cms_SC: 982
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 982 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 656 | E | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to develop and/or implement care plan interventions for turning and positioning for 3 of 8 sampled residents reviewed for pressure ulcers (Residents #26, #29, #68) and 1 of 6 sampled residents reviewed for activities (Residents #68). Additionally, measures were not implemented to minimize fall injuries per the care plan for 1 of 5 sampled residents reviewed for accidents (Resident #29) and the Care Plan was not followed related to use of devices/splints for 1 of 6 sampled residents reviewed for range of motion (Residents #68). The findings included: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Review of the 7-10-18 Quarterly Minimum Data Set (MDS) Assessment on 9/10/18 at 10:15 PM revealed that the resident was totally dependent on staff for bed mobility. Record review on 9/19/18 at 1:26 PM revealed physician's orders [REDACTED]. Review of the Care Plan on 9/19/18 at 3:01 PM revealed interventions for decreased mobility included turning and positioning every 2 hours. Multiple observations revealed Resident #26 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 10:28 AM, 12:15 PM, and 2:12 PM; on 9/10/18 at 8:43 AM, 9:30 AM, 11:03 AM, 12:37 AM, 2:16 PM, and 4:02 PM; on 9/18/18 at 9:31 AM, 11 AM, 12:31 PM, 2:15 PM, and 4:18 PM), indicating s/he had not been turned and positioned every 2 hours. During all observations, a positioning wedge was noted on the bedside table. No pillows or positioning devices were noted in the bed with the resident. During an observation and interview on 9/19/18 at 8:36 AM, the Director of Nurses (DON) verified that the resident was positioned on his/her back. S/he stated, He (she) should be turned every 2 hours and the wedge used for positioning. The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review of the 7-13-18 Quarterly MDS Assessment on 9/10/18 at 9:25 PM revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating a moderately impaired cognitive status. S/he experienced inattention, disorganized thinking, and trouble concentrating. The resident required extensive assistance for bed mobility and was totally dependent for transfers. The MDS noted a fall with minor injury had occurred since the previous assessment. A 11-5-17 significant change in status assessment noted the resident with a stage 3 pressure ulcer. Record review on 9/18/18 at 10:12 AM revealed physician's orders [REDACTED]. Review of the Care Plan on 9/18/18 at 12:47 PM revealed interventions for decreased mobility and skin breakdown included turning and positioning every 2 hours. Interventions for fall risk included a 5-25-18 entry for a Floor mat to right side (of) bed. Multiple observations revealed Resident #29 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 11:48 AM, 1:55 PM, and 3:59 PM; on 9/10/18 at 8:24 AM, 9:45 AM, 11:13 AM, and 12:47 PM; on 9/18/18 at 9:25 AM, 11:04 AM, 12:05 PM, 2:10 PM, 2:25 PM and 4:13 PM), indicating s/he had not been turned and positioned every 2 hours. No pillows or positioning devices were noted in the bed with the resident except to prop up [MEDICAL CONDITION] right arm. Multiple observations on 9/18/18 also revealed Resident #29 in bed without the floor mat in place as ordered and care planned (at 9:25 AM, 11:04 AM, 12:05 PM, 2:10 PM, and 2:25 PM). During an interview and observation on 09/18/18 at 2:25 PM, Licensed Practical Nurse (LPN) #3 verified that the mat was folded and leaning against the bedside table. S/he stated, That mat should be down. During an interview and observation on 9/19/18 at 8:43 AM, the DON verified the resident's positioning. S/he stated that the resident should be turned and positioned every 2 hours. Regarding the mat, the DON stated that it should be in place at all times. The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review of the 8-16-18 Quarterly MDS Assessment on 9/10/18 at 7:21 PM revealed that the resident required extensive assistance of staff for bed mobility, had impaired ROM in both upper and lower extremities, and had a stage 4 pressure ulcer. Record review on 9/18/18 at 3:21 PM revealed physician's orders [REDACTED]. resting hand splints 6-8 hours daily as tolerated. Review of the Care Plan on 09/19/18 at 8:50 PM revealed interventions for decreased mobility and skin breakdown included a turning and positioning program. Interventions for multiple contractures included Bilateral elbow & wrist braces as tolerated. During an interview on 9/09/18 at 2:36 PM, Resident #68's family asked, When does that (positioning) wedge go on? We never see it used. (Resident #68) is always on her (his) back when we're here. They also stated that facility staff used to put splints on but couldn't get it uncontracted. They never put splints on or rolls in her (his) hands. Multiple observations revealed Resident #68, with bilateral upper extremity contractures, positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 10:36 AM, 12:24, 2:19 PM, and 4:17 PM; on 9/18/18 at 9:32 AM, 11:30 AM, 2:17 PM, and 5:47 PM), indicating s/he had not been turned and positioned every 2 hours. During all observations, a positioning wedge was noted in the chair. No pillows or positioning devices were noted in the bed with the resident. No devices/splints were in place to prevent further decline in ROM and no splints were visible in the room until 9/18/18 at 11:30 AM, when one resting hand splint was noted on the left upper extremity. During an interview on 9/19/18 at 9:23 AM, the DON stated, They should turn her (him) every 2 hours and use the wedge. During an interview on 9/18/18 at 4:24 PM, LPN #4 verified that only the left resting hand splint was in place. S/he searched the room and was unable to locate any other splints. LPN #4 stated that the Certified Nursing Assistant was responsible for splint application. During an interview and observation on 9/19/18 at 9:23 AM, while Resident #68 was at [MEDICAL TREATMENT], the DON confirmed 2 resting hand splints on the cabinet next to the television. S/he did not know how long the splints had been missing. During an interview on 9/19/18 at 12:21 PM, after review of the therapy notes, the Rehab Coordinator stated that Resident #68 had been discontinued from skilled therapy on 3-9-17 with splints after caregiver education. S/he further stated, We will need to do a new evaluation since the elbow splints are missing to determine if contractures are worse. On 9/19/18 at 2:49 PM, the Occupational Therapist verified the physician's orders [REDACTED]. Additionally, observations on all days of the survey revealed that the resident was either in bed or out to [MEDICAL TREATMENT]. No activities were observed other than the television being on in the room. During an interview on 9/09/18 at 2:34 PM, Resident #68's family members expressed concern that they never saw her/him out of bed and would like to see her/him attend activities and get out of the room on days s/he didn't have [MEDICAL TREATMENT]. When asked, they stated they had expressed this to facility staff. They stated that Resident #68 had previously been very active individually (always on the go), in community groups, and had attended church every Sunday. Review of the 12-29-17 Annual MDS Assessment on 9/10/18 at 7:21 PM revealed that books, magazines, newspapers, music, news, groups, and religious services were very important to the resident. Section G noted that the resident transferred from bed only 1-2 times during the 7-day look-back period. Review of the Care Plan on 09/19/18 at 8:50 PM revealed that Resident needs one on one activities in room when not up and out of bed. (MONTH) also attend activities of interest out of room as tolerated. The goal was limited to one on one in room activities and did not address group activities. Although the resident was unable to communicate and only made eye contact, interventions included to Ask Resident about activity preferences and help plan. The plan did not include resident representatives' concerns. On 9/20/18 at 9:59 AM, review of One-to-One/Small Group Attendance Record Forms for 6/18 through 9/18 with the Activity Director (AD) revealed no attendance at group activities of any kind. During an interview on 9/19/18 at 11:38 AM, the Activity Director stated, The resident is not up and out to come to group. Basically, s/he's always in bed. That's why we do 1:1. The Activity Director reviewed the (MONTH) calendar and noted multiple events the resident would have enjoyed based on her/his noted interests, but that s/he had not been out of bed. S/he stated, We (Activities) can't get her (him) up but we would be glad to bring her (him) to programs. | 2020-09-01 |