cms_SC: 5871

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.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
5871 GOLDEN AGE - INMAN 425316 82 N MAIN STREET INMAN SC 29349 2015-03-05 155 D 0 1 YNC111 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of the facility policy entitled Advance Directives, and review of the South Carolina Adult Healthcare Consent Act, the facility failed to ensure that 1 of 15 sampled residents reviewed had the opportunity to develop their own advance directive. There was no documentation in the record to indicate Resident #23 desired a Do Not Resuscitate DNR status. An Emergency Medical Services EMS order for DNR was signed by the resident's Responsible Party. Two physicians had not determined that Resident #23 was unable to make his/her own healthcare decisions. The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Record review on 3/4/15 at 3:18 PM revealed current Physician's Orders for a DNR code status for Resident #23. Further review revealed a Physician's Telephone Order dated 8/13/13 stating Res(ident) is DNR since 8-8-13. A Progress Note Addressing Decisional Capacity dated 8/15/13 revealed one physician had signed that the resident was not able to make healthcare decisions for him/herself. A Nurse Practitioner's Progress Note dated 7/31/13 documented This patient lacks decision-making capacity. There was no documentation noted that a second physician had certified that the resident lacked decisional capacity. There was nothing noted in the record to indicate that facility staff had spoken with the resident about his/her code status and that a DNR status was what the resident desired. There was nothing noted in the record to indicate the resident was on hospice. During an interview on 3/4/15 at 3:40 PM, the Director of Nursing (DON) reviewed the documentation in the medical record and verified there was no evidence that 2 physicians had determined that Resident #23 was unable to make his/her own healthcare decisions. The DON stated s/he would check the thinned records to see if additional documentation could be found. During an interview on 3/5/15 at 11:27 AM, the Social Services Director (SSD) stated they could find no additional information. The SSD verified that 2 physicians had not determined that Resident #23 was unable to make his/her own healthcare decisions. When asked, the SSD stated s/he could not find documentation that the DNR was the resident's wishes. A review of the policy provided by the facility entitled Advance Directives revealed The resident has a right to .formulate an advance directive in accordance with state and federal law . According to the policy, on admission, .If a resident has not executed an advance directive and the resident has the capacity to make health care decisions, the social services department should contact the resident to determine whether the resident wishes to make an advance directive . Review of the South Carolina Adult Healthcare Consent Act Section 44-66-20 revealed that Unable to consent means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner . A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient. However, in an emergency the patient's inability to consent may be certified by a health care professional responsible for the care of the patient if the health care professional states in writing in the patient's record that the delay occasioned by obtaining certification from two licensed physicians would be detrimental to the patient's health. A certifying physician or other health care professional shall give an opinion regarding the cause and nature of the inability to consent, its extent, and its probable duration 2018-08-01