cms_SC: 8268
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8268 | HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA | 425289 | 1800 EAGLE LANDING BLVD | HANAHAN | SC | 29406 | 2016-03-02 | 514 | D | 0 | 1 | 3A0811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain accurate documentation in the medical records for 2 of 16 sampled residents reviewed. Resident #7's medical record had documentation in the social services notes that were in reference to another resident. Resident #273 had blanks/missing documentation on the Treatment Administration Record Sheet (TARS). The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. A review of the medical record on 3/01/16 at approximately 12:18 PM revealed a social services note dated 9/17/15 that indicated the resident and his/her sister requested to be prepared for discharge home. The social note further indicated that Resident #7 was using adaptive equipment to aid in dressing and needed assistance with a back brace; with another 2 weeks of rehab prior to discharge. A social services note dated 11/25/15 indicated there were no concerns at this time and there were no discharge plans due to physical care needs. There was no documentation to address the change in discharge planning from the 9/17/15 social services note to 11/25/15 social services note. During an interview on 3/02/16 at approximately 9:30 AM with Social Services Staff #1, after reviewing the 9/17/15 social services discharge note that indicated discharge plans were for Resident #7 to leave the facility after 2 weeks of rehab then reviewing the 11/25/15 social services note that indicated discharge was not the plan; the Social Services Staff #1 stated he/she was not sure if the information written on 9/17/15 was correct because there were no plans of discharge for Resident #7. An interview on 3/02/16 at approximately at 10:20 AM with Social Services Staff #1 revealed the 9/17/15 social services documentation should have been written in another resident's medical. The Social Services Staff #1 further stated the documentation was written on the wrong resident. The facility admitted Resident #272 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the Treatment Administration Record (TAR) on 3/1/2016 at 2:40 PM revealed that the wound care was not documented as done on the day shift on 2/26/2016, the evening shift on 2/27/2016 and the night shift on 2/29/2016. During an interview with Registered Nurse (RN) #3 on 3/1/2016 at 4:15 PM, RN #3 confirmed the wound care was not documented as done on 2/26 and 2/27/2016. RN #3 stated an agency nurse was working the night shift on 2/29/2016 and could not access the resident's electronic medical record. RN #3 stated the wound care for 2/29/2016 was documented on paper and was located elsewhere in the record. The facility later produced documentation that indicated the wound care was documented as done on the night shift on 2/29/2016. During an interview with Licensed Practical Nurse (LPN) #1 on 3/2/2016 at 11:20 AM, LPN #1 stated she/he completed the wound care on the day shift on 2/26/2015. She/he stated that after completing the wound care she/he was called away and later forgot to document the wound care as done. The facility provided a statement from the nurse working the evening shift on 2/27/2016 indicating that the wound care had been completed. | 2016-06-01 |