| 9501 |
DR RONALD E MCNAIR NURSING & REHABILITATION CENTER |
425309 |
56 GENESIS DRIVE |
LAKE CITY |
SC |
29560 |
2011-04-27 |
150 |
E |
1 |
1 |
I04T11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record reviews, staff interviews, and resident interviews, the facility failed to ensure that Residents #7 and #9 were afforded the right to make their own decisions related to leave of absence and notification of family. (Two of four alert and oriented resident's reviewed for resident rights) The findings included: The facility admitted Resident #7 on 7/9/10 with the following Diagnoses: [REDACTED]. During the initial tour with the wound care nurse on 4/25/11, the wound care nurse stated the resident was "interviewable". Record review of the resident's Minimum (MDS) data set [DATE] and 4/12/11 in section C indicated the resident was cognitively intact, with a BIMS (Brief Interview for Mental Status) score of 15. An individual interview with the resident on 4/25/11 at 12:30 PM revealed that the resident was alert and oriented to time, place, person and situation. The medical record review on 4/25/10 revealed a note taped in the front cover of the medical record, which stated the residents first cousin could take the resident on LOA (leave of absence) to Lake City (uptown) per the (RP) Responsible Party, without calling her. Further record review revealed the physician had not determined the resident as lacking capacity to make decisions. The resident had signed the necessary paperwork to determine his own advanced directive status. The residents bill of rights was signed on admission by the resident's sister. On 4/26/11 at 9:00 AM, when asked about going out of the facility, the resident stated " I go home sometimes with my brother or sister. I made a list of three people that can take me out. Well, I didn't, my sister did that before I got here. My sister can sign papers for me only if I am sick or it's an emergency." When asked about the facility calling his sister when he goes out for any reason he also stated "They do not need to call my sister when I go out. My cousin can even take me to my house, that is not up to her. My sister does not have anything to do with when I go out. I don't know why they have to call her.... I would like to go out more, but I didn't know I could. My brother (in New Jersey) and my sister (Anderson, SC) lives a long way and so I am limited as to who can take me out. I didn't know I could go with anyone else." During an interview with the SSD (Social Service Director) on 4/27/11 at 9:20 AM, when asked about the note placed on Resident #7's medical record regarding his LOA's, she stated: " It is our policy to notify the family member to let them know that the resident is leaving the building, even if they are alert and oriented." She also stated " He never asked to go out, but I can see how he thought he couldn't. I see how wrong that is, I'm so sorry". A SSD note placed on the chart on 4/27/11(dated 4/19/11) stated: " SW talked with resident today about his rights in the facility. Resident did not know why the facility had to call his emergency contact when he left the facility or wanted to go on LOA. SW talked to resident and reassured resident that he is totally in charge of what he wants or who he wants to go on LOA with. Sister will not be contacted to get permission for resident to leave facility or contacted to make decisions if resident does not want facility to. SW called MD (Medical Director) about a standing order for resident to have LOA's. Awaiting call back. SW also told resident about note in front of chart that it was wrong for SW to put note in chart for that reason. (LOA with cousin) Note taken out of chart. Resident was satisfied with conversation to assist resident with any contacts he would like to make for LOA's." The facility admitted Resident # 9 on 2/19/03 with the following Diagnoses: [REDACTED]. An individual interview with the resident on 4/25/11 at 4:30 PM revealed that the resident was alert and oriented to time, place, person and situation. Further record review revealed the MDS (Minimum Data Set) dated 3/16/11 (section C) BIMS (Brief Interview for Mental Status) score of 15, indicative of no cognitive impairment. The medical record review on 4/25/10 revealed a note taped in the front cover of the medical record, which stated "Attention Nurses No one (underlined 3 times) is allowed to take the resident on LOA's unless it is the Responsible Party. (The name of the resident's sister was listed). During a second interview with the resident on 4/26/11 at 10:00 AM, Resident #9 stated " I don't make my own decisions, my sister does. I don't like it, but she says she is the only one that can take me out. I would like to go out with my brother some and see some old friends but she won't let me. They won't let me... they call her." When ask about the note placed on the cover of the chart he stated: " They say if you don't go with her you can't go out. She thinks I just want to go out and drink, but I tell her I just want to go and be with friends and my brother. She said if I say you can't go out, then you can't go". " I sure would like for this to be straightened out. I want to be able to make my own decisions." During an interview with Licensed Practical Nurse # 3 (LPN) on 4/25/11 at 5:25 PM the LPN stated when asked about the note in front of the resident's chart, " if someone comes for him we have to call the RP and get it okayed with her." On 4/26/11 at 5:15 PM the Director of Nursing (DON) stated - " his sister just wants him not to go with a certain person that drinks. She is aware that it is up to him." On 4/27/11 at 10:30 AM LPN # 2 stated " If I saw that note on the front of the chart, I would let him go because he is alert and oriented. But, I would call the sister and let her know." On 4/26/11, the SSD made a note on the residents chart which stated " SW talked with resident about resident rights. SW explained to resident that his sister (RP) could not say who resident could go on LOA's with. The note that SW put in front of chart was taken off. Explained to resident that since he was alert and oriented times three he could make his own decisions. SW will not be calling his sister anymore without his permission. Resident verbally understands and was very happy about this information. SW will continue to educate on resident rights." |
2015-04-01 |