cms_SC: 10250
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10250 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 157 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview, closed record review, and review of facility policy titled Condition Change (9/03) and Documentation (4/06) the facility failed to provide evidence that the resident's physician and legal representative were notified when Resident # 11 experienced a significant change in his condition. The resident's temperature was significantly elevated to 103.9 and the resident was vomiting brown emesis with a foul odor. The findings included: The facility admitted Resident # 11 on 12/1/08. The resident's [DIAGNOSES REDACTED]. On 10/24/10, a review of the closed medical record revealed the resident was documented as having an elevated temperature of 103.9 on 10/1/10 at 2:30PM. The resident vomited twice. The emesis was noted to be brown, watery with a foul odor. There was no documentation that the attending physician was notified but rather standing orders were initiated which included [MEDICATION NAME] and Tylenol. There was no documentation that the responsible party was notified. During an interview with the facility Director of Nursing on 10/24/10 at 8:30PM, she indicated she felt the nurse had initiated the standing orders appropriately. When questioned about the brown emesis with a foul odor, she stated the resident constantly chewed tobacco and felt that was the cause of the foul odor and brown color. The Director of Nurses did not dispute there was no evidence that the family had been notified. On 10/25/10, at 5PM, during an interview with the attending physician, he stated he did not recall being aware of the resident's illness while in the building. He further stated that if he did see him that day it would have been because the resident was seated in the hallway per his usual custom. On 10/25/10 at approximately 5:45PM, during an interview with Licensed Practical Nurse # 1, she stated that the physician was in the building and was informed of the resident's condition and saw the resident. She stated she did not accompany the physician nor visually see the physician examine the resident. LPN # 1 also stated she called the resident's family and left a message. However, there was no documentation either by the nurse or the physician that had occurred. Review of the facility provided policy for condition change stated: "Any staff member who notices a resident/patient status change shall immediately notify the appropriate licensed personnel. After assessing the resident/patient, the licensed personnel shall contact the physician immediately regarding status change. Family members and or guardians...will be notified, except when the change in status regards such routine lab work, diet changes. and/or minor medication changes. ....Notification of the appropriate individuals is to be documented in the medical record. Documentation on the 24 hour report does not replace documentation in the medical record. Facility policy titled Documentation: Charting stated ...all pertinent information will be charted on each individual/patient/resident in accordance with accepted professional standards and practices. The records will be a complete, accurate and functional representation of the actual experience of the patient/resident. ...The chart is a legal document and must be kept up-to-date at all times. ...Pertinent information requiring documentation will include, but not be limited to the following:....A significant change in physical, mental or psychosocial status...clinical complications related to disease status...new behaviors." | 2014-02-01 |