cms_SC: 8253

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
8253 AGAPE REHABILITATION OF ROCK HILL 425159 159 SEDGEWOOD DR ROCK HILL SC 29732 2013-06-18 309 G 1 0 B96711 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being. Resident #1 was found on the floor beside her/his bed with the bed alarm sounding. The x-ray's obtained related to the fall were reported to a nurse as negative for a fracture, the x-ray's in fact showed a fractured wrist and hip. The facility failed to timely address Resident #1's injury. The findings included: Review of the facility investigation summary stated that a nurse received a verbal negative x-ray result called in to her/him for Resident #1. Because s/he received a negative verbal report, s/he did not thoroughly read the written reports when they arrived, instead placing them in the physician's box for review. Review of Resident #1's Nurse's Notes from 5/4/13 through 5/6/13 revealed the following: 5/4/13 8:00 AM indicated the resident was observed lying on his/her right side on the floor in his/her room beside the bed and the bed alarm was sounding. The nurse assessed the resident for injuries and noted the resident cried when moving his/her upper and lower right extremities. A new order for x-ray of the right side was received. 12:00 PM x-ray of resident's right side and the resident was medicated for pain. 3:00 PM x-ray results were back and no fracture was noted to the right side, the resident was medicated for pain. 10:00 PM Resident #1 was medicated for pain to the right side of the body. Tender to touch or move. 5/5/13 4:00 AM attempted to give [MEDICATION NAME] but refused to take. Appears in much pain during ADL's. 6:00 PM Resident in bed resting with eye's closed. Rt (right) side tender to touch. Pt (patient) medicated x 2 @ 7:00 AM and 2:00 PM with some effectiveness. Pt is unable to mover his/her (RLE) right lower extremities without having pain. 5/5/ - 5/6/13 at 8:00 PM medicated for pain and at 1:45 AM the doctor notified of (R) right [MEDICAL CONDITION]. Orders given to call family and tell them we can sent to ER (emergency room ) for evaluation and treatment or make an ortho (orthopedist) appt (appointment) ASAP on Monday. 2:10 AM left voice mail (for the resident's responsible party) have not heard back. 5/6/13 7:00 AM No returned call from family. Note to (staff) to plan on making ortho appt. ASAP. 5 AM [MEDICATION NAME] and [MEDICATION NAME] 1 mg (milligram) give 10:15 AM Off going nurse stated res had rt hip fx had spoken to MD and MD gave TO (telephone order). 9:10 AM order given to send res to ER . Review of Resident #1's Controlled Drug Record revealed the resident received [MEDICATION NAME] 5-500 milligrams on 5/4/13 at 8:00 AM, 2:00 PM, and 10:00 PM. Resident #1 received [MEDICATION NAME] 5-500 milligrams on 5/5/13 at 4:00 AM, 7:00 AM, 2:00 PM, and 8:00 PM. Resident #1 received [MEDICATION NAME] 5-500 milligrams on 5/6/13 at 5:00 AM. Resident #1 had an order for [REDACTED]. Review of Resident #1's Physician's Telephone Orders' dated 5/6/13 indicated at 7:00 AM May send to ER to evaluate and treat if family prefers or make appointment with ortho ASAP. A Physician's Telephone Order dated 5/6/13 at 9:10 AM indicated to transfer the resident to the emergency room for a right [MEDICAL CONDITION] and a right wrist fracture. Review of the Radiology Reports dated 5/4/13 indicated Resident #1 had an acute right [MEDICAL CONDITION] and a distal right radius fracture. Review of the Discharge Summary from the hospital dated 5/10/13 indicated Resident #1 had a right wrist fracture and a right [MEDICAL CONDITION]. Resident #1 underwent surgery for [REDACTED]. Licensed Practical Nurse (LPN) #1's facility-obtained incident statement indicated that Resident #1 had eight x-rays taken of his/her right side. LPN #1 received a phone call from the company that performed the X-rays and was given a verbal report stating that no fractures were found. S/he then retrieved the transmittal from the office fax machine and filed it in the doctor's communication book without reading it. On 5/5/13 LPN #1 updated the Director of Nursing (DON) on the incident and told the DON that s/he truly believed there was a fracture. Throughout the day s/he continued to monitor the resident and keep the resident as comfortable as possible until the end of his/her shift. In a telephone interview with the surveyor on 6/19/13 at approximately 4:55 PM LPN #1 confirmed the accuracy of her/his statement as written. Registered Nurse (RN) #1's facility-obtained statement indicated that s/he was told by the day shift nurse that several x-rays had been taken and they were all negative for fracture for Resident #1. RN #1 found a result of a right [MEDICAL CONDITION] for Resident #1 on the copier near the medication room at 1:45 AM. S/he called the doctor and received orders to send Resident #1 to the emergency room to evaluate and treat if the family preferred or to make an orthopedist appointment ASAP. The oncoming nurse (LPN #2) found a wrist fracture x-ray in the doctor's book. RN #1 did not think to look at those x-rays because s/he had already been told there were no fractures. Licensed Practical Nurse (LPN) #2's facility-obtained statement dated 5/9/13 indicated that on 5/6/13 s/he received report from the off going nurse that Resident #1 had fallen out of bed. The off going nurse stated that s/he had found an x-ray report on the fax machine that stated the resident had a right [MEDICAL CONDITION]. The off going nurse called the physician and received an order to notify the family to see if they wanted the resident sent out and if they didn't to have an orthopedist appointment ASAP. In a telephone interview with the surveyor on 6/19/13 at approximately 4:40 PM LPN #2 confirmed the accuracy of his/her statement as written. LPN #2 stated that the off going nurse noted in his/her statement was RN #1. LPN #2 stated s/he found the wrist fracture x-ray report while looking through the x-rays to show the supervisor the [MEDICAL CONDITION] x-ray report that RN #1 had found. 2016-06-01