cms_SC: 6271
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
6271 | MAGNOLIA MANOR - GREENVILLE | 425090 | 411 ANSEL ST | GREENVILLE | SC | 29601 | 2014-06-19 | 520 | D | 0 | 1 | 336311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on interview and record review, the facility failed to implement a quality assessment and assurance (QAA) plan of action for missing laboratory (lab) studies that included monitoring of the plan of action and implementing changes as needed to ensure that labs were obtained as ordered for Residents #6, 1 of 11 residents reviewed for labs. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 6/16/14 at 3:05 PM, review of 6/1/14 - 6/30/14 Physician order [REDACTED]. At 4:42 PM on 6/17/14, record review revealed no March or November results for the serum ferritin, iron level, iron sat, B12 level, or folate in the record. During an interview on 6/18/14 at 4:15 PM, the Director of Nursing (DON) confirmed the missing labs. The DON stated that the facility recognized a problem related to missing labs in November and December and that a PIP (Performance Improvement Plan) had been initiated in January related to missing labs. The DON stated that an audit had been done to identify any residents whose labs had not been done. The DON further confirmed the labs for Resident #6 were missed when the audit was completed and that the facility was not aware the labs were not done. On 6/19/14 at 9:30 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON confirmed a 100% audit had been conducted in March relative to the QAA Performance Improvement Plan and stated that the lab orders were now recorded in the lab book. The ADON further stated that, during the audit, any orders for labs that had not been done were re-written and recorded in the lab book. The ADON confirmed the lab orders for Resident #6 were missed and the labs were not obtained in March. When asked why the audit had not been done until March for a QAA that had been implemented in January, the ADON stated I don't know. I didn't realize we did it (the PIP) in January. On 6/19/14 at approximately 2:00 PM, the facility's Clinical Consultant declined to provide the QAA or PIP for review to the surveyor, stating that it was not a strong QAA. | 2018-04-01 |