cms_SC: 1083

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.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
1083 SUMTER EAST HEALTH & REHABILITATION CENTER 425107 880 CAROLINA AVENUE SUMTER SC 29150 2018-08-10 578 E 0 1 0H3T11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to offer alert and oriented residents the opportunity to formulate an advance directive and/or failed to ensure that residents were examined and deemed to lack the capacity for decision making by 2 physicians before allowing a resident representative to formulate the advance directive for Residents # 2, 93. 303, 61, and 139, 5 of 9 residents reviewed for advance directives. The findings included: The facility admitted Resident #2 on 6/1/16 with [DIAGNOSES REDACTED]. On 08/07/18 at 04:19 PM, record review revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt form dated 6/2/16 that was signed by the daughter of Resident #2. The form noted the resident was a full code per Social Services. There was no evidence that the resident had been examined by 2 physicians and deemed to lack the capacity to make informed decisions for her/himself. On 08/09/18 at 09:58 AM, review of the MDS (Minimal Data Set) Assessments revealed a 5/6/18 Significant Change in Status Assessment and a 8/1/18 Quarterly Assessment that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact for decision making. At 10:05 AM, review of the Social Services Notes revealed an Initial Social Services Assessment and History indicating the resident was alert and oriented to self, family, time, place and situation. There was no documentation that code status was discussed with Resident #2. The facility admitted Resident #93 on 01/10/17 with [DIAGNOSES REDACTED]. No documentation could be located in the medical record. On 08/07/18 at 04:50 PM, review of the monthly cumulative orders revealed Resident #93 had an advance directive for a code status of DNR. Further review on 08/10/18 at 10:06 AM revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt form dated 01/10/17 indicating a code status of Full Code. Review of a History and Physical dated 3/19/18 from the Hospital stated the resident was a DNR per wishes of the resident's niece and power of attorney. The facility admitted Resident #303 on 08/02/17 with [DIAGNOSES REDACTED]. On 08/07/18 at 04:40 PM, review of the record revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt form dated 08/02/17 and signed by the resident's representative indicating a code status of DNR. Further review revealed only 1 physician had certified the resident lacked the inability to consent. Review of the Annual MDS assessment indicated the resident had a BIMS score of 12. There was no evidence in the record that advance directives was discussed with the resident. During an interview on 08/10/18, the District Director of Clinical Services confirmed the findings as above. The facility admitted Resident #61 on 9/21/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident's Representative signed the Advance Directive/Medical Treatment Decisions Acknowledgment of Receipt form dated 9/22/17. Further record review revealed the Resident's Brief Interview Mental Status (BIMS) score was 11 which indicated the resident was alert and oriented. Record review revealed there was no form in the record with 2 physician's signatures attesting that the resident was not capable of making his/her own healthcare decisions. The documentation was reviewed and confirmed by the Social Services Director on 8/10/18 at approximately 11:30 am. The facility admitted Resident #139 on 1/26/18 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident's Representative signed the Advance Directive. The record did not contain a form with 2 physician's signatures attesting that the resident was incapable of making his/her own healthcare decisions. The documentation was reviewed and confirmed by the Social Services Director on 8/10/18 at approximately 11:30 am. Review of the facility's policy entitled Advance Directives stated that The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with State and Federal Law. The policy further indicated that, Capacity to Make Health Care Decisions means the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a health care decision. 2020-09-01