cms_SC: 1868

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
1868 PRUITTHEALTH-AIKEN 425145 830 LAURENS STREET NORTH AIKEN SC 29801 2019-12-19 698 D 0 1 HRL411 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure ongoing communication between the facility and the [MEDICAL TREATMENT] center for three of four sampled residents (R#10, R#34, and R#114). Findings included: 1. Review of R#10's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Care Plan revised 12/03/19 revealed R#10 is at risk for complications related to [MEDICAL TREATMENT] for [DIAGNOSES REDACTED]. The long-term goal with a target date of 03/01/2020 is R#10 will not develop complications related to [MEDICAL TREATMENT] through next review. Approaches included BP (blood pressure) and pulse before and after [MEDICAL TREATMENT]; check shunt site for signs and symptoms of infection, pain or bleeding daily and PRN (as needed); communicate with [MEDICAL TREATMENT] center regarding medication, diet, and lab results; coordinate care with [MEDICAL TREATMENT] center utilizing communication sheets; consult with dietitian for nutritional support related to [MEDICAL CONDITION] as needed; make transportation arrangements for [MEDICAL TREATMENT]; meds as ordered; No BP or venipuncture in shunted arm every shift; observe for signs and symptoms of fluid volume overload; observe for signs and symptoms of volume deficit; and refer to MD (medical director) or RP (responsible party) as needed. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R#10 was assessed as having a Brief Interview for Mental Status (BI[CONDITION]) score of 7 indicating the resident is moderately impaired in skills for daily decision-making. R#10 was assessed as needing extensive physical assistance of one person for bed mobility, dressing and personal hygiene; total physical assistance of two or more people for transfers; total physical assistance of one person for locomotion on the unit, toilet use and bathing; and supervision of one person for eating. R#10 was assessed as always incontinent of bladder and bowel. R#10 was assessed as receiving [MEDICAL TREATMENT] while a resident. Review of R#10's [MEDICAL TREATMENT] Center Communication Forms for the period of 9/18/19 through 12/9/19 revealed eight (8) out of 18 forms were not completed by the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] center failed to complete their section. No documentation was found in resident's chart indicating nursing attempted to obtain the information from the [MEDICAL TREATMENT] center. 2. Review of R#34's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Care Plan initiated on 9/18/18 revealed R#34 requires [MEDICAL TREATMENT] three times weekly related to DX. (diagnosis) of [MEDICAL CONDITION]. The long-term goal with a target date of 1/1/2020 is R#34 will be free from complications related to [MEDICAL TREATMENT] through next review. Approaches included BP and pulse before and after [MEDICAL TREATMENT]; check shunt for signs and symptoms of infection, pain or bleeding daily and PRN; check thrill and bruit as ordered; communicate with [MEDICAL TREATMENT] center regarding medication, diet, and lab results; coordinate care with [MEDICAL TREATMENT] center; coordinate transportation to the [MEDICAL TREATMENT] center as scheduled; diet as ordered; may take inhaler to [MEDICAL TREATMENT] and self-administer meds as ordered; no BP or venipuncture in shunted arm every shift; and observe for signs/symptoms of fluid volume overload. Review of the Quarterly MDS assessment dated [DATE] revealed R#34 was assessed as having a BI[CONDITION] score of 14 indicating the resident is cognitive in skills for daily decision-making. R#34 was assessed as needing extensive physical assistance of two or more people for transfers and personal hygiene; total physical assistance of two or more people for transfers and bathing; total physical assistance of one person for dressing and toilet use; and supervision of one person for eating. R#34 was assessed as always incontinent of bladder and bowel. R#34 was assessed as receiving [MEDICAL TREATMENT] while a resident. Review of R#34's [MEDICAL TREATMENT] Center Communication Forms for the period of 8/13/19 through 12/7/19 revealed 10 out of 14 forms were not completed by the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] center failed to complete their section. No documentation was found in resident's chart indicating nursing attempted to obtain the information from the [MEDICAL TREATMENT] center. 3. Review of #114's Face Sheet revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Care Plan initiated on 9/3/19 revealed R#114 has [MEDICAL CONDITION] and requires [MEDICAL TREATMENT] three times weekly. The long-term goal with a target date of [DATE] is R#114 will be free from complications related to [MEDICAL CONDITION] or [MEDICAL TREATMENT] through next review. Approaches included all labs via [MEDICAL TREATMENT] as able; coordinate care with [MEDICAL TREATMENT] via communication sheet; coordinate transportation to/from [MEDICAL TREATMENT]; document VS (vital signs) before and after [MEDICAL TREATMENT]; no BP/Vein sticks in shunted arm; observe access for signs/symptoms infection; observe for fluid overload; observe for fluid restriction - encourage compliance; observe for volume deficit; observe thrill/bruit/patency of graft/shunt as ordered; and refer to MD/RP/[MEDICAL TREATMENT] center as needed. Review of the Quarterly MDS assessment dated [DATE] revealed R#114 was assessed as having a BI[CONDITION] score of 11 indicating the resident is moderately impaired in skills for daily decision-making. R#114 was assessed as needing supervision of one person for bed mobility, dressing, toilet use and personal hygiene; independent with set-up help only for transfers and eating; and physical assistance with part of bathing from one person. R#114 was assessed as always continent of bladder and bowel. R#114 was assessed as receiving [MEDICAL TREATMENT] while a resident. Review of R#114's [MEDICAL TREATMENT] Center Communication Forms for the period of 9/3/19 through [DATE] revealed 10 out of 16 forms were not completed by the [MEDICAL TREATMENT] center. The [MEDICAL TREATMENT] center failed to complete their section. No documentation was found in resident's chart indicating nursing attempted to obtain the information from the [MEDICAL TREATMENT] center. Interview with Unit Nurse #2 on 1[DATE] at 11:30 a.m. revealed the [MEDICAL TREATMENT] communications sheets are filled out by the nurse on duty and sent with the resident to [MEDICAL TREATMENT]. Unit Nurse #2 said sometimes the form is filled out when it come backs and sometimes it is not. Unit Nurse #2 said she usually calls the [MEDICAL TREATMENT] center when the form returns incomplete. Unit Nurse #2 said the form is used as a communication tool between the facility and the [MEDICAL TREATMENT] center. During an interview with the Director of Health Services on [DATE] at 10:16 a.m. regarding [MEDICAL TREATMENT] Communication Sheets, she stated the sheets are used for communication between the [MEDICAL TREATMENT] center and the facility. She stated it is a form used to inform the facility of the treatments, issues or new physician's orders [REDACTED]. The DHS stated she understood efforts should be made by the nursing staff to ensure the communication sheets are completed. The DHS stated there is not a policy regarding the use of the communication sheet. 2020-09-01