cms_SC: 10235
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10235 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-16 | 157 | D | SPEH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to notify the physician, or failed to notify the physician timely, of changes in status for 3 of 11 residents reviewed for notification. The facility failed to notify the physician of a positive stool hemoccult test for Resident #1 and failed to notify the physician timely of complaints of pain for Resident #11. In addition, the facility failed to notify the physician of blood noted in Resident #9's brief and also failed to notify the family of the blood or of an order for [REDACTED]. The findings included: At 5:28 PM on 11/15/10, record review for Resident #9 revealed a physician's orders [REDACTED]." Review of the Progress Notes revealed a note by the FNP (Family Nurse Practitioner) dated 9/27/10 regarding debridement of eschar from the right heel wound. On 11/16/10 at 9:29 AM review of the Nurse's Notes revealed a note dated 9/27/10 at 2:00 PM that the wound had been debrided per the FNP. No documentation of family notification of the FNP evaluation or debridement was found in the record. On 11/16/10 at 9:29 AM, record review for Resident #9 revealed a Nurse's Note dated 9/22/10 of a late entry for 9/21/10 at 3:40 PM stating "noted dark red blood on brief + (and) penis size of quarter." Review of the physician's orders [REDACTED]. No new orders were initiated. The Nurse's Notes also revealed a note dated 9/24/10 at 12:00 noon "Res(ident) had another episode of small amt (amount) of dark rusty blood p (after) he voided clear urine." There was no documentation of physician notification of the second episode of blood in the resident's brief and there was no documentation that the family was notified of either episode. During an interview at 1:47 PM on 11/16/10, LPN (Licensed Practical Nurse) #4 confirmed there was no documentation that Resident #9's family was notified of the evaluation and debridement of his wound or of the blood in his brief. She also verified that the physician was not notified of the second episode of blood in the resident's brief. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and a re-admission on 8/30/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 9/24/2010 at 9:15 AM documented: "This nurse (LPN #1) brought to the DON's (Director of Nurses) office by res (ident) and granddaughter and also an employee @ facility. Res in DON office in w/c (wheelchair) accompanied by res nurse. This nurse approached res and res stated, "the CNA was rough with me last night." Then res stated the CNA offered to use lift to stand resident. Res states, "I said hell no." Res c/o (complains of) L(eft) ankle pain. Res nurse reported pain pill just given to Res @ 9 AM r/t (related to) same. No further complaints noted. This nurse told res that a different CNA would take care of her from now on. Resident stated "ok" and seemed pleased." A Nurses' Note dated 9/24/2010 at 3:30 PM, indicated "Res. daughter noted standing at desk talking with nursing staff. This nurse approached res. daughter and daughter states res ankle is hurting her and may need an x-ray." At 5:00 PM a nurses note documented "Reported res complaints of L ankle pain to Dr. Patterson. New orders to get x-ray of L ankle." Review of the Incident Report dated 9/24/2010 at 9:15 AM revealed "res stated to this nurse "the CNA was rough with me last night." Then resident stated the CNA offered to use lift to stand res. Res states "I said hell no." Res c/o left ankle pain." The physician and the responsible party were not notified until after 3:30 PM. During an interview on 11/16/2010, Resident #11 stated that she reported the pain in her left ankle to CNA #1 after a transfer on 9/23/2010. During interviews at 10:50 AM and 1:15 PM, LPN #1 stated that Resident #11 reported an allegation of abuse to her on 9/24/2010 at approximately 9:15 AM. LPN #1 stated that Resident #11 reported that CNA #1 was rough with her last night and reported left ankle pain. LPN #1 stated that she assessed the resident's ankle and did not notice anything abnormal. She also stated that Resident #11 had received pain medications that morning for the pain. LPN #1 stated that the Administrator and DON were not in the building. She stated that she did not contact either one until after 3:00 PM. LPN #1 confirmed that the Physician and the family were not contacted after 3:00 PM either. LPN #1 confirmed that she was aware of the allegation of abuse at 9:15 AM and waited 6 hours before contacting anyone regarding the allegation. She stated that she "did not think (the doctor) needed to know about the allegation." She stated that she "waited to call the doctor until the family member requested an x-ray." During an interview on 11/16/2010 the Administrator and Director of Nursing confirmed that CNA #1 did not report the ankle pain to the nurse. Both stated that she should have reported the incident immediately to the nurse or the charge nurse. Both the Administrator and the DON confirmed that LPN #1 did not report the allegation of abuse timely to administration, the physician or the family. The Administrator stated she expected changes in condition to be reported immediately to the nurse and the nurse should immediately notify the physician and the family. The Administrator stated that LPN #1 should not have waited 6 hours to notify the physician of the allegation of abuse or the pain. During an interview on 11/16/2010 at 11:15 AM, CNA #1 stated that she routinely took care of Resident #11 until 9/23/2010. CNA #1 stated that she wheeled Resident #11 into the bathroom where the resident pulled up and turned around and sat on the toilet. She stated that Resident #11 complained of pain in her ankle during the transfer. CNA #1 stated that she did not report the pain to the nurse. The facility admitted Resident #1 on 11/12/09 and readmitted the resident on 12/25/09 with [DIAGNOSES REDACTED]. Record review on 11/15/10 at approximately 2:55 PM revealed a Physician's Telephone Order dated 9/3/10 for "...Stool for Occult Blood x 3". Record review on 11/16/10 at 9:15 AM revealed Nurse's Notes dated 9/3/10 through 11/16/10. An entry dated 9/3/10 revealed that orders were received for "...Stool for occult blood x 3" and an entry dated 9/6/10 documented a negative stool for occult blood. There was no mention of a positive hemoccult result on 9/12/10 or that the Physician had been notified of the positive result. During an interview on 11/16/10 at 12:40 PM, the Director of Nursing (DON) provided the Treatment Flowsheet for Resident #1 dated 9/1/10 through 9/30/10. It revealed an entry "Stool for Occult Blood x 3". Recorded on 9/6/10 was a "-", recorded on 9/12/10 was a "+" result. During the interview the DON stated that she thought the Physician had discontinued the [MEDICATION NAME] on 9/16/10 due to the positive hemoccult. Review of Physician/Nurse Practitioner Progress Notes for 9/7/10, 9/16/10, and 10/7/10 revealed no mention of a positive hemoccult. According to the Nurse Practitioner's Progress Note dated 9/16/10, the resident's prn (As needed) [MEDICATION NAME] was discontinued "...as she really should not require that as she has [MEDICATION NAME] available". There was no mention that the Nurse Practitioner had been made aware of the positive hemoccult or that the [MEDICATION NAME] had been discontinued as a result of the positive result. During an interview on 11/16/10 at 3:30 PM, Licensed Practical Nurse #4 verified she had documented the positive stool for occult blood on the treatment sheet on 9/12/10. She stated she had not notified the Physician of the positive result because the third hemoccult had not been completed. During an interview on 11/16/10 at 3:38 PM, LPN #1 was told that LPN #4 stated she did not notify the Physician relative to the positive hemoccult. LPN #1 stated that she thought the Physician had responded to the positive result by discontinuing the resident's [MEDICATION NAME]. However, upon review of the Nurse Practitioner's note dated 9/16/10 which indicated that the [MEDICATION NAME] had been discontinued due to the resident having [MEDICATION NAME] available with no mention of a positive hemoccult, LPN #1 stated that she would have notified the Physician of the positive result. | 2014-03-01 |