cms_SC: 9290
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9290 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2012-01-17 | 225 | D | 1 | 0 | WZUA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, record review and interview, the facility failed to ensure residents were protected during an investigation, failed to conduct a thorough investigation and failed to report a potential incident of neglect. Resident #1's CNA (Certified Nursing Assistant) was suspended 5 days after the allegation of neglect. The allegation of neglect was not thoroughly investigated or reported to the State Certification Agency. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on 12/14/2011 Registered Nurse (RN) Supervisor documented: "This Elder was found in the floor sitting upright with blood on head, face and on the floor. She did not make any noise the companion just happen to walk to the front of the common area and saw her on the floor. The laceration to the back of her head measured 1.5 cm superficial. Site was cleansed by Primary Nurse. Neuro checks started per policy. Corrective action: Place tab alert to Elder to be worn anytime she is out of bed." On 12/15/2011 at 3:21 AM, Licensed Practical Nurse (LPN) #1 documented, "Regarding 12/14/2011 at (8:05 PM), this nurse was called to this cottage from (another cottage) by the CNA, stating there had been a fall. Upon arriving, elder was sitting upright on her buttocks on the tile area at the back of the cottage. There was blood present on elder in multiple small pools on the floor. Upon assessment, elder was noted to be alert and upset about the blood present on her hands and her clothes. One injury on back of head present; 1.5 cm x 0.2 cm in width. Site is superficial. No other apparent injuries. Approximate amount of blood lost: 40 ml. Assisted elder to lie down on pillow. Called RN supervisor and assisted with complete assessment. ROM of all extremities unchanged as compared with elder's prior ability. Pupils equal and round. Elder responds to verbal stimuli. Cleansed [MEDICAL CONDITION] site and assisted elder to change clothes and wash blood off skin. Gait belt and 3 person transfer was used to place elder in recliner. GS (geriatric services) contacted and received orders for neuro checks per policy and monitor and cleanse skin laceration to back of head Q shift and PRN until healed. IDON (Interim Director of Nursing) notified by RN supervisor. Family notified ...CNA's in cottage at time of incident report that they walked to the front of the cottage and saw elder sitting on the floor in the previously explained condition and called this nurse at that time. They were not alerted to the elder's condition by any noise. Elder currently has a pressure alarm and alarming seatbelt present while in w/c; tab alert to be added." Review of the CNA Documentation revealed CNA #2 documented at approximately 9:35 PM that the resident consumed 51-60% of her supper and was incontinent. No other documentation for Resident #1 was located for the 3-11 shift on 12/14/2011. Review of the Incident Report dated 12/17/2011 revealed "Elder was found sitting up on floor in front of the exit doors to cottage. Alarming seatbelt had not alarmed, but had been alarming earlier. CNA #1 not cooperating with investigation. Elder sustained a mild superficial [MEDICAL CONDITION]." Review of the 5 Day Report revealed the resident's condition prior to the incident was "Elder was having a usual day in the cottage rolling around in her w/c. Self releasing alarming seatbelt on. Elder frequently opens the seatbelt causing repeated alarms." Details of the incident were "elder was found sitting up on floor in front of the exit doors of cottage. Elder wears an alarming seatbelt that had been alarming earlier but did not alarm when elder fell . CNA #1 is suspected of removing/disconnecting her alarm d/t frequent alarms. Elder also had not been toileted x 4 hours prior to her fall. At shift change at 11:30 PM elder was found in her recliner and smelled of feces. Elder taken to the BR and was found with a saturated brief with dried feces. Elder was toileted, showered and prepared for bed. Care plan not followed r/t toilet and reposition elder every 2 hours." Interventions taken by the facility: "CNAs suspended for neglect. CNAs disciplined for neglect of elder in their care..." The facility substantiated neglect. CNA #1 was suspended on 12/15/2011. CNA #2 was suspended on 12/19/2011 for one day and then allowed to return to work. No disciplinary action was located in CNA #2's employee file. There was no evidence the allegation of neglect was thoroughly investigated and no evidence CNA #2 was disciplined for neglect of Resident #1. CNA #1 was allowed to return to work following the completion of the investigation, however, he failed to show up for his assignment and was terminated on 12/25/2011 for a "no call, no show." Review of the facility obtained statement by CNA #1 revealed: "I was on my to start charting when I found Resident #1 sitting upright on the floor bleeding, I then called over my co-worker (CNA #2) and to her to contact the nurse. We then waited for the nurse to arrive." Another interview was conducted on 12/19/2011 with CNA #1 and the IDON. "What times did you toilet (Resident #1) from 3 PM to 10:30 PM? At 4 PM and 8 PM. Why did you two not toilet her since 8 PM? Silence... Silence... I don't know why we didn't toilet her again." "Are you telling me you disconnected her alarm on purpose to quiet the alarm and did not turn it back on or forgot to turn it on? Yes." "Explained to Eric I had received a report in the past of incontinent care not being done on another elder and I should have brought it forth when I found out about it. I asked him has this been occurring? He reluctantly stated yes. I explained to him he must do the care, it is not an option. Review of time card revealed CNA #1 clocked in at 3 PM on 12/14/2011 and clocked out at 11:38 PM. Review of the assignment sheet revealed CNA #1 and CNA #2 were assigned to the Tea Olive Cottage from 3-11 on 12/14/2011. During a telephone interview on 1/17/2012 at 4:20 PM, CNA #1 stated that both he and (CNA #2) were caring for the residents together, however, (CNA #2) was "assigned" to Resident #1. He stated that the resident constantly was opening and closing her alarming seatbelt. CNA #1 stated that either he or (CNA #2) failed to reset the alarm prior to her fall so no alarm sounded to alert them to her standing. CNA #1 stated that all residents were to be toileted every two hours at least. When asked when Resident #1 was toileted during the shift he stated that he didn't know because he was "taking care of my side." Review of the facility obtained statement from CNA #2 revealed she "was her (Resident #1's) CNA (on 12/14/2011, 3-11 shift). "No alarm went off not her self release belt or her chair alarm, and both were cut on." "When was the last time elder was toileted before occurrence? Right before supper around 4:15/4:30 PM." "When was the last time you observed elder before occurrence (last rounding)? During supper because I fed her." During a telephone interview on 1/17/2012 at 3:15 PM, CNA #2 stated that the resident's alarms were working earlier in the shift. She stated that the resident was toileted at approximately 4:30 PM and then was toileted again after her fall at 8:30 PM. She stated that CNA #1 found the resident when she had fallen and that no alarm was sounding. CNA #2 stated that she checked on the resident at 10:15 PM and the resident's brief was dry. Review of the facility obtained statement from Licensed Practical Nurse (LPN) #1 revealed: "Has alarming seatbelt and elder keeps taking seatbelt off to where it alarms 90% of time. Feels staff may have been ignoring it..." During a telephone interview on 1/17/2012 at 3:15 PM, LPN #1 stated she last interacted with Resident #1 around dinnertime. She stated that her seatbelt alarm was on and working at that time. LPN #1 reported that she was notified of the fall by CNA #1. She stated that neither alarm was sounding at the time of the fall. LPN #1 stated that the resident was last toileted around 4:30 PM. Review of the facility obtained statement from LPN #2 revealed: "Elder was on a recliner and was trying to get out of it when I came in to get report at 2330 (11:30 PM). I explained to the 3-11 nurse that the recliner will tip over (Resident #1) if we don't get her out of it. (Resident #1) is used to being on the "go" and having her on the recliner is like a restraint for her. When we transferred the elder to her wheelchair we smelled feces odor. We took her to her bathroom and her diaper was saturated with urine and drying stool. After the elder finished voiding in the commode, I gave her a warm shower to clean her up and then we assisted elder to bed." LPN #2 was unavailable for interview during the survey. During an interview on 1/17/2012 at 5 PM, the Interim Director of Nurses confirmed CNA #2 was not suspended until 12/19/2011 (5 days after the incident) and was suspended for one day. The IDON also confirmed that the allegation of neglect related to incontinent care was not thoroughly investigated and stated that since everything was under CNA #1 nothing else was done. | 2015-05-01 |