| 3322 |
MARTHA FRANKS BAPTIST RETIREMENT CENTER |
425334 |
ONE MARTHA FRANKS DRIVE |
LAURENS |
SC |
29360 |
2018-05-17 |
623 |
F |
0 |
1 |
2M9S11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the required written notice of transfer to the resident/ resident representative for Resident's #12, #51, #35 and # 22 at the time of a facility initiated transfer. 4 of 5 reviewed for transfer to the hospital. The findings included: Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. muscle weakness, [MEDICAL CONDITION],chronic pain, history of UTI's, [MEDICAL CONDITIONS],Essential Hypertension, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] Reflux disease, overactive bladder, urinary incontinence, abnormal weight loss, Cognitive communication on deficit, Wedge compression fracture of first lumbar vertebra, Major [MEDICAL CONDITION], lack of coordination, shortness of breath, pain in unspecified knee and [MEDICAL CONDITION]. During record review there was no documentation that the Resident/ Resident's Representative was notified of the transfer to the hospital as soon as practicable. During an interview on 05/15/18 at approximately 03:45 PM, the Director of Nursing (DON) stated, We have not provided written notification to the resident/ Resident's Representative of the transfer to the hospital. On 05/16/18 at approximately 10:46 AM the Unit Manager confirmed and stated, We make the Residents Representative (RR) aware at the time of a transfer to the hospital, but we have not given written notification to the RR. The facility admitted Resident #22 on 4/4/17 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Progress Note dated 3/21/18 at 1:28 PM indicated, Sent to ER as ordered by Nurse Practitioner, (RP) notified . The Progress Note dated 3/21/18 at 10:49 PM indicated, This writer spoke with LCMH staff Nurse and informed resident admitted to Hospital 2nd floor with Dx: UTI. Called residents (RP) to inform but already aware . There was no documentation in the medical record to indicate the resident and/or resident's Responsible Party was provided with a written notification of the reason for the transfer to the hospital. The facility admitted Resident #12 on 01/30/17 with [DIAGNOSES REDACTED]. At 1:23 PM on 05/16/2018, review of the Nursing Progress Notes revealed on 04/26/18 Nurse called into residents room by concierge due to resident not responding appropriately. Upon entering room resident was observed to have slow response. Mental status checked and responses were as follows (sic) where are you resident stated Martha Stewart, year 1977, no response when asked who our current president was. O2 (oxygen) saturation was 78% via NC (nasal canula) 3L/min (liters per minute). Resident was unable to follow simple breathing technique instructions. Lung sounds were clear upper and lower right lobe but diminished in left upper and lower lobe. Resident observed using accessory muscles. Vital signs were obtained and were as follows: B/P (blood pressure) 143/67 Temp (temperature) 97.9 Pulse 110 Resp (respirations) 21 O2 saturations fluctuating between 78-90%. Due to unstable o2 saturations ems (sic) was called at 7:38 pm. Resident left via stretcher at 8:20pm en route to Greenville per request of POA ( .). Resident #12 was admitted to the hospital and returned on 04/30/18. There was no documentation that written notice of transfer was provided to the resident or the resident's representative. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. On 05/15/18 at 10:10 AM, review of the Electronic Health Record revealed Resident #35 was hospitalized from 3/9-3/19/18 following a fall resulting in a [MEDICAL CONDITION]. Further review revealed Resident #35 was also hospitalized from 05/07-05/09/18. On 05/15/18 at 10:12 AM, review of Nursing Progress Notes revealed on 3/09/18 the resident's roommate cam outside of the room calling for help. The nurse entered the room and observed the resident on the floor on the left side of the bed. The resident said the left hip hurts a lot when touched. The NP was notified and order received for hip x-ray 2 views and pelvic x-ray. At 9:46 PM, the nurse documented X-ray results were as follows: There is a comminuted left intertrochanteric fracture with impaction. The joint shows no dislocation. Conclusion: Acute left [MEDICAL CONDITION]. EMS (Emergency Medical Service) was called and the resident left via stretcher at 8:00 PM and the resident was admitted to the hospital. The RP was notified by phone of the transfer but there was no documentation that written notice of transfer was provided to the resident or resident representative. At 9:21 AM on 05/16/2018, further review of the Nursing Progress Notes revealed on 05/07/18 the CNA (Certified Nursing Assistant) observed the resident exhibiting [MEDICAL CONDITION] activity and called the nurse. Vital signs were taken, the MD (Medical Doctor) was notified and a new order received to send the resident to the emergency room for evaluation. The Responsible Party was notified by phone. There was no documentation that the resident or resident representative received written notice of the reason of transfer. |
2020-09-01 |