cms_SC: 3668

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
3668 OPUS POST ACUTE REHABILITATION 425379 300 AGAPE DRIVE WEST COLUMBIA SC 29169 2017-06-28 309 D 1 0 0BFI11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice. Resident #5 did not receive treatment timely for diabetic ulcers on his/her feet that were noted upon admission to the facility. Resident #5 was also noted to have a reddened area to the sacrum that was not addressed by nursing. One of ten residents reviewed for quality of care. The findings included: Review of Resident #5's medical record revealed the Admission Nursing assessment dated [DATE] indicated the resident had a right foot diabetic ulcer 4.5 x 6, and left foot diabetic ulcers 6 x 5.2 (anterior) and 4.8 x 5.2 (posterior). Review of the resident's Medication Administration Record [REDACTED]. Cover with ABD pad and secure with [MED] daily. Every day shift for diabetic ulcer. The order date was 5/24/17 at 1959 and was started on 5/25/17 per documentation on the MAR. There was also an order [REDACTED]. Every day shift with an order date of 5/24/17 at 2000. The order was first signed as administered on 5/25/17. Review of the Occupational Therapy Treatment Encounter Note dated 5/26/17 noted the resident had a red area on buttocks/sacrum and nursing was notified. The note indicated nursing was notified and observed the red area on Resident #5. Review of Resident #5's Nurses' Notes revealed no documentation related to the red area. Review of the resident's electronic medical record revealed there was no nursing documentation on 5/26/17. In an interview with the surveyor on 6/27/17 at approximately 3:20 PM, the Director of Nursing (DON) stated s/he would expect them to start treatment on Resident #5's ulcers to his/her feet when s/he was admitted . The Director of Nursing was not sure why treatment wasn't started until 5/25/17 and stated s/he would check with the wound care nurse. The DON stated that the nurse who observed the red area to the resident's sacrum when notified by the occupational therapist on 5/26/17 should have documented on the area. The DON stated the nurse may not have notified the MD because they have standing orders for red areas. The DON stated that if the standing order was initiated, it should have been documented in the medical record. In an interview with the surveyor on 6/27/17 at approximately 4:00 PM, the DON stated the wound care nurse was not sure why treatment was not started sooner for the diabetic ulcers on Resident #5's feet. In an interview with the surveyor on 6/27/17 at approximately 4:05 PM, the Assistant DON/wound care nurse stated s/he was not sure what happened with the order for Resident #5's diabetic ulcers. The ADON/wound care nurse stated s/he usually gets to the residents right away and it must have been a mistake. The ADON/wound care nurse stated s/he did see the areas on Resident #5's feet the day s/he was admitted , but did not order treatment that day. The ADON/wound care nurse was not sure why, and stated it was an error on his/her part. The ADON/wound care nurse stated s/he was never informed about a red area to the resident's sacrum. In an interview with the surveyor on 6/28/17 at approximately 11:05 AM, the DON stated that s/he goes back through the admission assessment and signs off on it. When s/he reviews the admission assessments, she will usually go back and verify that orders that need to be put in place are there. The DON stated s/he did not realize that there were no treatment orders for Resident #5's diabetic ulcers and stated s/he was not sure how s/he missed. 2020-09-01