cms_SC: 9123
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9123 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2014-01-06 | 281 | D | 1 | 0 | O2TO12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the first revisit survey based on record reviews and interviews, the facility failed to assess and/or document acute conditions for 3 of 3 residents with acute changes. Res. #18, #4, and #17 experienced acute changes in condition without assessments or documentation. Resident #18 was admitted with an order for [REDACTED].#4 and #17 had a change in condition requiring medical treatment but there was no documentation of assessment related to the treatments as administered. In addition, Resident #17 had physician orders related to monitoring intake and output which were not clarified by staff to allow for standard facility policy. The findings included: The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of the Hospital Transfer Record dated 1/2/14 stated the resident had a history of [REDACTED]. The resident had low hemoglobin and received packed red blood cells while in the hospital. Review of the hospital Medication Administration Record [REDACTED]. The hospital discharge medications included an order for [REDACTED].n. (as needed) for [MEDICAL CONDITION]. Review of the resident's Interim Care Plan dated 1/2/2014 revealed a problem, "at risk for bleeding R/T (related to) use of anticoagulant. [MEDICATION NAME] ([MEDICATION NAME]) had been checked and marked out. [MEDICATION NAME] was checked. Interventions included to monitor for bruising and bleeding" and "notify the MD (Medical Doctor)". Review of Resident #18's Physician's telephone orders dated 1/6/2014 stated, "Check CBC (Complete Blood Count) UA (urinalysis) CMP (Comprehensive Metabolic Panel) ". Under the section titled "Indication Dx (diagnosis)" gave the reason for the lab tests as "Tarry stool, dk (dark) urine". Review of the Departmental Notes revealed Nursing Notes dated 1/2/14 and 1/6/14 with no documentation related to "Tarry stool, dk (dark) urine". There was no documentation of an assessment of the resident's condition or a nurse's note that stated the resident had a change or when the episode occurred. On 1/7/14 at approximately 3:30 PM, the surveyor conducted a telephone interview with Nurse #2. The nurse stated at the end of her/his shift the CNA (Certified Nursing Assistant) came up and said the resident's urine was orange and the stool was black and tarry. The nurse stated s/he did not see the stool or urine. "I put it in the Doctor's book and on the 24 hour report. S/he was fine during the shift. I made rounds every hour opposite the CNAs. I forgot to write the note." When asked by the surveyor if the resident had been assessed after s/he was notified by the CNA, the nurse stated, "I saw her/him". "Her/his color was pink, s/he had capillary refill and s/he was alert and oriented." The nurse did not state s/he assessed the resident, checked for bowel sounds, distention or had assessed for any active bleeding. Resident #18 had a history of [REDACTED]. The resident's hemoglobin was noted in the hospital to be 6.1 (normal 12.0-16.0). S/he required transfusion of packed cells to increase her/his hemoglobin. S/he received [MEDICATION NAME] in the hospital and was discharged to the facility with an "as needed" order for [MEDICATION NAME]. The resident was noted to have tarry stools and dark urine. There was no evidence the resident was evaluated/assessed by the nurse when the tarry stools were noted. On 1/8/14 at approximately 11:00 AM the surveyor interviewed LPN (Licensed Practical Nurse) #1 who stated s/he would question an order for [REDACTED]. At 11:25 AM, the surveyor interviewed Registered Nurse (RN) #3. S/he stated that the supervisor handled orders from the hospital. "We look at them together and put them in the computer. PRN [MEDICATION NAME] order would be clarified with our physician". In an interview with the surveyor on 1/8/14 at approximately 2:15 PM the Supervisor (Assistant Director of Nursing/ADON) and the Director of Nursing (DON) stated the ADON wrote up the POF (Physician order for [REDACTED]. The doctor gets a copy of the POF and H&P (history and physical) from the hospital. S/he reviews the POF and hospital Discharge Summary. S/he knows the medications the resident comes in on". They confirmed they would expect a resident with dark tarry stools to be assessed and the medications checked. They confirmed the resident's abdomen should have been checked for distention, pain, active bleeding. Both agreed nurses should assess and document changes in condition. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record revealed an order dated 12/20/13 "...1. Monitor strict I(ntake) & O(utput)s. 2. If cannot void may bladder scan q (every) 8 h(ou)rs. If > 400 ml(milliliters) or uncomfortable may I(n) & O(ut) cath(eter). 3. Do not place foley." Review of Resident #17's Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. During an interview with the surveyor on 1/7/14 at approximately 2:30 PM, the Director of Nursing (DON) stated that s/he talked with the Nurse Practitioner about discontinuing the intake part of the order. The DON stated that the facility does not monitor I & Os and the order should have been changed to monitor output. The DON confirmed that there was no order on the record to stop the order to monitor strict I & Os. Review of the facility's Intake, Measuring and Recording policy revealed under preparation "... 1. Verify that there is a physician's order for this procedure and/or that the procedure is being performed per facility policy. (Intake not routine for indwelling catheters, feeding tubes, IV's)." Review of Resident #17's medical record on 1/7/14 revealed Physician Telephone orders dated 1/6/14 "[MEDICATION NAME] 875 BID (twice daily) #20" for "raised [MEDICAL CONDITION] left thigh" and "[MEDICATION NAME] powder to area between thighs bilaterally use powder QID (four times daily) x 10 d(ays)" for yeast infection. The nurse on 1/6/14 signed both orders at 8:00 PM. Review of the Daily Skilled Nurse's Note for Resident #17 on 1/6/14 revealed there was no documentation related to the resident's condition related to the above orders. Review of the Skin Condition section of the note revealed that there were no areas checked as being skin concerns. Review of the Comments/ Concerns section of the note revealed there was no mention of a [MEDICAL CONDITION] to the resident's left thigh or condition of the resident's thighs bilaterally. Review of the Departmental Notes revealed there was no nursing entry for 1/6/14. Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #4's medical record revealed an order on 1/2/14 "start INT (intravenous needle therapy) and give NS (normal saline) at 100 mls(milliliters)/hr (hour) x 2 liters then d/c (discharge) INT" for "dehydration". Review of the Departmental Notes revealed there was no nursing note for 1/2/14. Review of the Daily Skilled Nurse's Notes revealed there were no Daily Skilled Nurse's Notes completed on 1/2/14. Review of the physician progress notes [REDACTED]. Recently was in ER and was dehydrated..." The assessment and plan was noted as "will give 1 liter IVF (intravenous fluids). Encourage PO (by mouth) intake of fluids." Today's impression was noted as "monitor for diet, dementia decline." In an interview with the surveyor on 1/8/14 at approximately 1:55 PM, the Director of Nurses (DON) stated that nurses should document on a resident's condition when IV (intravenous) fluids are given for dehydration. The DON reviewed the computer and confirmed there were no Nurse's Notes completed on 1/2/14. | 2015-08-01 |