| 8323 |
ALPHA HEALTH & REHAB OF GREER, LLC |
425138 |
401 CHANDLER RD |
GREER |
SC |
29651 |
2013-05-15 |
225 |
F |
1 |
0 |
01DB11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Complaint and Extended Survey, based on record review, interviews and review of the facility policy Reporting Abuse to State Agencies and Other Entities, the facility failed to report and/or conduct a thorough investigation of 7 of 19 reviewed reportable's to the State Agency. At the time of the complaint inspection conducted on 5/14 - 5/15/2013 the facility was out of compliance at F-225 at a scope and severity of E related to Resident's #95 and #115 cited as part of the Recertification Survey conducted the week of 3/20/2013. F-225 was identified on 5/15/2013 at Substandard Quality of Care and the citation was elevated to a scope and severity of F related to Resident #1's alleged use of illicit drugs during his/her stay at the facility. One (1) of 1 resident with admitted illicit drug use while in the facility (Resident #1). Three (3) of 11 reportable incidents not reported to the State Agencies within 24 hours (Resident A, E, and K). One (1) of 11 [MEDICATION NAME] with a 5-Day Follow Up investigations not reported to State Agencies (Resident F). The findings included: Resident #1 was admitted with a history of drug abuse. While in the facility the resident had two (2) roommates within a 4 day period that requested room changes. They stated during interviews with the surveyor that they didn't get along with Resident #1, and one of the resident's admitted to being afraid. The facility found illicit drug paraphernalia and unknown drugs in the resident's room. The resident admitted to using drugs while a resident at the facility. The local Police were called related to the paraphernalia found. The facility failed to conduct an investigation of the resident's alleged use of illicit drugs while in the facility or the effect of the resident's behavior on other residents in the facility. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary dated 4/16/13, under admission and discharge [DIAGNOSES REDACTED]. The section titled Brief hospitalization Course stated, the resident was admitted to the hospital for IV (intravenous) therapy. .The patient has a history of [DIAGNOSES REDACTED] who was discharged during recent hospitalization . At that point, s/he was recommended to have IV [MEDICATION NAME]. She/he did not go home with a PICC (peripherally inserted central catheter) line at that point because of his/her history of drug abuse and the fact that s/he was not . safe to go home with a PICC line . His/her primary physician did order a PICC line for his/her antibiotic treatment . The facility Nurse's Note dated 5/1/13 at 2:00 PM stated, Resident has tennis ball sized powdered substance in bag at bedside, multiple syringes and spoons with burnt markings on them. Resident states s/he has hx (history) of drug abuse, has been using while in facility. Resident #1 was transferred to the hospital. Review of the facility admission and discharge records revealed 2 residents had been admitted to the room with Resident #1 between 4/28 and 4/30/13, both residents asked for a room changed within 48 hours of admission to the room. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Resident #4 was Resident #1's roommate from 4/28 - 4/29/13. In an interview with the surveyor on 5/15 at approximately 10:10 AM the resident was asked about her/his stay in the room with Resident #1. Resident #4 stated, The girl/guy in there seemed weird to me. S/he acted like s/he was on cloud 9 or something. There was something wrong with her/him. S/he was acting like s/he didn't know where s/he was. S/he gave you a weird feeling. I was only in the room with her/him for one (1) day and one (1) night. I told them I had to get out of that room. I got the feeling s/he could cause me harm. I didn't know what to expect of her/him. I never saw her/him take anything, .I don't know what his/her problem was but I was afraid of her/him. I never saw him/her take anything. S/he just acted like s/he already took it. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. The resident was admitted to the room with Resident #1 on 4/30/13. Review of the Nurse's Notes on 5/1/13 at 1:11 PM. stated, N/O (new order) to transfer resident to room [ROOM NUMBER] per pt (patient) request. Resident #5 was transferred to the emergency roiagnom on [DATE] and no longer at the facility. The surveyor on 5/15/13 interviewed the Social Services Director (SSD) at approximately 9:10 AM and again at 10:30 AM. S/he stated that both of the residents who moved out of the room requested the room change. The residents stated they didn't get along with Resident #1. SSD stated Resident #5 requested the room change. The resident stated s/he didn't feel s/he and roommate had a lot in common and didn't get along. The SSD stated Resident #4 requested the room change as the roommate looked like s/he was on cloud 9 and had a wild look in her/his eye. The surveyor on 5/14/13 interviewed the Director of Nursing (DON) at 3:30 PM. The DON stated s/he was not the DON at the time of the incident; s/he was working the unit at the time of the incident. The DON stated a CNA (Certified Nursing Assistant) found a spoon in the resident's room and took it to the Administrator and DON. They called the police. The police came in and asked permission to search his/her room . They found the other stuff. The police told the resident they could arrest him/her. I told the police that the resident was getting IV treatment, antibiotics for [DIAGNOSES REDACTED]. They let us know that if they arrested him/her, s/he would not receive the treatments. There would be no one to pull the PICC line or continue the treatments. About 30 minutes after the police left I had went in to talk to the resident. The nurse's note was written after the police had searched the resident's room . The surveyor on 5/14/13 interviewed the Administrator at approximately 3:45 PM regarding Resident #1's history of drug abuse and stay at the facility. The Administrator stated the facility knew the resident was a past drug user. A housekeeper had brought a spoon out of the resident room. I called the police. We asked if we could search the room. and the resident agreed. The police were with us when we found the paraphernalia. We asked where s/he got it. Our concern was if s/he was taking any kind of drug. S/he needed to continue his/her course of treatment. I was concerned if s/he went into DTs s/he may hurt someone. S/he was a big guy. The DON (Director of Nursing) called the Ombudsman. S/he (Ombudsman) came in wanted my internal investigation. There was no investigation. There was nothing done, s/he didn't do anything illegal while s/he was here. The police picked up the paraphernalia, don't know what the substance (powdered substance) was. We sent him out. We took steps to protect the other residents . The powdered substance and paraphernalia were found in the resident's bag containing his/her personal items. It was in the closet . The Administrator was unable to provide a police report for the police visit. As a result of the complaint survey the facility reportable files were requested. The facility provided a file with five (5) [MEDICATION NAME] (resident A, B, C, D and E), both 24 hour initial report and the 5 (five) day follow-up reports. There were no fax confirmations with the investigation files. The Director of Nurses and the Administrator stated the reports had been sent to the State Agency. The Triage Nurse at the State Agency was called to confirm that the State Agency had received the notifications of the reportable incidents. The State Agency Triage Nurse stated there were no 24 hour/initial reports sent in on three of the five facility [MEDICATION NAME]. No 24 hour reports were available for Resident A, E, and K. During the conversation with the State Agency Triage Nurse, a comparison was done regarding the facility's reportable incidents provided to the surveyor and those received by the State Agency. The Triage Nurse provided the names of the residents involved in the incidents reported by the facility. Five (5) additional residents had been reported to the State Agency (Residents F, G, H, I and resident # 5) evidence of these reports were not readily available by the facility. The Administrator stated the last DON had gone and they would have to search for them. Both the Administrator and DON stated the missing Initial reports were sent to the State Agency from the front fax machine. The current DON had faxed the 5 day reports from the fax in her/his office. The State Agency received the Five Day Reports but not the Initial 24 hour reports. On 5/14/13 at approximately 3:30 PM the Administrator provided a Fax Activity Log printout, which showed the fax machine, used to fax the 24 hour reports, had not been working from May 5 through 5/14/13. The facility was not aware, until the complaint survey, that anything faxed from the fax machine had not been received for the past 9 days. The facility failed to check for the fax confirmations, confirming the information allegedly faxed to the state agencies was received. |
2016-05-01 |