cms_SC: 68
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 68 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 281 | J | 1 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews and review of facility files, the facility failed to provide respiratory assessment and care to meet the residents needs for 1 of 3 residents reviewed for neglect. Resident #48, in a persistent vegetative state was gurgling. The resident's condition was reported to the nurse, but she/he did not assess or provide intervention of suctioning. The findings included: Cross refer to F223 Neglect of resident by failure not to assess or intervene with an identified change in respiratory condition. The facility admitted resident #48 with [DIAGNOSES REDACTED]. Review of Nurses' Notes from [DATE] through [DATE] revealed resident was total care for all Activities of Daily Living (ADL's). S/He was in a persistent vegetative state. On [DATE] at 9:30 AM: resident lying in bed with eyes open, when breathes makes a gurgling sound. resp even/unlabored. will continue monitoring. 10:20 AM called to room per Certified Nursing Assistant (CNA). Resident lying in bed with Head of bed (HOB) elevated ( ^) noted to have beige secretions coming out of mouth. No respirations noted. Code blue called &Cardiopulmonary Resuscitation (CPR) was initiated, no pulse, 911 called 10:30 AM Emergency Medical Services (EMS) here. took over CPR. To hospital via stretcher. Per Physician's Cumulative Orders for ,[DATE]-[DATE] an order for [REDACTED]. Review of the medical record revealed the resident was noted at 9:30 AM to have a gurgling sound when breathing. There was no indication the resident was assessed. No vital signs were available. There was no notation of the resident's breath sounds, no auscultation of the lungs. No evidence of any assessment of the resident's respiratory condition. At approximately 10:30 AM the resident was noted to be without respirations. Again, there was no evidence the resident had been assessed for vital signs before CPR was began. Interviews with the two Certified Nursing Assistants (Cross Refer to F223) revealed the nurse did not assess the resident at any time, from the time they first reported the resident's noisy breathing until the code was called and CPR started. On [DATE] the Administrator was advised of a second Immediate Jeopardy that began on [DATE] when a resident had a change in condition related to respiratory issues that was not addressed by the nurse. The resident became unresponsive and was transported out of the facility to the hospital and expired. The facility's Allegation of Compliance (A[NAME]) to address failure to assess and treat respiratory issues was submitted [DATE] to the surveyor and included the following: 1) Affected resident was transported to the hospital via 911 for evaluation and expired at the hospital. 2) Allegation of neglect was reported to the State Agency as required. 3) RN involved was suspended, terminated and reported to the SC Board of Nursing. 4) DON and Unit Managers to provide education on [DATE] to all nurses and Certified Nursing Assistants on neglect, oral suctioning procedure, location of suctioning equipment, recognizing change in condition and performing respiratory assessment. Inservice is mandatory and no one will be allowed to work until education is completed. 5) All resident's orders were audited by Nurse Management staff for identification of orders for advanced respiratory care/oxygen/suction. Findings were 2 residents in house with orders for continuous oxygen, 2 residents in house with orders for PRN (as necessary) oxygen and no residents in house with suction orders. 6) All respiratory care plans for affected residents have been reviewed and revised if needed on [DATE]. 7) Residents that have the potential for advanced respiratory care have been re-assessed for the need for suction on [DATE]. 8) Maintenance Director and Nursing verified that all 8 suction machines in the facility were functioning properly and central supply clerk verified that suction supplies are readily available on [DATE]. 9) A root cause analysis determined the nurse failed to respond to a change in condition of a resident and failed to respond appropriately to assess and treat. Equipment was available and functioning at the time of the incident. All staff including any new hires have been re-educated on neglect, respiratory assessment, equipment to use and location of equipment and recognizing change in condition. 10) The designated staff and DON will verify location of suction machines daily and nurses will check weekly their functionality. 11) This A[NAME] has been reviewed in an ad hoc QAPI meeting with the Medical Director's involvement and will be reviewed monthly at the QAPI meetings. The Immediate Jeopardy citations at F223, F281 and F328 were removed on [DATE] after observations and interviews were completed to ensure the A[NAME] was in place and in practice. These citations remained cited at a lower scope and severity of D. | 2020-09-01 |