cms_SC: 86
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 86 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-01-23 | 610 | D | 1 | 0 | S6DX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Resident #1 was noted with a fracture of unknown origin. The facility failed to interview all staff involved with the resident's care around the time the fracture was identified. The facility failed to clarify staff statements related to care provided to Resident #1 around the time the fracture was identified. One of three residents reviewed for abuse/neglect. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 10/19/17. The CNA (certified nurse aide) observed the resident's right lower leg to be swollen and warm to the touch. Resident #1 had a history of [REDACTED]. The physician was notified and a venous Doppler was ordered. The Doppler results were negative and the physician was notified. An x-ray was ordered and revealed a tiny cortical fracture in proximal tibia. Resident #1 was a stand assist transfer with stand up lift. Review of Resident #1's Nurse's Progress Note dated 10/18/17 at 9:50 AM revealed the CNA and nurse reported the resident having a swollen, discolored area to the right lower leg (shin area). The physician was called and notified with a new order for ultrasound of the right lower leg related to [MEDICAL CONDITION] and discoloration. On 10/18/17 at 4:47 PM the Doppler results were received and were negative for blood clot. The Nurse's Progress Note dated 10/18/17 at 5:37 PM indicated Resident #1's daughters requested the resident receive an x-ray of the leg. The nurse informed them that the physician would be in the facility and would look at the resident then. The resident's daughters insisted on an x-ray. The nurse called the nurse practitioner and left a message. Review of the Nurse's Progress Note dated 10/18/17 at 6:00 PM revealed received a call back from the nurse practitioner and an x-ray of the right leg was ordered. There were no Nurse's Progress Notes between 9/29/17 and 10/18/17 at 9:50 AM. Review of Resident #1's Physician's Progress Note dated 10/19/17 revealed the resident was seen for right leg pain and swelling. The note indicated the other day the resident began to experience swelling and pain in the right lower extremity. They were unable to determine any specific traumatic event or problem which occurred. Unfortunately due to the resident's dementia, s/he could not provide any reliable history. Review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed the resident's Brief Interview for Mental Status score was 7, which indicated the resident was non-interviewable. The surveyor requested a copy of the facility's complete investigation into the injury of unknown origin. Review of the facility's investigation revealed there was no statement from the nurse assigned to Resident #1 on the 7:00 PM - 7:00 AM shift on 10/17/17 and 10/18/17. There was also no statement from the nurse assigned to the resident on the 7:00 PM - 7:00 AM shift on 10/15/17 or the nurse assigned to the resident on 7:00 AM-7:00 PM shift on 10/16/17. There were also no statements from the CNAs that were assigned to Resident #1 on 10/15/17 on the 7:00 AM -7:00 PM shift and the 7:00 PM-7:00 AM shift. There was no statement from the CNA that was assigned to Resident #1 on 10/16/17 on the 7:00 AM- 7:00 PM shift. There was no statement from the CNA that was assigned to the resident on 10/17/17 on the 7:00 AM-7:00 PM shift. There was no statement from the CNA that was assigned to Resident #1 on 10/18/17 on the 7:00 AM - 7:00 PM shift. CNA #1's facility-obtained statement dated 10/19/17 revealed on Tuesday night (10/17/17) on the 7:00 PM- 7:00 AM shift s/he put Resident #1 to bed., pivot to stand. Resident #1 was able to stand and was transferred to bed with no complaints of pain. CNA #1 immediately called LPN (Licensed Practical Nurse) #1 to the room to assure the resident that s/he was on the bed and not on the floor. LPN #1 came in and assured Resident #1 that everything was okay and that s/he was on the bed. LPN #1's facility-obtained statement dated 10/19/17 indicated s/he was called to Resident #1's room by CNA #1 on 10/17/17. The CNA stated Resident #1 was really confused and kept asking the CNA to get him/her out of the floor but the resident was in the bed. LPN #1 walked over to the resident and told him/her that s/he was in the bed and not in the floor. Resident #1 stated No I am not, I am in the floor. The resident was redirected that s/he was in bed and not on the floor. In an interview with the surveyor on 1/23/18 at approximately 12:05 PM, the DON (Director of Nursing) stated s/he completed the investigation into Resident #1's injury of unknown origin. The DON stated for an injury of unknown injury, they interview everyone who worked with the resident for 24-48 hours prior to the identification of the injury. That would include nurse aides, nurses, and anyone else who may have been involved with the resident. The DON confirmed the investigation did not include statements from all staff who worked with Resident #1 prior to the identification of the injury. In a telephone interview with the surveyor on 1/23/18 at approximately 12:45 PM, CNA #1 confirmed s/he transferred Resident #1 as a stand and pivot per his/her statement. CNA #1 stated Resident #1 was a one person assist, which means s/he was a stand and pivot transfer. CNA #1 stated that was the information on Resident #1's CNA information sheet. CNA #1 stated the paperwork in Resident #1's room and in the PCR (patient care record) book both said one person assist and not sit to stand lift. In an interview with the surveyor on 1/23/18 at approximately 12:55 PM, the DON stated s/he talked with CNA #1 and s/he said s/he used a lift and pivoted the resident. The DON did not have CNA #1 clarify his/her statement related to how Resident #1 was transferred or make a note that they talked with CNA #1 to clarify the statement related to him/her pivoting the resident. | 2020-09-01 |