cms_SC: 8773

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.

Data source: Big Local News · About: big-local-datasette

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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
8773 LIFE CARE CENTER OF HILTON HEAD 425147 120 LAMOTTE DRIVE HILTON HEAD ISLAND SC 29926 2011-09-14 152 D 0 1 6MCR11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, based on interviews, record review and review of the facility's policy Policies and Procedures Social Services Manual Section Advance Directives and the South Carolina Code of Laws/ Title 44, Chapter 66, Adult Health Care Consent Act, the facility failed to ensure that two Physicians had examined and certified the inability to consent in accordance of State Law for Resident # 1, (1 of 14 sampled residents reviewed for advanced directives.) The findings included: The facility admitted Resident #1 on 4/14/11 with [DIAGNOSES REDACTED]. On 9/13/11 at 2:48 PM, record review revealed a letter stating This resident has been deemed without capacity by one medical physician whom is currently pending a second physician signature regarding the resident's choice of treatment preference as of . The family has elected the following code status per the resident's desire until the second physician signature is received, the resident desires : DNR (Do Not Resuscitate.) as of per (resident's daughter.) Also noted in the record were 2 Emergency Medical Services Do Not Resuscitate Orders dated 8/26/11; one also contained a note stating pending order per (MD). In addition, the Advance Directives / Medical Treatment Decisions Acknowledgement of Receipt stated that one of the resident's daughters was unaware of Advance Directives and directed the facility to check with another daughter. The second daughter was the daughter who elected a DNR Code Status for the resident. A Physician's Telephone Order was noted dated 8/30/11 for Do Not Resuscitate. Review of the care plan on 9/14/11 at approximately 2:30 PM revealed a care plan for Advanced Directives indicating the resident has elected a FULL CODE status r/t (related to) her choice of treatment preference which is in effect. No Power of Attorney or Living Will was located in the resident's record. Review of the resident's MDS (Minimal Data Set) revealed the resident to be severely cognitively impaired with a BIMS (Brief Interview of Mental Status) of score 4 on 7/25/11. During an interview at 4:13 PM on 9/13/11, the Social Services Director confirmed the resident had not been deemed incompetent to consent for DNR or other health care decisions by 2 physicians. She confirmed that she was aware that 2 physician signatures were required to determine the resident's ability to consent. She further reported that the facility has only 1 contracted Physician and that they have been having difficulty obtaining a second physician's signature to determine residents' capacity to consent to treatments. She also confirmed that the resident's daughter had not provided the facility with any paperwork that named her as the resident's Power of Attorney or a Living Will declaring the resident's desires related to DNR status. Review of the facility's policy revealed Chapter 1 of the Policies and Procedures Social Services Manual Section Advance Directives page 1-45 under Procedure stated the facility complies with applicable state and federal laws regarding advance directives . In addition, the policy stated If the resident has an advance directive, the social worker will request a copy of the directive so that it may become part of the medical record . The policy further stated Note: The advance directive copy should always remain in the resident's record, protected in a plastic cover, even if the record is thinned. During an interview on 9/14/11 at 2:50 PM, the Director of Nursing stated they clearly were not following the policy related to Advance Directives and confirmed the code status was very confusing and that the care plan indicated the resident was a Full Code despite other documentation. Review of the South Carolina Code of Laws, Title 44 - Health, Chapter 66, Adult Health Care Consent Act ,Section 44-66-20 revealed the statute stated, in part: (6) A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient. 2015-12-01