cms_SC: 6265
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 |
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6265 | MAGNOLIA MANOR - GREENVILLE | 425090 | 411 ANSEL ST | GREENVILLE | SC | 29601 | 2014-06-19 | 333 | E | 0 | 1 | 336311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification survey, based on record review and interview, the facility failed to ensure that 3 of 11 residents reviewed for medication assessment were free of significant medication errors. The facility failed to administer insulin per Fingerstick Blood Sugar (FSBS) results as ordered for Resident #3 and Resident #4. Resident #11 did not receive [MEDICATION NAME] as ordered for low hemoglobin results. The findings included: The facility admitted Resident #3 to the facility with [DIAGNOSES REDACTED]. On 6/18/14 at approximately 4:00 PM, record review revealed a 1-4-11 physician's orders [REDACTED].Check BS (blood sugar) before meals and HS (bedtime). Give additional 15 units of [MEDICATION NAME] if BS > (greater than) 400 then Recheck in 1 hour and call MD (physician) if > 400. Review of the 4/14 Medication Flowsheet on 6/18/14 revealed that a FSBS was not checked on 4/23/14 at 11:30 AM and 4/13/14 at 9:00 PM. The FSBS was not rechecked in 1 hour as ordered for results > 400 on 4/6/14 at 11:30 AM when the BS was 508 and on 4/14/14 at 11:30 AM when the BS was 495. Review of the 5/14 Medication Flowsheet revealed that on 5/2/14 at 9:00 PM, a blood sugar of 422 was recorded with no noted insulin given or recheck of the BS as ordered. On 5/12/14 at 4:30 PM, a blood sugar of 507 was recorded with no noted insulin given or BS recheck. Also, there were no FSBS results documented for 5/31/14 at 4:30 PM. Review of the 6/14 Medication Flowsheet revealed that the blood sugar for 6/13/14 at 4:30 PM was not done as ordered. During an interview with the Assistant Director of Nursing on 6/18/14 at approximately 4:00 PM, s/he verified that the blood sugars were not documented as done per the physician's orders [REDACTED]. The facility admitted Resident #11 with [DIAGNOSES REDACTED]. On 6/19/2014 at approximately 8:30 am, record review revealed 1-29-13 physician's orders [REDACTED].Injection .Give if Hgb (Hemoglobin) Review of the Medication Administration Records (MARs) revealed that [MEDICATION NAME] was not given as ordered from 10/2013 through 6/2014 based on the hemoglobin and hematocrit levels. Record review revealed that the dates scheduled for [MEDICATION NAME] administration on the MAR indicated [REDACTED]. On 10-23-13, the Hgb was 10.3 g/dL (normal range 13.0-16.5). [MEDICATION NAME] was scheduled for administration on the MAR for 10-25-13, but was not initialed as given. On 11-22-13, the Hgb was 10.1. [MEDICATION NAME] was scheduled for administration on the MAR for 11-22-13, but the nurse's initials were circled, indicating the medication was omitted. On 4-7-14, the Hgb was 9.4. The MAR indicated [REDACTED]. On 4-23-14, the Hgb was 8.8. [MEDICATION NAME] was scheduled for administration on the MAR for 4-25-14, but was not initialed as given. The MAR indicated [REDACTED]. The [MEDICATION NAME] was not initialed as given on 5-9-14. On 5-23-14, [MEDICATION NAME] was given, but the lab test was not drawn until 5-28-14 (Hgb = 8.9). On 6-6-14, the nurse's initials were circled on the MAR indicated [REDACTED]. During an interview on 6/19/14 at approximately 9:55 AM, the Assistant Director of Nursing confirmed that there was no evidence the [MEDICATION NAME] was administered as ordered/or was incorrectly administered. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. On 6/16/14 at 4:19 PM, review of the Physician order [REDACTED]. Further review revealed an order for [REDACTED]. On 6/17/14 at 10:14 review of the Medications Flowsheet dated 6/1/14 - 6/30/14 revealed FSBS's greater than 300 on 6/3 at 4:30 PM, 6/4 at 6:30 AM and at 4:30 PM, 6/5 at 4:30 PM, 6/7 at 6:30 AM, 6/8 at 4:30 PM, 6/9 at 6:30 AM and at 4:30 PM and 6/10/14 at 6:30 AM with no administration of [MEDICATION NAME] documented. Review of the Medications Flowsheet dated 5/1/14 - 5/31/14 revealed a FSBS of 384 on 5/2/14 with no documentation of insulin administration. Further review of the 4/1/14 - 4/30/14 Medications Flowsheet revealed FSBS greater than 300 on 4/8 at 4:30 PM, 4/14 at 4:30 PM, 4/23 at 4:30 PM, 4/24 at 4:30 PM, 4/26 at 4:30 PM, 4/28 at 4:30 PM and 4/30 at 4:30 PM with no documentation that the [MEDICATION NAME] was administered as ordered. Review of the laboratory reports revealed the resident had a HgbA1C (Glycated hemoglobin) (used as a standard tool to determine blood sugar control for patients with diabetes) on 2/3/14 with a result of 9.5 with a notation that the result was slightly worse. During an interview on 6/18/14 at 10:25 AM, Registered Nurse #2 confirmed the [MEDICATION NAME]was not administered as ordered for FSBS greater than 300 and confirmed the result of the elevated HgbA1c. | 2018-04-01 |