cms_SC: 10145
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10145 | LAKE CITY SCRANTON HEALTHCARE CENTER | 425149 | 1940 BOYD ROAD | SCRANTON | SC | 29591 | 2011-03-02 | 250 | E | HLEE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interview, the facility failed to provide documented evidence that sufficient medically-related social services were provided to meet the needs of 3 of 12 sampled residents reviewed for social services. Resident # 6 experienced a significant personal loss and expressed suicidal thoughts, which were addressed by the physician in 2/2011. The last documented social service intervention was November 2010. Resident # 8 had a planned discharge which was to occur on 3/1/11. The resident left unexpectedly on 2/28/11. There was no evidence of the anticipated discharge plans/interventions documented by social services. Resident # 24's social service noted did not include an accurate description of the resident's behaviors, the room change with subsequent change in social work providers, or behavior interventions. The findings included: The facility admitted Resident #6 on 3/24/10 with [DIAGNOSES REDACTED]. A review of the medical record revealed a Physician's progress note dated 2/24/11 that the resident had lost her husband of [AGE] years recently. A follow-up note dated 2/25/11 documented the resident was seen and that grief and tearfulness was normal as a reaction to loss of her husband. A nursing note dated 2/24/11 documented indicated that the resident had stated "I just want to die" during the morning medication pass. Medicine for increased anxiety was given and the resident seemed to be calmer after the nurse talked to her for a while. The Responsible party was notified and she was going to visit. Follow-up monitoring dated 2/27 revealed no signs or symptoms of depression. Documentation by the Facility psychiatrist dated 3/1/11 revealed that the resident was seen. Group therapy and receiving activity out of the facility was discussed. The resident felt very positive about the opportunity to get out and about the opportunity to socialize with new people. The psychiatrist also addressed the vaguely suicidal comments and concluded there was no suicidal ideation and certainly no intent. A review of the Social Service notes revealed no entries since November 2010. In an interview with Social Worker (SW) #2 on 3/1/11 at 1:55 PM, she stated she had made a referral to Senior Renewal for outpatient counseling and that group therapy had been done. She also stated she did room rounds every morning to check on her residents, but these interventions were not documented in her notes on this resident. The Social Service notes did not mention the resident's spouse dying. An entry by Social Worker #2 dated 3/1/11 documented that she had spoken to nursing about the statement "I just want to die. It was not reported to her due to the fact that the resident was calmer after receiving the medicine for anxiety. A 3/2/11 note documented that the resident was out of the facility from 9:30-1:30 at Senior Renewal. The facility admitted Resident #8 on 12/22/10 with [DIAGNOSES REDACTED]. Resident #8 was admitted for short term rehabilitation. During the Initial Tour it was mentioned the resident was due to be discharged on [DATE] but left on 2/28/11. Review of the Social Worker notes revealed her last note was dated 12/22/10 with no further documentation related to discharge planning. In an interview with SW (Social Worker) #2 on 3/1/11 at 1:55 PM, she stated that the resident went home with his sister-in-law instead of living by himself. Home Health was contacted to do an evaluation. The prescriptions were given to his sister-in-law, but the Social Worker had not documented the discharge planning interventions in the Social Services notes . A final nursing note dated 2/28/11 documented the "res(ident) d/c (discharged at 2:15 P with all meds (medications) and order for referral to home health. MD notified of d/c. All meds explained. BA (body audit) complete. No new areas noted." The facility admitted Resident #24 on 1/28/10 with [DIAGNOSES REDACTED]. During initial tour of the facility on 2/28/11, the ADON (Assistant Director of Nursing) stated that the resident was diagnosed with [REDACTED]. Record review revealed a Social Services note dated 10/21/10 which stated that the resident has been referred to Senior Renewal Program to address behaviors and will be able to attend "when the foot heals from sprain." Further notations in the Social Services notes for 11/3/10 states "Annual Assessment....... Referral has been made to "Senior Renewal", which is an out patient counseling service provided by.....She is eligible for this service but had to be able to make transfers from W/C ( wheel chair) to toilet appropriately before she can attend the program." Another note from Social Services dated 11/15/10 stated "Resident returned to facility on 11/13/10, returned medicare...." Additional notes were written on 11/16 related to a medication change; 11/22 related to diet changes and behavior; 11/23/10 related to a room change. The additional November documentation did not address follow up participation of the Senior Renewal program. There was no social service progress notes from 11/23 to 2/4/11 which addressed the resident's participation eligibility in the program. An interview with Social Worker #1 on 3/1/11 at 4:15 PM revealed that the resident had been referred to the above mentioned program. The consent from the family was not obtained in a timely manner. The resident then had been admitted to the hospital and returned to the facility under Medicare and could not attend the program while on Medicare. She further stated that they once again are waiting for the family to sign the consent forms. This surveyor then obtained the medical record for Resident #24 from the nurses station on 3/1/11 at 5:00 PM and noted that there was an additional notation in the Social Services notes dated 2/25/11 which had not been there prior to the 4:15 PM interview with Social Worker #1. An interview was done at 5:15 PM with Social Worker #1, the Administrator and several Corporate Consultants. Social Worker #1 confirmed that she had just written the note and asked if she should have put todays date for the note. The note addressed sending the family a consent form and waiting for a response. Resident #25 was admitted by the facility on 10/08/09 with the following [DIAGNOSES REDACTED]. On 3/1/11 at 4:45 PM Resident #25 stopped a fell ow surveyor in the hall and reported that Resident #24 exhibited behaviors in the dining room and used profanity. In an interview with Resident #25 on 3/2/11 at 9:05 AM she further explained that Resident #24 "scares me to death" when she "takes over" in the dining room and it takes "four to handle (her) sometimes... she (Resident #24) tries to fight and I have to leave." She stated that Resident #24 has "never hurt me". During an interview with Social Worker #1 on 3/2/11 at 11:30 AM, she stated that the facility had tried some behavior modification programs with Resident # 24 but they were not effective. When questioned about the resident's behaviors, she stated that the ADON (Assistant Director of Nursing) had very good communication skills with the resident and could deal with her behaviors. She further stated that Social Worker #2 was working with this resident up until her room change on 11/23/10. Social Worker #1 shared that the resident had been seen by the Psychiatrist on 2/8, 2/15, 2/17 and 2/22/11. An accurate description of the resident's behaviors, the room change with subsequent change in social work providers, nor any of the above mentioned interventions were noted by Social Worker #1 or #2 in the documentation. She stated that it should have been documented in the notes what was being done for the resident. | 2014-04-01 |