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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate ▼ |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10266 | 10266 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 281 | D | THIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews and review of acceptable standards of practice for licensed staff , the facility failed to assure for 1 of 2 residents reviewed for accurate documentation related to a [MEDICAL TREATMENT] site that the documentation was thorough and accurate as entered. Resident #4 had documentation of thrill and bruit checks after the shunt site was changed and the physician discontinued the order. The findings included: The facility admitted Resident #4 on 6/26/09 with the following Diagnoses: [REDACTED]. The record review on 4/12/10 revealed a physician's orders [REDACTED]. Further review revealed another order written on 11/5/09 for removal of infected [MEDICAL TREATMENT] catheter and replacement of [MEDICAL TREATMENT] catheter- a tummeled catheter due to permanent placement access. During an interview with Registered Nurse (RN) #1 on 4/12/10 he/she stated " a thrill and bruit is not checked because the resident has a catheter in her right chest, the other site was removed." The nurse's notes revealed that Licensed Practical Nurse (LPN) # 2 documented in the notes "thrill felt and bruit heard" on the following dates 3/11/10, 3/13/10, 3/27/10 and 4/10/10. LPN #1 documented in the nurse's notes on 3/13/10 "bruit and thrill felt". LPN #3 documented in the nurse notes on 3/30/10 "thrill felt and bruit heard". During an interview with LPN #1 on 4/12/10 at 4 PM, when asked how he/she checked for a thrill and bruit, he/she stated "I just put the stethoscope above the catheter and hear a "LUB-DUB". During an interview with LPN #2 on 4/12/10 at 4:15 PM when asked how he/she checked for a thrill and bruit, he/she stated " you have to check that in the arm, but hers is in the chest". When ask why he/she documented that the thrill and bruit was checked, the LPN stated "I don't know". | 2014-01-01 | ||
| 10267 | 10267 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 315 | D | THIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of facility policy and procedure, the facility failed to provide appropriate catheter care for one of one catheter treatments observed. The Registered Nurse (RN) failed to properly anchor the catheter tubing during Resident # 3's catheter care. The findings included: The facility admitted Resident #3 on 7/27/09 with the following Diagnoses: [REDACTED]. During the catheter care observation on 4/13/10 at 9:15 AM RN #2 failed to secure the tubing to prevent pressure from tugging of the suprapubic catheter while cleaning, then drying the tube. At 9:20 AM on 4/13/10 during an interview with RN #2 he/she stated when ask about anchoring the tube "I didn't anchor it because its in the stomach." The facility policy titled Catheter Care, Suprapubic, stated under Procedure #11 "Gently grasp the catheter with non-dominant hand and use clean wash cloth to work down the tubing approximately 6 inches" | 2014-01-01 | ||
| 10268 | 10268 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 323 | E | THIH11 | On the days of the survey, based on observations and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Three bathrooms in the common area observed to be used by residents had no call light system in place. The findings included: A random observation on 4/12/10 revealed a female resident in a wheelchair coming out of the bathroom unsupervised directly across from the main dining room. Another random observation on 4/13/10 revealed a male resident in a wheelchair coming out of the bathroom unsupervised directly across from the main dining room. An inspection of the bathrooms 1. located on the back hall next to the main dining room, 2. the bathroom directly across from the main dining room and 3. the bathroom located between the beauty shop and the activity room, all revealed no call light system in place. During an interview with the Director of Nursing (DON) on 4/13/10 at 11:40 AM, he/she confirmed that "these bathrooms are used by everyone, staff, visitors and residents". The DON stated that "the residents are assisted". When he/she was informed of the observations of residents using the bathroom alone, he/she stated "well we do have some that can go by themselves." | 2014-01-01 | ||
| 10269 | 10269 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 279 | D | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, observations and interviews, the facility failed to develop and implement care plans with interventions to prevent aspiration for Residents #1, #2, #3 and #4 prescribed mechanically altered diets with nectar thick liquids and assessed as at risk for aspiration. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Observation on 09/13/2010 at approximately 3:00 PM of Resident #1's room revealed a white Styrofoam cup dated 09/11/2010 filled with water. In an interview with the surveyor on 09/13/2010 at 3:30 PM Licensed Practical Nurse #1 confirmed the date on the cup and the liquid. LPN #1 stated that a Speech Therapist had been working with Resident #1 and she was to have thickened liquids only. "The cup must have been left by the weekend staff." Record review on 09/13/2010 revealed a hospital transfer summary dated 08/23/2010 with discharge [DIAGNOSES REDACTED]. The physician ordered on [DATE] Speech-Language Pathology 5 days per week daily with precaution listed as aspiration; a pureed diet with nectar thick liquids was prescribed. Review of Resident #1's care plan revised 08/31/2010 listed as a focus area "Alteration in nutritional status r/t (related to) therapeutic mechanically altered diet with thicken liquids. Has severe dysphagia with high aspiration risk, family declines feeding tube." Interventions listed "will provided diet/snacks as ordered, will report hypo/hyper glycemia, will honor food preferences, will provide OHA's (oral hypoglycemic agents) as ordered". The facility admitted Resident #2 on 03/10/2008 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed physician's orders [REDACTED]. Review of Resident #2's care plan revised 09/13/2010 listed as a focus area "History of weight loss r/t receives daily diuretic and has dx (diagnosis) of dysphagia..." Interventions included "will provide honey thick liquids as… | 2014-01-01 | ||
| 10270 | 10270 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 315 | G | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on record review and interviews the facility failed to provide appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents reviewed for urinary tract infections. On 08/13/2010 the physician ordered a STAT urinalysis and culture/sensitivity for Resident #1 to be done on 08/14/2010; the urine obtained by an in and out catheterization was left in the refrigerator, the test was not performed and treatment was delayed. Resident #1 was admitted to the hospital on [DATE] with a urinary tract infection. Resident #3's with increased blood sugars and a low grade temperature had a urinalysis and culture/sensitivity done on 08/05/2010, which was carried to the wrong lab, treatment was delayed for 4 days. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, "Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS state in AM; pt tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP. RP would like for resident to be evaluated. MD notified. Resident sent to hospital..." Record review on 09/13/2010 of the hos… | 2014-01-01 | ||
| 10271 | 10271 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 281 | G | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observations, record review and interviews, the facility failed to provide care that met professional standards of practice for 2 of 3 sampled residents reviewed for standards of practice related to urinary tract infections and for 4 of 4 sampled residents reviewed for standards of practice related to aspiration precautions. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, "Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS STAT in AM; pt (patient) tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD (medical doctor) notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT (computerized tomography) of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP (responsible party). RP would like for resident to be evaluated. MD notified. Resident sent to hospital..." Record review on 09/13/2010 of the hospital admission history and physical dated 08/16/2010 at 3:33 PM revealed an admission assessment and plan that stated, "Urinary tract infection..." On 09/13/2010 a review of the laboratory studies revealed no results for the STAT UA/CS ordered by the physician for the AM of 08/14/2010. In an interview with the surveyor on 09/14/… | 2014-01-01 | ||
| 10272 | 10272 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-09-16 | 328 | D | UGRJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, interviews and record review the facility failed to ensure residents received timely foot care. The physician saw resident #2 and prescribed an antibiotic and cleaning to the right toenail bed until seen by the podiatrist related to redness of the toenail bed; resident #2 had a history of [REDACTED]. The findings included: The facility admitted Resident #2 on 08/21/2009 with [DIAGNOSES REDACTED]. Resident #2 was sampled as a result of a complaint related to skin care. Review of the current medical record on 09/16/2010 revealed the most recent Podiatry visit as 01/20/2010. A review of the nurse's notes revealed documentation that the podiatrist on 01/10/2010 for routine care saw Resident #2. On 03/10/2010 the physician saw Resident #2 due to pain in the left great toe and ordered triple antibiotic ointment for 7 days and Keflex 250 milligrams for 10 days. Nurse's notes from 03/11, 03/12, and 03/13/2010 documented a purulent yellow discharge from the left great toe. The Nurse's notes on 03/14/2010 at 3:45 PM stated, "CNA (certified nurse aide) reported to me Res (resident) in need of toenail trim. Removed bil (bilateral) bunny boots and both feet extremely dry and cracked no open areas noted. Velcro closure of top of (L) foot has rubbed reddened area to skin but intact. Attempted to trim toenail of (L) great ft (foot) and pus actively comin (sic) out. Toenail fell off. Trimmed all toenails and all came off either whole or crumbled. Skin underneath old nail pink and very healthy in appearance. Cleansed feet multiple times with warm water at bedside... Has had trx (treatment) ongoing to (L) great toes for inf (infection) with TAO. Had foul odor and purulent pus before cleaning. At present no active bleeding. Continued review of the nurse's notes revealed the physician was not notified about the drainage on 03/11, 03/12 and 03/13/2010 or that during care the toenails came off on 03/14/2… | 2014-01-01 | ||
| 10273 | 10273 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-09-16 | 157 | D | UGRJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review the facility failed to notify the physician of changes for one of five residents reviewed for foot care. Resident #2 with prescribed antibiotics for an infection of the left great toe developed "a purlent (sic) yellow discharge" that was not reported timely to the physician. The findings included: The facility admitted Resident #2 on 08/21/2009 with [DIAGNOSES REDACTED]. Resident #2 was sampled as a result of a complaint related to foot care. A review of the nurse's notes revealed documentation that the podiatrist on 01/10/2010 for routine care saw Resident #2. On 03/10/2010 the physician saw Resident #2 due to pain in the left great toe and ordered triple antibiotic ointment for 7 days and Keflex 250 milligrams for 10 days. Nurse's notes from 03/11, 03/12, and 03/13/2010 documented a purulent yellow discharge from the left great toe. The Nurse's notes on 03/14/2010 at 3:45 PM stated, "CNA (certified nurse aide) reported to me Res (resident) in need of toenail trim. Removed bil (bilateral) bunny boots and both feet extremely dry and cracked no open areas noted. Velcro closure of top of (L) foot has rubbed reddened area to skin but intact. Attempted to trim toenail of (L) great ft (foot) and pus actively comin (sic) out. Toenail fell off. Trimmed all toenails and all came off either whole or crumbled. Skin underneath old nail pink and very healthy in appearance. Cleansed feet multiple times with warm water at bedside... Has had trx (treatment) ongoing to (L) great toes for inf (infection) with TAO. Had foul odor and purulent pus before cleaning. At present no active bleeding. Continued review of the nurse's notes revealed the physician was not notified about the drainage on 03/11, 03/12 and 03/13/2010 or that during foot care the toenails came off on 03/14/2010. The physician examined Resident #2's toes on 03/16/2010. | 2014-01-01 | ||
| 10274 | 10274 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 225 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and review of facility documents, the facility failed to report an injury of unknown origin within the allowed time frame, failed to promptly begin an investigation into the injury, and failed to thoroughly investigate the resident's injury for a possible explanation of how it occurred for 1 of 1 resident reviewed who had an injury of unknown origin (#3). The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instruments of 5/14/09 and 4/23/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. Communication was sometimes understood. The resident required total care from the staff for all activities of daily living. Staff transferred the resident by mechanical lift. The resident received nutrition and hydration via feeding tube and maintained a steady weight (206 pounds recorded on the 5/14/09 assessment and 204 pounds on the later assessment.) Resident Assessment Protocol (RAP) notes revealed the resident had left side weakness from the stroke. She could mumble some words and was able to relay simple messages at times. The resident understood simple communication and followed simple commands. Two staff members assisted with bed mobility and transfers with the mechanical lift. Review of the medical record and facility documents showed the resident first showed signs of injury on 7/13/10 when a bruise was discovered after the resident's shower. Review of the Change Of Condition Nurses Notes and Resident Incident Report showed the discoloration was to the left back. There was no inflammation or [MEDICAL CONDITION] noted to the area. The facility did not report this injury of unknown origin or begin any investigation into the injury's possible origin. The facility did report to the State survey and certification agency on 7/15/10 that the resident's weekly skin audi… | 2014-01-01 | ||
| 10275 | 10275 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 496 | D | LLC411 | On the days of the survey, based on review of employee information provided, the facility failed to ensure that registry verification was completed before allowing an individual to serve as a Certified Nursing Assistant (CNA) for 2 of 3 employees reviewed who were hired in 2010 as CNAs. The findings included: During the complaint investigation, information concerning the staff on duty around the time of an injury of unknown origin was requested from the facility. The information provided failed to show that two of the CNAs had registry verification checks done prior to hire. The Director of Nurses (DON) was asked for this information on 9/28/10. On 9/29/10, the DON stated she knew the registry verification checks were done before hire, but Human Resources could not produce evidence of this. | 2014-01-01 | ||
| 10276 | 10276 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 514 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, the facility failed to ensure that resident records were complete and accurately documented for 1 of 3 resident records reviewed (#3). Documentation in the medical record concerning Resident #3's injury of unknown origin was incomplete and inaccurate. The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the Change Of Condition Nurses Notes showed staff found a discoloration on the resident's left back. The area was without inflammation or [MEDICAL CONDITION]. The nurse's note by LPN #1 did not describe the discoloration's size, shape, color, or specific location on the resident's left back. Certified Nursing Assistant (CNA) #3 found the area on 7/13/10 after the resident's shower and reported it to the nurse for assessment. This CNA was interviewed on 9/28/10 at 4:20 PM and stated what he saw was an area under the resident's left axilla extending to the left breast, it was blackish blue in color, and was approximately 4 by 4 centimeters big. LPN #1 was interviewed on 9/29/10 at 10:35 AM. She stated that on 7/13/10, she observed an elongated; approximately 3 inches by 1 inch, reddish purple area on the resident's upper back at the axilla level. LPN #1 denied seeing a blackish bruise under the resident's arm, extending under the left breast. Documentation in the Change of Condition Nurses Notes on 7/14/10 by LPN #1 described the "left flank discoloration" as not as large as yesterday. The medical record showed no information of any discolored area on the resident's flank. LPN #1 did not reference the resident's left flank in either her interview or in her statement. The information at the top of the page on the 7/15/10 Change of Condition Nurses Notes showed the resident's bruise on the left back was not as large. Purple discoloration was noted on the upper anterior left arm and left chest. Farther down the page, under the Current Care Plan Interventions and physician's orde… | 2014-01-01 | ||
| 10277 | 10277 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 323 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and review of facility documents, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed who had an injury of unknown origin (#3). The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instruments of 5/14/09 and 4/23/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. Communication was sometimes understood. The resident required total care from the staff for all activities of daily living. Staff transferred the resident by mechanical lift. The resident received nutrition and hydration via feeding tube and maintained a steady weight (206 pounds recorded on the 5/14/09 assessment and 204 pounds on the later assessment.) Resident Assessment Protocol (RAP) notes revealed the resident had left side weakness from the stroke. She could mumble some words and was able to relay simple messages at times. The resident understood simple communication and followed simple commands. Two staff members assisted with bed mobility and transfers with the mechanical lift. Review of the medical record and facility documents showed the resident first showed signs of injury on 7/13/10 when a bruise was discovered after the resident's shower in the left axilla area. On 7/15/10, the resident's weekly skin audit on 7/15/10 showed purple discoloration on the upper anterior left arm and chest. The resident grimaced when the left arm was manipulated. X-ray and assessment at the hospital showed a fractured left humeral head. The facility began an investigation into the resident's injury at that time. The Five-Day Follow-Up Report dated 7/20/10 stated the area found on 7/13/10 was a discoloration to the left flank. Review of the facility's investigative materials showed on their final report: "Res. wa… | 2014-01-01 | ||
| 10278 | 10278 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 425 | E | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the pharmacy, supplying medications to the facility, failed to assure the accurate administration of all drugs for 1 of 6 residents observed during medication pass. Resident A with a physician's orders [REDACTED]. The findings included: On 7/27/10 at 8:50 AM during observation of medication pass for Resident A, Licensed Practical Nurse (LPN) #4 was observed to measure Miralax Powder to the 15 milliliter mark in a medication cup used to measure liquid medications. The Miralax Powder was dissolved in 7 ounces of water and administered to the resident along with 8 other medications. Reconciliation of medication pass for Resident A revealed a current physician's orders [REDACTED]. DX (diagnosis) CONSTIPATION". The identical physician's orders [REDACTED]. All of the orders were signed by the physician without clarifying the ambiguous dosage. Further review revealed that the Physician's admission orders [REDACTED]. Dx Constipation". During an interview on 7/28/10 at 8:40 AM, the pharmacist at the pharmacy supplying the medications to the facility, stated that the pharmacy did not have the original order for the Miralax Powers (written 1/20/04) on hand. She/he stated that, on the pharmacy side, they have 17 Gms in 8 ounces of water as the standard (manufacturer's recommended) dose for Miralax and confirmed that the dosage on the monthly orders, printed by the pharmacy, was not clear. She/he further stated that, if there was an error, it was the pharmacy's fault. During an interview on 7/28/10 at 8:47 AM, LPN #4 stated that the pharmacist came to the facility yesterday (7/27/10) at about 5 PM, after the observation of medication by this surveyor the morning of the same day, and changed the dose for the Miralax on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. | 2014-01-01 | ||
| 10279 | 10279 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 314 | D | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview and review of the product insert sheet for Santyl/facility policy for the application of a [MEDICATION NAME] product, the facility failed to assure that one of two sampled resident's reviewed for pressure ulcer care received appropriate treatment and services. During observation of the pressure ulcer treatment for [REDACTED]. Facility staff was unaware if the pressure relieving mattress in use was appropriately set for the resident's use. The findings included: The facility last admitted Resident # 3 on 7/24/10. The resident's [DIAGNOSES REDACTED]. On 7/27/10 at 9:10am, an observation of the resident's pressure ulcer treatment was conducted. During the the procedure, the wound care nurse was observed to clean the outside raised edge of the pressure ulcer but not clean the wound bed itself. The wound bed was noted to contain slough and tunneling was noted. Following the treatment, the wound care nurse was questioned as to why the wound bed was not cleaned. S/he stated s/he did not want the spray the "collect" where the wound was undermined and did not want to injure the wound bed by having to pat it dry. S/he also stated s/he felt the use of Santyl cleaned the wound bed when the previous dressing was removed. Review of the product insert sheet from Santyl revealed the manufacturers recommendation stated to clean the wound bed prior to the application of Santyl. The instructions stated the wound bed should be cleansed prior to application.. remove as much loose debris as possible, gently cleanse the wound bed with saline or wound cleanser followed by saline each time the dressing is changed. Additionally, the facility policy also stated the wound bed should be cleansed prior to the application of a [MEDICATION NAME] product. Also following the completion of the treatment, the facility wound care nurse was questioned related to the use of the pressure relieving mattress wh… | 2014-01-01 | ||
| 10280 | 10280 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 373 | D | 1BYP11 | On the days of the survey, based on observation, interview and record review, the facility failed to identify the use of a paid feeding assistant program and failed to implement the approved program consistent with State law. The findings included: On 7/26/10, upon entrance to the facility, the Administrator stated the facility did not utilize a paid feeding assistant program. On 7/27/10, at approximately 1:30pm, the Administrator and Nurse Consultant again stated the facility did not have or use a paid feeding assistant program. During random observations during the evening meal on 7/26/10, two activity staff members were observed feeding residents in the "B" building. One resident was being fed in a small alcove in the "B" building and another resident was being fed in his/her room. Both staff members stated they were not Certified Nursing Assistants. During the noon meal on 7/27/10, the activity members were again observed feeding residents either in their rooms (building "B") or dining room (main building). Further investigation revealed the facility did have an state approved feeding assistant program. On 7/27/10 at 2PM, during an interview with the Staff Development Coordinator (SDC) , s/he stated s/he had not taught the feeding assistant program since her return to the facility 12/09 but s/he previously had taught it at the facility. S/he stated an awareness that both activity personnel had previously completed the feeding assistant program. When asked which residents a staff member who had completed the program could feed, the SDC stated they would feed "easier" residents. S/he further stated one particular activity staff member would feed "anyone she felt comfortable with...s/he would not step out of her comfort zone." A review of personnel files revealed both staff members had completed the paid feeding assistant program at the facility (in 2005 and 2007). On 7/28/10, during an interview with the Administrator it was verified that the facility was not cognizant that using trained staff members to feed r… | 2014-01-01 | ||
| 10281 | 10281 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 441 | E | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. Interview and observation of the Laundry Department revealed a lack of knowledge of appropriate infection control practice. Personal Laundry was not being sanitized. Following observation of catheter care for Resident # 3, handwashing concerns were identified. The findings included: On 7/27/10 at 11AM, an observation of the facility laundry department was conducted. Laundry worker # 1 was observed placing soiled laundry into a washing machine. After the soiled laundry was placed, s/he was observed to remove the protective gown by pulling it over his/her head when unable to untie the strings. The same laundry worker was asked to explain the process on how to handle laundry from an infected resident. Both Laundry worker # 1 and # 2 stated they would wear two pair of gloves and put on two gowns for protection. When asked how the two gowns would be applied, they stated one frontward and one backward. A box containing 3 pillows (1 cloth and 2 vinyl covered) was observed in the soiled area. When asked how the pillows would be cleaned, Laundry worker # 1 stated one pillow would be discarded because it was torn. The other two pillows would would be cleaned the same by spraying and wiping off with a disinfectant cleaner and then dried with a towel. Review of the label of the product indicated would be used stated it was to be used for non-porous surfaces. Further interview revealed that no bleach or other disinfecting chemical was used when washing the resident's personal laundry. The facility water temperature for personal laundry was identified as cold/warm. Appropriate chemical sanitization was used for bedding and other linens when washed. On 7/27/10 at 11:25AM, an interview was conducted with the Maintenance Supervisor, identified as in charge of the … | 2014-01-01 | ||
| 10282 | 10282 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 156 | D | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure a Resident's responsible party's stated interest in a Do Not Resuscitate order was acted upon timely. Resident # 11's responsible party expressed interest in formulating an Advanced Directive. After the Resident was determined to lack capacity for healthcare decisions, the facility took no further action. (1 of 13 sampled resident's reviewed for Advanced Directives) The findings included: The facility last admitted Resident # 11 on 7/7/10. The resident's [DIAGNOSES REDACTED]. On 7/26/10 a review of the current medical record revealed a Social progress note dated 7/8/10 which stated: "Res (resident) has POA (Power of Attorney) copy placed on chart and no living will. RP (Responsible party) is interested in DNR (Do not Resuscitate)." On 7/14/10 two physicians documented the resident lacked capacity to make healthcare decisions. Additional Social progress notes were documented on 7/16 and 7/19/10 noting resident behaviors and family visits/contacts. However, there was no further documentation related to the resident's advanced directive status. On 7/26/10 at 4:10pm, during an interview with the nurse consultant, s/he stated the resident was a "full code." On 7/27/10 at 11am, during an interview with social services employee # 1, s/he stated once a resident's capacity has been determined, appropriate action related to the residents/responsible party stated wishes for advanced directives should "happen quickly". S/he verified no action had been taken by the facility after the resident's capacity has been determined. S/he further stated the RP had been contacted and would be coming to the facility "today" to sign the paperwork for the resident's Do Not Resuscitate status. | 2014-01-01 | ||
| 10283 | 10283 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 281 | D | OR4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to clarify and follow a Physicians order related to discontinuing [MEDICATION NAME] for Resident # 12, 1 of 1 resident reviewed on anticoagulant therapy. The findings included: Resident # 12 was admitted by the facility on 3/16/10 with [DIAGNOSES REDACTED]. The record review on 9/21/10 revealed a physician's orders [REDACTED].= 2.0". Further record review revealed an INR drawn on 9/13/10 was 4.05 and on 9/14/10 the INR was 3.03. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The INR results dated 9/9/10 had an order written [REDACTED].> 2). On 9/21/10 at 1:00 PM Licensed Practical Nurse (LPN) # 2 stated during an interview that "the order should have been clarified, because the orders are not the same. Someone should have called the doctor and asked about it, I think it should be stopped after it is greater than 2.0." The Unit Manager for the 100 hall stated during an interview on 9/21/10 at 2:00 PM " It (the [MEDICATION NAME]) should have been stopped when they got a INR of 2.0 or greater." During a telephone interview with LPN # 3 on 9/22/10 at 10:40 AM she confirmed that she took the order and stated " they were to stop the [MEDICATION NAME] when the INR is 2.0 or greater, I don't know why I would have written equal, that is just a slip of the pen or something, but it should be stopped when the INR is 2.0 or greater.". LPN # 2 called the Physician and received a clear order on 9/21/10 at 1:00 PM which reads "D/C [MEDICATION NAME] when INR greater than or equal to 2.0". | 2014-01-01 | ||
| 10284 | 10284 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 329 | E | OR4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to decrease [MEDICATION NAME] as ordered for Resident # 12. The resident received 30 mg (milligrams) of [MEDICATION NAME] instead of 15 mg as ordered. The findings included: Resident # 12 was admitted by the facility on 3/16/10 with [DIAGNOSES REDACTED]. The record review on 9/21/10 revealed an order written [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Licensed Practical Nurse (LPN) # 2 stated during a interview on 9/21/10 that "the nurse who checked the MAR indicated [REDACTED]." The Unit Manager for Hall 100 stated during an interview on 9/21/10 " I checked those MAR's and I missed that, it is a problem." Both nurses stated " we will need to do a medication error report on this." | 2014-01-01 | ||
| 10285 | 10285 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 502 | D | OR4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview the facility failed to ensure that laboratory services were provided in a timely manner for 1 of 13 residents (Resident #4) reviewed for laboratory services. The findings included: The facility admitted Resident # 4 on 6/18/10 with the following Diagnoses: [REDACTED]. The record review on 9/20/10 revealed an order for [REDACTED]. On the bottom of this report a note/recommendation was made that stated " Mixed culture: 3 or more organisms isolated suggest repeat culture to rule out contamination." No other reports were found on the medical record. During an interview with Licensed Practical Nurse # 2 she stated " we should get another urine sample". This resident does have a Foley catheter and a history of Urinary Tract Infections with the last one documented and treated in July 2010. | 2014-01-01 | ||
| 10286 | 10286 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 441 | E | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and review of facility policies, the facility failed to develop and maintain an infection control program which prevented the spread of infection. During three of four pressure ulcer treatment observations, concerns were identified related to glove use or handwashing. (Resident's # 1, #2, and #5) During observation of three of three gastric tube flushes, the nursing staff failed to clean the stethoscope either before or following the treatment. (Resident's #2, #3, and #8) In two of three medication rooms, supplies were found stored beyond the manufacturer's expiration date. (One hundred and three hundred units) The findings included: The facility last admitted Resident # 1 with [DIAGNOSES REDACTED]. On [DATE] at 10:45AM, Licensed Practical Nurse (LPN) # 5 was observed performing wound care for the resident. LPN # 5 was observed to remove the soiled dressing from the residents left hip area, and without changing gloves proceeded to clean the wound using clean supplies. The facility last admitted Resident # 5 with [DIAGNOSES REDACTED]. On [DATE] at approximately 11AM, Licensed Practical Nurse # 5 was observed performing pressure ulcer care. LPN # 5 removed the soiled dressing from the residents sacrum and without changing gloves proceeded to clean the Stage IV pressure area with clean supplies. After cleaning the area with normal saline and drying the area, LPN #5 removed her gloves, washed her hands and donned clean gloves. The nurse then skin prepped the perimeter of the wound, fanned the area dry, applied Santyl to the areas containing slough, wet a dressing with saline, unfolded it, folded it into a smaller size and placed it directly onto the wound. A cover dressing was applied. LPN #5, continuing to wear the same gloves, reached into her uniform pocket, removed a pen and tape which were used to initial and date the dressing. After moving the bedside table away from the bed, the nu… | 2014-01-01 | ||
| 10287 | 10287 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 520 | E | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to fully identify quality concerns related to restraints. Resident # 2 with a known restraint, had no quarterly assessment to determine if the restraint was the least restrictive device and whether or not the restraint continued to be necessary. The facility conducted weekly restraint quality assurance reviews and failed to fully identify missing documentation related to the restraint. The findings included: The facility admitted Resident # 20 with a primary [DIAGNOSES REDACTED]. During the initial tour of the facility on 12/6/10 the resident was identified as wearing a hand mitt restraint, "at the families request." The resident was observed with an oven mitt with a splint applied over the mitt on the right hand. On 12/8/10, record review revealed an order was written on 2/2/10 for: "Oven mitt to right hand(with) left hand Spica. Remove for ADL's (Activities of Daily Living) + (and) check skin integrity Q (every) shift d/t (due to) restlessness, Dementia, playing in feces and self scratching." Further review revealed a Quarterly Restraint Review dated 1/8/10 (before the restraint order) which stated: ' Continue current restraint order. ...Look for alternative to mitt that is less restrictive." The quarterly physical restraint review was completed thirteen times, each time recommending the continued use of the restraint. On 12/8/10 from 10AM to approximately 11:15AM, interviews were conducted with the Director of Rehabilitation who stated she was responsible for restraint documentation and the Physical therapist. It was questioned what follow up was done to obtain an alternative which was less restrictive and or whether the resident still required the use the use of the restraint. In reviewing the nurses notes, there was no documentation of the resident scratching or attempting to play in feces when the restraint was released for ADL's. The last… | 2014-01-01 | ||
| 10288 | 10288 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 164 | D | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to ensure 1 of 3 residents received privacy during wound care. (Resident # 2) The findings included: The facility admitted Resident # 2 on 12-30-08 with [DIAGNOSES REDACTED]. During observation of wound care on 12-7-10 at approximately 1:30 PM, the Licensed Practical Nurse (LPN # 1) entered the room, pulled the privacy curtain between the beds to the foot of the bed, and asked the room mate if she wanted to leave the room while care was being given to Resident # 2. The room mate declined to leave the room, and was moving around her side of the room in her wheelchair. The privacy curtain which could have surrounded Resident # 2's bed was left at the head of her bed and not pulled around her bed. During the treatment LPN # 1 used up all of the supplies and stated to this surveyor, that he needed to leave the room to obtain more supplies to complete the treatment. At that time, Resident # 2 was lying on her side facing the door, with her brief unfastened and her entire backside exposed to view. When LPN # 1 left the room, the door was left ajar and unidentified persons were noted to be walking in the hall past the door. | 2014-01-01 | ||
| 10289 | 10289 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2010-12-08 | 315 | D | R42P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, review of the South Carolina Nurse Aide Candidate Handbook, and review of the facility policy on catheter care, the facility failed to provide appropriate treatment for 1 of 1 resident observed for catheter care. During observation of catheter care for Resident # 7, the Certified Nursing Assistant failed to secure the catheter close to the meatus to prevent tension or pressure on the bladder wall when cleaning the catheter tubing. The findings included: The facility admitted Resident # 7 on 6-7-10 with [DIAGNOSES REDACTED]. ,During observation of catheter care on 12-7-10 at approximately 10:00 AM, Certified Nursing Assistant (CNA # 1) knocked, entered the room, provided privacy, washed hands and gloved. CNA # 1 then set up the supplies on the over the bed table: 3 separate cups, one containing soapy water and gauze wipes, one containing clear water and gauze wipes, and the third containing dry gauze wipes. After Resident # 7 was positioned for the treatment, CNA # 1 again washed hands and gloved. CNA # 1 then positioned her left hand to separate the labia and secure the catheter. Using her right hand she used a soapy gauze wipe to clean around the left side of the labia, and discarded the gauze wipe, then repeated the procedure on the right side. CNA # 1 then used the third soapy gauze wipe to clean the catheter, beginning at the entry point of the catheter into the body, she wrapped the gauze around the catheter and pulled away from the body to where the fingers of her left hand secured the catheter (about 4 inches from the body). Tension was observed when the catheter was being cleaned. This entire process was repeated with the clear water rinse, and in drying. Review of the facility policy revealed the following: "Female residents: Separate labia with one hand. With the soapy gauze, cleanse from front to back one stroke down one side, discard the used gauze then stroke down the ot… | 2014-01-01 | ||
| 10290 | 10290 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2012-02-01 | 251 | C | 2C1L11 | On the days of the survey, based on interviews and review of the "South Carolina Code of Laws Title 40-Professions and Occupations Chapter 63: Social Workers", the facility, with more than 120 beds, failed to employ a Licensed Social Worker as required by state law. The facility Social Worker had a Bachelor's Degree and had not been licensed. The findings included: During an interview on 02-01-12 with the facility Social Worker, she revealed she had a Bachelor's degree and had not been licensed. During an interview on 02-01-12 with the Administrator, she revealed she did not know a Licensed Social Worker was required. She stated the facility would contract with a Licensed Social Worker as a Consultant to oversee the facility Social Worker at least 20 hours per month. Review of the "South Carolina Code of Laws Unannotated, Current through the end of the 2011 Session, Title 40-Professions and Occupations, Chapter 63: Social Workers" revealed in Section 40-63-30: License as prerequisite to practice or offer to practice; providing social work services through telephone or electronic means. A) No individual shall offer social work services or use the designation "Social Worker", "Licensed Baccalaureate Social Worker", "Licensed Masters Social Worker", "Licensed Independent Social Worker-Clinical Practice", "Licensed Independent Social Worker-Advanced Practice", or the initials "LBSW", "LMSW", or "LISW" or any other designation indicating licensure status or hold themselves out as practicing social work or as a Baccalaureate Social Worker, Masters Social Worker, or Independent Social Worker unless licensed in accordance with this chapter". | 2014-01-01 | ||
| 10291 | 10291 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2012-02-01 | 252 | E | 2C1L11 | On the days of the survey, based on observation and interviews, the facility failed to ensure that the residents' room and care equipment were clean and sanitary for 1 out of 3 units observed for cleanliness. Resident rooms that contained feeding pumps were noted with soiled areas; stains were noted on ceiling tiles; dust was apparent under resident beds and a base board was not intact. The findings included: Observation during the initial tour on 1/30/2012 at 11:00 AM and follow up observation on 1/31/2012 at 9:30 AM on the Ventilator Unit revealed the following concerns. -12-A---tube feeding spills in bathroom; on grab bar; and shower chair. -12-B-- tube feeding noted at the base of the feeding pump. -12-D--wall at the head of the bed had dried spills. -13-C--tube feeding noted on the floor and wall behind the bed. -14-- noted stained ceiling tiles. -14-B---tube feeding noted on feeding pump. -14-D-- tube feeding noted on feeding pump. -15-C-- tube feeding noted on feeding pump and dust under the bed -15-D-- tube feeding noted on feeding pump and dust the under the bed. -16-A-- tube feeding noted on feeding pump and dust under the bed. -17-A-- dust particles noted behind the bed. -17-B-- tube feeding noted on the feeding pump. -18--wall and floor noted with spills. -19--dust noted behind the bed and portion of the base board was not intact. During an interview with the Unit Manager on 1/31/2012 at 3:15 PM, she stated that all staff were responsible for keeping the resident's care equipment and room clean. The Housekeeping and Laundry Supervisor verified all of the following listed above during a walking tour on 1/31/2012 at 4:00 PM. The Housekeeping and Laundry Supervisor stated that is was the responsibility of everyone to ensure all equipment and rooms are kept clean and sanitary. | 2014-01-01 | ||
| 10292 | 10292 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 441 | F | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews and interviews, the facility failed to provide Tracheostomy care for one of one resident reviewed for tracheostomy care in a manner that would prevent possible infection on Resident #11. In addition the facility failed to track/trend infectious organisms and failed to adequately notify visitors of contact precautions. The findings included: The facility admitted Resident #11 on 5/12/10 with [DIAGNOSES REDACTED]. Review of the September 2010 cumulative physician's orders [REDACTED]. Observation on 9/28/10 at approximately 4:50 PM revealed Licensed Practical Nurse (LPN) #5 entered the resident's room. After assessing the resident, he put on a pair of clean gloves and suctioned inside and around the tip of the tracheostomy opening with a [MEDICATION NAME] suction catheter. He did not wash his hands prior to putting on the gloves. With the same gloved hands that he had used to suction with the [MEDICATION NAME] catheter, he opened a new inner cannula from a box container, removed the inner cannula from the resident's tracheostomy, and inserted the new inner cannula into the tracheostomy. With the same gloved hands, he then opened the drawer to the bedside table and removed a sterile suction kit. He put one sterile glove on his left hand without removing the other gloves and proceeded to perform endotracheal suctioning to the resident. During an interview on 9/29/10 at 5:13 PM, LPN #5 verified he put on gloves without washing his hands first, put on a sterile glove over a dirty one, and touched the drawer handle and supplies with the same gloved hands used for suctioning. He stated that the reason he put the sterile glove over the dirty one was that the sterile gloves were too small and ripped causing mucus to get on his hands. Review of the policy provided by the facility entitled "Suctioning of Tracheostomy" (dated 11/25/97) on 9/29/10 at 12:58 revealed under Procedure..."3. Assembl… | 2014-01-01 | ||
| 10293 | 10293 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 225 | D | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and review of the policy provided by the facility entitled "Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint, Complaint Responsibilities" dated 8/7/09, the facility failed to report to the state agency and investigate the alleged verbal abuse of Resident #13, one of 18 residents reviewed for abuse and neglect; the facility failed to complete an incident report related to a skin tear on Resident #30. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an individual interview on 9/29/10 at 11:05 AM, Resident #13 stated that she was lying on her side when a Certified Nursing Assistant (CNA) laughed and made an unprofessional/inappropriate remark related to the resident's size.. Resident #13 stated the CNA pushed her so hard she almost pushed her out of the bed. The resident stated that it had not been long since the incident occurred. She stated she had asked that the CNA not be allowed to take care of her and stated that the CNA had been taken off the floor. During an interview on 9/29/10, the Assistant Director of Nursing (ADON) stated she was unaware of the incident and it had not been reported to her. During an interview on 9/30/10 at approximately 11:00 AM, Nurse A stated she was aware of the incident, but hadn't been on duty at the time the incident occurred. Nurse A stated she had reported the incident to her supervisor, RN #2. Nurse A stated the CNA involved in the incident had requested to be moved off the floor, and had not been moved as a result of any disciplinary action. During an interview on 9/30/10 at approximately 11:30 AM, RN #2 denied any knowledge of the incident and stated that the nurse must have reported the incident to another nursing supervisor. During an interview on 9/30/10 at 12:00 Noon, the Director of Nursing (DON) stated she was unaware of the incident. After reviewing the CNA's personnel record, the D… | 2014-01-01 | ||
| 10294 | 10294 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 280 | D | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to review and update the Care Plans for 2 of 18 sampled residents reviewed for comprehensive Care Plans. Resident #13's Care Plan was not updated related to [MEDICAL CONDITION] and drug seeking behaviors; Resident #30's Care plan was not updated related to skin tears. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an interview on 9/30/10 at approximately 12:15 PM, Registered Nurse (RN) #2 stated Resident #13 had been exhibiting drug seeking behavior. According to the nurse, the resident told the physician on 9/20/10 that the [MEDICATION NAME] wasn't working any more and he subsequently discontinued it. Review of the physician's orders [REDACTED]. The nurse stated that the resident kept asking for the [MEDICATION NAME] again, so the nursing staff had to call the on-call physician that same night who gave an order for [REDACTED]. MD (physician) will evaluate in AM". When asked what was being done to address this issue, the nurse stated the resident had been seen by Psychiatry and had a trial of [MEDICATION NAME]. Review of the "Psych Consult and Progress Notes" dated 3/10/10 revealed that Resident #13 had been diagnosed with [REDACTED]. According to the note "Case discussed with staff. Pt. (Patient) had been refusing q (every) hs (Bedtime) [MEDICATION NAME] (Secondary) to "SE" (Side Effects) Upset stomach, [MEDICAL CONDITION] of feet which attributed to (increased) dose. Pt. would like to try another medicine & asks for [MEDICATION NAME]. I explain(ed) to her that this will not help (with) depression & Pt. is already taking [MEDICATION NAME] which is similar. Pt denies SI (Suicidal ideation). She has been cooperating with care. (No) voiced [MEDICAL CONDITION]. Pt is oriented x3. Meds (Medications) [MEDICATION NAME] 1 mg (milligram) PO (By Mouth) Q (every) AM. [MEDICATION NAME] 60 mg PO Q AM, [MEDICATION NA… | 2014-01-01 | ||
| 10295 | 10295 | BMC SUBACUTE REHAB CENTER | 425340 | 1330 TAYLOR AT MARION STREET | COLUMBIA | SC | 29203 | 2011-06-07 | 371 | F | VIJL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the recertification survey, based on observation, record review, review of the facility's policy entitled HACCP/FOOD SAFETY PROGRAM and interviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. The facility failed to dispose of expired foods, failed to label foods in storage to ensure expired foods could be identified and failed to implement policies and procedures to ensure expired items were discarded appropriately. The facility also failed to sanitize the thermometer between foods while testing temperatures on the tray line. In addition, the facility failed to develop and implement a policy for thawing meat to ensure that previously frozen, thawed meats were not refrigerated for extended periods prior to cooking. The findings included: Initial tour of the kitchen was conducted on 6/7/11 beginning at 9:15 AM with the Store Room Manager, the Certified Dietary Manager (CDM) and the Executive Chef. Tour of the dry food storage area revealed a box of [MEDICATION NAME] Extra with an expiration date of 4/11 and a box of muffin mix with an expiration date of 2/16/11. In addition there were 6 boxes of corn muffin mix and 8 boxes of buttermilk biscuit mix with no expiration dates and an opened bag of macaroni with no label. During the tour, the Store Room Manager confirmed there were multiple items without expiration dates and confirmed the items should have been labeled when removed from the case boxes. During an interview at approximately 12:00 PM, the Store Room Manager stated dry goods were rotated with each delivery to ensure "first in, first out." He stated that he doesn't "pay attention" to items already on the shelf if he hasn't ordered any of that item but also stated "I guess I should." He also stated he did not know if there was a policy stating how often the store room should be checked for expired food items. Review of the facility's Operational Standard: Food Storage, dated A… | 2014-01-01 | ||
| 10296 | 10296 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2010-09-14 | 328 | E | DZ1T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure that residents received treatments as ordered by the physician for 1 of 2 residents reviewed who had nebulizer treatments ordered (#2). Resident #2 did not receive the nebulizer treatments ordered on [DATE] until 8/17/10. The findings included: Resident #2 with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes revealed a note on 8/12/10 at 10:15 PM stating: "Resident noted to have cough (with) congestion. Notified MD." The physician saw the resident on 8/13/10 and wrote in his progress note that the resident was "... quite short of breath and feeling terrible. ..." A treatment plan was documented in the progress note including "Start [MEDICATION NAME] solution 2.5 mg/3mL (2.5 milligrams per 3 milliliters), (0.083%), 3 mL, Q 4 hrs. (every four hours) while awake x (times) 5 days, then prn (as needed for) wheeze. ..." Antibiotics, nasal oxygen, a chest x-ray, and a speech therapy consult were also ordered for suspected aspiration pneumonia. The 8/13/10 Daily Skilled Nurses Note at 6 PM documented that the resident was coughing but had no complaint of pain. He was resting in bed. The nurse's note documented that the physician wrote new orders for oxygen, nebulizer treatments, and a chest x-ray. The chest x-ray was done and no infiltrates were noted. Speech Therapy evaluated the resident and changed his diet. A swallow study was scheduled for 8/16/10. The nurse's note ended with "... No distress when eating supper. Will monitor." Review of the physician's orders [REDACTED]. "Chest x-ray Re: poss (possible) aspiration pneumonia "[MEDICATION NAME] 100 mg PO (by mouth) BID (two times a day) x 10 days, 1st dose STAT "[MEDICATION NAME] 500 mg PO BID x 10 days, 1st dose STAT "[MEDICATION NAME] 2.5mg/3mL via neb q 4 (hours) while awake x 1 week, then PRN "Oxygen 2 L/min (liters per minute) via nasal cannula" This order was signed by the physician … | 2014-01-01 | ||
| 10297 | 10297 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 272 | D | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents were comprehensively assessed related to a history of falls for 2 of 2 residents reviewed who had repeated falls (#1 and #3). Both residents had a history of [REDACTED]. The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation. She was discharged home on[DATE]. The admission nursing fall assessment showed a score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) notes revealed the resident was at risk for falls. "She is at risk for falls related to Hx (history of) falls and Dx ([DIAGNOSES REDACTED]. The note failed to provide any history of the resident's falls, and therefore there was no evaluation of any pattern or possible triggers for the falls. The RAP note did not evaluate the resident's internal or external risk factors. The resident fell three times while at the facility, 7/27/10, 7/28/10, and 8/22/10. One fall, the one on 7/28/10, resulted in a fractured distal right clavicle. Review of the medical record revealed the resident was independent and wanted to do for herself. She also participated in therapy with improving functional status. However, the facility failed to use this information to adapt to the resident's changing status in an effort to prevent accidents. There was no evidence of a comprehensive assessment of the resident's falls either on admission o… | 2014-01-01 | ||
| 10298 | 10298 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 280 | G | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents' care plans were periodically reviewed an updated to reflect changing status for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized after a fall for evaluation of hip pain. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation after hospitalization . She was discharged home on[DATE]. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed a fall in the last 30 days. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility. One of the falls resulted in a fractured distal right clavicle. Review of the care plan showed it was not updated to show the falls and no new interventions were planned to assist the resident in fall prevention. Resident #3 with [DIAGNOSES REDACTED]. An admission nursing assessment for falls revealed a score of 22, any score above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10, the resident had had multiple falls. Review of the RAI of 7/25/10 showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. Review of the care plan dated 8/3/10 revealed a problem of "high risk for falls related to Hx (history of) falls, decreased mobility." Interventions included: gather information on past falls; be sure call light is in … | 2014-01-01 | ||
| 10299 | 10299 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 323 | G | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. Resident #1 went to the facility for short term rehabilitation. Review of the admission nursing assessment showed a fall risk score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. The note did not provide any history of the past falls. There was no evaluation of any pattern or triggers for the falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility: 1. A Nurse's Note on 7/27/10 at 7 AM stated the resident was found lying on the floor in her bathroom. The resident could not explain how she got on the floor. A small skin tear on the left elbow resulted from the fall. There was no evidence the facility changed or added interventions to the resident's care plan after this fall. 2. On 7/28/10, at 7 PM, the Nurse ' s Note said her Certified Nursing Assistan… | 2014-01-01 | ||
| 10300 | 10300 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 496 | D | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of a Certified Nursing Assistant's employee file and interview, the facility failed to ensure that information was sought from every State registry before allowing an individual to serve as a nurse aide for 1 of 1 employee file reviewed. The findings included: The employee file of a Certified Nursing Assistant (CNA) who was assigned to a resident who fell and was later diagnosed with [REDACTED]. The facility checked the South Carolina CNA Registry for information prior to hire, but failed to check with the Massachusetts CNA Registry. The Assistant Director of Nurses confirmed this after she spoke with Human Resources personnel. | 2014-01-01 | ||
| 10240 | 10240 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2011-09-21 | 314 | E | MKPP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and review of a facility provided article from " Primary Intention" which included a reference from Barr J." Principals of Wound Cleansing" and an facility provided article printed from the Internet related to Management of Pressure Ulcers, the facility failed to provide appropriate wound care. The Pressure ulcers for Resident #2 & #3 were not appropriately cleaned. during the observation of wound care. (2 of 3 pressure ulcer care observed). The findings included: The facility readmitted Resident #3 on 08/18/2011 with [DIAGNOSES REDACTED]. On 9/20/11 at !0:05 AM, during observation of wound care for Resident # 3, the Wound Nurse sprayed wound cleanser on the sacral ulcer and wiped the ulcer edges with a four by four gauze four times, using a clean gauze each time, but failed to clean the wound bed. The resident was then turned and repositioned on the left side and wound care to the right hip was observed. The Wound Nurse sprayed the ulcer and wiped the wound bed three times using a separate four by four gauze each time but failed to clean the periwound tissue. The facility admitted Resident # 2 on 3/14/07 with the following Diagnosis: [REDACTED]. On 9/20/11 at 3:30 PM, during observation of wound care for Resident # 2, the Wound Care Nurse (WCN) cleaned the wound from side to side. During a interview with the WCN on 9/20/11 at 2:00 PM when ask about wiping/swabbing the wound from side to side she stated " I was told not to clean it from the center, because you don't know where you started." When ask how she was taught to clean a wound, she stated from the center outward. The wound care nurse was observed during the survey to clean three pressure ulcers. Her methodology varied during all three procedures. The facility Nurse Consultant provided this surveyor with documentation of an article titled "Wound Cleansing: sorely neglected? " ( Primary Intentions Volume 14 Number 4 November 200… | 2014-02-01 | ||
| 10241 | 10241 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2011-09-21 | 315 | D | MKPP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observation and interview the facility failed to provide appropriate catheter care for Resident # 12. (1 of 2 catheter care observations conducted.) The findings included: The facility admitted Resident # 12 on 9/29/10 with the following Diagnosis: [REDACTED]. During the observation of the catheter care provided by Certified Nursing Assistant (CNA) #1 on 9/19/11 at 1:35 PM, the CNA lifted the penis by raising the catheter tubing. The catheter tubing was held approximately 2 inches from the urinary meatus. While securing the penis in an upright position by holding the catheter tubing, she then cleaned the penis using downward [MEDICAL CONDITION] from tip to the base of the penile shaft. During a interview with the CNA on 9/21/11 at 9:45 AM she did not dispute the observation. | 2014-02-01 | ||
| 10242 | 10242 | KERSHAWHEALTH KARESH LONG TERM CARE | 425080 | 1315 ROBERTS STREET | CAMDEN | SC | 29020 | 2010-10-29 | 225 | D | CXO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of facility files related to an allegation of abuse and misappropriation of resident property, the facility failed to report the allegation to the State survey and certification agency for 1 of 1 allegation reviewed. On 5/5/10, Resident #1's [MEDICATION NAME] ([MEDICATION NAME]) patch was missing. All staff on duty were drug tested that day. Laboratory test results reported to the facility on [DATE] confirmed the presence of the drug in Certified Nursing Assistant (CNA) #1's system. The findings included: Resident #1 arrived at the facility on 1/22/03. His [DIAGNOSES REDACTED]. The resident suffered from chronic pain and received [MEDICATION NAME] 25 micrograms per hour via [MEDICATION NAME]. The patch was changed every 72 hours. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the investigative materials revealed LPN #1 went to the resident on the morning of 5/5/10 and applied a new [MEDICATION NAME]. She secured the patch with a dated piece of tape. The LPN was unable to find the old patch for removal. LPN #1 tried to find the old patch again at approximately 10 AM and could not. She made another attempt at 12 noon only to discover the 8 AM patch was missing. A search of the resident, his bed, and his room failed to locate the [MEDICATION NAME]. LPN #1 reported her findings to Administration. The facility conducted searches of all employees on duty. The employees were also held for drug testing. Only one employee's drug test returned with positive results for [MEDICATION NAME], CNA #1. The Bureau of Drug Control was called to investigate. CNA #1 was terminated on 5/29/10. The facility could not provide any evidence showing they reported this incident to the State survey and certification agency. | 2014-02-01 | ||
| 10243 | 10243 | RIVERSIDE HEALTH AND REHAB | 425082 | 2375 BAKER HOSP BLVD | CHARLESTON | SC | 29405 | 2010-10-12 | 225 | E | 8JQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on limited record review, interview, and review of the facility's reportable file since 4/9/10, the facility failed to report to the State survey and certification agency 4 of 8 allegations of misappropriation of resident property (Residents A, B, C, D), failed to report timely 3 of 4 allegations of misappropriation (Residents #1, E, F), and failed to thoroughly investigate 4 of 8 allegations of misappropriation (Residents A, B, C, and D). The findings included: Resident #1 reported to the facility on [DATE] that her wallet was missing. The Complaint/Grievance Report stated the resident reported that approximately $30.00 was in the wallet. The facility's initial 24 hour report also noted the resident's debit card was taken and that there had been some activity on the resident's debit card account. The initial report to the State survey and certification agency was dated 9/28/10, which exceeded the 24 hour deadline for reporting allegations of misappropriation. Review of the facility's grievance files revealed three addition allegations of misappropriation around the same time Resident #1 made her complaint. Resident A reported $4.00 missing on 9/24/10. Resident B reported $14.00 missing on 9/27/10. Resident C reported $9.00 missing on 9/28/10. Residents B and C had notations on their grievance stating "resolved by personnel action (secondary to) cluster of similar events on Unit 200." None of these allegations was reported to the State survey and certification agency or thoroughly investigated. Continued review of the facility reportable incidents revealed another cluster of allegations concerning misappropriation of resident property in April 2010. Resident E reported on 4/10/10 that $63.00 was missing. The resident's allegation was not reported until 4/12/10. Resident F reported on 4/16/10 that $20.00 was missing. The allegation was reported to State agency on 4/20/10. Resident D reported "missing $" on 4/16/… | 2014-02-01 | ||
| 10244 | 10244 | WHITE OAK MANOR - ROCK HILL | 425088 | 1915 EBENEZER RD | ROCK HILL | SC | 29732 | 2010-10-19 | 225 | D | YPDS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record reviews and interviews the facility failed to ensure that all allegations of abuse/neglect were thoroughly investigate to prevent further abuse to residents #1 and #5. There was no documentation that the facility interviewed all staff on duty at the time of the incident (2 of 5 sample residents reviewed) The findings included: The facility admitted Resident #1 on 06/25/2010 and readmitted the resident on 07/30/2010 with [DIAGNOSES REDACTED]. Review of the facility investigation regarding a facility reported incident involving Resident #1 on 07/23/2010 revealed a statement written by Licensed Practical Nurse #1 that stated, "...I asked her when it started hurting she said yesterday at white guy help me from my bed to my chair he was in white uniform - he was with other workers. He picked me up under my arms and lifted me to the w/c (wheelchair) - felt a little pain not much..." The witness statement indicated the resident informed the facility staff that "he was with other workers". A review of the facility investigation revealed no interviews were done with the staff working at the time of the incident. The Social Services Director (SSD) stated that the facility did not have statements from staff on the unit at the time of the incident with Resident #1. The facility admitted Resident #5 on 12/20/2005 with [DIAGNOSES REDACTED]. Record review revealed a Quarterly MDS (Minimum Data Set) dated 06/17/2010 that indicated the resident had memory problems but had no cognitive problems with daily decision making. Review of the facility grievance log revealed Resident #5 informed the facility on 08/05/2010 that a nurse, in the presence of three CNAs (certified nurse aides), grabbed her wrist and told her to move. There was no documentation the facility investigated the allegation and reported to the State Survey Agency. In an interview on 10/19/2010 at approximately 11:30 PM the DON (Director of Nursing) and… | 2014-02-01 | ||
| 10245 | 10245 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 157 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interview, the facility failed to notify the physician and family promptly of a change in condition which potentially required physician intervention. Resident #4, one of four residents reviewed for notification, had a temperature of 103.2 without timely physician/family notification of a change in condition. The findings included: The facility admitted Resident #4 on 6/18/10 and readmitted the resident on 7/28/10 with [DIAGNOSES REDACTED]. Review of Interdisciplinary Progress Notes on 10/27/10 at 10:20 AM revealed a note dated 7/20/10 at 1:50 PM that stated "130/76, 100.3, 78, 18. Prn (As needed) Tyl(enol) admin(istered) (with) f/u (follow up) temp (temperature) of 98.8. Pt (Patient) total care continues. Up in w/c (wheelchair) daily max assist (with) mech(anical) lift. Skin warm-tx (treatment) to sacral area continues. Moderate drainage noted (with) scant odor. Will cont(inue) to monitor...". The next note was dated 7/21/10 at 3 AM and stated "At 1 AM resident had rapid breathing, skin warm & moist. VS (Vital Signs) as follows 103.2, 98, 24, 136/92. PRN (As Needed) Tylenol given for (increased) temp. Recheck temp @ 3 A(M) (down) to 99.9. Respiration(s) even + nonlabored...". There was no mention that the physician or family had been notified of the change in condition for this resident when her temperature, heart rate, and respiratory rate increased at 1 AM. The next entry was dated 7/21/10 at 10:40 AM and stated "@ 9 am, pt alert, responsive-meds (medications) given per g-(gastrostomy) tube (without) difficulty. g tube patent (with no residual). HOB (Head of Bed) elevated per norm. Tyl(enol) PRN admin(istered) @ this time prior to wound care tx (treatment). @ 9:55 called to pt rm (room) d/t (due to) pt lethargic et facial drooping upon assessment noted pt (with) L(eft) side facial drooping, open mouth breathing-labored respirations @ 26. Lungs full, SpO2 @ 90% RA (Room Air… | 2014-02-01 | ||
| 10246 | 10246 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 166 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interview, and review of the policy provided by the facility entitled "Grievances & Complaints", the facility failed to actively work towards resolution of a complaint/grievance for one of one sampled residents with a grievance. Family member concerns regarding the care of Resident #4 were not addressed by the facility. The findings included: The facility admitted Resident #4 on 6/18/10 and readmitted the resident on 7/28/10 with [DIAGNOSES REDACTED]. A complaint faxed to DHEC (Department of Health and Environmental Control) Certification was reviewed on 10/26/10 prior to the survey. The complaint included a letter dated 7/29/10 addressed to the Admissions Director and Marketing Director of Springdale Health Care Center. It contained the following: "Gentlemen: (Resident #4) is back at Springdale, as you know, and I'd like to review with you the matters regarding her care that we discussed recently. (Marketing Director) informed us that she would be placed on the "100" wing/hall with different nurses/staff caring for her. (Admissions Director) addressed personally taking care of/supervising her wound care, including the "wound vac". To prevent dehydration, her feeding tube is to be flushed multiple times daily. Insuring that the feeding tube area remains clean. Monitoring excessive therapy (exercise) on her left arm. To make sure that she isn't sitting on the affected area for prolonged periods, and that she is turned on a regular basis. That someone communicates with Dr. --, myself and/or my (other family member) for any change in her condition or care. FYI, her home caregiver --, will continue to make regular visitations with (Resident #4). I am optimistic that the "situation" that occurred last week has been resolved, corrected, and that (Resident #4's) care will be the best that Springdale has to offer. Please contact me immediately if any of the foregoing is incorrect or mis… | 2014-02-01 | ||
| 10247 | 10247 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 253 | D | K6DC11 | On the days of the complaint inspection, based on observation, the facility failed to provide a safe, clean, comfortable and homelike environment for 3 of 6 resident rooms observed. Soiled and malodorous carpets were observed in 3 of 6 resident rooms on Unit 2. The findings included: Observations on 10/26/2010 at 10:10 AM of room 209 revealed 3 large grayish brown spots on the floor under the tube feeding pole and pump; room 213 was noted with a large amount of clothes piled on a chair and a pair of bedroom shoes on the floor; both room had a musty odor throughout. Observations on 10/26/10 at 12:02 PM revealed a fly light position on the floor in room 212B near the window, the ionizer contained approximately 15 dead flies on the base, under the light. There was also a musty odor noted throughout the room. The tan carpet on the floor was worn and had stains along with darker areas that looked like black scuff marks. At 12:24 the Director of Nursing verified the findings but stated she could not smell any odors. She stated that there might be an odor, but that she smoked and didn't have a good sense of smell. | 2014-02-01 | ||
| 10248 | 10248 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 279 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review and interview, the facility failed to development comprehensive plans of care, which addressed the needs of 1 of 6 sampled residents. Resident #3 with a [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #3 on 10/15/2010 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/26/2010 for Resident #3 revealed a Interdisciplinary Progress Note dated 10/23/2010 at 1:00 PM that stated, "Res (resident) noted with nephrostomy valve leaking. Supervisor notified and MD made aware. MD order given to tape around valve to seal and to monitor until Monday and let nephrologist address then. Urine draining in nephrostomy bag without problems..." A care plan dated 10/25/2010, noted the following problem area: "Is at risk for injury related to falls as evidence by...has nephrostomy with drng (drainage) bag and suprapubic cath (catheter)"; "Admits related to weakness from acute hospital stay...suprapubic cath and groin pain"; "Potential for pain related to [DIAGNOSES REDACTED]. staff for ADL's (activities of daily living) related to: suprapubic cath in place..." The care plan identified the left nephrostomy tube as a suprapubic catheter. The plan of care did not document that Resident #3 had a left nephrostomy tube in place or the need to monitor on a routine bases the care of the tube and insertion site. The Director of Nursing verified the resident was not care plan for a left nephrostomy tube. | 2014-02-01 | ||
| 10249 | 10249 | SPRINGDALE HEALTHCARE CENTER | 425169 | 146 BATTLESHIP ROAD | CAMDEN | SC | 29020 | 2010-10-27 | 309 | D | K6DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, interviews and observation, the facility failed to assure each resident received care and services in accordance with the plan of care as ordered by the physician. Resident #1 had current physician orders [REDACTED]. Resident #3 with an order documented in the Interdisciplinary Progress Notes for a follow-up with the nephrologist related to a leaking nephrostomy tube that was not transcribed and carried out. (2 of 6 sampled residents reviewed for care and services related to following physician orders.) The findings included: The facility admitted Resident #1 on 10/04/2010 with [DIAGNOSES REDACTED]. As a result of a complaint the closed medical record for Resident #1 was reviewed on 10/26/2010, a physician's orders [REDACTED].#1 complained of loose stools through the night and the standing order for Immodium was initiated, there was no further documentation related to loose stools until 10/10/2010. A late entry dated 10/12/2010 at 8:00 PM for 10/10/2010 4:00 PM stated, "Resident c/o (complains of) loose stool. Medicated with Immodium, ineffective continues to have loose stool. MD aware n/o (new order) received: obtain stool sample, decrease TF (tube feed) 50 cc/hr (centimeters/hour); have dietician assess." On 10/10/2010 the Resident #1 was transferred to the hospital at the request of the family due to their concerns related to her having loose stools. Review of the Activities of Daily Living (ADL) Flow Record showed Resident #1 had extra large stools on all three shifts 10/08/2010; had no stool on the 11-7 shift, an extra large stool on the 7-3 shift and a small stool on the 3-11 on 10/09/2010; had extra large stools on all three shift on 10/10/2010. Review of the 24 hour report from 10/08/2010 thru 10/10/2010 documented on 10/08/2010 for the "Day" shift (7-3) "c/o loose stools, initiated s.o. (standing order) Immodium..."; the 24 hours reports revealed no further documentatio… | 2014-02-01 | ||
| 10250 | 10250 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 157 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview, closed record review, and review of facility policy titled Condition Change (9/03) and Documentation (4/06) the facility failed to provide evidence that the resident's physician and legal representative were notified when Resident # 11 experienced a significant change in his condition. The resident's temperature was significantly elevated to 103.9 and the resident was vomiting brown emesis with a foul odor. The findings included: The facility admitted Resident # 11 on 12/1/08. The resident's [DIAGNOSES REDACTED]. On 10/24/10, a review of the closed medical record revealed the resident was documented as having an elevated temperature of 103.9 on 10/1/10 at 2:30PM. The resident vomited twice. The emesis was noted to be brown, watery with a foul odor. There was no documentation that the attending physician was notified but rather standing orders were initiated which included [MEDICATION NAME] and Tylenol. There was no documentation that the responsible party was notified. During an interview with the facility Director of Nursing on 10/24/10 at 8:30PM, she indicated she felt the nurse had initiated the standing orders appropriately. When questioned about the brown emesis with a foul odor, she stated the resident constantly chewed tobacco and felt that was the cause of the foul odor and brown color. The Director of Nurses did not dispute there was no evidence that the family had been notified. On 10/25/10, at 5PM, during an interview with the attending physician, he stated he did not recall being aware of the resident's illness while in the building. He further stated that if he did see him that day it would have been because the resident was seated in the hallway per his usual custom. On 10/25/10 at approximately 5:45PM, during an interview with Licensed Practical Nurse # 1, she stated that the physician was in the building and was informed of the resident's condition and saw the resident. She stated… | 2014-02-01 | ||
| 10251 | 10251 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 281 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review, interview and review of the facility provided policy for documentation, the facility failed to meets professional standards of quality. Resident # 11 was documented as having a rapid onset of illness with elevated temperature and foul smelling emesis at 2:45PM. At 6PM, a facility staff member documented the effect of medications administered. There was no further documentation of the resident until 355AM, the following morning when the resident was mottled, with unstable vitals signs and transferred to acute care. A History and Physical completed by the attending physician failed to address a complete assessment of the resident. The findings included: The facility admitted Resident # 11 on [DATE]. The resident's [DIAGNOSES REDACTED]. On [DATE], a review of the closed medical record revealed the resident was documented as having an elevated temperature of 103.9 on [DATE] at 2:30PM. The resident vomited twice. The emesis was noted to be brown, watery with a foul odor. Licensed Practical Nurse # 1 documented she administered [MEDICATION NAME] two times that day (at 8:30AM and 2PM) and Tylenol at 2PM for and elevated temperature. The last documented complete physical assessment of the resident was at 2:45PM on [DATE]. Review of the 24 hour report and nursing worksheet contained no additional information. Licensed Practical Nurse # 2 documented on the back side of the Medication Record that Tylenol and [MEDICATION NAME] were repeated at 6PM and were "effective." No further documentation of the resident's condition was found. The next documentation of an assessment of the resident's condition occurred at 3:55AM on [DATE] when the resident was transferred to acute care and admitted to the hospital. The admission History and Physical obtained from the hospital stated the resident was to be admitted with [DIAGNOSES REDACTED]. The resident expired while in the hospital on [DATE]. The Discharge summary s… | 2014-02-01 | ||
| 10252 | 10252 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 428 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the consulting pharmacist failed to identify that Resident # 11 with known bradycardia was not having a pulse taken prior to administration of the medication. The findings included: The facility admitted Resident # 11 on 12/1/08. The resident's [DIAGNOSES REDACTED]. On 10/24/10, a review of the closed medical record revealed the resident was documented as having known Bradycardia. The resident was ordered by the physician to receive Metoprolol 12.5 milligrams daily. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The pharmacist was questioned as to why there had not been a previous recommendation to take the resident's pulse prior to the administration of the medication, especially since she had acknowledged the resident's known bradycardia. The pharmacist stated that some facilities had policies which required a pulse be obtained prior to the administration of this class of drug, but this facility did not. On 10/25/10 at 5PM, during an interview with the attending physician, he stated he was not aware the resident's pulse was not being taken prior to the administration of the medication. The Nursing Drug Handbook 2011 Edition available as a resource for the nurses on the nursing unit, stated on page 383: "Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately." There was no documentation found that the resident's pulse was being obtained prior to the administration of the Metoprolol or that the consulting pharmacist had reported the irregularity to the physician. | 2014-02-01 | ||
| 10253 | 10253 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 156 | B | M5SK11 | On the days of the survey, based on record review and interview, the facility failed to provide timely Notice of Medicare Provider Non-Coverage notification for 4 of 5 residents reviewed for Change in Pay Source. The findings Included: Review of residents files for change in pay source revealed four of five residents had not received timely notification of Medicare Provider Non-Coverage. Resident A's Notice of Medicare Provider Non-Coverage indicated that effective 1/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until 1/11/2010. Resident B's Notice of Medicare Provider Non-Coverage indicated that effective 6/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 6/11/10. Resident C's Notice of Medicare Provider Non-Coverage indicated that effective 6/11/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 6/11/2010. Resident D's Notice of Medicare Provider Non-Coverage indicated that effective 1/14/2010 his/her coverage of current skilled nursing services would end. Further review revealed the resident had not received notification of the change in pay source until the 1/14/2010. During an interview with the Business Office Manager (BOM) on 10/25/10 at approximately 3:30 PM he/she stated " They wanted to go home that day, so we did not have time to give notice". The medical records for residents B and C showed a form titled Notification of Therapy Change which was dated 6/2/10 for resident C. (7 days in advance). and Resident B's form was dated 6/7/10. (4 days in advance). The BOM stated when asked what this form was for, "that is how they let us know the time is ending." | 2014-02-01 | ||
| 10254 | 10254 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 157 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to consult with the resident's physician when there was a significant change in the resident's condition. Resident #6 had clinical record documentation on 07/24/2010 at 0615 as sweaty, which required a linen and clothing change, later in the day he was described as lethargic. The next day (07/25/2010) at 2:00 AM it was documented that he had a temperature of 100 degrees and twitching of his extremities when touched; at 4:00 AM the twitching continued; at 6:00 AM he pulled away when care was provided and would not take fluids. The documentation indicated that the resident was lethargic at 10:50 AM and was sent to the emergency room at his daughter's request. There was no evidence the resident's physician was notified of the change in condition. (One of six sampled residents reviewed for notification) The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to (sic) cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Will pass to next shift to monitor. 1:35 PM Resident was lethargic at breakfast could not wake up enough to eat. Ate 100 % of lunch. Has been holding head down and drooling excessively all day. Afebrile with VS WNL (within normal limits). Will cont. (continue) to monitor. 2300 Remains in bed. Skin cool to touch and dry at this time. N… | 2014-02-01 | ||
| 10255 | 10255 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 281 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews and interviews, the facility staff failed to meet professional standards of quality for 1 of 6 residents reviewed for an acute change in condition. The physician was not consulted when Resident #6, treated [MEDICATION NAME] for recurrent urinary tract infections and recently treated with a course of antibiotics for a urinary tract infection, showed evidence of a change in condition. On 07/24/2010 at 6:15 AM he was noted with sweating; blood pressure 141/72, temperature 97.5, pulse 85 and respirations 22, he was described as lethargic at breakfast there was no other documentation until 11:00 PM when it was stated that no twitching of extremities was noted. On 07/25/2010 at 2:00 AM his blood pressure was not noted, temperature 100, pulse 100, respirations 18 and twitching of extremities when touched was noted; "opens eyes when spoken to with no awareness of staff. At 4:00 AM twitching when touched was again documented; at 6:00 AM his blood pressure was 110/50, temperature 99.9, pulse 180, fluids not accepted; at 10:50 AM he was lethargic, unresponsive; his BP was 110/80, temperature 97.5, pulse 115, respirations 20. Resident #6 was transferred to the emergency room . The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Wil… | 2014-02-01 | ||
| 10256 | 10256 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 312 | D | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint survey based on observations, record review and interviews, the facility failed to ensure that care and services necessary to maintain or attain the highest practical physical well being related to grooming and personal hygiene was provided for Resident #3 observed on 10/12/2010 with blood on the left side of the nose; with long fingernails on both hands and what appeared to be blood under her fingernails. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Resident #3 observed at 11:00 AM seated in the day room on Unit 3 with dried blood on the left side of her nose; her fingernails on both hands, were noted to be long, with what appeared to be blood under the index finger and on the thumb of the right hand. At 11:10 AM Resident #3 was rolled in her Geri-chair to her room and transferred to her bed for incontinent care. CNA #2 stated that the resident preferred her nails long and that nails were done on Tuesday. Review of the Weekly Nursing Assessment from 06/19/2010, 09/11/2010,09/25/2010, and 10/09/2010 documented a scab in the crease of the resident's nose on the left side and stated, "scratches won't leave band aid on." On 10/12/2010 at 11:30 AM Resident #3's fingernails were observed with the Director of Nurses, at that time the nails had been cut and cleaned, but were still uneven and rough. The Director of Nurses confirmed that Resident #3 still needed nail care, which should include filing. | 2014-02-01 | ||
| 10257 | 10257 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 280 | D | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to revise and update the Care Plan for 1 of 6 sampled residents reviewed for Comprehensive Care Plans. Resident #1 had 4 reported incidents where she "slid" out of chairs to the floor without changes to the approaches used to address her falls. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated "8-22-10 at 7:45 AM". Under "Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage." was a handwritten note. "Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor...". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale". Review of a 2nd Incident/Accident Report dated 09/1/2010 revealed that Resident #1 had been "..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she "slid out". She was out of site for app(roximately) 2 minutes". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ...". Review of a 3rd Incident/Accident Report dated 09/13/2010 revealed "Resident found sitting on floor in front of chair". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall". Review of a 4th Incident/Accident Report dated 09/14/2010 revealed "Sitting in w/c trying to push nurse away, slipped to floor from w/c. Also hitting at nurse". There were no additional commen… | 2014-02-01 | ||
| 10258 | 10258 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 272 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure two of four sampled residents were assessed for transfers. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device for each resident. Resident #3's CNA Care Plan Guide revealed no mention of the level of assistance required for transfers or the mode of transfer. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a [MEDICAL CONDITIONS] and tib-fib (tibia-fibula) [MEDICAL CONDITION] leg. In a letter dated 10/1/2010 from the facility's Director of Nursing (DON), the facility reported that "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aide caring for (Resident #1). Her left foot was moved approx.(approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record conducted on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the … | 2014-02-01 | ||
| 10259 | 10259 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 225 | E | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, observation and record review, the facility failed to thoroughly investigate and/or report two incidents involving Resident #1, two incidents involving Resident #2, one incident involving Resident #3 and one incident involving Resident #5. These residents were 4 of 6 sampled residents reviewed for reportable incidents. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated "8-22-2010 at 7:45 AM". Under "Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage." was a handwritten note. "Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor...". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the Director of Nursing (DON) stated there had been no investigation conducted since the incident had been witnessed. When asked if she knew what had happened to cause the shower chair to tilt forward she did not know. Review of a 2nd Incident/Accident Report for Resident #1 dated 09/1/2010 revealed that she had been "..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she "slid out". She was out of site for app(roximately) 2 minutes". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ...". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the DON verified an investigation had not taken place. She stated the resident had been in the Day Room … | 2014-02-01 | ||
| 10260 | 10260 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 253 | D | GYKK11 | On the day of the complaint inspection, based on observations and interviews the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 1 Unit reviewed. There were 2 blue wheelchair with cracked, rough and peeling arm supports; 2 black wheelchairs with soiled seats and frames with food particles; 1 Geri-chair with a cracked arm support frame and torn upholstery on the back of the back support at the top. The findings included: Observations on 10/12/2010 at approximately 10:40 AM revealed maintenance issues on Unit 3. The Director of Nurses confirmed the following at 11:30 AM: One Geri-chair with a crack approximately 10 inches long on Resident #3's Geri-chair, right arm support frame; back support, top right back with exposed foam. Resident #2 seated in a blue wheelchair with both armrests torn and cracked. A blue wheelchair with both arm rests torn and cracked; 2 black wheelchairs with soiled seats and frames with food particles. Review of Schedule of Events/Activities revealed that Gerri Chairs and Wheelchairs were to be cleaned once a week and as needed; there was no cleaning log maintained. | 2014-02-01 | ||
| 10261 | 10261 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 323 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a Deep Vein Thromboses (DVT) and tib-fib (tibia-fibula) fracture of the left leg. In a letter dated 10/1/10 from the facility's Director of Nursing (DON), the facility reported, "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aid caring for (Resident #1). Her left foot was moved approx. (approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the physician deferred the issue of transfers… | 2014-02-01 | ||
| 10262 | 10262 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 280 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint survey, based on record review and interview, the facility failed to revise and update the Care Plan for 1 of 4 sampled residents reviewed for Comprehensive Care Plans. Resident #1's Care Plan had not been updated regarding approaches used for proper positioning and to prevent and/or care for Pressure Ulcers. The findings included: The facility admitted Resident #1 on 09/06/2002 and readmitted her on 12/10/2004 with [DIAGNOSES REDACTED]. Observation on 10/18/2010 at 12:35 PM revealed the resident lying on a specialty mattress with the head of bed elevated. Review of the cumulative Physician order [REDACTED]. Review of the Physician/Nurse Practitioner Progress Notes on 10/18/2010 at 1:15 PM revealed the following: 06/16/2010- "S(ubjective): Resident had an area of skin compromise noted to her sacrum. Initial treatment was the use of [MEDICATION NAME] although wound treatment nurse reports the skin was intact at that time. However, we were called to see the resident today due to changes in the sacral wound...P(lan): ...Also, initiate a specialty mattress surface for the resident to minimize skin breakdown and to offload this area". 07/12/2010- "Patient is an elderly white female with a known history of advanced dementia, ... and essentially total care for activities of daily living (ADLs) and instrumental activities of daily living (IADLs)...". 07/14/2010- "Chief Complaint: Pressure Area. S(ubjective): Resident is frail and debilitated, cachectic, with wound on her sacrum...O(bjective): The wound is open...Heels are intact... P(lan): ...Keep resident turned and positioned...". 07/28/2010- "P(lan): She is on double shot protein q.i.d. (4 Times daily)...Heels are intact...Encourage turning and repositioning". 08/09/2010- "P(lan): ...Keep resident turned and repositioned". 08/30/2010- "P(lan):...Encourage turning and repositioning, although due to her frailty and debility would contribute greatly to poor wound healing.… | 2014-02-01 | ||
| 10263 | 10263 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 157 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review, interview, and review of the policy provided by the facility entitled "Physician Communication Grid", the facility failed to notify the physician with changes related to pressure ulcers for 2 of 4 sampled residents reviewed with pressure ulcers. Residents #3 and #4 had pressure ulcers worsen without physician notification. The findings included: The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Record Review on 10/18/2010 revealed a Wound Treatment & Progress Record dated for September 2010. On the front was an order dated "9-15-10" that stated "Cleanse sacral area (with) wound cleanser, pack (with) calcium alginate & cover (with) adhesive foam dsg.(dressing), (Change) qd (daily) & PRN (When needed)". Under this was written "crush [MEDICATION NAME] 500 mg (milligrams) (1) tab(let) into wound on coccyx qd". On the back of the sheet were 3 entries. One of the entries, dated 09/22/2010 revealed that the wound had measured "Length 5.0, Width 8.0, depth 1.0, Undermining 3.9". On 9/29/10 the wound had increased in size to "Length 5.9, Width 8.0, Depth 1.6, and Undermining 4.1". Another Wound Treatment and Progress Record dated October 2010 revealed two entries, one dated for 10/07/2010 that stated the wound measured "Length 6.1, Width 8.0, Depth 1.5, Undermining 3.8"; and one dated 10/14/2010 that stated "Length 6.5, Width 8.0, Depth 1.5, Undermining 4.1". Review of the Physician/Nurse Practitioner Progress Notes revealed the last note in the chart was dated 09/06/2010 and did not mention the sacral wound. Review of Physician order [REDACTED]. Review of the Nurse's Notes for September and October 2010 revealed no mention that the Physician or Nurse Practitioner had been notified that the Pressure Ulcer had gotten bigger. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (… | 2014-02-01 | ||
| 10264 | 10264 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 514 | E | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, the facility failed to ensure that nursing staff initialed treatments when completed for 2 of 4 sampled residents reviewed for completeness and accuracy of clinical records. Residents #3 and #4 had blanks on their treatment record where the nurse failed to initial the treatment as having been completed. Review of the Narcotics Log and Medication Administration Records for the Blue Wing revealed inaccuracies in documentation of narcotic/hypnotic medication administration for Residents A, B, C, D, E, and F. The findings included: The facility initially admitted Resident #4 on 08/11/2009 and readmitted him on 03/07/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for July, August, September, and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd (daily) & PRN (As needed)". Blank spaces were noted for 10/2, 10/3, 10/6, 10/8, 9/4, 9/6, 9/12, 9/13, 9/21, 8/1, 8/24, 8/25, 8/30, 8/31, 7/9, and 7/11/2010. -physician's orders [REDACTED]. Secure (with) tape. May cover loosely (with) gauze. (Change) qd and PRN". Blank spaces were noted for 10/6 and 9/21/2010. -physician's orders [REDACTED]. Wrap (with) Kerlix. (Change) qd & PRN". A blank space was noted for 10/01/2010. The Treatment Nurse on 10/18/2010 verified the blanks for September and October 2010. The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for August and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd & PRN". A blank space was noted for 10/06/2010. -physician's orders [REDACTED]. (Change) qd & PRN". Blank spaces were noted for 8/24 and 8/29/2010. The Director of Nursing on 10/18/2010 veri… | 2014-02-01 | ||
| 10265 | 10265 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 314 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review, interview, and review of the policy provided by the facility entitled "Physician Communication Grid", the facility failed to assess and address with the physician changes related to pressure ulcers for 2 of 4 sampled residents reviewed with pressure ulcers. Residents #3 and #4 had pressure ulcers worsen without physician notification. The findings included: The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Record Review on 10/18/2010 revealed a Wound Treatment & Progress Record dated for September 2010. On the front was an order dated "9-15-10" that stated "Cleanse sacral area (with) wound cleanser, pack (with) calcium alginate & cover (with) adhesive foam dsg.(dressing), (Change) qd (daily) & PRN (When needed)". Under this was written "crush [MEDICATION NAME] 500 mg (milligrams) (1) tab(let) into wound on coccyx qd". On the back of the sheet were 3 entries. One of the entries, dated 09/22/2010 revealed that the wound had measured "Length 5.0, Width 8.0, depth 1.0, Undermining 3.9". On 9/29/10 the wound had increased in size to "Length 5.9, Width 8.0, Depth 1.6, and Undermining 4.1". Another Wound Treatment and Progress Record dated October 2010 revealed two entries, one dated for 10/07/2010 that stated the wound measured "Length 6.1, Width 8.0, Depth 1.5, Undermining 3.8"; and one dated 10/14/2010 that stated "Length 6.5, Width 8.0, Depth 1.5, Undermining 4.1". Review of the Physician/Nurse Practitioner Progress Notes revealed the last note in the chart was dated 09/06/2010 and did not mention the sacral wound. Review of Physician order [REDACTED]. Review of the Nurse's Notes for September and October 2010 revealed no mention that the Physician or Nurse Practitioner had been notified that the Pressure Ulcer had gotten bigger. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Pr… | 2014-02-01 | ||
| 10194 | 10194 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 441 | E | A4CW11 | On the days of the survey, based on observation and interview, the facility failed to sanitize residents' personal laundry. The findings included: During observation on 9/14/10 at approximately 1:36 PM, Laundry Aid #1 loaded multiple residents' personal laundry into the washer and set the cleaning solution pump on "F1." The sign posted on the wall stated F1 solution was without bleach. During an interview at that time, the laundry aid stated she always used setting 1 for residents' personal clothes so they wouldn't be damaged. At 1:46 PM, during an interview, the Area Mechanic stated the water in the washer was between 115 and 120 degrees. He further stated the water used to be at 180 degrees but, after changing chemicals, they had been told the water temperature didn't need to be that high. At approximately 3:08 PM on 9/14/10, the Director of Environmental Services confirmed that the F1 setting did not include bleach and stated the (solution) pump should have been set on the F2 setting which added bleach after five minutes. Review of the detergent container did not reveal that the detergent contained any sanitizer. The Director of Environmental Services did not provide any additional information that the detergent had any bateriocidal properties. | 2014-03-01 | ||
| 10195 | 10195 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 333 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure that one of 20 residents reviewed for medication assessment was free of significant medication errors. Potassium was not administered as ordered to Resident #6 for a period of 5 days. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Prognosis was "nil" at the time of admission. Record review on 9-14-10 at 1:55 PM revealed 7-19-10 physician's orders [REDACTED]. Review of the 7-19-10 Basic Metabolic Profile revealed the following results: Sodium = 130 LOW (reference 135-145 mmol/L); Potassium = 4.9 (reference 3.6-5.0 mmol/L); Chloride = 95 LOW (reference 101-111 mmol/L); Blood Urea Nitrogen = 52 HIGH (reference 6-20 mg/dl); Creatinine = 1.8 HIGH (reference 0.5-1.2 mg/dl). Review of the 7-10 Documentation Record (Medication Administration Record/MAR) revealed that the medication was held as ordered and that the [MEDICATION NAME] was resumed on 7-27-10. The Potassium (20 milliEquivalents daily) was not initialed on the MAR indicated [REDACTED]. During an interview on 9-15-10 at 9:40 AM, the Director of Nurses verified that the medication had not been initialed as given for the five day period as noted. She stated she had been unaware of the omissions, no medication error report had been completed, and the physician had not been notified. She reviewed the record and verified that no recent Potassium level had been drawn. | 2014-03-01 | ||
| 10196 | 10196 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 315 | E | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview, and review of the policy provided by the facility entitled "Skills Checklist for Suprapubic Catheter Care", the facility failed to ensure appropriate treatment and services for residents with catheters. The Certified Nursing Assistant (CNA) failed to properly anchor the suprapubic catheter tubing during catheter care for Resident #2, one of three residents observed with catheter care. Also, the facility failed to assess oral intake and urinary output as indicated by residents' medical condition for one of two sampled residents reviewed with an indwelling Foley catheter and Care Plan for intake and output monitoring. Resident #6, with a history of fluid imbalance and [MEDICAL CONDITION], had incomplete intake and output documentation. The findings included: The facility admitted Resident #2 on 10/22/09 with [DIAGNOSES REDACTED]. Observation of catheter care on 9/14/10 at 12:23 PM revealed CNA(Certified Nursing Assistant) #2 cleaning, rinsing, and drying the catheter tubing. She held the tubing between her index finger and thumb, approximately 4 inches from the insertion site, and anchored it to the resident's thigh while wiping down the tubing. The CNA cleansed from the insertion site distally toward where she held the catheter, causing undo tension on the catheter tubing. During an interview on 9/15/10 at 11:25 AM, CNA #2 verified she had anchored the catheter tubing at the resident's thigh instead of at the insertion site while performing catheter care. She stated she thought she was supposed to anchor the tubing to the thigh. Review of the policy entitled "Skills Checklist for Suprapubic Catheter Care" on 9/15/10 revealed "...6. Apply soap to one wet cloth, 7. Hold tubing (Without pulling) in other hand, 8. Wash around one side of tubing with soapy cloth-, 9. Using a different, clean part of cloth- wash around the other side of the Tubing, 10. Hold the tubing closest… | 2014-03-01 | ||
| 10197 | 10197 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 332 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews and the Drug Facts and Comparisons book (updated monthly), the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 6.5 %. There were 3 errors out of 46 opportunities for error. The findings included: Error #1: On 9/13/10 at 8:36 PM, during observation of medication pass, Registered Nurse (RN) #5 was observed to administer two Klor-Con 10 (Potassium Chloride Extended Release) tablets and 7 other medications to Resident #10. During an interview on 9/13/10 at 8:48 PM, RN #5 revealed that supper trays arrived on the unit at about 6 PM and that Resident #10 had eaten in his room (approximately 2 and one-half hours before the potassium was administered). The Drug Facts and Comparisons book, page 49 (Potassium Replacement Products), states (under "Patient Information"): "May cause GI (gastro-intestinal) upset; take after meals or with food and with a full glass of water." Error #2: On 9/13/10 at 9 PM, during observation of medication pass, RN #2 was observed to administer one drop of [MEDICATION NAME] Ophthalmic Solution and one drop of [MEDICATION NAME] Ophthalmic Solution to the right eye of Resident A with one minute and 56 seconds between the two drops. RN #2 then administered one drop of the same two eye drops to the resident's left eye with 2 minutes and 4 seconds between the 2 drops. The Drug Facts and Comparisons book, page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "Because of rapid lacrimal drainage and limited eye capacity, if multiple drop therapy is indicated, the best interval between drops is 5 minutes. This ensures that the first drop is not flushed away by the second or that the second drop is not diluted by the first.". Error #3: On 9/14/10 at 7:47 AM, during observation of medication pass, RN #1 was observed to instill one drop of [MEDICATION … | 2014-03-01 | ||
| 10198 | 10198 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 225 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the policy provided by the facility entitled "Alleged Violations of Mistreatment, Neglect and Abuse Including Injuries of Unknown Origin and Misappropriation of Property" dated 2/09, the facility failed to complete a thorough investigation for one of one reportable incidents reviewed for misappropriation of funds. The findings included: One of three reportable incidents reviewed on 9/15/10 revealed that a resident reported $44.00 missing from his room on 9/7/10. According to the DHEC (Department of Health and Environmental Control) Five-Day Follow-Up Report dated 9/13/10, "He had noticed this the week prior to the report". Under "Witnesses and other Staff on duty at time of/or prior to Reportable Incident:", there was nothing written. According to the report, the missing money had been reported by the facility to the Union County Sheriff's Office on 9/8/10. The "Summary Report of Facility Investigation:" stated "(Resident) keeps various items in the basket where he reported the money had been stored. (Numerous pieces of mail, straws, playing cards, and various other items). He has been reminded again to lock up any large amounts of money." Attached to the Five-Day Follow-Up Report was a letter dated May 4, 2010 from the Administrator addressed to residents and their families reminding them that the facility could store valuables and that residents are encouraged to not keep any items of personal or monetary value in their room. The letter went on to state that "The facility will take every precaution to protect belongings but cannot be accountable for valuables left in resident rooms". There were no resident or staff statements attached or evidence of a thorough investigation being completed. During an interview on 9/15/10 at approximately 12:30 PM, the Social Services Director (SSD) stated the resident had a history of [REDACTED]. After reviewing the Five-Day Follow-… | 2014-03-01 | ||
| 10199 | 10199 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 323 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record reviews, and interviews, the facility failed to ensure that the resident environment remained free of accident hazards as was possible and that each resident received assistance devices to prevent accidents. Random observations were made of unattended paint thinner accessible to cognitively impaired, mobile residents and of bottles of Hydrogen Peroxide (H2O2) stored unsecured in Resident #3's bathroom. The facility also failed to provide interventions as required to minimize injury for one (1 )of 6 sampled residents reviewed for falls. Resident # 6 who was assessed at high risk for falls did not have a low bed and mats provided as per the plan of care. The findings included: On 9/14/10 at 10:50 AM a random observation was made by two surveyors on Unit 1 Maple Lane in the patient shower area of an unattended 1 gallon container of Paint Thinner on the window sill and 2 paint cans without covers containing paint thinner, soaked brushes, and rags soaked in paint thinner. There was a strong odor of the chemical in the shower area and in the Maple Lane Hall. The label on the Paint Thinner read, "DANGER: COMBUSTIBLE LIQUID, FLAMMABLE--HARMFUL OR FATAL IF SWALLOWED". The Material Safety Data Sheet (MSDS) provided by the Administrator on 9/14/10 read : "RISK STATEMENTS-Irritating to eyes, respiratory system, and skin. Harmful by inhalation, may cause lung damage if swallowed. Harmful in contact with skin. Vapors may cause drowsiness and dizziness". SAFETY STATEMENTS on the MSDS read: "Avoid contact with skin and eyes, Keep container tightly closed. Do not breathe gas, fumes, vapor, or spray, Keep away from sources of ignition. Take precautionary measures against static discharges." HANDLING AND STORAGE SECTIONS of the MSDS stated, "STORAGE : Vapors may ignite explosively and spread long distances. Prevent vapor build up. Keep cool and keep in the dark. Do not store above 49 C/120 F(Fahrenheit). K… | 2014-03-01 | ||
| 10200 | 10200 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 309 | E | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and record review, the facility failed to follow physician's orders for application of Knee High TED (antiembolism stockings) Hose for Resident # 11, 1 of 4 residents reviewed with orders for TED Hose. The facility also failed to include provision of Services from a Chaplain and Social Services in the care plan and no documentation of visits from these disciplines were found in the record for Resident #18, 1 of 2 resident's reviewed receiving Hospice Services . The findings included: The facility admitted Resident #11 on 4/26/04 with [DIAGNOSES REDACTED]. Record Review on 9/14/10 at approximately 6:15 PM revealed a Physician's Order for "Knee high TED hose on in the morning before getting out of bed & (and) remove at bedtime ([MEDICAL CONDITION])" with a start date of 9/16/08. Observation of the resident at 6:25 PM on 9/14/10 revealed the resident was not wearing TED Hose. During an interview on 9/15/10 at 1:15 PM, the resident stated she had never had any stockings and that she did have swelling in her feet "sometimes." Review of the resident's Minimal Data Set revealed the resident was coded as not having any short or long term memory problems. The resident was named on the list provided by the facility of Interviewable Residents and she was a member of the Resident Council. Record Review on 9/15/10 at approximately 1:30 PM revealed that the TED Hose had been signed off daily for August and September, including being signed off for being applied the morning of 9/15/10. During an interview on 9/15/10 at approximately 2:15 PM, Registered Nurse (RN) #4 stated she had just received a new pair of TED Hose for the resident the previous week. Upon observation of the resident, RN #4 confirmed the resident was not wearing TED Hose. RN #4 was unable to locate any TED Hose in the resident's drawers. When informed of the resident's statement that she had never had any stockings, RN #4 stated:… | 2014-03-01 | ||
| 10201 | 10201 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 322 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews, and review of the facility's policies entitled "Gastrostomy Tube Check List" and "Procedure for Cleaning 60 cc (cubic centimeters) Syringes Used for Resident Feeding", the facility failed to utilize universal precautions and clean technique when flushing the Gastrostomy (G-) Tube and when cleaning and storing the piston syringes and gravity set for 2 of 3 residents observed for Gastrostomy Tube flushes. The findings included: The facility admitted Resident #5 on 7/17/09 with [DIAGNOSES REDACTED]. On 9/14/10 at approximately 12:33 PM, Licensed Practical Nurse (LPN) #6 was observed by two surveyors providing a Gastrostomy Tube flush before and after medication administration without washing her hands prior to initiating the procedure. LPN #6 opened the Medication cart, retrieved a bottle of liquid Tylenol from the drawer and poured 20 milliliters (ml) of Tylenol into a medication cup. LPN #6 proceeded to the resident's room, knocked, entered the room and filled the 2 empty medicine cups with 30 ml of water from the sink and placed all 3 medicine cups on the over-bed table. She then closed the door, opened a plastic bag and placed it on the foot of the bed and donned a pair of non-sterile gloves. LPN #6 proceeded to check for and replace residual, checked for placement of the [DEVICE], and administered the 30 ml flush, the medication and ended with another 30 ml flush. Upon completion of the procedure, the piston syringe was rinsed and placed wet, back into the bag. Review of the "Gastrostomy Tube Check List" provided by the facility on 9-14-10 revealed "2. Placement check: Check placement before flushes,...Gather supplies..., Explain procedure to Resident, Provide Privacy, Wash Hands, (apply) Non-sterile gloves, ..." The facility admitted Resident #3 on 4-8-01 with [DIAGNOSES REDACTED]. Prior to observation of a Gastrostomy (G-) feeding and flush on 9-14-10 beginning at 9:55 AM, two C… | 2014-03-01 | ||
| 10202 | 10202 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 328 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to follow the Physician's Orders for the administration of oxygen for 1 of 4 sampled residents reviewed with oxygen. Resident # 18 oxygen rate was observed above the stated physician's order. The findings included: The facility admitted Resident #18 on 7/6/10 with [DIAGNOSES REDACTED]. She was placed on Hospice Services on 7/30/10 for [DIAGNOSES REDACTED]. Review of the record on 9/15/10 at approximately 11:00 AM revealed a Physician's order for O2 (oxygen) at 2 liter per minute (lpm) via NC (nasal cannula.) Review of the Hospice Nursing Visit Note revealed the Hospice nurse had documented the oxygen at 3 lpm via NC on 9/15/10, 9/8/10 and on 8/23/10. Review of the Documentation Record (MAR) revealed facility nursing staff was signing off the O2 at 2 lpm via NC each shift including the days of the survey. Observation on 9/15/10 at approximately 11:30 revealed the oxygen was flowing at approximately 3 1/2 lpm via NC. At approximately 1:00 PM on 9/15/10, Registered Nurse (RN) # 4, verified the oxygen was flowing at 3 1/2 lpm via NC. Upon questioning, she stated "I'd have to check the MAR (Documentation Record) but I'm pretty sure it's supposed to be at 2 (lpm)." RN #4 also reviewed the record and confirmed the Physician's Orders and the MAR indicated and could not locate any new order to increase the flow rate. During an interview on 9/15/10 at 2:28 PM, the Hospice Nurse stated the oxygen was supposed to be at 2 lpm and had been since admission to Hospice. She stated she thought the oxygen flow rate had inadvertently been changed on 9/15/10 when the Certified Nursing Assistant had reached to turn the oxygen back on after the resident's AM care had been completed. She stated the 3 lpm documented on the Nursing Visit Note for 9/15/10 had been a documentation error only. The Hospice Nurse later changed the documentation on the 9/8/10 Nursing Visit Not… | 2014-03-01 | ||
| 10203 | 10203 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 468 | E | A4CW11 | On the days of the survey, based on observation and interview, the facility failed to equip multiples areas in the corridors with handrails. The findings included: On 9/15/10 at approximately 1:55 PM, multiple areas leading into or on corridors were observed without handrails affixed to the walls. Areas included, but were not limited to: -an area approximately 3 1/2 feet at the entrance to Rocky Road Hall on the left and right sides of the hall -an area approximately 3 1/2 feet at the entrance to Rainbow Row Hall on the right side of the hall -approximately 5 feet across from the Unit I Nurses Station -a section approximately 8 feet long in a corridor behind the Unit I Nurses Station -the entire length of the corridor connecting Unit I and Unit II on both sides of the hallway -two 5 foot sections and two 3 1/2 foot sections on Unit II at the Nurses Station and several other areas leading into the 3 halls from the nurses station. During an interview on 9/14/10 at approximately 4:15 PM, the Maintenance Director verified multiple areas were without handrails and stated that the corridor between Units I and II had never had handrails as far as he knew. He also stated that the area behind the Unit I Nurses Station "looks like there used to be one there." | 2014-03-01 | ||
| 10204 | 10204 | FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2010-11-08 | 323 | G | CCT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record review, interviews, review of the facility's policy on Falls, and review of the facility's inservices, the facility failed to assure each resident was free of accidents as was possible for 1 of 6 sampled residents. Resident #1 sustained 3 falls in 3 days without new interventions implemented. Resident #1 fell on ,[DATE], 7/30 (sustained injuries to the face and mouth) and on 8/1/2010, no interventions were implemented until 8/2/2010. The findings included: The facility admitted Resident #1 on 6/29/2010. [DIAGNOSES REDACTED]. Review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a short-term and long-term memory problem with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as needing extensive 1 person assistance with transfers and bed mobility and completely dependent for locomotion on and off the unit. Resident #1 was also coded as dependent for eating, dressing, hygiene, and bathing with no behaviors coded as occurring during the assessment period. The resident was coded as receiving Hospice services. Resident #1 was not coded as having any accidents within 180 days. Review of the Nurses' Progress Notes dated 7/29/2010 at 12:30 PM indicated Resident #1 "fell forward out of wheelchair and hit his R(ight) forehead. He reports no pain and no sign of injury." A Nurses' Note dated 7/30/2010 at 5 PM documented that Resident #1 was "observed on floor laying on L(eft) side of body with blood on floor (small amount) from nose and mouth. Resident helped off the floor and into bed and pressure to nose applied. Writer took out bottom and top dentures and noted a small piece of the palate of the denture was broke off and a few small cuts on top of gums..." Further review revealed an entry dated 8/1/2010 at 6 AM, "slid off of the bed on to floor, Resident observed sitting on floor with back against bed." On 8… | 2014-03-01 | ||
| 10205 | 10205 | FELLOWSHIP HEALTH & REHAB OF ANDERSON, LLC | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2010-11-08 | 280 | G | CCT011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record reviews and interviews, the facility failed to assure 1 of 6 resident's care plans were reviewed and revised appropriately. Resident #1's care plan was not reviewed and revised with each fall. The findings included: The facility admitted Resident #1 on 6/29/2010. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 7/29/2010 at 12:30 PM indicated Resident #1 "fell forward out of wheelchair and hit his R(ight) forehead. He reports no pain and no sign of injury." A Nurses' Note dated 7/30/2010 at 5 PM documented that Resident #1 was "observed on floor laying on L(eft) side of body with blood on floor (small amount) from nose and mouth. Resident helped off the floor and into bed and pressure to nose applied. Writer took out bottom and top dentures and noted a small piece of the palate of the denture was broke off and a few small cuts on top of gums..." Further review revealed an entry dated 8/1/2010 at 6 AM, "slid off of the bed on to floor, Resident observed sitting on floor with back against bed." On 8/2/2010 at 11 AM, the nurses' note indicated an order was obtained for a bed alarm and 1/2 lap tray. Review of the care plan revealed a risk for injury (falls) related to weakness, history of [MEDICAL CONDITION], dementia and [MEDICAL CONDITION] was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included "observe frequently, call light within reach..., provide assistive devices for mobility, provide assistance with mobility, review circumstances of how falls occur to try to eliminate further falls, keep floor/pathway free of debris, notify MD/hospice PRN (as needed)." The care plan was updated on 7/29/2010 with a handwritten note to "observe res(ident) frequently when up." The care plan was not updated with the 7/30/2010 fall or the 8/1/2010 fall. On 8/2/2010 the bed alarm was written on the care plan, however the lap tra… | 2014-03-01 | ||
| 10206 | 10206 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-11-04 | 323 | G | GK1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on limited record reviews, interviews, observations, and review of facility files, the facility failed to provide residents and staff with adequate supervision to ensure it's system for safe transfer of residents was followed by Hospice and facility staff members for 1 of 1 resident reviewed who sustained injury from an inappropriate transfer (Resident #1). Resident #1 was transferred from bed to chair on [DATE] by manual lift instead of by mechanical lift by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized from [DATE] to [DATE] because of acute renal failure and congestive heart failure exacerbation. Several medications were discontinued on his return to the facility including the Prednisone the resident had taken for years. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the care plan, dated [DATE] and reviewed by the facility and the resident's Hospice nurse, showed no direction to the staff to use a mechanical lift for transfers. The care plan noted problems with fragile skin due to steroid use, risk for pathological fractures related to osteoporosis, risk for falls, risk for complications due to CVA with left side weakness, and impaired mobility. Approaches to these problems included: handle resident cautiously; handle gently during care; transfer resident with care; assist with mobility as n… | 2014-03-01 | ||
| 10207 | 10207 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-11-04 | 282 | G | GK1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interviews the facility failed to ensure that care plans were followed for Resident #1, 1 of 3 sampled residents care planned for a mechanical lift with transfers, was transferred from bed to chair on [DATE] by manual lift by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the care plan, dated [DATE] and reviewed by the facility and the resident's Hospice nurse, showed no direction to the staff to use a mechanical lift for transfers. The care plan noted problems with fragile skin due to steroid use, risk for pathological fractures related to [MEDICAL CONDITION], risk for falls, risk for complications due [MEDICAL CONDITION] left side weakness, and impaired mobility. Approaches to these problems included: handle resident cautiously; handle gently during care; transfer resident with care; assist with mobility as needed; provide assistive devises for transfer as needed; and evaluate the use of assistive devices for transferring from bed to chair. review of the resident's medical record revealed [REDACTED]. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical … | 2014-03-01 | ||
| 10208 | 10208 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-11-04 | 225 | D | GK1G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on limited record reviews, interviews, observations, and review of facility files, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). Resident #1, 1 of 1 sampled resident that sustained an injury during a transfer, was transferred from bed to chair on [DATE] by manual lift instead of by mechanical lift, as care planned, by his Hospice Certified Nursing Assistant (CNA) and two facility CNAs resulting in bruising to the left axilla and chest. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was admitted to Hospice on [DATE]. Review of the resident assessments of [DATE] and [DATE] showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident was dependent on staff for all activities of daily living. The Significant Change Assessment of [DATE] noted mechanical lift was needed for transfers. According to the Resident Assessment Protocol (RAP) notes of [DATE], the resident required mechanical lift for transfers. Review of the Resident Care Plan used by CNAs showed a sling lift was needed for transfers. The form was completed in pencil and showed no date of completion. Observations of resident rooms for three residents on Unit #3 who required mechanical lift transfers showed each resident had a sign at the head of the bed noting how the resident needed to be transferred. Resident #1's sign stated he needed a sling lift. Review of the Nurses' Notes revealed that on [DATE], the resident's daughter notified staff of new discolored areas on her father's left arm, axillary area, and left upper chest. Although the resident had a history of [REDACTED].#1 revealed the areas she saw on the ax… | 2014-03-01 | ||
| 10209 | 10209 | MOUNTAINVIEW NURSING HOME | 425027 | 340 CEDAR SPRINGS ROAD | SPARTANBURG | SC | 29302 | 2010-11-10 | 280 | D | 0LRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the compliant inspection, based on observations, interviews and record reviews, the facility failed to ensure that Resident #4's care planned was review and revised regarding one-to-one supervision by the staff (1 of 4 sampled reviewed with behaviors). The findings included: The facility admitted Resident #4 on 10/23/09 with [DIAGNOSES REDACTED]. Review the of Nurse's Progress Notes dated 10/03/10 at 1250 documented at 1145 the staff was paged to the facility's canteen and that Resident #4 was in the canteen area and he threw a chair at a snack machine, hit a visiting family member of another resident and slammed a nurse's finger in a cabinet. The Nurse's Note further indicated that once the resident calmed down he requested to call law enforcement. At 1245 physician's orders [REDACTED].#4 returned to the facility from the hospital; at 1930 Resident #4 was noted running his wheelchair into people and things. The resident later calmed down and went to bed. A Nurse's Note dated 10/04/10 at 2330 indicated the staff was at the bedside with no behaviors noted. A Nurse's Note dated 10/05/10 at 0830 indicated the staff was at the bedside with no behaviors noted; at 2145 the resident became agitated and talked about hitting the vending machine on 10/03/10. Nurse's Note date 10/06/10 indicated that a staff member was at the bedside and in attendance when family and friends visited the resident. A Nurse's Note dated 10/07/10 at 1340 indicated Resident #4 was in the facility lobby with a staff member when he knocked over a table in the front lobby and tried to hit a staff member with a chair. The resident was return to the unit and given 5 mg (milligrams) of [MEDICATION NAME] IM for combativeness. An observation on 11/03/10 at 11:10 AM, 1:30 PM and 2:10 PM revealed staff seated in the room with the resident. There was nothing in the chart to indicate why a staff was seated in the room with the resident. There was no care plan to indicate … | 2014-03-01 | ||
| 10210 | 10210 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 241 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and observation of meal service, the facility failed to provide services that respected resident's dignity during a random observation of a meal. Resident # 5 and 2 other unidentified residents were not served their meal in a timely manner. The findings included: The facility admitted Resident # 5 on 10/30/06 with [DIAGNOSES REDACTED]. On 11/16/10, at 12:20 PM, the lunch trays were delivered to the dining room. Resident # 5 was observed along with two other residents sitting in the dining room facing the other residents. Meal trays were served and the other residents ate or were assisted with their meals. Resident # 5's meal tray was noted to be on the cart. Resident # 5 and the other two residents were not assisted to a table or served the meal until 1:00 PM. This observation was shared with the DON during sharing. The facility admitted Resident # 3 on 6/23/10 with [DIAGNOSES REDACTED]. Prior to observation of wound care on 11-16-10 at 1:35 PM, Licensed Practical Nurse (LPN) #3 and Registered Nurse (RN) #5 entered the room without knocking. During the course of the treatment from 1:35 PM until 2:55 PM, the LPN left the room two times to obtain needed supplies and reentered without knocking. The nurse entered the shared bathroom to wash her hands four times without knocking to ensure that residents from the adjoining room were not using the commode. At 2:30 PM, when the nurse entered the bathroom for the fifth time (without knocking) to wash her hands, she walked in on a resident who was using the commode. After this incident, the nurse continued to enter the bathroom door three more times without knocking while completing the wound care. The privacy curtain was not closed at the foot of the resident's bed during the entire treatment. During an interview with LPN # 3 on 11-17-10 at 12:40 PM, the nurse verified that she had failed to knock when entering the room and each time she entered the ba… | 2014-03-01 | ||
| 10211 | 10211 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 250 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, no medically related social services were provided for Residents #21 and #26 related to behaviors. ( 2 of 6 residents reviewed for specific medically related social services.) The findings included: The facility admitted Resident # 26 on 3/23/10 with [DIAGNOSES REDACTED]. Record review on 11/16/10 revealed numerous nurse's notes documenting sexually inappropriate behaviors towards staff and residents and wandering into other resident rooms. This was also confirmed on 11/16/10 at 1:30 PM by 4 of 4 residents who attended group meeting. These residents stated they had been touched on the arms, toe, and asked "give me some sugar." Nurse's note on 5/18/10 documents " CNA (Certified Nursing Assistant) - resident touching and rubbing her leg - won't quit." On 5/25/10 " MD (Medical Doctor) in today for touching staff inappropriately. CNA reported resident asked for a kiss." On 5/26/10 note documents " CNA makes resident hold to side rails to keep him from reaching for her." Nurses notes continue: 6/12/10- touches staff inappropriately at times; 6/14/10 - started on Lexapro 10 mg (milligrams) r/t (related to) inappropriate sexual disinhibition; 6/16/10 - continues to enter resident rooms, continues to attempt to touch staff and residents- redirect as necessary; 9/1/10 CNA and PT (Physical Therapist) reported resident made inappropriate gestures and sexual comments. Resident attempted to enter other resident's rooms without permission; 9/4/10 - inappropriate sexual remarks at staff at times; 10/17/10 - staff and residents reported resident has been making inappropriate comments "give me some sugar and I want a lick." staff will continue to monitor behavior. On 11/16/10 resident approached a surveyor and asked "when can we meet" and made an explicit sexual gesture. Only two physician progress notes [REDACTED]. Review of Social Service Notes revealed a note on 4/22/10 -Resident has been not… | 2014-03-01 | ||
| 10212 | 10212 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 281 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide nursing services that met professional standards of practice. The facility nurse failed to transcribe Resident # 7's medication order correctly and multiple nurses administering medications to the resident failed to clarify the entry on the MAR (Medication Administration Record) for [MEDICATION NAME] as needed on Monday, Wednesday and Friday, resulting in a medication errors. The findings included: The facility admitted Resident # 7 on 11/10/10 with [DIAGNOSES REDACTED]. On 11/16/10, review of the resident's medical revealed a physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) revealed that the order had been transcribed incorrectly to the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. On 11/16/10 at approximately 4:00 PM interview with RN (Registered Nurse) # 4 revealed that she had transcribed the order incorrectly. She stated that the computer system being used will not recognize Monday, Wednesday, Friday orders unless entered as a prn order. She stated that she had failed to mark out the PRN as needed when the MAR indicated [REDACTED]. | 2014-03-01 | ||
| 10213 | 10213 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 279 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop a plan of care which addressed the non compliance of Resident # 21 with safety regulations within the facility and failed to address the resident's non compliance with fluid restrictions. (One of one sampled resident known to be noncompliant with smoking regulations and one of one sampled resident reviewed with a fluid restriction reviewed for the development of care plans) The findings included: Resident # 21 was recently readmitted with a [DIAGNOSES REDACTED]. On 11/14/10, at 6:50PM, the resident was observed to be out of bed sitting near the nurses station and in the dining room. The resident was observed to obtain glass(es) of water from a drinking cooler three times during the observation which lasted approximately one hour. No staff intervened or spoke with the resident about his fluid consumption. During an interview with the unit manager, when asked if the resident was compliant with the fluid restriction, she stated "no." The unit manager further verified that the resident's plan of care did not address his non-compliance or the facility plan to address the concern. Further record review revealed the resident had been noncompliant with the facility smoking regulations which had been addressed by the facility Administrator. On August 21, 2009 and on September 10, 2010, the resident had received a letter from the facility addressing his non-compliance. Nursing notes also revealed that on 9/16/10, two cigarette lighters had been removed from the resident's room. When the Administrator was questioned if he was aware of the 9/16/10 occurrence, he did not respond. Further review of the resident's comprehensive plan of care did not reveal any concern/plan related to the residents non-compliance with the facility safety/non-smoking regulations. A copy of the smoking policy (7/06) stated; "All residents are prohibited from keeping any type of smo… | 2014-03-01 | ||
| 10214 | 10214 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 309 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to provide physician-ordered care and services for one of two residents reviewed with orders for Hospice services and one of one residents reviewed for provision of [MEDICAL TREATMENT]. There was no evidence of implementation of a 10-6-10 hospital transfer order for Hospice for Resident #17. Intake and output was not monitored to ensure compliance with a fluid restriction order for Resident #21. The findings included: The facility initially admitted Resident #17 on 10-5-09 and readmitted him following a hospitalization from [DATE] to 10-6-10. Record review on 11-15-10 at 12:45 PM revealed a hospital Patient Transfer Form dated 10-6-10 which was noted as faxed to the facility on the same date. Instructions on the cover page of the form included to "Arrange hospice". Additionally, the same Discharge Instruction was listed as a line item on an attached Order Confirmation Report. There was no evidence in the medical record that the order had been implemented. During an interview on 11-15-10 at 3:30 PM, the Director of Nurses reviewed the transfer document and confirmed the order for Hospice. She stated she "did not see" and had not been aware of the order until 10-26-10, the date of the resident's death. During an interview on 11-16-10 at 11:35 AM, Registered Nurse (RN) #6 also confirmed the Hospice order and stated that she had been unaware of the Hospice order until after the resident's death when she "found the Hospice note". The RN stated that the transfer information usually came from the hospital in a packet and that the nurse who received the resident should have written the order for the referral. She stated that, when she became aware of the order, she questioned the nursing staff and they "said they never saw the order". The nurse further stated that the admitting nurse "should have made the referral". Resident # 21 was recently readmit… | 2014-03-01 | ||
| 10215 | 10215 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 314 | G | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, facility policy on care and assessment of Pressure Ulcers, and interview, the facility failed to ensure that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for four of seven sampled residents reviewed for pressure ulcers. Resident # 23 was admitted [DATE] with a known pressure ulcer. treatment for [REDACTED]. Resident # 22 with a known red area to the back, receiving treatment, was not assessed weekly for changes in the area and effectiveness of treatment. Resident #1 failed to have ongoing documentation available of a pressure ulcer as it was treated to allow staff to accurately determine response to the treatment and the need for possible changes in treatment. During a pressure ulcer treatment observed on Resident #3 the licensed staff failed to implement infection control techniques to ensure healing. The findings included: The facility admitted Resident # 23 on 3/6/10 with [DIAGNOSES REDACTED]. On the weekly skin documentation form dated 3/6/10 the resident was documented by nursing to have a black area to the right heel with no further description/measurement noted. On 3/15/10 the area was documented as "soft and black." There was no physician order for [REDACTED]. ... He has a large decubitus over the right heel. It is covered by skin" . He previously had a blister and nursing staff reported that this has drained and there is some serosanguineous type drainage....Small area in the plantar surface of the right foot that is measuring approximately .5cm (centimeter) in diameter Wound bed in this area is pink, moist. This again is a very superficial area ..." The NP at this time ordered vitamin C, Prosource and Vitamin with Minerals, treatments to both areas, continued use of Podus boots, and floating of the heels while in bed. The physician saw the resident on 3/23/10 and made no change… | 2014-03-01 | ||
| 10216 | 10216 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 367 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to provide the diets as ordered by the physician for two of seven sampled residents reviewed for therapeutic diets. Resident #17 was provided solid foods on a mechanically-altered (pureed) diet and an order for [REDACTED]. The findings included: The facility initially admitted Resident #17 on 10-5-09 and readmitted him following hospitalization from [DATE] to 10-6-10 for Aspiration Pneumonia, Dehydration, and [MEDICAL CONDITION]. Additional/chronic [DIAGNOSES REDACTED]. Record review on 11-15-10 at 12:45 PM revealed that Resident #17 was on a "Puree diet with nectar thick liquids for pleasure" prior to hospitalization and received an "egg salad sandwich c (with) ea(ch) meal" per a physician's orders [REDACTED]. The hospital Patient Transfer Form dated 10-6-10 noted "Instructions" for a Discharge Diet of "TF (tube feeding)". The hospital Discharge Summary noted that the resident was to receive "[MEDICATION NAME] 1.5 at 80 ml (milliliters)/hour for 18 hours, start at 3 PM, off at 9 AM." physician's orders [REDACTED]. There was no evidence in the record that the sandwiches had been reordered. A copy of a Diet Order & Communication form dated 10-7-10 was found in the medical record. Pureed Texture and Nectar-Like Thickened Liquids were checked to indicate the type of diet to be provided. During an interview on 11-15-10 at 4 PM, the Speech Language Pathologist (SLP) reviewed the Rehabilitation Screen form she had completed on 10-8-10. She stated that the resident had been on caseload prior to the 9-26-10 hospitalization , but had reached a plateau. He had received the sandwich with meals prior to hospitalization and was "safe" with it. Upon readmission, she stated that the resident was uncooperative with the screening process for oral motor assessment and noted that the resident was "WFL (within functional limits) for puree". She did not request a… | 2014-03-01 | ||
| 10217 | 10217 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 156 | C | JNTL11 | On the days of the survey, based on record review and interview, the facility failed to provide Liability Notices to 3 of 3 residents reviewed for notification of Medicare Provider Non- Coverage. The facility did not utilize form or any of the 5 denial letters to inform residents or their responsible party of the items and services expected to be denied under Medicare Part A. The findings included: On 11/17/10 at 10:20 AM, a review of 3 random Medicare Non-Coverage Notices revealed that there were no Liability Notices included in the information given to the resident or responsible party. An interview with the Admission Coordinator revealed that she had not been aware until yesterday that Liability Notices were required. According to information provided by the Admission Coordinator, Resident A had used 50 days and his last covered day was 10/27/10 due to therapy being discontinued. Resident B had used 64 days and no longer required skilled services. His last covered day had been 9/2/10. Resident #8 had used 36 days and her last covered day had been 8/20/10 due to her therapy having been discontinued. | 2014-03-01 | ||
| 10218 | 10218 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 159 | D | JNTL11 | On the days of the survey, based on record review and interview, the facility co-mingled personal funds with facility funds for 2 of 5 residents reviewed with Resident Trust Fund Accounts. Resident D had personal funds withdrawn from her Trust Fund Account and deposited into the facility account. Resident E had retirement checks deposited into the facility account instead of being deposited into her Trust Fund Account first. In addition, there was no evidence of notification of balances that would jeopardize Medicaid eligibility for Resident D. The findings included: Review of Resident D's Trust Fund Account record on 11/17/10 at 1:42 PM revealed a Care Cost Payment dated 9/17/10 of $3.04, a second Care Cost Payment dated 10/7/10 for $11.28, and a third Care Cost Payment dated 11/5/10 for $30.06. When asked about what these payments were for, the Business Office Manager stated that she withdrew these amounts from the resident's Trust Fund Account and deposited the monies into the facility account since the resident had reached her $1800.00 limit in which she would need to start spending down her account since she was a Medicaid recipient. According to the Business Office Manager, the monies deposited into the facility account would go towards payment of any remaining balances the resident might have. When asked if the resident owed a balance, she stated "no". She stated the facility account was not interest bearing. When asked if she had contacted the family of the resident to try to see if they could spend down her account she stated she had never seen the family and hadn't recently tried to get ahold of them, but she would try now. Review of the Resident Fund Management Service reports revealed that these funds had been withdrawn from the resident's Trust Fund Account and had been deposited into the facility account. During the funds interview on 11/17/10 at approximately 9:30 AM, the Business Office Manager stated that when a Medicaid resident's account reached #1800.00, she told the resident or responsible pa… | 2014-03-01 | ||
| 10219 | 10219 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 160 | D | JNTL11 | On the days of the survey, based on record review and interview, one of five resident records reviewed for conveyance of funds revealed disbursement of funds without written authorization. The findings included: On 11/17/10 at approximately 9:30 AM, the Business Office Manager stated that Resident #19 had $30.00 in the Resident Trust Fund Account that had been sent to the funeral home at the family's request after her death. According to the Business Office Manager, the family wanted the cash money, however, she told them she could send it to the funeral home or the estate. The family requested the money sent to the funeral home. According to the Business Office Manager, there was no Power of Attorney in effect over the resident's financial matters. Review of the Admission Agreement revealed a "Beneficiary Designation:" section that was not filled out and did not designate a person to receive the resident's personal funds. | 2014-03-01 | ||
| 10220 | 10220 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 167 | C | JNTL11 | On the days of the survey, based on observations, the facility failed to post the most recent survey report within the facility. The facility failed to post the most recent complaint survey with citations from 9/16/10 and failed to post a complaint survey with citations from February 2010. The findings included: Observation on 11/15/10 at approximately 5:00 PM revealed a plastic holder mounted on the wall in the hallway near the front lobby. Observation of the contents of the holder revealed a labeled notebook containing the annual recertification survey report from September 2009. The complaint surveys with citations from 9/16/10 and February 2010 were not posted as required. On 11/17/10 at approximately 4:30 PM, the surveyor reviewed the contents of the notebook with the Administrator. The Administrator confirmed that the complaint surveys were not posted at that time. | 2014-03-01 | ||
| 10221 | 10221 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 282 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the care plan was not followed related to pacemaker checks for Resident #9 and analysis of causative factors of behavior for Resident # 26. ( 1 of 2 residents reviewed with pacemakers and 1 of 1 resident reviewed for socially inappropriate behaviors.) The findings included: The facility admitted Resident #9 on 5/13/09 with [DIAGNOSES REDACTED]. Record review on 11/15/10 revealed the resident to have a pacemaker. The Physician's History and Physical listed a [DIAGNOSES REDACTED]. Dates of 5/14/09, 9/3/09, 12/17/09 and 3/4/10 were listed on the sheet as to when checks should be done. The only documentation of testing in the medical record was dated 9/03/09. No other documentation could be found. There was no physician order to do pacemaker checks. The care plan for pacemaker also documented pacemaker check as ordered q 3 months ( every 3 months). An interview with RN # 1 (Registered Nurse) and the Unit Manager revealed that the nurse did not know the resident had a pacemaker. She was unable to find any information in the record related to the checks other than the one report of 9/03/09. RN #1 placed a call to the Clinic and found that a check had been done on 9/03/10. There were no other reports sent at this time. The facility admitted Resident # 26 on 3/23/10 with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a problem which stated, "Resident exhibits socially inappropriate behaviors IE: wandering into others room, touching peers and staff inappropriately, pulling fire alarm. Under approaches were listed: assess resident's understanding of the situation, monitor resident frequently, analyze key times, places, circumstances, triggers, and what de-escalates behavior, and Psychiatric evaluation as indicated. An interview with the Unit Manager of 100 unit and Social Services on 11/17/10 revealed that no one had done an analysis, and no psychiatric evaluation had b… | 2014-03-01 | ||
| 10222 | 10222 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 441 | E | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interviews, the facility failed to provide evidence that all personal laundry was effectively cleansed/sanitized to destroy microorganisms. Also, based on observations and interviews, the facility failed to follow a procedure whereby expired topical agents, irrigation trays, and wound care supplies were removed from current stock and were available for daily use in two of four medication rooms reviewed. The findings included: During observation of the laundry on [DATE] at 10:15 AM, two home-type washers were noted (in use) not to be connected (via the chemical dispensing system) to any type of sanitizing agent. Bleach was set up to be dispensed on an automatic dispensing system to a third commercial-type washer. A sign was noted on the wall above a dryer indicating "no bleach" formula to be used on given wash cycles. When asked at this time, the Laundry Aide confirmed that bleach was not used for some personal laundry. She stated that the water temperature ranged from 120 to 160 degrees and was monitored by maintenance. She was unaware if any type of sanitizer was used and deferred to the Housekeeping Supervisor. During an interview on [DATE] at 2 PM, the Maintenance Supervisor provided laundry water temperature logs for review. Water temperatures ranged from 129 to 141 degrees Fahrenheit over the previous six month period. When informed that personal laundry was being washed without bleach, or water temperatures over 160 degrees, the Housekeeping Supervisor stated that he could provide no information to verify use of any other type of sanitizing agent. During an interview at 2:35 PM on [DATE], a second maintenance employee stated that he had checked the dispensing mechanism on the two home-type washers and that the commercial bleach product had not been connected. At that time, the Housekeeping Supervisor verified that he could provide no information on use of any type of sanitizing agent, … | 2014-03-01 | ||
| 10223 | 10223 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 164 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, and review of facility protocol entitled "Survey Readiness", the facility failed to provide privacy to 1 of 3 residents observed for wound care and 1 resident randomly observed in the bathroom during the same wound care procedure. Resident # 3 was exposed during wound care to the buttock when a Certified Nursing Assistant (CNA) entered the room without knocking. The Licensed Practical Nurse (LPN) entered an occupied bathroom without knocking during this same treatment. The findings included: The facility admitted Resident #3 on 6/23/10 with a [DIAGNOSES REDACTED]. During observation of wound treatment for [REDACTED].#3 entered the room through the closed bathroom door without knocking, left the bathroom door open while she got the lift and then left the room through the same bathroom door. The wound care treatment was in progress with Resident #3's buttock exposed and the privacy curtain was not pulled at the foot of the bed. During observation of the same wound treatment for [REDACTED].#3 entered the bathroom to wash her hands and did not knock. A resident was using the bathroom at the time when the nurse entered without knocking. During an interview with LPN #3 on 11-17-10 at 12:40 PM, the nurse verified that she did enter the occupied bathroom without knocking. She also verified that CNA #3 entered the room without knocking while Resident #3 was exposed. On 11-17-10 at 1:05 PM, the Staff Development Coordinator (SDC) provided a document entitled "Survey Readiness" which stated: "Remember Privacy: Knock on each door, close the door, pull the privacy curtain, and close the blinds." The SDC stated that she goes over this information with new hires and periodically as needed. During a discussion with the Director of Nursing (DON) related to privacy issues identified during treatments on 11-17-10 at 1:00 PM, the DON said she had in-serviced the staff on closing blinds, pulling curtains… | 2014-03-01 | ||
| 10224 | 10224 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-11-17 | 315 | D | JNTL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, record review, review of the facility policy entitled "Suprapubic Catheter Care", and review of the training manual "Assisting in Long Term Care, Second Edition", the facility failed to provide appropriate treatment and services to prevent Urinary Tract Infections for 2 of 4 sampled residents reviewed with indwelling catheters. Resident #3 had the catheter anchored inappropriately during catheter care causing a potential for trauma. Resident # 14's catheter tubing was on the floor throughout catheter care observation. The findings included: The facility admitted Resident #3 on 6/23/10 with a [DIAGNOSES REDACTED]. On 11-17-10 at 10:45 AM during observation of suprapubic catheter care for Resident # 3, Licensed Practical Nurse (LPN) #3 anchored the catheter tubing approximately 4 inches away from the insertion site and cleansed the tubing from the insertion site in an outward motion causing potential trauma. Review of the facility policy entitled "Suprapubic Catheter Care" step # 12 stated: 'With the third wipe, clean the catheter tubing about 4 inches, while holding the catheter securely." The facility admitted Resident # 14 on 6/12/09 with [DIAGNOSES REDACTED]. During observation of suprapubic catheter care by Registered Nurse (RN) # 5 on 11-17-10 at 10:30 AM, the catheter tubing was noted to be lying on the floor upon entering the room and remained there during the entire procedure. After completion of the procedure, RN #5 was questioned about the cloudy character of the urine. The nurse stated that the resident was currently being treated for [REDACTED]. Record review revealed a Physician's Telephone Order dated 11/14/10 which stated: "Keflex 250 mg. (milligrams) po (by mouth) TID (three times daily) X 10 days for positive urinalysis." RN # 5 confirmed that the tubing was on the floor during an interview held on 11-17-10 at 12:30 PM. The nurse verified that she was aware that the t… | 2014-03-01 | ||
| 10225 | 10225 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 225 | D | PITJ11 | On the day of the inspection, based on record review and review of facility files, the facility failed to ensure that all allegations of neglect were reported within twenty-four hours to the State survey and certification agency for 1 of 1 allegation of neglect reported (Resident #1). The findings included: On 10/22/10, after Resident #1 complained of pain in her right ankle, the physician found a dressing dated 9/27/10 on her ankle. The dressing had originally covered a callus. When the physician removed the dressing, he found the resident's ankle red and swollen with an open and infected ulcer. Review of the medical record revealed the resident was to have a DuoDerm dressing to the site, changed every three days. The facility reported this allegation of neglect to the State survey and certification agency on 10/25/10, which exceeded the twenty-four hours allowed. | 2014-03-01 | ||
| 10226 | 10226 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 281 | G | PITJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review, interviews, and review of facility files, the facility failed to ensure that services provided by the facility met professional standards of quality for 1 of 1 resident who developed redness, swelling, pain, and an open area under a [MEDICATION NAME] dressing that was not changed for 23 days (Resident #1). Facility staff failed to ensure the resident's treatment order was carried forward to the new month, and failed to thoroughly assess and accurately document the resident's changing skin condition. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The physician found an occlusive dressing on the right lateral ankle dated 09/27/10. There was pus underlying the dressing and an infected open area measuring 1 X 1 cm (centimeter) surrounded by a 3 by 3 cm area of [MEDICAL CONDITION]. The physician ordered wet to dry dressings, and antibiotic treatment with [MEDICATION NAME] 250 milligrams three times a day for ten days. Review of the medical record and the facility's investigative materials revealed none of the staff providing care to the resident (five nurses and thirteen nursing assistants), from 9/27/10 to 10/22/10, noticed the unchanged dressing and the developing decline in the resident's skin condition. CNAs (Certified Nursing Assistants) doing daily skin inspections noted the resident's skin was "clear." Licensed staff documented on the weekly body audits that the resident had a callus on her right ankle. The licensed staff failed to update the monthly cumulative orders for October 2010 to show the dressing change order for DuoDerm to the right ankle every three days. This order was initiated on 6/30/10. Licensed staff failed to realize the omission of the order and therefore, failed to provide the resident with the treatment. The staff also failed to provide the appropriate care and ongoing assessment required to manage the resident's skin care. Cross refer to F-314 related… | 2014-03-01 | ||
| 10227 | 10227 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 314 | G | PITJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review and interview, the facility failed to ensure that a resident received treatment to promote healing, prevent infection, and prevent new sores from developing for 1 of 1 resident reviewed who developed an infected sore when facility staff left a protective dressing in place from 9/27/10 to 10/22/10 (Resident #1). The resident did not have her dressing changed because the treatment order was omitted from the October 2010 orders and treatment record. Facility staff failed to recognize the omission. As the resident's ankle declined in condition, the staff failed to thoroughly assess and accurately document her condition in the medical record. The daily skin inspection and weekly body audit documentation showed no changes in the condition of the resident's ankle. These failures lead to a lack of appropriate interventions. The findings included: Resident #1 with [DIAGNOSES REDACTED]. The physician's progress note, dated 10/22/10 and signed on 11/18/10, stated he found an occlusive dressing on the right lateral ankle "which was dated 09/27 and had pus underlying the dressing." Under the dressing was "a 3 X 3 cm (centimeter) stage 2 ulceration and a 1 X 1 cm stage 3 ulceration with surrounding [MEDICAL CONDITION]." The physician ordered wet to dry dressings, and antibiotic treatment with [MEDICATION NAME] 250 milligrams three times a day for ten days. According to the physician's progress note, it was his understanding the Wound Care team was assessing this wound at least weekly. The physician wanted to know why the dressing had "apparently not been changed for 23 days." He showed the wound to the Unit Manager and wanted to know why the dressing had not been changed. The facility began an investigation to answer the physician's questions. Review of the medical record revealed the resident had an ulcer on her right lateral ankle in February 2010. The pressure ulcer was treated with antibiotics for tw… | 2014-03-01 | ||
| 10228 | 10228 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2010-11-18 | 514 | G | PITJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection, based on record review, the facility failed to ensure medical records were complete and accurately documented for 1 of 1 resident who developed an infected open area under a [MEDICATION NAME] dressing that was not changed for 23 days (Resident #1). On 11/18/10, the physician's progress note of 10/22/10 was not on the record. Facility staff failed to ensure monthly cumulative orders were complete related to treatments ordered, and failed to accurately document the resident's changing skin condition. The findings included: Resident #1 with [DIAGNOSES REDACTED]. On 10/22/10, the resident complained to the physician of pain in her ankle. While examining the resident, the physician found a DuoDerm dressing on the ankle 9/27/10. Under the dressing was an open and infected ulcer. Review of the resident's medical record on the morning of 11/18/10 failed to show a physician progress notes [REDACTED]. The physician signed and sent his progress note for 10/22/10 via facsimile on the afternoon of 11/18/10. Review of the Nurse's Notes for 10/22/10 showed no descriptive documentation of the resident's right ankle. The redness, swelling, and open area found by the physician was not included in the nurse's note. The pressure ulcer's characteristics were documented in the Skin Condition Report, but other than the physician's progress note, the medical record did not show that a dressing dated 9/27/10 was found on the resident on 10/22/10. Facility staff failed to note the omission of the DuoDerm treatment order on the printed cumulative orders for October 2010. Therefore, the order was not listed on the Documentation Sheet for treatments and the resident did not receive the DuoDerm treatment 10/1-22/10. Review of the CNA Daily Skin Inspection Record and the Body & Skin Audits done by the nurses on a weekly basis revealed documentation for September 2010 and up to October 22, 2010 showing no changes in the resident's condition alt… | 2014-03-01 | ||
| 10229 | 10229 | C M TUCKER NURSING CARE CENTER / STONE & FEWELL | 425074 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2010-11-30 | 225 | D | 5NE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on record review, interviews, and review of the facility's policy on Abuse and Neglect, the facility failed to provide evidence that an incident involving the care of Resident #1 was thoroughly investigate. The facility failed to interview and obtain witness statements from the Certified Nursing Aide (CNA) assigned to Resident #1 at the time of the incident and the Registered Nurse (RN) on duty at the time of the incident; Resident #2's family's concern about his eye was not investigated and reported to the state agency. (2 of 5 sampled residents reviewed). The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the facility investigation file revealed a facility accident/incident report dated 11/08/2010 at 11:22 AM Section One: To be completed by person reporting/witnessing the incident. CNA #1 described the incident as follows: "staff turn back and res (resident) rolled over and hit head on closet. Section Two: To be completed by a licensed nurse dated 11/08/2010 at 1500 under Corrective/preventive measures RN #1 stated, "Resident receiving AM care staff turned and resident rolled OOB (out of bed) struck head on closet. Orders written to pad closet and nightstand to prevent this type of injury. Matts were on floor..." The facility investigation included incident witness statements from three staff members who stated they were unaware of the incident; there were no credentials/job titles to identify the three witnesses. The facility failed to obtain interview statements from CNA #1 and RN #1. In an interview on 11/17/2010 at 10:40 AM the Director of Nurses confirmed there were no witness statements completed by CNA #1 and RN #1. The facility admitted Resident #2 on 11/29/2004 w… | 2014-03-01 | ||
| 10230 | 10230 | C M TUCKER NURSING CARE CENTER / STONE & FEWELL | 425074 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2010-11-30 | 282 | G | 5NE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review and interviews the facility failed to ensure that care plans were followed for 1 of 5 sampled residents reviewed. Resident #1 care planned as a total assist with two care givers with bathing, dressing and grooming, was injured on 11/08/2010 when Certified Nurse Aide #1 provided care unassisted. The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 11/04/2010 coded the resident as having short and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as being totally dependent on staff for transfer, hygiene and dressing. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt (sic) with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the care plan with a start dated of 05/31/2010 identified as Problem #6 "Self care deficit r/t (related to) Alzheimer's dementia with inability to follow directions, impaired mobility..." Interventions included, "1. Requires total assistance of two care givers with bathing, dressing and grooming needs..." In an interview with the surveyor on 11/17/2010 at 10:05 AM Certified Nurse Aide (CNA) #1 stated that on 11/08/2010 Resident #1 rolled over and fell from the bed when she turned around "to grab things" while providing care. CNA #1 stated, "I turned away for a few seconds and the resident rolled out of bed." CNA #1 stated she was the only CNA providing care. In an interview with the surveyor on 11/17/2010 at 10:20 AM Registered Nurse (RN) #1 stated that when he entered the room the resident was lying in bed on he back and he noted an injury to the right side of the resident's forehead. RN #1 stated that CNA #1 told him she went to the closet and the resident fell . RN #1 stated that CNA #1 was the only CNA … | 2014-03-01 | ||
| 10231 | 10231 | C M TUCKER NURSING CARE CENTER / STONE & FEWELL | 425074 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2010-11-30 | 323 | G | 5NE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observations, record review and interviews the facility failed to ensure that Resident #1's environment remains as free of accident hazards as possible. Resident #1 injured on 11/08/2010 when a Certified Nurse Aide (CNA) bathed him alone, was care planned to have two people with bathing. The review of the Nursing Guide To Care sheet, the CNA care guide, dated 10/01/2010 did not include the number of caregivers required for care. Following the injury the care plan was updated on 11/09/2010 to include padded edges to the nightstand and closet, observation on 11/17/2010 revealed no padded edges. The findings included: The facility admitted Resident #1 on 5/12/2010 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 11/04/2010 coded the resident as having short and long-term memory problems with moderately impaired cognitive skills for daily decision-making. The MDS coded the resident as being totally dependent on staff for transfer, hygiene and dressing. Review of the Nurses' Note dated 11/08/2010 at 10:40 AM stated, "Called to room Resident on floor matt (sic) with laceration to right forehead measuring 1.5 cm (centimeters)..." Review of the care plan with a start dated of 05/31/2010 identified as Problem #6 "Self care deficit r/t (related to) Alzheimer's dementia with inability to follow directions, impaired mobility..." Interventions included, "1. Requires total assistance of two care givers with bathing, dressing and grooming needs..." On 11/09/2010 the care plan was updated with an intervention to include "Pad night stand and closet." Review of the Nursing Guide To Care sheet, the CNA care guide, dated 10/01/2010 did not include the number of caregivers required for care. In an interview with the surveyor on 11/17/2010 at 10:05 AM Certified Nurse Aide (CNA) #1 stated that on 11/08/2010 Resident #1 rolled over and fell from the bed when she turned aroun… | 2014-03-01 | ||
| 10232 | 10232 | UNIHEALTH POST ACUTE CARE - AIKEN, LLC | 425145 | 830 LAURENS STREET NORTH | AIKEN | SC | 29801 | 2010-11-22 | 153 | G | 6LCC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection, based on record review and interviews, the facility failed to provide access to all medical records for 1 of 4 residents sampled for the request of medical records (Resident #1). A written request made by the wife (personal representative) of Resident #1 made initially to the facility on [DATE] and then again on [DATE] was denied. The Regional Ombudsman, after numerous attempts to assist the resident's wife in obtaining the medical records of Resident #1, filed a complaint with the State Survey Agency on [DATE]. Nurses' Notes documented that the facility notified Resident #1's wife with any change in condition and acknowledged her as his personal representative. The facility failed to acknowledge the Health Care Consent Act (SC Code [DATE] et. esq.) and failed to recognize Resident #1's wife as his personal representative when she requested copies of his medical record. The findings included: On [DATE] the facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS assessment dated [DATE] coded the resident as having short-term and long-term memory problems with severely impaired cognitive skills for daily decision-making. Resident #1 required extensive to total assistance for all activities of daily living on the Admission and Quarterly MDS. Review of the current medical record revealed a Do Not Resuscitate (DNR) Authorization for Patient/Resident Without Decision-Making Capacity for Resident #1 signed [DATE] by two physicians and by the resident's wife ([DATE]). During an onsite visit to the facility on [DATE], Resident #1 was sampled as a result of a complaint received by the State Agency on [DATE]/2010, which alleged that the resident's wife failed to receive requested medical records. The allegation stated that the Ombudsman had worked since [DATE] to resolve a complaint filed against the facility related to the denial of … | 2014-03-01 |
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CREATE TABLE [cms_SC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );