cms_SC: 23
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 23 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2017-08-23 | 224 | D | 1 | 0 | O8U111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Abuse policy and interview, the facility failed to conduct a thorough investigation for Resident #1, 1 of 3 sampled residents reviewed for Injury of Unknown Source. Resident #1 suffered a fracture of unknown origin. The facility failed to interview and obtain statements from direct care staff who provided care for Resident #1, on or around the time the resident suffered the fracture. The cause or exact date of the fracture could not be determined. Cross refer to F225 The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the Initial 24-Hour Report, dated 3/30/2017, on 8/23/2017 at 9:40 AM revealed Resident #1 suffered an injury of unknown source on 3/30/2017 at 12:00 AM. Record review of the Five-Day Follow-Up Report, dated 4/4/ on 8/23/2017 at 9:40 AM revealed the resident suffered an acute non-displaced left fibula and tibial shaft fracture. The injury was discovered on 3/30/2017 at 12:00 AM. Per the Five-Day Follow-Up Report, Resident #1 complained of pain to the left leg with repositioning on 3/29/2017. The resident was able to move her/his left leg. The resident also had a witnessed [MEDICAL CONDITION] on 3/27/2017. In addition, staff attempted to obtain a urine sample on 3/27/2017 via a in and out catheter. Per the report, the resident became very combative with thrashing around in bed while his/her legs were trying to be abducted. The resident spent all day in bed with intermittent diarrhea 3/28/2017. The facility's investigation concluded that the fracture appeared to be the result of the combative behavior during the in and out catheter procedure. Record review of the Telephone Orders on 8/23/2017 at 10:08 AM revealed an order, dated 3/27/2017 at 4:00 PM, for a in and out catheter to obtain a urine sample for urinalysis. A Telephone Order dated 3/28/2017 discontinued the in and out catheter order. Record review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The resident had no pain on 3/27 and 3/28. The resident had mild pain (2/10) on the day shift on 3/29 and 3/30. Record review of the Nurses Notes on 8/23/2017 at 10:16 AM revealed a note, dated 3/27/2017 at 3:45 PM, that indicated at 3:30 PM the resident was in her/his wheelchair pale, limp, drooling and lethargic. At 3:40 PM, the resident was combative, alert and talking. The Nurse Practitioner (NP) was notified and gave new orders, including the in and out catheter. There were no further Nurse's Notes on 3/27/2017 indicating the resident had any additional behaviors. There were no Nurse's Notes indicating the resident became combative during the in and out catheter attempt. A Nurse's Note, dated 3/28/2017, indicated the resident spent the day in bed due to loose stools. The note did not indicate the resident was having pain. A Nurse's Note, dated 3/29/2017, indicated the resident was screaming when staff touched or moved her/his left leg and left foot. There were no open areas, redness, swelling or bruising to the left leg/foot. The NP was notified and an X-ray was obtained at 6:30 PM. A Nurse's Note, dated 3/30/2017 at 12:01 AM, indicated the facility had received the X-ray results and the on call physician was notified. Record review of the practitioner Progress Notes on 8/23/2017 at 10:59 AM revealed a note, dated 3/27/2017. The note indicated the NP was seeing the resident due to a witnessed [MEDICAL CONDITION] a minute that occurred at 3:00 PM. At the time of the NPs exam the resident was alert and combative. The NP ordered a urinalysis and labwork (re 3/27/2017 Telephone Order at 4:00 PM). A 3/29/2017 Progress note indicated that the NP was seeing the resident for pain in the left leg. The note indicated the resident had a [MEDICAL CONDITION] 3/27, was in bed on 3/28 and today (3/29) yells/screams whenever you attempt to raise her/his leg, touch her/his feet. The NPs exam indicated the resident had no obvious fracture and no bruising. In addition, the note indicated the resident's legs were contracted at the knees and the pain could be muscle spasms. The NP ordered scheduled Tylenol and X-rays. A Progress Note from 3/30/2017 indicated the resident was seen for follow up of the acute non-displaced left fibula and tibial shaft fracture. New orders were written, interventions were implemented and the care plan and family were updated on treatment/comfort options. Staff statements related to the incident were reviewed on 8/23/2017 at 11:02 AM. A statement by LPN (Licensed practical Nurse) #1, dated 3/31/2017, indicated that on the night shift on 3/28/2017 nothing abnormal was reported or observed. On 3/29/2017 it was reported to LPN #1 that the resident was having left leg pain during the day shift. LPN #1 Received the X-ray results on her/his shift and called those results to the provider. LPN #1 indicated that the resident was not observed to be in pain and was sleeping during observations that night. A Statement by CNA (Certified Nursing Assistant) #1 indicated that CNA #1 provided care during and after the resident's [MEDICAL CONDITION] on 3/27/2017. The statement did not indicate the resident was having any pain or behaviors. A statement by CNA #2 indicated he/she worked the night shift on 3/27, 3/28, 3/29 and 3/30/2017. CNA #2's statement indicated the resident rested throughout the night each night he/she worked. A statement by LPN #2, dated 4/3/2017, indicated LPN #2 was on duty when the resident had the [MEDICAL CONDITION] on 3/27. LPN #2 notified the NP and the NP saw the resident about 30 minutes later. The resident was agitated during the NP's exam. The NP ordered a in and out catheter, but LPN #2 did not attempt the in and out catheter. A statement by CNA #3 indicated that she/he cared for the resident on 3/27 and 3/28/2017 on the day shift. CNA #3 assisted during the [MEDICAL CONDITION]. On 3/28/2017 the resident was weak, sleepy and having loose stools. CNA #3 provided personal care and dressed the resident. The resident remained in bed for the day per the daughter's request. After supper, CNA #3 required assistance providing evening personal care because the resident was screaming and resisting care. There was no statement from LPN #3, the nurse who performed the in and out catheter procedure on 3/27/2017. There was no documentation in the record of any combative behaviors the resident may have had during the in and out catheter procedure. Review of the Care Plan on 8/23/2017 at 1:17 PM revealed the resident had a problem area for Dementia and Sometimes I resist care and refuse to take my medications. An intervention listed for this problem was to Gently redirect me when I become angry or combative. If I don't respond to redirection, leave me alone for a little while. The problem onset date was 12/9/2016. The care plan was reviewed and revised each quarter and as needed. Record review of the daily Behavior and Mood monitoring flowsheets on 8/23/2017 at 12:22 PM revealed that no problem behavior was noted on 3/27, 3/28, 3/29 and 3/30/2017. During an interview with the NHA (Nursing Home Administrator) on 8/23/2017 at 10:06 AM, the NHA stated that only one staff person attempted the in and out catheter procedure for resident #1 on 3/27/2017. The NHA stated that LPN #3, attempted the procedure and was not assisted by any staff. The NHA stated that LPN #3 was an agency nurse (contracted nurse). During an interview with LPN #3 on 8/23/2017 at 11:42 AM, LPN #3 stated she remembered very little about Resident #1. LPN #3 stated she/he vaguely remembered doing the in and out catheter, but did not remember if it was successful or not. In addition, LPN #3 stated she/he did not recall if Resident #1 was combative or not during the procedure. During an interview with LPN #1 on 8/23/2017 at 12:33 PM, LPN #1 confirmed her/his written statement. LPN #1 stated she/he cared for Resident #1 on the 7:00 PM-7:00 AM shift (night shift). LPN #1 stated she/he did not recall the resident being combative or having any behaviors on 3/28/2017 or 3/29/2017. In addition, LPN #1 stated, she/he did not recall the resident having any behaviors during her/his shifts. During an interview with LPN #4 on 8/23/2017 at 12:55 PM, LPN #4 stated she/he worked with the resident on the 7:00 AM-7:00 PM (day shift). LPN #4 did not recall any specific details about the resident from 3/27-3/30/2017. LPN #4 stated the resident could be a little belligerent at times, but found if you left her/him alone for a bit, she/ he would calm down. LPN #4 stated the resident usually didn't display any behaviors when she/he worked with her/him. In addition, LPN #4 stated that the resident was much more cooperative with staff that she/he recognized and had worked with before. LPN #4 stated that if the resident refused any care, medicine or treatments, she/he would usually cooperate once you left her/him alone and went back to her/him. During an interview with CNA #3 on 8/23/2017 at 1:00 PM, CNA #3 confirmed her/his written statement. CNA #3 stated she/he cared for the resident on the day shift. CNA #3 stated the resident went limp during the [MEDICAL CONDITION] on 3/27 and did not fall from her/his chair or appear to suffer any injury as a result of the [MEDICAL CONDITION]. CNA #3 stated that it was normal for the resident to resist care, become agitated and scream during care. CNA #3 did not think the resident was in any pain during dressing or personal care during her/his shift on 3/28/2017. During an interview with the NP on 8/23/2017 at 1:10 PM, the NP stated she/he ordered the in and out catheter on 3/27/2017 after examining the resident. The NP recalled that the staff were unable to get a urine sample with the in and out catheter and that is why an order to discontinue the in and out catheter was given on 3/28/2017. In addition, the NP recalled she/he looked at the documentation to find out why the in and out catheter was not successful, but found that there was no documentation related to the procedure. During an interview with the Risk Manager with, the DON (Director of Nursing) present, on 8/23/2017 at 10:44 AM, the Risk Manager stated that no statement or interview was obtained from LPN #3 related to the in and out catheter procedure on 3/27/2017. The Risk Manager stated she/he was unable to reach LPN #3 by phone. The Risk Manager confirmed that the facility's investigation concluded that the resident's fracture appeared to be a result of combative behavior during the in and out catheter procedure. During an interview with the Risk Manager on 8/23/2017 at 11:32 AM, the Risk Manager confirmed there was no documentation or staff statements to indicate that Resident #1 was combative during the in and out catheter procedure on 3/27/2017. The Risk Manager also stated that she/he had just spoken to LPN #3 and LPN #3 did not remember anything related to the in and out catheter procedure, including whether the resident had combative behaviors or not. The Risk Manager also stated that CNA #4 may have been present in the room for the in and out catheter procedure. The Risk Manager stated she/he did not have a statement from CNA #4. In addition, the Risk Manager stated CNA #4 did not recall if she/he was in the room or not on 3/27/2017. The Risk Manager stated it was concluded the resident was combative during the procedure based on statements from day shift staff who reported that the resident had been frequently combative or resistant to care on the day shift. During an interview with the DON on 8/23/2017 at 12:22 PM, the DON confirmed there was no documentation or Nurse's Notes to indicate that the resident was combative during the in and out catheter procedure. The DON also confirmed that the daily Behavior and Mood monitoring flowsheets indicated the resident was not having any behaviors on 3/27/2017. During an interview with CNA #4 on 8/23/2017 at 1:27 PM, CNA #4 stated she/he did not recall who Resident #1 was or any details related to the resident's care. Review of the facility's Abuse Prevention Program policy revealed: [NAME] The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes the name of the resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred. | 2020-09-01 |