cms_SC: 8223
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8223 | CHESTER NURSING CENTER | 425061 | 1 MEDICAL PARK DRIVE | CHESTER | SC | 29706 | 2012-05-03 | 490 | L | 0 | 1 | WII411 | July 17, 2012 - Ammended to reflect changes to the original Scope and Severity to K and lowered Scope and Severity to E. On the days of the Recertification and Extended survey, based on record reviews, interviews and review of facility policy and procedures related to providing heat treatments, the facility administration failed to effectively and efficiently utilize resources to prevent one of one sampled resident from harm due to inappropriate application of a warm compress treatment. The facility failed to obtain clarification orders related on how to apply heat to a resident and failed to monitor the treatment which resulted in a burn to a resident. The facility failed to complete a thorough investigation of the burn incident and failed to report the injury as neglect to the State survey and certification agency. In addition the facility failed to develop policies on using paid sitters in the facility and were unaware of sitters currently working in the facility at the time of survey. The findings included: Cross Refers to F-223 as it relates to the failure of the facility to ensure that staff monitored visitors/sitters interactions with residents to ensure the residents safety and well being in the facility. Cross Refers to F-225 as it relates to the facility's failure to report an allegation of neglect to the State survey and certification agency. Cross Refers to F-226 as it relates to the facility's failure to ensure that staff was adequately trained to define, recognize and report allegations of abuse/neglect. Cross Refers to F-281 as it relates to the facility's failure to ensure that the licensed staff received adequate training to request clarification orders on applying a warm compress treatment and the monitoring of the treatment to prevent injury. Cross Refers to F-323 as it relates to the facility failure to prevent accidents and hazards for a resident that was burned during a warm compress treatment. Cross Refers to F-520 as it relates to the facility's failure to ensure each resident receiving warm compress treatments was adequately and accurately assessed for burns/injury due to warm compress treatments. The systemic failure of the facility to identify, accurately assess, and monitor residents receiving a warm compress treatment, after having knowledge a resident in the facility was harmed, placed other residents at risk for additional injury and/or harm. At the time of the survey, there was no evidence that the facility provided training to staff in order to prevent inappropriate heat treatments after a resident was harmed during an incident resulting in a burn noted on 3/27/12. There was no evidence that the incident was thoroughly investigated and reported as possible neglect to the State survey and certification agency. An interview on 5/02/12 at approximately 12:10 PM with the facility Administrator revealed the burn incident was not reported as abuse/neglect because he thought it was an isolated incident. The Administrator stated the facility wrote an incident report and the nurse that performed the treatment incorrectly was released from the nursing home as an employee. The Administrator further stated no re-education of the staff was provided due to the 3/27/12 burn incident. A visitor was observed during the survey yelling at a resident with no staff intervention. It was later learned by the facility that the perpetrator was not a visitor but a paid sitter. The Administrator failed to ensure the safety of residents due to being unaware of private sitters currently working within the facility. The facility had no policies in place related to the private sitters role while in the facility. On 5/2/12 at 10:30 AM, the Administrator and the Director of Nursing were notified that Substandard Quality of Care and/or Immediate Jeopardy was identified. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 3/27/2012 when Resident #11 was noted with a burn from a heat treatment which was executed and applied incorrectly. On 5/02/12 at 1:55 PM, the facility was notified that a second Immediate Jeopardy/Substandard Quality of Care had been identified. The Jeopardy existed on 5/01/12 when a routine visitor at the facility was observed standing over, yelling and pointing his finger at a resident without any facility staff intervening to protect the resident from further abuse. Interviews with licensed nurses, certified nursing assistants, admissions staff, activity staff and other facility staff revealed the visitor talked loud all the time. The three certified nursing assistants and licensed nurse on the unit at the time of the incident stated the visitor generally talked loud and they did not think any thing was wrong. The investigation of the incident found the alleged perpetrator was not a visitor but a sitter for the roommate of the resident allegedly abused. The facility staff were not aware the visitor had been employed by a resident's family and was in the building for that purpose. Documentation of inservices, observations, and interviews revealed the Allegation of Compliance submitted by the facility on 5/3/2012 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility nursing staff had been educated and were knowledgeable of abuse policies and procedures and the proper use of heat treatments The Administrator was informed of this on 5/3/12. The citation at F-490 remained at a lower scope and severity of E. | 2016-06-01 |