documentation for the dates of the survey were brought to the nurses attention. For August 23rd and 24th, the Orthopedic Device Sling To Left Arm had been initialed as having been worn for the 11-7, 7-3, and 3-11 shifts. For August 25th, the Orthopedic Device Sling To Left Arm had been initialed as having been worn for the 11-7 and 7-3 shifts. LPN #4 verified she/he was the nurse that documented on the Treatment Record regarding the use of the sling. When asked about the discrepancy between the surveyor observations and documentation on the Treatment Record, LPN #4 stated that she/he had been asking Physical Therapy (PT) if Resident #7 had been wearing her/his sling. LPN #4 stated she/he thought that PT had supplied the sling for the resident. The surveyor and LPN #4 then went to see Resident #7, who was not wearing the ordered sling. | 2014-04-01 |