cms_SC: 88
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 88 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-01-23 | 689 | G | 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 ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was noted with a fracture of unknown origin. Resident #1 was transferred as a stand and pivot, the CNA (certified nurse aide) did not use the sit to stand lift the resident required. The resident's Nurse Aide Information sheet did not contain accurate information related to the resident requiring a lift for transfers. One of three residents reviewed for accidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 10/19/17. The CNA 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 (MONTH) (YEAR) physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Radiology Report dated 10/19/17 revealed the resident had a tiny proximal tibial metaphyseal cortical fracture. Review of Resident #1's care plan revealed resident needs assist with ADL's (activities of daily living) due to decreased cognition and decreased mobility was identified as a problem area. Interventions and approaches were listed on the care plan and included transfers with mechanical lift and sling lift pad in wheelchair for positioning. There was no indication what type of lift the resident required. A copy of the Nurse Aide's Information Sheet for Resident #1 was included in the facility's investigation file. Review of the form revealed the resident's status was noted as lift to chair with two assist. Review of Resident #1's Nurse Aide's Information Sheet revealed nothing that indicated the resident required a lift for transfers. There was no additional information related to transfers on the form. 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. 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 11:50 AM, CNA #3 stated s/he had worked at the facility almost 3 years. CNA #3 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR (patient care record) book. It's the same information, they have it in two places. CNA #3 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 11:55 AM, CNA #4 stated s/he had worked at the facility almost 6 months. CNA #4 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR book. CNA #4 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 12:05 PM, the DON (Director of Nursing) stated the CNAs look at the Nurse Aide Information sheet which is in the PCR book and the wall locker in the resident's rooms. The DON confirmed Resident #1's Nurse Aide Information sheet indicated two assist, but did not have information that the resident required a lift for transfers. The DON stated Resident #1 had been back and forth between the sit to stand lift and the total lift. Resident #1 required a sit to stand lift at the time the fracture was identified. The DON stated the nurses and the unit coordinator (RN (Registered Nurse) supervisor) are responsible for updating the care plan when there are changes in care. If the care plan says mechanical lift it is a generic term, it could be different types of lifts. They have sit to stand, hoyer, and a steady lifts that will go all the way to the floor to pick residents up. The DON stated it should be on the CNA Information Sheet what type of lift is required. 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 book both said one person assist and not sit to stand lift. | 2020-09-01 |