cms_SC: 6597
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6597 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2014-02-25 | 248 | E | 0 | 1 | NBGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey based on observations, staff interview, record review and review of facility policies, the facility failed to provide an ongoing program of activities for 3 of 4 residents reviewed for activities during the days of the survey. The facility also failed to assess individual residents with regards for activity preferences and personal interest. The facility failed to implement the plan of care related to the Activity program for Resident # 118. Resident # 21 and Resident # 123 were not assessed and there was no documented evidence of the resident's participating in Activities. The findings included: The facility admitted Resident # 118 with the [DIAGNOSES REDACTED]. Review of Resident #118 ' s Plan of Care for Activities on 2/20/14 at approximately 3:14 PM, it stated Resident needs to participate in out of room activities for socialization to prevent depression . According to the resident's Plan of Care, the interventions stated - include resident in group activities, provide variety in activities based on residents preferences, monitor and record attendance and assist to and from activities as needed. Review of Resident #118 ' s Admission Minimum Data Set Assessment. Section F. (Preferences for Customary and Routine activities) noted that the resident thought it was important to listen to the music he/she likes and somewhat important to do things with groups of people and to participate in his/her favorite activity. Further review of the resident ' s medical record on 2/20/14 at approximately 5:15 PM did not reveal a facility activity assessment for the resident to assess the resident ' s preferences for activities since his/her admission of 12/12/13 to the facility. Review of the facility provided policy titled Activity Assessment stated Within 72 hours a resident's admission to the facillity, an Activities Assessment will be conducted to assist in developing an activity plan that reflects the choices and interest of the resident. Observations were made of Resident #118 on the days of the survey; not participating in activities. On 2/19/14 at 11:14 AM, the resident was observed sitting in his/her room watching television while a group activity was in progress. On 2/20/14 at 2:39 PM, the resident was observed in his/her room facing the wall. Checkers for guys was in progress in the Activity room. On 2/21/14 at 9:41 AM, the resident was observed sitting in the hallway across from the nurse ' s station with head down and no staff interaction. On 2/21/14 at 10:10 AM, the resident was observed sitting in the hall across from the nurses station. Activities were in progress at time but the resident had not been included. Review of the facility's Activity Attendance Log dated 2/17/14-2/21/14 did not document Resident #118 had participated in any group activity held by the facility. During an interview on 2/20/14 at 5:00 PM with the Activity Assistant s/he stated, Resident #118 does not like coming out of the room. I go by the room daily to speak with the resident. The resident rarely participates in activities. The Certified Nursing Assistants usually do not get (him/her) up out of the bed during the evenings when religious activities are held. The Activity Assistant confirmed that no activity assessment was completed for Resident #118. During a random interview with a resident in the Dining area on 2/21/14 at 6:11 PM, he/she stated that there were limited activities especially on the evening and weekends. The resident stated the activities they do have during the week are not interesting. The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Record review on 2/20/14 revealed the resident's Brief Interview for Mental Status(BIMS) was coded as having short and long term memory problems and Moderately Impaired Cognitive Skills for daily decision making. Further review of the current (1/30/14) MDS(MInimum Data Set) revealed there was no resident response to questions related to activity preferences. Per the Care Area Assessment(CAA) resident is not able to actively participate in activities at this time. The CAA also revealed the resident was up in a geri-chair daily as tolerated and from prior assessments likes to attend church services. The care plan reviewed had an onset date of 2/5/14, goal date of 5/6/14 and included approaches as follows: 1) Provide variety in activities based on residents preferences; 2) Include resident in group activities; 3) Maintain positive manner when inviting resident to activities; 4) Introduce to other residents; 5) Encourage to talk about family members and past life; 6) Monitor and record attendance and interactions during activities; 7) Place activity calendar in room; 8) Assist to and from activities. Review of the Activity Section in the medical record revealed there was no Activity Assessment or activity notes. On 2/20/14, activity assessments, notes, and any one to one activities were requested. During multiple observations of the resident on 2/20/14 at 9:35 AM, 11:25 AM, and 4:08 PM, the resident was observed lying in bed with no activities noted. On 2/21/14 at 11:11 AM and 3:30 PM the resident was observed at the nurse's station and/or in the bed with no activities noted. Review of the Activity Attendance Log from 2/17/14-2/21/14 revealed the resident was not in attendance during any of the activities offered. The facility admitted Resident #123 with [DIAGNOSES REDACTED]. Record review on 2/20/14 of the MDS dated [DATE] revealed the resident had short and long term memory problems and severe cognitive skills for daily decision making. Further review of the MDS revealed there was no resident response to the interview for daily preferences. Review of the Care Area Assessment for activities revealed the resident was invited to out of room activities and assisted by staff. The CAA reflected Resident #123 enjoyed listening to music and would often sit in the hallway near the nurses desk. Review of the Activities care plan with an onset date of 11/21/13 included approaches that included the following: 1) Provide variety in activities based on residents preferences. Invite resident to listen to music, bands and church activities; 2) Include resident in group activities; 3)Maintain positive manner when inviting resident to activities; 4) Introduce to other residents; 5) Encourage to talk about family members and past life; 6) Monitor and record attendance and interactions during activities; 7) Place activity calendar in room; 8) Assist resident to and from activities. It was noted that the plan of care for Resident # 21 and Resident # 123 were identical and not individualized to the resident's needs and or preferences. Further record review of the Activity section of the medical record revealed there was no activity assessment or activity notes. The activity assessment and notes were requested on 2/20/14. Multiple observations of Resident #123 on 2/18/14 at 4:33 PM, 2/19/14 at 9:44 AM and 4:12 PM, and on 2/21/14 at 11:08 AM revealed the resident was in the bed and no activities in progress during the times of observation. Review of the Activity Attendance Log for 2/17/14-2/21/14 revealed the resident did not attend any activities during this timeframe. On 2/20/14, activity assessments and notes were requested. On 2/20/14 at 4:40 PM, the Activity Assistant was asked if the activity assessments and notes had been located. At that time, the Social Service Director informed the surveyor several different people had been in the Activity position since July. He/she confirmed Resident #21 and #123 did not have an activity assessment or activity notes. One to one activities was requested on Resident #21 and #123 and the Social Service Director stated he/she would look for the documentation. During the interview, the Social Service Director was asked since the facility was aware of the turnover in the area of staffing for the Activity area, what did the facility do to ensure that the residents were assessed appropriately and were provided activities? He/she stated it appeared an audit would have to be done. No evidence of one to one visits were presented for Resident #21 during the survey. On 2/21/14 one to one activities documentation was provided for Resident #123. On 2/21/14 at 3:20 PM, the Activity Assistant verified no documentation of one to one activities had been available on 2/20/14. An audit for activity assessments was performed by the facility on 2/20/14. The audit revealed 16 residents did not have an initial activity assessment and 12 other residents had no documentation of whether an assessment had or had not been done per the audit appearing to result in an incomplete audit. Review of correspondence from the Administrator to the previous Activity Director dated 12/16/13 revealed that during the stand up meeting concerns related to Ambassador reports were discussed. Activities was discussed due to residents indicating they have little desire to participate(so they do not); the activities offered did not interest them and no one from activities visits with them. During an interview with the Administrator on 2/21/14 at 9:30 AM, he stated that the previous person in the Activity Director position was qualified based on the regulations. H/she continued by stating the Activity Director left the faciity on [DATE] without working out a full notice and the person who was in the activity assistant position did not have any experience. Upon further explanation, advertisements had been placed in the paper and resumes had been received, but the facility had been hindered by the weather in filling the position. H/she confirmed an audit had been done on 2/20/14 and sixteen residents did not have an activity assessment and/or notes. H/she stated that a quality assurance on charts had been implemented prior to the survey, but activities was not at the forefront. The Administrator stated during the interview that the assessments and one to one activities had fallen through the crack. | 2017-12-01 |