cms_SC: 13
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
13 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 842 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately document a medical record (paper/electronic) for 1 of 42 sampled residents reviewed for advanced directives and clinical accuracy. Resident #82 paper charting was noted with full size red sheet of paper that indicated Do Not Resuscitate (DNR) and the electronic documentation indicated Cardiopulmonary Resuscitation (CPR). There was an inconsistency in the resident's admitted . The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. A review of the paper charting and electronic charting on [DATE] at approximately 11:28 AM revealed the resident's chart for advanced directive was coded as DNR and CPR. The paper charting was noted with a red sheet of paper that indicated DNR. The electronic record indicated the resident's advance directive was CPR (full code). Further review of the medical record review that one physician's signed resident's inability to consent on [DATE] and the second physician signed the inability to consent on [DATE]. The decisional capacity forms indicated Resident #82 was admitted on [DATE] and the Cumulative physician's orders [REDACTED]. An interview on [DATE] at approximately 12:09 PM with Licensed Practical Nurse (LPN) #2 confirmed the findings that the paper chart indicated DNR and the computer documentation was CPR. | 2020-09-01 |