cms_SC: 1028

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.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
1028 MILLENNIUM POST ACUTE REHABILITATION 425105 2416 SUNSET BOULEVARD WEST COLUMBIA SC 29169 2019-11-07 690 D 1 0 QOW511 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident interview, staff interview, and policy review, the facility failed to ensure that a resident experiencing incontinence received appropriate assessment, treatment and services to prevent decline or to restore as much normal bladder function as possible for 1 of 1 sampled resident (Resident #8). The facility was unable to provide documentation that any type of restorative program was attempted and/or implemented. The findings included: Review of the Incontinence Managing Guidelines, Revised 11/2007 noted: All incontinent residents should be evaluated on admission and on condition change for potential incontinence management program Review of the facility's document titled Bowel and Bladder Assessment Policy, with a revision date of 5/2007 documented: It is the policy of this facility that a Bowel and Bladder assessment will be completed within the first fourteen (14) days of admission. Purpose: The purpose of the bowel and bladder assessment is to offer a structured, goal-oriented approach with the intent that the resident attains the highest level of independence in bowel and/or bladder continence. Procedures: 1. A bowel and bladder assessment will be completed by day fourteen (14). 2. Resident's care plan will be updated accordingly 3. Residents will be re-evaluated by the Interdisciplinary Team (IDT) quarterly and when a significant change occurs. Review of Resident #8's record revealed that the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #8 was assessed to have intact cognition. The resident was assessed to require extensive assistance with bed mobility, transfers, activities of daily living (ADLs), toileting and personal hygiene. The resident was also assessed as being occasional incontinent of urine and frequently incontinent of bowel. Review of the skilled nursing progress notes revealed that the resident utilized a brief for incontinence. Further review of the record revealed that Resident #8 utilized incontinence briefs at times; however, the resident was not care planned for incontinence or use of incontinent products. Progress notes 10/13/2019: Daily Skilled Note: GASTROINTESTINAL: Bowel Sounds are Present Bowel Sounds are Active, No GI changes observed. No GI appliance(s) used No nutritional deficits observed. [MEDICAL CONDITION] and RENAL: Urine is brief in place for incontinence. yellow, no odor. No GU changes observed. No GU appliances used. 10/16/2019: Daily Skilled Note: GASTROINTESTINAL: Bowel Sounds are Present Bowel Sounds are Active, No GI changes observed. No GI appliance(s) used, No nutritional deficits observed Nutritional approaches include Therapeutic diet. Other observations and interventions include not observed brief in place for incontinence. yellow, no odor. [MEDICAL CONDITION] and RENAL: Urine is not observed brief in place for incontinence. yellow, no odor. No GU changes observed. No GU appliances used. Review of the resident's care plan dated, 10/14/19, revealed there was no care plan developed for the resident's incontinence issues. Additional record review revealed the facility failed to complete a bowel and bladder assessment according to facility policy. An interview was conducted with the Assistant Director of Nursing (ADON) on 11/7/19 at approximately 11:28 AM., who confirmed that a bowel and bladder assessment should have been completed based on the facility policy. The ADON stated that the unit nurses are responsible for completing the assessments. An interview was conducted with the Director of Nursing (DON) on 11/7/19 at approximately 12:15 PM. The DON inquired about the issues regarding Resident #8. The DON was informed that since admission on 10/11/19, Resident #8 had not had a bowel and bladder assessment done within the 14 days as outlined on the facility policy; neither had an assessment been completed at all. The DON was informed that the resident had been assessed as incontinent of bowel and bladder on the MDS and had not been care planned. The DON was informed that the lack of an assessment prevented the facility from providing care and determining the resident's potential for bladder retraining. The DON expressed an understanding of the situation. 2020-09-01