cms_SC: 53
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 53 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 657 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, facility nursing staff failed to update 3 of 24 sampled residents' care plans (Residents #15, #16, and #17). The findings included: Review of the facility's Policy and Procedure for RAI (Resident Assessment Instrument)/Care Plans (not dated) revealed 3. Care plan team meets every Thursday to review care plan with family and residents who choose to attend unless arrangements are made for different time or date. Resident #15 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #15 exhibited no behaviors (i.e. no physical behaviors and no self-injurious behaviors) and no signs/symptoms of depression, during the assessment periods. According to the MDS, Resident #15 required the extensive assistance of one staff person for bed mobility, transfers, toileting, dressing, walking in the room, and locomotion on and off the unit. The Annual MDS assessment, noted Resident #15 had impairment to one side of lower extremities and utilized a wheelchair for mobility. Resident #15 had no falls during either MDS assessment period. Continued review of the MDS revealed Resident #15 was administered no anti-coagulant medications; however, the resident did receive antipsychotic medication for seven (7) days during the assessment period. Review of Resident #15's Progress Notes revealed the following: 11/11/8 - While the CNA had the resident in the bathroom, she noticed bruises on resident's left arm, reddish purple in color. The resident was not able to state what might have happened. No complaint of pain or sign or symptom of pain noted to left arm when touched. Resident was able to move bilateral upper extremities on her own without difficulties or distress noted. No swelling noted to left arm. Resident observed by nurse using bilateral arms to push herself up out of w/c without difficulties or distress noted. MD made aware, no new orders noted at this time. RR (Resident Representative) made aware and stated, She had bruises on her arm when I was down there on Monday, but I didn't recognize them as bruises, I just thought they were smudges. Review of the facility's Investigation Report dated 11/13/18 confirmed Resident #15 sustained unexplained bruising. Review of Resident #15's Comprehensive Care Plan revealed the following care areas were addressed: 8/1/19 - Problem: Resident at times may resist care or make physical contact with staff or other residents due to Dementia and [MEDICAL CONDITION]. Goal: Talk to resident in a calm, reassuring tone of voice (through review date 11/1/19). Interventions (all initiated before 11/22/18) : Talk to resident in a calm, reassuring tone of voice; explain all procedures to resident prior to assisting; If resident is resistant or combative with care, give her time to calm down and re-approach at a later time; Administer [MEDICATION NAME] per MD's (doctor's) orders; and family contacted/informed about drug use and possible side effects. 8/1/19 - Problem: Resident displays socially inappropriate/disruptive behaviors due to [MEDICAL CONDITION] Dementia. Goal: Decline in disruptive behaviors (through review date 11/1/19). Interventions (all initiated before 11/22/18): Place resident in area where constant observation when possible; Approach resident warmly and positively; Talk to resident in a calm voice when behaviors are recent; Remove resident from area when behaviors are unacceptable/disruptive; Offer food/drink when behaviors are present; Check to see if resident is soiled or cold; Administer [MEDICATION NAME] per MD orders. Monitor for effectiveness, for possible side effects or adverse reaction and report to MD as needed; and family informed/contacted about drug use and possible side effects. 8/1/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to left [MEDICAL CONDITION], Dementia, Urinary tract infection, Constipation,[MEDICAL CONDITIONS]. Goal: Resident will not suffer injury related to falls (through review date 11/1/19). Interventions (all initiated before 11/22/18) : Monitor for safety and maintain a safe environment; Assist as needed in all ADL (activities of daily living) areas; Offer reminders not to arise unassisted as needed and transport to high visibility area as needed; Encourage to wear shoes with non-slip soles; Keep room free from clutter and pathway to be clear. Mop up all spills promptly; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; Notify responsible party (RP) and MD of all fall instances; Monitor for signs and symptoms of [DIAGNOSES REDACTED], such as tingling of extremities, muscle cramps, twitching, stooped posture and brittle bones; Provide diet per order, encourage consumption of calcium rich foods, such as eggs, milk, cheese and other dairy products served within diet; and monitor labs per order. Report to MD as needed. 8/1/19 - Problem: Potential for skin tears and bruising related to fragile condition of skin. Goal: Skin tears will heal without complication (through review date 11/1/19). Interventions (all initiated before 11/22/18): Monitor for safety and maintain a safe environment. Handle gently and protect from injury; Provide treatment to skin tears per order. Monitor effectiveness of treatment and progression of healing; Monitor for s/sx (signs/symptoms) of infection, such as redness, warmth, pain, tenderness, [MEDICAL CONDITION] and purulent drainage; Have resident wear long sleeves/pants/geri-sleeves as needed to protect extremities (2/24/19); Provide adequate lighting to reduce the risk of bumping into furniture or equipment; offer fluids with medication pass, at meals and as needed between meals in an effort to ensure hydration; Apply lotions and moisturizers to skin as needed; Use a lift sheet to move and turn resident when in bed as needed; Pad wheelchair arms and leg supports as needed; Support dangling arms and legs with pillows and blankets as needed; and perform skin tear risk assessment initially upon admission and quarterly thereafter, as needed. 8/1/19 - Problem: Resident requires extensive to total assistance from staff for ADLs related to limited mobility and poor endurance related to history left [MEDICAL CONDITION], Dementia, UTI, Constipation,[MEDICAL CONDITIONS]. Goal: Resident will continue to participate in ADLs after set-up by staff (through review date 11/1/19). Interventions (all initiated before 11/22/18): Provide showers three times per week and sponge baths daily. Shampoo hair weekly with a shower unless other arrangements are made; Provide routine oral hygiene; Clean and trim fingernails/toenails as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide preventative skin care daily and as needed; Provide tray set up for meal consumption and assist with meals as needed in an effort to ensure adequate nutritional intake; Assist the resident to turn and reposition ever two hours and as needed while in bed; Assist to transfer from bed to wheelchair as tolerated; Transport to specific destinations once up; Provide Range of Motion (ROM) exercises to all extremities throughout nursing care as tolerated; and assist to dress/undress appropriately and groom hair daily and as needed. The comprehensive care plan was not updated after Resident #15 sustained unexplained bruising to her left arm on 11/11/18. 2. Review of Resident #16's clinical record revealed Resident #16 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored four (4) out of 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired and exhibited no behavioral symptoms. Continued review of the assessment noted the resident required the total assistance of one staff person for bed mobility, transfers, locomotion on and off the unit, dressing, toileting and bathing. Resident #16 had no impairment to upper and lower bilateral extremities and did not utilize a mobility device. During the assessment period, Resident #16 had no falls and received no therapy services. Review of Resident #16's Annual MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired and exhibited no behavioral symptoms during the assessment period. The Annual MDS noted Resident #16 required the total assistance of one staff person for bed mobility, transfers, locomotion off and on the unit, dressing, toileting, personal hygiene and bathing. Resident #16 had impairment of one side of lower extremity, and according to the MDS, the resident did not utilize a mobility device. During the assessment period, Resident #16 had no falls, was administered opioid medication for seven (7) days and received no therapy services. Review of Resident #16's Progress Notes revealed the following: 12/31/18 at 10:40 a.m. - Upon getting up this morning, resident complained (of) left leg pain. No swelling or bruise noted .when staff tries to push her to go to the activity she hollers and says that her leg is still hurt. When this nurse checked her leg once again, her leg just below the knee is swollen, tender to touch but not warm. No redness or bruise on the area. (MD) notified and made aware with no new order noted at this time. Continue monitoring resident condition. Review of Resident #16's Radiology report dated 12/31/18 revealed Resident #16 sustained an Acute proximal left lower leg fracture. Review of Resident #16's Care Plan revealed the following care areas were addressed: 9/12/19 - Problem: Requires extensive to total assistance from staff for ADLs (activities of daily living) related to limited mobility, poor endurance and intermittent episodes of confusion related to [MEDICAL CONDITIONS], Abnormality of Gait, Debility, [MEDICAL CONDITIONS], History of Pneumonia, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITIONS], Dysphasia, Hypertension, Obesity, Anxiety and Dementia. Goal: Resident will be cleaned and well-groomed by staff (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Clean and trim fingernails/toenails as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide incontinent skin care after each incontinent episode; Provide preventative skin care daily and as needed; Provide tray set up for meals. Monitor self- feeding performance and meal consumption and assist with meals as needed in an effort to ensure adequate nutritional intake; Transport to specific destinations once up; Provide range of motion (ROM) exercises to all extremities throughout nursing care as tolerated; Provide showers three times weekly and sponge baths daily as tolerated. Shampoo hair weekly with a shower unless other arrangements are made. Encourage to wash face, hands and upper body after set-up and cueing from staff. Monitor performance and assist as needed; Dress/undress appropriately and groom hair daily and as needed; Turn and reposition every two hours and as needed while in bed; Side rails up x 2 when in bed to assist with turning and repositioning. Check every 30 minutes and release every two hours. Allow free time during meals, care and family/social visits; Perform positioning assessment quarterly; and transfer from bed to chair with Hoyer lift or sit-to-stand. 9/12/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Cardiovascular Accident ([MEDICAL CONDITION]), Debility, Abnormal Gait, [MEDICAL CONDITIONS], Anxiety, Age-related [MEDICAL CONDITION] without current pathological fracture and intermittent episodes of confusion related to Dementia. Goal: Resident #16 will not suffer injury related to fall (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Monitor for safety and maintain a safe environment; Assist as needed in all ADL areas; Offer reminders not to arise unassisted as needed and transport to high visibility area as needed; Encourage to wear shoes with non-slip soles; Keep room free from clutter and pathway to bathroom clear. Mop up all spills promptly; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding factors and eliminate if possible; Notify responsible party (RP) and MD of all fall instances; Monitor for s/sx of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; Provide diet per order. Encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; and administer medications and monitor labs per MD orders. Report to MD as needed. 9/12/19 - Problem: Potential for pain or discomfort related to limited mobility and [MEDICAL CONDITION] and history of proximal left lower leg fracture. Goal: Resident #16 will obtain relief from pain/discomfort 30-60 minutes after medications/measures taken (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Monitor for s/sx of pain/discomfort such as verbal complaints, moaning, crying, facial grimace, loss of appetite, withdrawal and resistance to care; Maintain calm and reassuring environment. Avoid stressors; Position for comfort with pillow supports as needed; Provide diversionary activities so resident does not focus only on pain; Encourage and assist with exercise to tolerance within physical limitations within. Allow resident to guide pacing of movements and provide frequent rest periods; and administer medications per MD orders. The comprehensive care plan was not updated to address Resident #16's potential to sustain pathological fractures related to the [DIAGNOSES REDACTED]. 3. Record review revealed Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one staff person for bed mobility, locomotion on and off of the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one staff person for transfers and had impairment to one side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Progress Notes revealed the following: 7/13/19 - CNA (Certified Nursing Assistant) was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of the facility's Investigation Report dated 7/16/19 revealed the following interventions were to be added to Resident #17's fall care plan: Floor pads placed on floor resident is facing when she is in bed and make sure chair is not right beside bed. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fractures, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will not suffer injury related to falls (through review date 12/5/19). Interventions: Monitor for safety and maintain safe environment; Assist as needed in all ADLs (activities of daily living) areas; Offer reminders not to arise unassisted as needed and transport to high visibility areas as needed; Encourage to wear shoes with non-slip soles; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; Notify Responsible Party and MD of all fall instances; Monitor for s/sx of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; Provide diet per order, encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; Strive to keep room free from clutter and pathway to bathroom clear, mop all spills; and administer med and monitor labs per MD orders. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will be clean and well-groomed by staff (through review date 12/5/19). Interventions: Provide routine oral hygiene; Clean and trim fingernails/toenails; Dress/undress appropriately and groom hair daily and as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide incontinence skin care daily and as needed; Turn and reposition every two hours and as needed while in bed; Transport to specific destinations once up; Provide ROM (range of motion) exercises to all extremities throughout nursing care as tolerates; Provide showers three times weekly and sponge baths daily shampoo hair with shower unless other arrangements are made; Spoon feed all meals by staff in an effort to ensure adequate nutritional intake; Transfer from bed to geri-chair as tolerated; and perform treatments per MD orders. Resident #17's care plan was not updated to include the interventions to place floor pads on the floor and to make sure a chair was not right beside Resident #17's bed. Observation in Resident #17's room on 10/16/19 at 2:14 p.m. revealed a chair was placed next to the head of Resident #17's bed. Interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator revealed residents' care plans were maintained in the electronic health record, and a hard copy was also maintained in the resident's paper chart. The MDS Coordinator said that nursing staff can update residents' hard copy care plans when needed by writing in newly developed interventions. The MDS Coordinator said that updated information documented on the hard copy care plans was formally added to residents' electronic care plans on a quarterly basis when care plan meetings were held. The DON and MDS Coordinator acknowledged that care plans for Residents #15, #16, and #17 were not updated; however, they should have been. | 2020-09-01 |