cms_SC: 7960
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7960 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-10-12 | 514 | E | 1 | 0 | O2TO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 7 of 12 residents reviewed. Resident #2, 3, 7, 8, 10 and 11 had omissions on the Medication and/or Treatment Records. Resident #3 had discrepancies in the medical record related to having a pressure sore. Resident #6 had a discrepancy related to an ostomy. Nurses failed to document discharge notes for Resident #10 for 7/23/13 and 8/3/13. Resident #10 also had a discrepancy in date/time of an incident/fall. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on 10/10/13 revealed the following omissions on the Medication and/or Treatment Records: August 2013 Treatment Record- 1) Floor mat at bedside -8/12/13; 2) Pad alarm to bed-8/12/13; 3) Cleanse ST(skin tear) to left forearm with NS(Normal Saline), pat dry, apply TAO(Triple Antibiotic Ointment) and cover with [MEDICATION NAME] Q(every)D(day)-8/2, 3, 6, 7, 10, 11, 12, 13, 15, 16, 17, 18, 20, 21, 22, 24, 27,28, 29, 30, and 31/13. 4) Clean area to sacrum with NS and pat dry. Apply Exuderm, change q3days and prn(as needed)-8/11/13, 8/14/13, 8/17/13, 8/23/13, and 8/29/13. 5) Clean area to left pointer finger with NS and pat dry. Apply TAO and cover with bandaid. Change QD(every day) and prn-8/3, 4, 7, 11, 12, 13, 14, 16, 17, 19, 21, 22, 23, 25, 28, 29, 30, and 31/13. 6) Clean PEG(Percutaneus [MEDICAL CONDITION] Gastrostomy) tube site with NS, apply dry dressing QD-8/3, 4, 6, 7, 12, 13, 14, 16, 17, 19, 21, 22, 23, 25, 29, 30, and 31/13. 7) Skin Prep to bilateral heels q shift-8/1, 3, 4, 7, 12, 13, 14, 16, 17, 19, 21, 22, 25, 28-31/13. 8) Float heels while in bed-8/1, 3, 4, 7, 12, 16, 17, 19, 21, 22, 25, 28-31/13. 9) Tab alarm for safety-8/1, 3, 4, 7, 12, 13, 14, 16, 17, 19, 21, 22, 25, 28-31/13. 10) Monitor [MEDICATION NAME] Patch site for adverse reactions and placement-8/1, 3, 4, 7, 12, 13, 14, 16, 17, 19, 21, 22, 25, 28-31/13. 11) [MEDICATION NAME] Cream to sacrum q shift, may leave at bedside for CNA(Certified Nursing Assistant) to apply.-8/3, 4, 12, 13, 14, 16,17, 19, 21, 22, 25, 28-31/13. 12) Skin Prep to bilateral heels q shift-8/1, 3, 4, 7, 12, 13, 14, 16, 17, 19, 21, 22, 25, 28-31/13 13) 02(oxygen) at 3l(liters)/min(ute) via NC(nasal cannula) to keep 02 sats(saturation) greater than 90%-8/1, 3, 4, 7, 12, 13, 14, 16, 17, 19, 21, 22, 25, & 28-31/13. 14) Monitor and record BM's(bowel movements) q shift-8/1, 3, 4, 6, 7, 12, 14, 16,17, 19, 21, 22, 25, & 28-31/13. 15) Change 02 tubing, connector, humidifier, and clean filters q week- 8/16/13, 8/23/13 & 8/30/13. September Medication/Treatment Record 16) [MEDICATION NAME] 30 mg(milligrams) [MEDICATION NAME] 1 via PEG tube qd-9/6/13 17) Floor mat at bedside- 9/25 & 26/13 18) Pad alarm to bed- 9/25 & 26/13 19) Cleanse ST to left forearm with NS, pat dry, apply TAO and cover with [MEDICATION NAME] qd- 9/2, 3, 6, 9, 10, & 11/13. 20) Clean sacral wound with NS and pat dry, apply [MEDICATION NAME] 4x4 dressing adhesive, change q 3days and prn- 9/25/13 21) Clean area to sacrum with NS and pat dry, apply Exuderm. Change q 3 days and prn- 9/4, 7, & 10/13. 22) Clean area to left pointer finger with NS and pat dry. Apply TAO and cover with bandaid. Change qd and prn- 9/3, 4, 7, 10, 11, & 13/13. 23) Clean PEG tube site with NS, apply dry dressing qd- 9/3, 4, 7, 10, 11, 13, 20, 26, 27, & 29/13. 24) Skin Prep to bilateral heels q shift-9/2, 3, 4, 7, 10, 11, 13, 20, 25, 26, 27, & 29/13. 25) Float heels while in bed- 9/3, 4, 7, 10, 11, 13, 20, 25, 26, 27, & 29/13. 26) Tab alarm for safety- 9/3, 4, 7, 10, 11, 13, 20, 25, 26, 27, & 29/13. 27) Monitor [MEDICATION NAME] Patch site for adverse reactions and placement- 9/3, 4, 7, 10, 11, 13, 20, 25, 26, 27, & 29/13. 28) [MEDICATION NAME] Cream to sacrum q shift, may leave at bedside for CNA to apply-9/2, 3, 4, 7, 10, 11, 13, 20, 25, 26, 27, & 29/13. 29) 02 3l/min via NC to keep 02 sats greater than 90%- 9/2, 3, 4, 7, 10-13, 17, 19, 20, 26, 27, & 29/13. 30) Monitor and record BM's q shift- 9/2, 3, 4, 7, 10, 11, 13, 20, 25, 26, 27, & 29/13. 31) Clean area to right posterior heel with NS and pat dry. Apply TAO and cover with dry nonadhesive dressing, secure with cling and tape- 9/2/13 and 9/25/13. 32) Change 02 tubing, connector, humidifier, and clean filters q week-9/13, 20, & 27/13. 33) Out of bed to geri-chair as tolerated for positioning- 9/20, 25, 26, 27, & 29/13 34) Bunny boots to both right and left feet to protect skin integrity. Apply q shift. 9/25, 26, 27, & 29/13. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 10/11/13 revealed the following omissions on the Medication/Treatment Records: August 2013 Treatment Record: 1) Monitor and record meal percentages-8/3, 4 & 28/13; 2) [MEDICATION NAME] Cream to sacrum every shift, may be left at bedside and applied by CNA-8/3, 11 & 30/13; 3) Monitor and record bowel movements every shift-8/1, 3, 4, 11, 21,22,28, & 30/13; 4) Geri-chair for protection and comfort-8/3, 11 & 30/13; 5) Air mattress to bed-8/3, 11 & 30/13; 6) Keep turned off sacrum every 2 hours and as needed-8/3, 11& 30/13; 7) Cleanse area to sacrum with NS, apply Santyl, cover with dry dressing q shift-8/1, 3, 11 & 30/13. 8) Apply skin prep to bony prominences elbows, heels bilaterally q shift-8/30/13; 9) Clean area to center of back with NS apply Exuderm change q 3 days-8/1, 10, 16 & 28/13; September Treatment Record: 1) Monitor and record meal percentages-9/2, 12, 13, 17, 24, 25 & 26/13; 2) [MEDICATION NAME] Cream to sacrum q shift maybe be left at bedside and applied by CNA-9/10, 13, 23, 24, 25 & 26/13. 3) Monitor and record bowel movements q shift-9/2, 10, 12, 13, 17, 23, 24, 25 & 26/13. 4)Geri chair for protection and comfort-9/10, 13, 23, 24, 25 & 26/13. 5) Air mattress to bed-9/10, 13, 23, 25 & 26/13. 6) Keep turned off sacrum q 2 hours and prn-9/10, 13, 23, 25 & 26/13. 7) Cleanse area to sacrum with NS. Apply Santyl, cover with dry dressing q shift-9/10, 12, 13, 17 & 23/13. 8) Apply skin prep to boney prominences elbows, heels bilaterally q shift-9/10 and 13/13; 9) May crush meds-9/23, 24, 25 & 26/13. 10) Clean with NS apply Santyl to wound bed. Lay Collagen and fill lightly all wound depth. Cover with bordered foam. Change BID(twice a day)-9/26/13 11) Bunny boots to both Right and Left feet to protect/maintain skin integrity. Apply q shift.-9/25-26/13. October Treatment Record: 1) [MEDICATION NAME] Cream to sacrum q shift may be left at bedside and applied by CNA-10/6, 7, & 10/13; 2) Monitor and record BM's(bowel movements) q shift-10/6, 7 & 10/13; 3) Geri-chair for protection and comfort-10/6, 7 & 10/13; 4) Air mattress to bed-10/1, 6, 7 & 10/13; 5) Keep turned off sacrum q 2 hours and prn-10/1, 6, 7 & 10/13. 6) May crush meds-10/1, 6, 7 & 10/13 7) Sacral wound-clean with NS, apply Santyl to wound bed. Lay Collagen and fill lightly all wound depth. Cover with bordered foam. Change BID-10/1/13; 8) Bunny boots to both Right and Left feet to protect/maintain skin integrity-10/1, 6, 7 & 10/13; 9) Sacral wound-clean with NS. Lay Collagen and lightly fill all wound depth. Skin Prep periwound and cover with bordered foam. Change BID and prn-10/6, 7 & 10/13. Review of the Medical Nutrition Therapy assessment dated [DATE] listed Resident #3 as not having a pressure ulcer. Per the Pressure Ulcer Report dated 5/13/13 listed the resident as having a Stage I of the sacrum measuring 12 x 11 cm(centimeters) and 6/9/13 the stage was determined to be SDTI measuring 3.5 cm x 1.5 cm. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Review of the resident's care plan on 10/11/13 listed the resident as having an ostomy. Review of the MDS(Minimum Data Set) dated 9/25/13 did not list the resident as having an ostomy. Review of the nurse's notes did not indicate the resident having an ostomy. The MDS listed the resident as frequently incontinent of bowel and bladder. Incontinent care was observed on the resident on 10/10/13 at 1:20 PM and no ostomy was observed. Review of the September MAR(Medication Administration Record) revealed discrepancies with [MEDICATION NAME] administration. On page 3 of the MAR indicated [REDACTED]. A duplicate order was written on pg 7 of the MAR indicated [REDACTED]. Staff failed to clarify the order and [MEDICATION NAME] was signed as given on both MAR's on 9/2-4/13 at 12:00 AM and 6:00 AM. During an interview with the Director of Nursing, he/she stated that the medication came in a syringe. There was no evidence that the order was clarified until 9/4/13. On 9/6/13 at 12:00 PM and 6:00 PM nurse's documentation not administered. On 9/7/13 at 6:00 AM nurse's documentation held until md assess on hold until md assess IV intravenous not subq(subcutaneous). On 9/8/13 at 12:00 AM [MEDICATION NAME] was not administered. The following omissions were noted on the TAR(Treatment Administration Record) as follows: September 2013 1) Toilet every 2 hours-9/20,22, 24, 25, 26, 27 & 28/13; 2) Monitor and record meal %(percentages)-9/2, 20, 23, 24, 25, 26, 27 & 28/13; 3) Skin prep to bilateral heels-9/3, 4, 7, 10, 11, 21, 23, 28, 29 & 30/13; 4) Monitor and record bowel movements q shift-9/2, 3, 4, 7, 10, 11, 21, 23, 24, 26, 27, 28, 29 & 30/13; 5) Float heels q shift while in bed-9/3, 4, 7, 10 & 11/13. 6) Apply [MEDICATION NAME] Cream to sacrum with each brief change. May be kept at bedside and applied by CNA-9/3, 4, 7, 10 & 11/13; 7) Encourage frequent meals and po(oral) fluids-9/7, 9 & 10/13; 8) Monitor and record amount of fluid cc(cubic centimeters) intake and amount of wet briefs per each shift-9/7, 8, 10 & 11/13. 9) Weight every Mon-Wed-Fri-9/23, 25, 27 & 30/13. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Record review of the MAR/ TAR's revealed the following omissions: July 2013 MAR: 1) Check fingerstick blood sugar BID before meals-7/30/13; 2) [MEDICATION NAME] 20 mg per PEG BID-7/30/13; 3) [MEDICATION NAME] 500 mg per PEG-7/30/13; 4) [MEDICATION NAME] 100 mg per PEG BID-7/30/13; 5) [MEDICATION NAME] 400 mg per PEG BID-7/30/13; 6) [MEDICATION NAME] 100 mg per PEG BID-7/30/13; 7) Glucerna 1.0 1 can q4h with 150 cc H2O Flush q4hr-7/30/13 8) [MEDICATION NAME] 325 mg per PEG qd-7/30/13; 9) Plavic 75 mg per PEG qd-7/30/13; 10) [MEDICATION NAME] 10 mg per PEG qAM-7/30/13 July 2013 TAR: 1) Clean open area to sacrum with NS. Pat dry. Apply [MEDICATION NAME] change q 3 days and prn until healed: 7/29/13; 2) Monitor and record BM's: 8/18, 19, 20, 28-30/13; 3) Change PEG tube setup & syringe q night: 7/18, 19, 20, 28, 29 & 30/13; 4) Cleanse PEG tube with NS, apply dry dressing q day- 7/18, 19, 20, 28, 29 & 30/13; 5) Check for PEG tube placement & record residual- 7/18, 19, 20, 28, 29 & 30/13; 6) Skin prep to bilateral heels q shift, float heels while in bed: 7/19, 25, 27, 28, 29 & 30/13; 7) Bowel movements every shift: 7/30/13 August 2013 TAR: 1) Cleanse area to sacrum with NS, pat dry apply Hydrogel to wound bed cover with [MEDICATION NAME] and change qd until healed-8/3-6/13; 2) Monitor and record BM's-8/2-5/13; 3) Change PEG tube setup & syringe q night-8/2-5/13; 4) Cleanse PEG tube with NS, apply dry dressing q day-8/2-5/13; 5) Check for PEG tube placement & record residual-8/2-5/13; 6) Skin prep to bilateral heels q shift. Float heels while in bed-8/2-5/13; 7) Bowel movements q shift-8/2-5/13 The facility admitted Resident #11 initially on 7-31-13 and readmitted her/him post hospitalization on [DATE] for acute [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Review of the 9-13 Medication and Treatment Records revealed multiple blanks, indicating the medication/ treatment was omitted without explanation or was not documented by the nurse as required: [MEDICATION NAME]- 9-24-13 Oyster Shell Calcium-Vit (amin) D tablet -9-24-13 [MEDICATION NAME] Powder-9-24-13 [MEDICATION NAME] Sodium-9-24-13 Megistrol- 9-23-13, 9-27-13 Dronabinol- 9-23-13, 9-27-13 Alprazalam 9-21-13, 9-25-13?2 , 9-27-13 [MEDICATION NAME] Dressing 9-6-13, 9-15-13,9-21-13, 9-30-13 [MEDICATION NAME] sacral treatment- 9-8-13, 9-17-13, 9-23-13, 9-29-13 Contact Precautions -9-6-13, 9-7-13?3, 9-8-13, 9-10-13, 9-12-13. Monitor and record BMs (bowel movements)- 9-27-13, 9-28-13, 9-29 -13, 9-30-13 X 2 Further review revealed the Admission (Nursing) Assessment failed to address The facility admitted Resident #10 initially on 5-30-13 for short-term rehabilitation following a fall resulting in a right femoral fracture. [DIAGNOSES REDACTED]. Record review on 10-10-13 at 3:55 PM revealed that Resident # 10 was sent to the hospital and admitted for Acute [MEDICAL CONDITION] secondary to Flash [MEDICAL CONDITIONS] on 7-23-13. S/he was readmitted to the facility on [DATE]. On 8-3-13, Resident #10 was hospitalized following a fall for treatment of [REDACTED]. S/he was readmitted on [DATE] and discharged home on 9-16-13. Record review on 10-11-13 at approximately 9 AM revealed a 7-23-13 physician's orders [REDACTED].#10 to the hospital. The last Nurse's note in the record was untimed and dated 7-22-13 when the resident was noted with increased anxiety and [MEDICATION NAME] was administered. No Nurse' s Note could be located regarding the resident's change in condition warranting the transfer. During an interview on 10-12-13 at 9:25 AM, the Director of Nursing (DON) confirmed that s/he had also been unable to find the note. The DON referred the surveyor to the Nurse Practitioner's note made after the telephone encounter. Review of Resident Incident Reports on 10-10-13 at 4:15 PM revealed that on 8-8-13 at 6:15 PM, just five days after readmission, Resident #10 was lying on the floor when nurse arrived. 3 CNA's (Certified Nursing Assistants) in the room with patient . lifted her (him) off the floor and placed her (him) in w/c. No Nurse's Note could be located regarding this incident. There were no notes found between 8-1-13 at 10:15 AM and 8-3-13 at 12:00 PM. The note for 8-3-13 noted that Res (ident) C/0 (complained of) pain in left leg every time it is moved . hollers out loudly. X-ray completed . broken left femur. The resident was to be sent to the ER for an orthopedic evaluation as soon as possible. No further notes were found. Further review revealed a time discrepancy between the fall at 6:15 PM on 8-8-13 and the 12 PM summary Nurse's Note. The 8-3-13 Resident Incident Report also indicated that the resident was not examined by a physician or taken to a hospital when, in fact, Resident # 10 was admitted to the hospital for treatment of [REDACTED]. During an interview on 10-12-13 at 9:25 AM, the DON confirmed that s/he had also been unable to find the any other notes. S/he noted that the incident date was actually 8-3-13 instead of 8-8-13 and manually changed the date on the report, but made no mention of the incident time. Record review on 10-10-13 at approximately 4:25 PM revealed 5-30-13 physician's orders [REDACTED]. Review of the Treatment Records revealed that this order was reinstated after return from her/his hospital stay on 7-30-13 and again on 8-9-13. Review of the Treatment Records revealed meal intake was not recorded on the following dates: 6-1,6-3 X 3, 6-14 X 3, 6-16 X 3, 6-17 X 3, 6-18 ? 3, and 6-22 ? 3 ; on 7-4 X3, 7-8?3, 7-9, 7-10?3 , 7-11?3, 7-13, 7-15?3 , 7-17?3, 7-19 , 7-22?2 , 7-23, 7-31; on 8-2 x 3, and 8-3-13; on 9-13, 9-14 x 3, 9-15 x 1, 9-16 x 1-13. Documented intake ranged from 0-100% throughout the resident's admissions. Certified Nursing Assistants' (CNA) documentation was also noted with many meal intake percentages missing (6-1?2, 6-3?2, 6-4?2, 6-5?2, 6-6?2, 6-7 Xl, 6-10 X1, 6-12x2, 6-13x2, 6-16?3, 6-17?3, 6-19?1, 6-21X2, 6-22x2, 6-23?2 , 6-24x3, 6-25X2, 6-26X2, 6-27X2, 6-28X2, 6-29x2, and 6-30X3; on 7-2?2 , 7-3?2, 7-4?1 ,7-5x1, 7-6?2 , 7-7X3, 7-8?2 , 7-9x2, 7-10?3 , 7-12?1 , 7-13X2, 7-14X2, 7-16?2, 7-17X2, 7-18X3, 7-19?1, 7-20x2, 7-21?2, 7-22?2, 7-30X2 and 7-31X2- 13; on 8-1?2, 8-8?2, 8-9X2, 8-10?3, 8-11X2, 8-12X2, 8-13?2, 8-14?2, 8-15?1, 8-17?2 , 8-18X1, 8-20 X1, 8-21x1, 8-22x2, 8-23?2, 8-24?2, 8-25?1, 8-29 x 3-13; on 9-4X2, 9-5?2, 9-6?2, 9-7?2 , 9-9x2, 9-10?3, 9-12x1, 9-13?2, 9-14?2 , 9-15?2-13. Of the meal percentages documented in both locations, multiple discrepancies were noted in documented intake (l5 in June, 9 in July, 42 in August, and 16 in September). Review Medication/Treatment Records revealed that Ensure Plus was sent with meals starting on 8-23-13, but no percentage of intake was documented. The facility admitted Resident #7 following a fall resulting in hospitalization for treatment of [REDACTED]. Additional [DIAGNOSES REDACTED]. Review of Completed Care tasks and the Medication/Treatment Administration Records on 10-11-13 revealed that meal intake was not consistently monitored. No meal intake was recorded for 9-5-13, 9-6-13, 9-7-13, 9-8-13, 10-3-13, 10-5-13. One meal was not documented on 10-6-13. Two meals were not documented on 9-14-13, 9-30-13, 10-4-13, and 10-7-13. Multiple discrepancies were noted in documented meal intake percentages (9-9-13, 9-11-13, 9-12-13, 9-16-13, 9-17-13, 9-18-13, 9-19-13, 9-22-13, 9-25-13, 9-26-13, 9-27-13, 9-28-13, 9-29-13). Cross Refer CFR 483.25(i) Maintemance of Nutritional Status-The facility failed to consistently monitor the dietary intakes of Residents #7 and #10 who were identified with significant weight loss. | 2016-10-01 |