cms_SC: 1131
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1131 | SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2020-01-15 | 657 | D | 1 | 0 | 62ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and policy review it was determined the facility failed to revise care plan interventions for 1 of 19 sampled residents, (Resident #5). Resident #5 was discovered engaging in a sexual activity with Resident #6 on 10/14/19. The facility separated the residents, called the police and prohibited the two residents from visiting privately the rest of the evening. Findings include: Review of Resident #5's face sheet, located under the Profile tab of his/her Electronic Medical Record (EMR) revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/30/19, located under the MDS tab of the EMR, revealed he/she had a Brief Interview of Mental Status (BI[CONDITION]) score of 14, indicating he/she was cognitively intact. Review of Resident #5's care plan, located in the EMR, documented a focus area for an alteration in mood state initiated on 09/07/17. On 10/12/18 the focus area was amended to include, . resident prefers to engage in sexual activity with other residents. A new intervention of, resident will be redirected when inappropriate behavior is noted, was added on 10/12/18. Review of Resident #5's Interdisciplinary Team (IDT) progress notes, located under the Prog Notes tab of the EMR, revealed Resident #5 was discovered engaging in a sexual activity with another resident on 10/14/19 at 7:41 PM. Further review of the IDT notes revealed the residents were separated, the police were called, and the residents were prohibited from visiting privately the rest of the evening. Review of Resident #5's clinical record revealed a Death in Facility Tracking Record which documented she passed away on [DATE], thus was unavailable for observation or interview during the survey. An interview with the Social Services Director (SSD) on 01/14/19 at 10:45 AM revealed he/she had been informed that it was Resident #5's right to be sexually active and it was commonplace for the resident to exercise that right. The SSD stated Resident #5 initially had a visitor from the community with whom he/she was intimate in the facility, then became active with other residents. The SSD stated he/she was not sure why staff intervened the way they did when the event was discovered, based on Resident #5's known history. The SSD agreed Resident #5's preference to engage in sexual activity should have been included on his/her care plan. An interview with the psychologist (Phy. D.) on 01/14/20 at 11:00 AM revealed he/she engaged in regular treatments with Resident #5 beginning in either June or July of 2019. The psychologist stated Resident #5 had consistently shown the ability to make his/her own decisions and that he/she had made his/her preference to engage in sexual activity known to the facility. The psychologist stated he/she would have expected Resident #5's preference to be documented on his/her care plan. An interview with the Administrator on 01/14/20 at 11:45 AM revealed he/she became aware of the incident the following day. The Administrator stated that Resident #5's call light had been on, and as such it had been appropriate for the Certified Nurse Aide (CNA) to enter the room. The Administrator stated it was common knowledge amongst the staff that Resident #5 had been sexually active in the past so he/she was not sure why the CNA responded the way he/she did at the time of the event. The Administrator stated Resident #5's care plan should have directed staff how to respond. An interview with the Director of Nursing (DON) on 01/14/20 revealed that he/she was not in the facility but was called when the event occurred. The DON stated if the interaction was consensual there should not have been a problem with the interaction continuing. The DON stated a care plan would have given staff direction in this instance. Review of the facility's Care Planning IDT policy, dated November 2019, revealed, . the facility must develop . a comprehensive person-centered care plan . consistent with resident rights . | 2020-09-01 |