cms_SC: 2185

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
2185 ROLLING GREEN VILLAGE 425160 1 HOKE SMITH BOULEVARD GREENVILLE SC 29615 2017-02-09 157 D 0 1 NK0T11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure the Physician and Dietician were notified of Resident (R) 53's significant weight loss and that the Physician was notified of the increase in the size of R91's pressure ulcer. The facility census was 67 and 29 residents were included in the stage 2 survey sample. Findings include: A review of R53's electronic health record (EHR) revealed an admission date of [DATE]. A review of the Activities of Daily Living (ADL) section of the quarterly Minimum Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) revealed R53 was dependent on staff to eat and had had a significant weight loss of either 5% in the last month or 10% in the last 6 months. A review of R 53's weights recorded in the EHR revealed monthly weights on 11/24/16 of 94 pounds and 12/28/16 of 89 pounds, a >5% weight loss. R53's weight on 1/2/17 was 90 pounds and on 2/2/17 was 91 pounds. A review of the Clinical Notes - Dietary Notes in R53's EHR back to 11/8/16 did not reveal notes authored by the Registered Dietician (RD). The last Nutrition Risk Evaluation in the EHR was on 10/2/16 authored by the Certified Dietary Manager (CDM). revealed the last Registered Dietician note in the EHR was dated 10/28/14. A review of the Clinical Note - Nursing Note dated 1/3/17 in R53's EHR, written by a Licensed Practical Nurse (LPN) 1 at 7:35 a.m., noted .Residents' weight was 99lb on 1/2/17 and 98lb on 12/28/16 She is on a Regular diet, mechanical soft meats with thin liquids. On 1/5/17 at 12:20 p.m., LPN2 charted Staff noticed resident's physical condition is declining and barely weight bearing. Notified NP (Nurse Practitioner) and PT (physical therapy) eval (evaluation) and treatment order given. A note by LPN1 on 1/10/17 at 2:45 a.m. stated .Residents' weight was 99lb on 1/2/17, and 98lb on 12/28/16 She is on Regular diet, Mechanical soft meats with thin liquids. In an interview on 2/9/17 at 8:30 a.m. the CDM stated R53 had not been reviewed since the 1/1/17 MDS assessment and provided the last Registered Dietician Clinical Note - Dietary Note was dated 10/28/14. In an interview on 2/9/17 at 3:55 p.m. the Director of Nursing stated there was no documentation that the physician had been notified of R53's weight loss. When asked about the last RD note date, the DON rhetorically questioned if residents shouldn't be reviewed more often than that. A review of the facility provided policy Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised (MONTH) 2012, stated: Assessment and Recognition: 1. The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. 3. The threshold for significant unplanned and undesired weight loss will be based on the following criteria a. 1 month - 5% weight loss is significant; great than 5% is severe . 4. The Physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition . The facility provided policy Weight Assessment and Intervention, revised (MONTH) 2008, stated . 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. 4. The Dietician will respond within 24 hours of receipt of written notification. 2020-09-01