cms_SC: 8252
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8252 | AGAPE REHABILITATION OF ROCK HILL | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2013-06-18 | 282 | E | 1 | 0 | B96711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review, observation and interview, the facility failed to ensure that each resident care plan was followed. The facility failed to follow care planned safety devices to prevent fall for 4 of 5 residents reviewed for falls (Resident #4, #5, #6 and #7). The findings included: Resident #4 was admitted to the facility on [DATE] for rehabilitation after having a hip repair. Review of the Discharge Summary from the hospital revealed Resident #4 was admitted to the hospital on [DATE] for a left [MEDICAL CONDITION] after s/he fell . Review of Resident #4's Fall Risk assessment dated [DATE] revealed the resident had a total score of 14. The Fall Risk Assessment form indicated that a total score above 10 represents high risk for falls. Review of Resident #4's Interim Care Plan revealed the resident was at risk for falls and bed/chair alarms were used as an intervention. Review of the Care Plan revealed a risk for falls was identified as a problem area. Interventions and approaches were listed on the care plan and included to ensure any safety devices ordered were in place and functioning properly every shift. Review of Resident #4's Treatment Record for June 2013 revealed Bed alarm to bed (clip) and Clip alarm to chair. The alarms were not signed for on the 7 AM - 7 PM shift for 6/10/13 when reviewed at 5:05 PM. On 6/10/13 at approximately 4:05 PM Resident #4 was observed to stand up from her wheelchair across from the nurse's station and fall. The surveyor informed Registered Nurse (RN) #2 and Certified Nurse Aide (CNA) #3 at the nurse's station that the resident had fallen. Resident #4 was noted to have a clip alarm dangling from her/his clothing but no alarm was sounding. During interview on 6/10/13 at approximately 4:19 PM RN #2 stated that Resident #4's alarm was not turned on. During interview on 6/10/13 at approximately 4:22 PM CNA #3 stated that if the alarm was turned on it would have sounded. CNA #3 and the surveyor walked to Resident #4's room and CNA #3 demonstrated by turning the alarm on and removing the string with the clip attachment. The alarm sounded when the clip was removed. During an observation on 6/10/13 at approximately 4:55 PM Resident #4 was noted in bed. Resident #4 did not have a clip alarm on. The clip alarm was noted attached to the resident's wheelchair. Review of the Necessary Information for Direct Care Staff form for Resident #4 revealed that a clip alarm was not checked under Safety Devices When Out of Bed or Safety Devices When In Bed. The form indicated the staff was to check the function of the alarm at the beginning of each shift. During an interview on 6/10/13 at approximately 5:25 PM CNA #2 stated that s/he was assigned to Resident #4. CNA #2 stated that s/he did not know that Resident #4 required an alarm while in bed. Resident #5 was admitted to the facility on [DATE]. Review of Resident #5's physician's orders [REDACTED]. Observation of Resident #5 on 6/10/13 at approximately 5:10 PM revealed that the resident was in bed. There was a clip attached to the resident's clothing, but the alarm box was not attached to anything and was lying next to the resident in bed. During interview on 6/10/13 at approximately 5:10 PM RN #2 stated that the alarm box should be attached to the bed rail to anchor the alarm. Resident #6 was admitted to the facility on [DATE]. Review of the History and Physical from Resident #6's hospital stay 5/4/13- 5/8/13 indicated that the resident was admitted after s/he fell out of a wheelchair. Review of Resident #6's Physician order [REDACTED]. Review of Resident #6's Fall Risk assessment dated [DATE] revealed the resident had a total score of 14. The Fall Risk Assessment form indicated that a total score above 10 represents high risk for falls. Observation of Resident #6 on 6/10/13 at approximately 5:15 PM revealed that there was no alarm on the resident. Resident #6 stated that s/he did not have an alarm on. Review of Resident #6's Care Plan revealed resident sustained [REDACTED]. Interventions and approaches were noted on the care plan that included to ensure any safety devices ordered are in place and functioning properly every shift. At approximately 5:25 PM CNA #2 was unable to locate Resident #6's Necessary Information for Direct Care Staff form in the resident's room. Review of Resident #6's Admission Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview for Mental Status score of 15. Review of Resident #7's Treatment Record revealed an alarm to prevent falls. Observation of Resident #7 on 6/10/13 at approximately 5:20 PM revealed the resident was in bed with no alarm. RN #2 stated that Resident #7's alarm was under the resident's bed. | 2016-06-01 |