cms_SC: 21
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 21 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 842 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of facility policy the facility failed to maintain a complete and accurate medical record for Residents #366 and 365, 2 of 27 sampled residents reviewed for complete and accurate records. Resident #365's record did not have complete and accurate documentation related to an incident of alleged abuse. Resident #366's record lacked documentation related to controlled substance medication administration. The findings included: The facility admitted Resident #366 with [DIAGNOSES REDACTED]. Review of a Facility Reported Incident on 5/15/19 at 1:49 PM revealed Resident #366's pain medication [MEDICATION NAME] 50 milligrams (mg) was accidentally placed in a bin for discontinued medications on 4/21/19. After a complete investigation by the facility, the medication was found on 4/23/19. Record review of Medication Administration Records (MAR) and narcotic count sheets on 5/15/19 at 1:51 PM revealed an order for [REDACTED]. The narcotic count sheets revealed the resident's 4/21/19 morning dose of [MEDICATION NAME] was signed out at 8:50 AM and administered to the resident per the MAR. The narcotic count sheets revealed the 2 tablets of [MEDICATION NAME] 50mg were signed out on 2 separate occasions on 4/23/19. The time the [MEDICATION NAME] was signed out was not documented by either nurse signing out the [MEDICATION NAME] on 4/23/19. Record review of notes from the MAR on 5/16/19 at 9:12 AM revealed 2 tablets of [MEDICATION NAME] were administered to Resident #366 on 4/23/19 at 5:06 PM and 10:13 PM, about 5 hours apart. The orders were to receive the [MEDICATION NAME] every 12 hours. During an interview with the Assistant Director of Nursing (ADON) on 5/15/19 at 2:26 PM, the ADON confirmed the narcotic count sheets did not indicate what time Resident #366 [MEDICATION NAME] was signed out on 4/23/19. The ADON stated the resident's [MEDICATION NAME] was found around 4:00 PM on 4/23/19 and the resident requested to receive both the morning and evening doses of [MEDICATION NAME] on 4/23/19. The ADON stated s/he told the resident that would be ok, but the 2 doses would have to be spaced apart due to the every 12 hour order. The ADON stated s/he should have documented this conversation with the resident in the nurse's notes but did not. During an interview with the ADON on 5/16/19 at 9:12 AM, the ADON confirmed Resident #366 received 2 tablets of [MEDICATION NAME] 50mg on 4/23/19 at 5:06 PM and 10:13 PM. The ADON confirmed the orders were to give the [MEDICATION NAME] every 12 hours. The ADON stated the Nurse Practitioner (NP) was called on 4/23/19 and a onetime verbal order was received to allow the resident to have the 2 doses of [MEDICATION NAME] at the times they were administered on 4/23/19. The ADON stated a note and order should have been entered reflecting the NP's orders, but this was not done. During an interview with the NP on 5/16/19 at 9:38 AM the NP stated s/he was on call on 4/23/19 and remembered the nurse calling around 4:50 PM for a verbal order. The NP gave an order for [REDACTED]. Review of the facility's Controlled Substances policy revealed the controlled substance record must contain the time of administration. Additional record review of Resident #366 nurse's notes, the MAR and pain assessments revealed the resident did not experience a decline in functioning or uncontrolled pain as a result of the missing [MEDICATION NAME]. The resident had [MEDICATION NAME] ordered as needed for pain and received 1 dose of this while the [MEDICATION NAME] was missing. The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement further indicated the family member demanded that the resident see a physician and the nurse notified the resident. The nurse practitioner was notified, and pain medication was ordered. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. A review of the electronic medical record on 5/15/19 at approximately 9:34 AM revealed no documentation to indicate the resident and/or family member expressed concerns about a Certified Nursing Aide's alleged mistreatment/verbal abuse of a resident. Nurses notes dated 3/23/19 (admission) to 4/01/19 (discharge) did not indicate any allegations of abuse. During an interview on 5/15/19 at 10:27 AM with Registered Nurse (RN) #1 revealed he/she did not document anything in the electronic medical record about the allegation of abuse related to Resident #365. RN#1 further stated he/she could not recall when the incident occurred after reading his/her undated written statement. RN #1 stated the incident could have occurred on 3/28/19 then stated it happened when the CNA was fired. RN #1 further stated that it had been a long time ago and honestly, he/she does not remember. | 2020-09-01 |