CMS-Nursing-Home-Full-Deficiencies
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9501 | DR RONALD E MCNAIR NURSING & REHABILITATION CENTER | 425309 | 56 GENESIS DRIVE | LAKE CITY | SC | 29560 | 2011-04-27 | 150 | E | 1 | 1 | I04T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record reviews, staff interviews, and resident interviews, the facility failed to ensure that Residents #7 and #9 were afforded the right to make their own decisions related to leave of absence and notification of family. (Two of four alert and oriented resident's reviewed for resident rights) The findings included: The facility admitted Resident #7 on 7/9/10 with the following Diagnoses: [REDACTED]. During the initial tour with the wound care nurse on 4/25/11, the wound care nurse stated the resident was "interviewable". Record review of the resident's Minimum (MDS) data set [DATE] and 4/12/11 in section C indicated the resident was cognitively intact, with a BIMS (Brief Interview for Mental Status) score of 15. An individual interview with the resident on 4/25/11 at 12:30 PM revealed that the resident was alert and oriented to time, place, person and situation. The medical record review on 4/25/10 revealed a note taped in the front cover of the medical record, which stated the residents first cousin could take the resident on LOA (leave of absence) to Lake City (uptown) per the (RP) Responsible Party, without calling her. Further record review revealed the physician had not determined the resident as lacking capacity to make decisions. The resident had signed the necessary paperwork to determine his own advanced directive status. The residents bill of rights was signed on admission by the resident's sister. On 4/26/11 at 9:00 AM, when asked about going out of the facility, the resident stated " I go home sometimes with my brother or sister. I made a list of three people that can take me out. Well, I didn't, my sister did that before I got here. My sister can sign papers for me only if I am sick or it's an emergency." When asked about the facility calling his sister when he goes out for any reason he also stated "They do not need to call my sister when I go out. My cousin can even take me to my house, that is not up to her. My sister does not have anything to do with when I go out. I don't know why they have to call her.... I would like to go out more, but I didn't know I could. My brother (in New Jersey) and my sister (Anderson, SC) lives a long way and so I am limited as to who can take me out. I didn't know I could go with anyone else." During an interview with the SSD (Social Service Director) on 4/27/11 at 9:20 AM, when asked about the note placed on Resident #7's medical record regarding his LOA's, she stated: " It is our policy to notify the family member to let them know that the resident is leaving the building, even if they are alert and oriented." She also stated " He never asked to go out, but I can see how he thought he couldn't. I see how wrong that is, I'm so sorry". A SSD note placed on the chart on 4/27/11(dated 4/19/11) stated: " SW talked with resident today about his rights in the facility. Resident did not know why the facility had to call his emergency contact when he left the facility or wanted to go on LOA. SW talked to resident and reassured resident that he is totally in charge of what he wants or who he wants to go on LOA with. Sister will not be contacted to get permission for resident to leave facility or contacted to make decisions if resident does not want facility to. SW called MD (Medical Director) about a standing order for resident to have LOA's. Awaiting call back. SW also told resident about note in front of chart that it was wrong for SW to put note in chart for that reason. (LOA with cousin) Note taken out of chart. Resident was satisfied with conversation to assist resident with any contacts he would like to make for LOA's." The facility admitted Resident # 9 on 2/19/03 with the following Diagnoses: [REDACTED]. An individual interview with the resident on 4/25/11 at 4:30 PM revealed that the resident was alert and oriented to time, place, person and situation. Further record review revealed the MDS (Minimum Data Set) dated 3/16/11 (section C) BIMS (Brief Interview for Mental Status) score of 15, indicative of no cognitive impairment. The medical record review on 4/25/10 revealed a note taped in the front cover of the medical record, which stated "Attention Nurses No one (underlined 3 times) is allowed to take the resident on LOA's unless it is the Responsible Party. (The name of the resident's sister was listed). During a second interview with the resident on 4/26/11 at 10:00 AM, Resident #9 stated " I don't make my own decisions, my sister does. I don't like it, but she says she is the only one that can take me out. I would like to go out with my brother some and see some old friends but she won't let me. They won't let me... they call her." When ask about the note placed on the cover of the chart he stated: " They say if you don't go with her you can't go out. She thinks I just want to go out and drink, but I tell her I just want to go and be with friends and my brother. She said if I say you can't go out, then you can't go". " I sure would like for this to be straightened out. I want to be able to make my own decisions." During an interview with Licensed Practical Nurse # 3 (LPN) on 4/25/11 at 5:25 PM the LPN stated when asked about the note in front of the resident's chart, " if someone comes for him we have to call the RP and get it okayed with her." On 4/26/11 at 5:15 PM the Director of Nursing (DON) stated - " his sister just wants him not to go with a certain person that drinks. She is aware that it is up to him." On 4/27/11 at 10:30 AM LPN # 2 stated " If I saw that note on the front of the chart, I would let him go because he is alert and oriented. But, I would call the sister and let her know." On 4/26/11, the SSD made a note on the residents chart which stated " SW talked with resident about resident rights. SW explained to resident that his sister (RP) could not say who resident could go on LOA's with. The note that SW put in front of chart was taken off. Explained to resident that since he was alert and oriented times three he could make his own decisions. SW will not be calling his sister anymore without his permission. Resident verbally understands and was very happy about this information. SW will continue to educate on resident rights." | 2015-04-01 |
| 6574 | SUNNY ACRES NURSING HOME | 425093 | 1727 BUCK SWAMP ROAD | FORK | SC | 29543 | 2014-12-11 | 151 | G | 1 | 0 | IW3O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to respect resident rights for 1 of 1 resident who refused the flu vaccine. Resident #1 refused to receive the flu vaccine. The findings included: On 12/3/14 Resident #1 refused to receive a flu shot. The administrator and a nurse went to the resident to talk the resident into taking the flu shot. The resident refused the flu shot again. The administrator continued to insist the resident take the flu vaccine. The resident began cursing, said no and told the administrator to get out of the room. The administrator did not leave and told the resident the door could not be closed. The resident attempted to push the administrator out of the room. The administrator was observed holding the residents forearms and lying across the resident in the bed. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurse's Notes on 12/3/14 at approximately 10:00 AM, Resident approached by myself and administrator re (regarding): taking flu shot. 'Resident stated hell no get the hell out.' Administrator continued to talk to resident. Resident became more agitated and stood up in front of the administrator. I left the room to call 911 as administrator requested and when I got back was reported that resident had grabbed administrator by the tie and nurse had to get it loose then resident was lying on bed with arms pinned down and admin (administrator) laying on him/her. Resident then bit administrator as was reported to me. Resident was checked for injuries per nurse. None noted . On 12/10/14 at approximately 1:25 PM the floor tech was interviewed. S/he stated, I was buffing hall 4. I heard them fussing and s/he (Resident #1) kept telling the administrator to get out and close the door. The administrator told him/her s/he could not close the door. The resident said s/he would close the door and got up. S/he tried to push the administrator out. S/he could not move the administrator. The administrator kind of like walked the resident back to the bed. Licensed Practical Nurse (LPN) #2 had just walked out. The resident's hands were on the administrators shoulders, neck region. I couldn't see clearly from the angle. The administrator was trying to tell the resident to calm down. S/he laid the resident down on the bed. The administrator had his/her hands on the resident's forearms. On 12/10/14 at approximately 2:20 PM Licensed Practical Nurse (LPN) #1 was interviewed by the surveyor. The LPN stated on the morning of December 3, 2014 the resident had been on a list of residents who refused the flu shot. The LPN reported to the administrator that the resident refused the flu shot. The administrator and the nurse went to the resident's room. The resident was told s/he needed to take the flu shot. The resident said no. The resident was in the bed, s/he was cussing the administrator, telling us to get the hell out of his/her room. I told the administrator I could document his/her refusal and his/her behavior and it would be fine. The administrator stated the resident could go to _____ (psych hospital) or be discharged . The administrator had talked to another resident that had refused the flu shot. The other resident said no. The administrator told the resident that flu shots were going to become mandatory. The other resident agreed to take the flu shot. In an interview with the surveyor on 12/10/14 at 1:40 PM LPN #2 stated, About 10:30 AM the LPN #1 came and said _____ (Resident #1) had refused the flu shot again. The administrator said ok lets go see. They walked down the hall and I heard them. The resident screaming and cussing and said no. I though I heard the table fall. When I got down to the room ______ (floor tech) had picked up the table and walked back out. LPN #1 had walked down the hall and said, 'S/he (administrator) wants him/her (resident sent to _____ (psych hospital)'. When I walked in the room, the administrator was laying over the bed. Feet toward bottom, on floor with head-waist up across bed. I didn't know if the resident had a hold of the administrator. Then I saw the resident had the administrators tie. I pulled the tie but it was tight. I said ______ (resident's name) let go and s/he eased and I was able to get the tie out. I put my hands on resident's forearms and told the administrator s/he could get up. Administrator continued to lay on the resident and told me to go call 911. | 2017-12-01 |
| 8027 | FAIRFIELD HEALTH CARE CENTER | 425158 | 117 BELLEFIELD ROAD | RIDGEWAY | SC | 29130 | 2012-11-08 | 151 | D | 0 | 1 | BCNQ11 | On the days of the survey, based on initial tour and staff interviews, the facility failed to provide the opportunity to vote for 2 of 22 Residents in the Manor House facility who stated they would like to vote in this years election in a timely manner. (Resident A and B). The findings included: During initial tour on 11/5/12 at approximately 6:15pm, two residents approached a surveyor and stated I want to vote tomorrow. A Surveyor notified the Unit Manager of the Manor House on 11/6/12 at 9:32am that Resident A and B had requested to vote today. During the evening meal observation on 11/6/12 at approximately 5:50pm, Resident A and B again requested to vote today. During an interview with the Director of Recreation Therapy on 11/6/12 at 6:10pm, she stated I just picked up the voting ballots and need to transport Resident's to vote and next year I will mark my calendar to ask all Resident's sooner if they want to vote. During review of the Admissions Packet on 11/7/12 at 4:35pm, review of the Resident Rights: Bill of Rights stated under #2 The Resident has the right to exercise his or her rights as a resident of the facility and as a citizen of the United States. | 2016-09-01 |
| 8079 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2012-05-22 | 151 | E | 0 | 1 | SDRR11 | On the days of the survey, based on interviews and review of the Resident Council Minutes, the facility failed to keep the residents informed of their rights to vote in the generally elections and keep the rights informed of their rights to review their medical records. (4 of 4 group member not aware of rights to vote and 3 of 4 not aware they could look at their medical records) The findings included: Group meeting was conducted on 5/21/12 at approximately 2 PM with 4 residents. The residents attending were determined to be alert and interview-able by facility. It was revealed that 4 of 4 residents were not informed of their rights to vote when an election process takes place. When asked if they were informed about their right to participate in last primary election in held January 21, 2012 (Republican Primary), the residents stated they were not informed. Three of 4 group members stated they were not informed they had a right to review their medical records. Review of Resident Council Minutes for the months of February 2012, March 2012, April 2012 and May 2012 did not indicate resident rights were shared or discussed during the meetings. An interview on 5/22/12 at approximately 11:30 AM with the Social Services Director revealed she was not sure if the residents were informed of their rights to vote while living in the facility. An interview on 5/22/12 at approximately 2:30 PM with the facility Administrator revealed she was last aware the residents exercised their rights to vote in the presidential election of 2008. | 2016-07-01 |
| 8399 | VALLEY FALLS TERRACE | 425096 | 400 LOCUST GROVE ROAD | SPARTANBURG | SC | 29303 | 2012-06-13 | 151 | C | 0 | 1 | 7JIJ11 | On the days of the survey, based on interviews, the facility failed to keep the residents informed of their rights to vote in the most recent generally elections. Five of 5 group members stated they were not informed of their rights to vote in the January 2012 primary elections. The findings included: During the group interview on 6/12/12 at approximately 11:20 AM with 5 residents determined to be alert and interview-able by facility, 5 of 5 residents present stated they were not informed of their right to vote in the most recent election process. When asked if they were informed about their right to participate in last primary election held January 21, 2012, the reply was no. An interview on 6/13/12 at approximately 8:25 AM with the Activity Director (AD) and the Social Services Director (SSD) confirmed the residents were not informed of the rights to vote in the most recent primary election. The AD stated she thought the SSD had the responsibility of ensuring that the residents exercised their rights to vote. The AD and SSD further stated the last time the residents voted was during the Presidential Election in 2008. When the surveyor asked the AD and SSD as to why the residents were not informed of the most recently primary election, the AD stated No, reason, we just did not know about it. | 2016-04-01 |
| 8472 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2013-03-08 | 151 | D | 1 | 0 | KEIY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observation, interviews and limited record review, the facility failed to provide Resident #1 the right to visit with her/his family without interference from the facility. The findings included: Resident #1 admitted to the facility with [DIAGNOSES REDACTED]. Review of the Nurse's Notes from 1/2/2013 through 3/8/2013 revealed the following documentation related to the Responsible Party giving the resident medication: 2/22/12 11 AM CNA came to this nurse stated s/he saw resident's . (RP) give resident something in her/his mouth. Social service notified . Review of the Social Service Notes revealed documentation that on 1/25/2013 and 2/1/2013 Social Services spoke with the resident's Responsible Party (RP) regarding leaving medications in the resident's room. The Responsible Party confirmed that s/he had given the sitter Tylenol Cold and Flu to give the resident to help with headaches. It was explained to the Responsible Party that medications (meds) could not be given by the family or the sitter employed by the family. The resident's room was searched sometime between 1/25/2013 and 2/1/2013; laxatives, stool softeners, and razors were found in his/her room. The Responsible Party was again questioned about medications being brought in and s/he stated that s/he was giving the sitter [MEDICATION NAME] to give the resident to calm her/him down. Social Service explained to the responsible party that the sitter could not give the resident medication and medications were not allowed in her/his room. The Social Service Progress Note on 2/22/2013 stated, .Social was notified by nurse that resident's . (RP) had given her some kind of meds, CNA saw and reported . (RP) states that resident was sick and s/he gave her/him something for nausea, [MEDICATION NAME] was given by (RP) . On 3/2/2013 at 12 PM the Social Service Progress Notes documented a meeting with the facility Administrator, the Weekend Nurse Supervisor, the Responsible Party and the private sitter regarding supervised visitation. The Administrator stated that a member of the facility staff would be with the resident at all times even when the sitter was here or the family was visiting . The observation on 3/1/2013 by the staff of the resident swallowing a substance from a tissue was discussed by the Administrator with the RP and sitter, both denied providing the substance. Review of a Resident Incident/Accident Investigation Worksheet dated 3/1/2013 at 1:30 PM stated, .CNA was 1:1 with resident (res) - states res. went to sink put water in a cup took the cup and sat it on overbed table. Put herself/himself to bed - reached over into a kleenex box pulled out kleenex quickly took a white oval (small) pill out of the wadded kleenex put it in her/his mouth before CNA could intervene and swallowed it with water the CNA asked her/him what it was and the resident said candy . Findings and Analysis: .Spoke with family RP (responsible party) and sitter - denys leavin (sic) meds with resident . The facility failed to provide evidence that the family/sitter provided the unidentified substance the resident swallowed. Review of Resident #1's Care Plan initiated 11/06/2012 and updated 3/4/2013 identified a problem with unmanaged mood, behavior and psychosocial distress that included verbally and physically abusive behaviors. A revised approach to managing the resident's behavior dated 3/4/2013 stated, .CP (care plan) reviewed resident now has 1 on 1 with our staff even when resident's family/sitter . family seen giving resident meds. In an interview on 3/8/2012 at approximately 3:00 PM the Administrator was unable to provide evidence that the Responsible Party gave the resident medication after s/he was warned on 2/22/2013. There was no evidence that the Responsible Party and/or Resident #1 participated in the decision made by the facility to have a sitter with the resident/family/sitter at all times. The facility failed to provide evidence that a plan with objectives, goals and time frames was in place regarding the sitter and the resident's rights to visit without the facility interfering. | 2016-03-01 |
| 8853 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2012-06-14 | 151 | E | 0 | 1 | GQ7W11 | On the days of the Recertification, Complaint and Extended Survey, based on the group and staff interviews, the facility failed to provide the opportunity to vote for 2 of 6 residents from the group interview who stated that they would have voted if a way had been provided by the facility. (Resident A & B) The findings included: During the group interview on 6-12-12 at approximately 11:15 AM, this surveyor asked if anyone had been given the opportunity to vote. The group stated that no staff at the facility had mentioned it. Resident B stated that he always voted, even in the primaries, but that no one had told him that he could vote while in the nursing home. Resident A stated that her husband usually took her to vote, but that he was not able to take her and she was not aware that the facility could assist her in obtaining an absentee ballot. On 6-13-12 at approximately 1:20 PM, the Activity Director stated that he had not discussed voting with the residents during the most recent Resident Council Meetings. He further stated that he was aware of the primary being held, but that he was new to the area and didn't think about offering the opportunity to vote to the residents. | 2015-12-01 |
| 9491 | CHESTERFIELD CONVALESCENT CENTER | 425302 | 1150 STATE ROAD | CHERAW | SC | 29520 | 2011-04-21 | 151 | E | 1 | 1 | 9LOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey the facility failed to make residents aware of how to exercise their right to vote, to review the survey results, and to be knowledgeable of the ombudsman and how to access the services of the ombudsman. Ten of 10 group members and 3 of 3 interviewable residents revealed they were not aware of their right to vote, their right to review the survey results from the previous year, or who the ombudsman was and their right to contact the ombudsman. The findings included: On 04/19/11 at 3:25 PM until 4:25 PM a Resident Council Group was conducted by the surveyor and 10 interviewable residents attended the group meeting. During the Group meeting the surveyor asked about resident rights and 10 of the 10 group members stated they were not informed of their right to vote, they did not know they had a right to look at last year's survey results and were not aware of its location, and were not aware of the ombudsman and his/her role. The facility admitted Resident #8 on 10/25/06 with the following [DIAGNOSES REDACTED]. Her most recent Brief Interview for Mental Status (BIMS)score on the Minimum Data Sets((MDS) dated [DATE] was 13 and she was listed on the facility's current Interviewable List. During an individual interview with Resident #8 on 4/21/11 at 12:15 PM she stated that she did not know about the ombudsman or anything about the survey results. The facility admitted Resident #10 on 5/26/09 with the following [DIAGNOSES REDACTED]. Her most recent BIMS score on the MDS dated [DATE] was 15 and she was listed on the facility's current Interviewable List. During an individual interview with Resident #10 on 4/21/11 at 11:50 AM the resident was unaware of her right to vote in the facility, the ombudsman, or anything about the survey results. The facility admitted Resident #16 on 4/9/10 with the following [DIAGNOSES REDACTED]. Her most recent BIMS score on the MDS dated [DATE] was 15 and she was listed on the facility's current Interviewable List. During the individual interview with Resident #16 on 4/21/11 at 12:25 PM the resident stated she did not recall her resident rights being discussed with her at the time she was admitted or at the Council meetings. She stated that she had seen the information on the board in the hall about the Ombudsman, but had never had anyone tell her anything about the Ombudsman, the survey results, or voting information. | 2015-04-01 |
| 9558 | CHESTER NURSING CENTER | 425061 | 1 MEDICAL PARK DRIVE | CHESTER | SC | 29706 | 2011-05-18 | 151 | F | 0 | 1 | JW5S11 | On the days of the survey based on interviews and record review, the facility failed to inform 12 of 12 residents in the Group Interview of their resident rights. The findings included: A Group Interview was conducted on 5/17/11 at 11:15 AM and 12 residents identified as alert and oriented by the facility were present. When questioned by the surveyor about the right to vote, make a living will and if they knew about the survey results and where posted, all 12 residents stated that they had not been informed of this information. All 12 residents in the group did know who or what the ombudsman was, were not aware that they could see their medical record and stated that no one had discussed any of these rights with them In a review of the Resident Council Minutes for January 2011, February 2011, March 2011, and April 2011 on 05/17/11 at 4:00 PM there was no documentation in the minutes that any of the resident rights were discussed with the residents. In an interview with the Administrator on 5/18/11 at 10:15 AM he stated he thought that the Activity Director had talked with the Resident Council members about the survey results at some point, but no documentation was provided to the surveyor to support this. | 2015-03-01 |
| 4622 | LINLEY PARK REHABILITATION AND HEALTHCARE CENTER, | 425016 | 208 JAMES STREET | ANDERSON | SC | 29625 | 2016-06-24 | 152 | D | 0 | 1 | UZHC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain 2 physicians' signatures to certify inability to consent before allowing the responsible party and/or Power of Attorney to sign consents for DNR (Do Not Resuscitate) orders for Residents #79, #74 and #269, 3 of 20 residents reviewed for code status. The findings included: The facility admitted Resident #79 with [DIAGNOSES REDACTED]. On 06/21/2016 at 5:48 PM, record review revealed an order for [REDACTED]. The Physician's Certification that the resident was unable to exercise his or her rights and make health care decisions was signed by the attending physician on 5/4/16. There was no certification by a second physician of the resident's inability to consent. On 06/21/2016 at 5:54 PM, review of the care plan dated 5/2/16 revealed a care plan that the Resident / Family has chosen DO NOT RESUSCITATE STATUS and interventions included Review code status per state regulations. During an interview on 6/22/16 at 2:52 PM, the Director of Nursing (DON) confirmed the DNR consent was not valid as 2 physicians had not certified the resident was unable to make health care decisions as required by the South [NAME]ina Health Care Consent Act. The DON stated the resident should have been a Full Code. The DON stated the process for DNRs was that when a resident was admitted to the facility, the attending physician signed the DNR paperwork and wrote the order for DNR. The paperwork was then placed in a box for the second physician to review the chart, examine the resident and sign the paperwork. The paperwork, including the order for DNR, was then placed in the resident's record. The DON was unable to say why the process wasn't followed for Resident #79. At approximately 4:15 PM, the DON stated that s/he had spoken to the resident's physician who stated a second physician signature was not required as the hospital history and physical had stated the resident was unable to recall events that occurred earlier in the day and was what the facility physician considered the 1st physician certification and that his/her signature at the facility was actually the second certification. Review of the hospital history and physical revealed the resident had a [DIAGNOSES REDACTED]. The facility admitted Resident #74 with [DIAGNOSES REDACTED]. On 06/22/2016 at 4:15 PM, record review revealed a DNR order dated 3/29/16 and signed by the physician on 3/30/16. The DNR consent was signed by the Power of Attorney (POA) on 3/29/16. There was no certification that the resident was incapable of making health care decisions. On 06/22/2016 at 4:27 PM, the Director of Nursing confirmed the DNR consent was signed by the POA and the order written by the physician. The DON further confirmed there was no physician certification of the resident's inability to consent. The facility admitted Resident #269 with [DIAGNOSES REDACTED]. On 06/22/2016 at 4:22 PM, record review revealed a DNR order dated 6/16/16 and signed by the physician on 6/16/16. The DNR consent was signed by the Responsible Party (RP) on 6/15/16. There was no certification that the resident was incapable of making health care decisions. On 06/22/2016 4:25:02 PM, the Director of Nursing confirmed the DNR consent was signed by the RP and the order written by the physician. The DON further confirmed there was no physician certification of the resident's inability to consent. | 2019-09-01 |
| 5207 | COVENANT PLACE NURSING CENTER | 425402 | 2825 CARTER ROAD | SUMTER | SC | 29150 | 2016-07-07 | 152 | D | 0 | 1 | 1NTX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to obtain certification from 2 physicians of inability to consent prior to allowing the personal representative to sign authorization for DNR (Do Not Resuscitation) for Resident #33, 1 of 8 residents reviewed for DNR. The findings included: The facility admitted Resident #33 with [DIAGNOSES REDACTED]. At 10:12 AM on [DATE], review of the Advance directives revealed the Responsible Party signed an Authorization for Do Not Resuscitate status dated [DATE]. The Certification of Patient's Inability to Consent to Health Care Decisions was not signed by a physician. At 10:23 AM on [DATE], review of the hospital discharge summary revealed the resident had a rapid decline in mental status during the hospitalization and it was uncertain if the resident would return to the prior level of function. At 10:36 AM on [DATE], review of the admission Physician order [REDACTED]. Review of the telephone orders revealed no DNR order had been written. At 10:41 AM on [DATE], review of a Progress Note dated [DATE] revealed the resident's code status to be Full Code. Further review revealed a History and Physical dated [DATE] that indicated the code status as Do Not Attempt Resuscitation (DNR/no CPR) (CardioPulmonary Resuscitation). At 11:08 PM on [DATE], review of the Clinical Notes revealed a Change in condition identified on [DATE] at 9:02 PM. The resident was noted to be unresponsive to verbal stimuli, cold and clammy to touch with loose stools. The vital signs were recorded as blood pressure of ,[DATE], pulse of 98, temperature of 97.7 degrees with cheyne stokes respiration and oxygen saturation of 90% on room air. The resident's daughter was notified of the resident's condition and came to the facility. At that time, the daughter reaffirmed that they only wanted comfort measures. At 5:45 AM on [DATE], the nurse documented Resident expired at 0545 with daughter at bedside. Verified by two RNs (Registered Nurses) . During an interview on [DATE] at 2:04 PM, the Director of Nursing declined to confirm or deny the findings. At 2:31 PM, the DON stated there was supposed to be a second page to the DNR paper and that they were looking for that. At approximately 4:30 PM, the DON provided a copy of the resident's Declaration of a Desire for a Natural Death. The DON and Administrator informed the surveyor that the Declaration had been in a file in the Business Office and not on the resident's medical record. | 2019-03-01 |
| 5377 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2015-04-24 | 152 | D | 0 | 1 | BTZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy titled Advance Directives Policy, the facility failed to afford residents the right to formulate their own advanced directives or verify that the resident's responsible party and/or family member had the authority to make healthcare decisions for 2 of 17 residents reviewed. Resident #112 and #142 were both deemed competent and the responsible party and/or family member signed the residents' Code Status Form. The findings included: The facility admitted Resident #112 with [DIAGNOSES REDACTED]. Review of the Medical Record on 4/24/15 revealed a Cheraw Healthcare Code Status Clarification and Competency Form dated 12/30/14 and 1/5/15 in which two physician's deemed that Resident #112 was able to make health care decisions. Further review revealed a family member signed the Code Status form for the resident to be a Do Not Resuscitate(DNR) on 12/26/14. Review of the Social Services Progress Note dated 12/26/14 stated the resident asked for her daughter to sign all paperwork. Further review revealed the daughter who is the Responsible Party for the resident did not sign the paper work but the granddaughter signed. During an interview with the Social Services Coordinator(SSC) on 4/24/15 at 5:08 PM, he/she stated that he/she did not admit the resident and that she had knowledge of the resident not feeling well at the time of admission. He/she continued by stating on admission the facility asks if the resident has a Power of Attorney or Living Will. The facility goes over what advance directives entails and it is also in the facility's admission packet. During the admission process, we discuss life support. If the resident is in attendance at the time of the meeting, he/she signs the paperwork if not, the family signs. The SSC stated upon returning to work he/she had spoken to the resident and it was the resident's wishes to be a DNR and he/she had just neglected to document or have her sign the paperwork for a DNR. The facility admitted Resident #142 with [DIAGNOSES REDACTED]. Record review on 04-23-15 at approximately 11:00 AM of the Physician's Telephone Orders dated 01-16-15 revealed the following order, Do Not Resuscitate (DNR). Additional record review on 04-23-15 at approximately 11:00 AM of the Cumulative Physician's Orders dated 04-01-15 through 04-30-15 revealed the following order, Code Status: DNR. Record review on 04-23-15 at approximately 11:00 AM of the Code Status Clarification and Competency Form dated 01-07-15 revealed Resident #142 had been determined to be competent by 2 Physicians. Further review of the Code Status Clarification and Competency Form revealed Resident #142's Responsible Party (RP) had signed the form on 01-07-15 designating Resident #142's Code Status as DNR. Record review on 04-23-15 at approximately 11:00 AM of Resident #142's Healthcare Power of Attorney revealed the following, i.e 2. Effective Date and Durability: By this document I intend to create a durable Power of Attorney effective upon, and only during, any period of mental incompetence. Review of the facility policy titled, Advance Directives, revealed the following, It is the desire of Cheraw Health Care to inform each resident of his/her right to make an informed decision concerning their medical care including their right to refuse or accept medical and surgical treatment and the right to formulate Advanced Directives. During an interview on 04-24-15 at approximately 5:15 PM with the Social Service Coordinator, he/she, after record review, verified Resident #142's RP had signed the Code Status Clarification and Competency Form on 01-07-15 designating Resident #142's Code Status as DNR. | 2018-12-01 |
| 5680 | SENECA HEALTH & REHABILITATION CENTER | 425139 | 140 TOKEENA RD | SENECA | SC | 29678 | 2015-04-23 | 152 | D | 0 | 1 | CF2B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility allowed the Responsible Party of Resident #5 to sign for a Do Not Resuscitate (DNR) order without two physicians deeming the resident unable to make own health care decisions. ( 1 of 11 residents with DNR's reviewed.) The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. The Minimum Data Set revealed the resident's Brief Interview for Mental Status Score (BIMS) to be 9. Only one physician, of the two physicians required, had indicated the resident to be incapable of making his/her own health care decisions. The Responsible Party had signed the consent for the DNR. An interview with the Director of Nursing (DON) on [DATE] at 9:15 AM revealed the second physician's signature had not been obtained. The Social Service Director told the DON that the form had been placed in the doctor's book to be signed but had not been signed yet. Interviews with the DON and Licensed Practical Nurse (LPN) #2 revealed that nurses and staff looking in the chart for resuscitation status for this resident would have not done CPR (Cardio [MEDICAL CONDITION] Resuscitation) on this resident in the event of a [MEDICAL CONDITION] due to the DNR sticker in the front of the chart. When in fact CPR would have needed to be done until all the necessary paperwork had been completed. | 2018-10-01 |
| 6412 | LAKE CITY SCRANTON HEALTHCARE CENTER | 425149 | 1940 BOYD ROAD | SCRANTON | SC | 29591 | 2014-04-03 | 152 | D | 0 | 1 | S8GD11 | **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 who had not been judged incompetent by the State court resident's rights were exercised to the extent provided by State law. The facility failed to have two physicians sign a certification of capacity for Resident # 7 prior to writing a Do Not Resuscitate order. The findings included: Review of Resident #7's medical record revealed s/he was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of Resident #7's record on [DATE] revealed a facility Physicians Certification of Competency of Resident form with one Physician signature that indicated the resident was unable to comprehend the Residents Rights and Responsibilities of the facility due to dementia. Only one Physician on [DATE] signed the form on [DATE]. Further review of the medical record revealed a physician's orders [REDACTED]. There was a Nurse's Note dated [DATE] at 1:45 PM Resident DNR entire stay per family & MD. Review of the Advance Directives form and the Advance Directive Flash Sheet form revealed Resident #7 ' s granddaughter on [DATE] signed them both. The forms both indicated that Resident #7's granddaughter did not wish for CPR (Cardiopulmonary Resuscitation) to be performed on Resident #7. Review of the Social Progress Notes dated [DATE] at 1:00 PM indicated that Resident #7's family meeting was held that day. The Social Services progress notes documented the Physician was present to discuss with the family about how the resident's cognitive status and health had changed. Resident #7 was no longer able to make good health care decisions due to a change in competency status. Resident #7's family agreed and Resident #7 has a DNR status in place. Physician has deemed Resident #7 incompetent. In an interview with the surveyor on [DATE] at approximately 11:30 AM, Social Service staff stated that Resident #7 was competent but had a decline in health. Social Service staff stated that one Physician signed the Certification of Competency form during the meeting with the family and that the nurse wrote the order at the meeting. Social Service staff provided a facility Physicians Certification of Competency of Resident form for Resident #7 that had a second Physician's signature dated [DATE]. Social Service staff stated that the form with two Physician's signatures was located in medical records and was placed on the chart after the surveyor reviewed the chart on [DATE]. In an interview with the surveyor on [DATE] at approximately 12:10 PM the Social Services Director stated that the facility did not have a policy on resident inability to consent for code status. The Social Services Director stated that the facility uses the Adult Health Care Consent Act and provided a copy. Review of the Adult Health Care Consent Act revealed, A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient. | 2018-03-01 |
| 6441 | MARION NURSING CENTER, INC. | 425015 | 2770 SOUTH HIGHWAY 501 | MARION | SC | 29571 | 2013-08-21 | 152 | D | 0 | 1 | 6G2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the recertification, complaint and extended survey, based on record review and interviews the facility failed to provide evidence that two physicians had deemed Resident #16 (1 of 16 residents reviewed for healthcare decision making capability) incompetent to make his/her own healthcare decisions. The findings included: The facility admitted Resident #16 on 7/31/13 with [DIAGNOSES REDACTED]. During the record review the resident was documented as being alert and oriented to person, place and time. It was noted that Resident #16's sister had signed the Designated Decision Maker For A Person Unable to Consent form on the resident's chart. Upon further review of the record, no documentation from a physician could be found deeming Resident #16 incompetent to make his/her own healthcare choices. An interview on 8/7/13 at 3:30 pm with the Social Services Director (SSD) stated, I do not have the Power of Attorney papers if they are not on the chart. The SSD also stated that s/he did not have the two physician signature sheet deeming Resident #16 incompetent. S/he stated that her sister became Resident #16's RP (responsible party) when s/he was diagnosed with [REDACTED]. | 2018-02-01 |
| 6761 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2013-09-12 | 152 | D | 0 | 1 | FS9511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review, interviews, review of the South Carolina Code of Laws (Unannotated) Title 44 Chapter 66 Adult Health Care Consent Act, and review of the facility's policy entitled Patients Without Advance Directives, the facility failed to ensure that 2 licensed physicians signed the Code Status Clarification and Competency Form declaring Resident #7 lacked capacity to make health care decisions, 1 of 24 residents reviewed for code status. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. On 9/10/13 at approximately 3:40 PM, record review revealed a Code Status Clarification and Competency Form dated 5/24/13 and signed by the Advanced Nurse Practitioner (ANP) on 6/3/13 and by the physician on 6/5/13. During an interview on 9/11/13 at 4:45 PM, the Social Services Director (SSD) confirmed the ANP had signed the statement of non-competency and was unaware that the ANP did not have authority to sign the form. Review of the South Carolina Code of Laws (Unannotated) Title 44 Chapter 66 Adult Health Care Consent Act Section 44-66-20 (6) revealed .A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient . Review of the facility's policy entitled Patients Without Advance Directives on 9/12/13 at approximately 12:00 PM revealed 3. The patient's inability to consent to care or to make health care decisions must be certified by two licensed physicians, each of who has examined the patient. The policy further outlined the documentation required of the certification of a resident's inability to consent. | 2017-09-01 |
| 6779 | PEACHTREE CENTRE | 425095 | 1434 N LIMESTONE ST | GAFFNEY | SC | 29340 | 2013-12-19 | 152 | D | 0 | 1 | G10C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, based on record review, interviews, and review of the South Carolina Code of Laws (Unannotated), the facility failed to obtain 2 physicians' signatures declaring Resident #4 lacked capacity to make his/her own healthcare decisions prior to allowing the resident's responsible party to make the decision that the resident would have a DNR (Do Not Resuscitate) Code Status. The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. On 12/17/13 at 12:43 PM, record review revealed an Advance Directive signed by the resident's daughter. Further review revealed no evidence the resident lacked the capacity to make his/her own healthcare decisions. During an interview on 12/18/13 at 9:28 AM, the Social Services Assistant (SSA) stated that the doctor had requested a STAT (as soon as possible) DNR and that the physician had already written the DNR order. The SSA further stated that a discussion with the resident was attempted 3 times but the resident became very upset so the discussions were terminated. The SSA also stated that the resident's daughter stated that Resident #4 was cognitively clear when at home. The SSA confirmed that because of the daughter's description of the resident's cognitive status, s/he did not attempt to obtain a statement signed by 2 physicians as required. Review of the South Carolina Code of Laws (Unannotated), Chapter 66, Adult Health Care Consent Act, Section 44-66-20 (6) revealed the following .A patients inability to consent must be certified by two licensed physicians, each of whom has examined the patient . | 2017-09-01 |
| 7174 | PRINCE GEORGE HEALTHCARE CENTER | 425295 | 901 MAPLE STREET | GEORGETOWN | SC | 29440 | 2013-05-30 | 152 | D | 0 | 1 | 2OTX11 | On the days of the survey, based on record review and interviews the facility failed to provide evidence that 2 physicians had deemed Resident #4 lacked capacity to make his/her own healthcare decisions for 1 of 24 residents reviewed for Code status. The findings included: During record review on 5/21/13 at approximately 9:15 AM a DNR (Do Not Resuscitate) form was found on Resident #4's Medical Record and signed by his/her daughter. Further review of Resident #4's Medical Record revealed the healthcare decisional capacity form which is to be signed by 2 Physicians to determine if a resident has capacity to make his/her own decisions was not found. Also, a POA (Power of Attorney) giving his/her daughter authority to make health care decisions for him/her could not be located in the Medical Record for Resident #4. On 5/21/13 at approximately 10:20 AM, an interview with the Licensed Social Worker, revealed that no healthcare decisional capacity form had been completed. S/he stated the facility was in the process of a comprehensive assessment and the attending Physician was waiting for the results before deeming the resident's capacity to make healthcare decisions. During an interview with Resident #4's daughter, s/he verified s/he did not have a Power of Attorney for making medical decisions for his/her family member. | 2017-05-01 |
| 7392 | HOSANNA HEALTH AND REHAB OF PIEDMONT | 425314 | 109 BENTZ ROAD | PIEDMONT | SC | 29673 | 2012-12-05 | 152 | D | 0 | 1 | ILF211 | On the days of the survey, based on record reviews and interviews, the facility failed to give 2 of 17 residents reviewed for code status the opportunity to sign a Do Not Resuscitate for himself/herself. Resident #10 and #11 had not been determined to lack capacity to make their own health care decisions. Both residents had Do No Resuscitate forms signed by their responsible party. The findings included: During record review for Resident #10 on 12/4/12 revealed that the resident had a Telephone Order (TO) for DNR (Do Not Resuscitate) dated 1/16/12. A Physician's Progress Note dated 1/3/12 stated that the resident did not have capacity DNR per conversation with daughter. An additional Telephone Order was written and signed by a physician on 1/10/12 indicating that Resident #10 was made a DNR. There was no evidence the resident lacked the capacity to make his/her own healthcare decisions. Review of Resident #11's record on 12/5/12 at 12:10 PM revealed that the resident's DNR form was signed by the resident's Responsible Party on 10/24/12. A Telephone Order was written and signed for DNR status on 10/25/12. There was no evidence the resident lacked the capacity to make his/her own healthcare decisions. On 12/5/12 at 12:50 PM, during an interview with the Director of Nursing (DON), the DON confirmed there was no documentation on the medical record indicating Resident #10 and #11 did not have the capacity to make their own healthcare decisions. No additional documentation was provided prior to the survey team exiting the facility. | 2017-03-01 |
| 7540 | DIAMOND HEALTH & REHAB OF SIMPSONVILLE, LLC | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2014-01-15 | 152 | D | 1 | 0 | CUCE11 | **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 have admission paperwork signed by the responsible party for 1 of 1 residents determined to be unable to make health care decisions. Resident #1 with limited mental capacity was asked to sign paperwork for medical treatment. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Patient Consent to Treat Authorization Release of Information Assignment of Benefits/Financial Agreement was signed on 12/3/13. The signature on the agreement was not legible. Review of Nurse's Notes from 12/3/13 through 12/11/13 revealed on 12/3/13 the facility received a report from the hospital. In the report the responsible party was identified to be the resident's, sister. The resident was stated to have the mental capacity of a 3 (three) year old. A Physician's Certification of Resident's Decision form was completed on 12/4/13. The Physician's Certification stated, I certify that I have medically examined resident (#1) and it is my opinion that s/he is unable to exercise his /her rights and make Health Care Decisions as a result of the following diagnosis (es). MR (Mental [MEDICAL CONDITION]) was listed. The Physician's Progress Note on 12/4/13 stated the resident was without decision abs (abilities). On 12/11/13 a second physician wrote, Pt (patient) is without Decisional Capacity unable to answer any questions. On 1/21/13 at approximately 12:00 PM, the Business Office Manager (BOM) was interviewed by phone by the surveyor. The BOM identified the signatures on the Patient Consent to Treat Authorization Release of Information Assignment of Benefits/Financial Agreement to belong to resident #1. The BOM stated, I do the initial forms on admission, s/he (resident #1) signed the admission agreement, arbitrary agreement and consent to treat. When I met with him/her, s/he was literally here less than an hour when I had that paperwork signed. The BOM stated the resident was his/her own responsible party. The surveyor asked the BOM if s/he was aware the resident was not capable to make health care decisions, by his/her medical record. S/he stated, I was not aware. If I know or I am told, I will review with the resident's family if I see them. | 2017-01-01 |
| 7599 | POINSETT REHABILITATION AND HEALTHCARE CENTER, LLC | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2012-12-12 | 152 | D | 0 | 1 | 5JYQ11 | **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 allow Resident # 12 the opportunity to sign advanced directives for himself/herself. Resident #12 had not been deemed to lack capacity to make health care decisions. Resident #12's Responsible Party (RP) signed the consent for a DNR (Do Not Resuscitate) order to be written by the physician. (1 of 14 residents reviewed for resident rights.) The findings included: Record review for Resident #12 on 12/10/12 revealed that the resident had a Telephone Order (TO) for DNR (Do Not Resuscitate) per RP (Responsible Party) dated 8/17/12. A Physician's Progress Note dated 12/6/11 stated that the resident had questionable decisional making capacity and the facility should obtain a second opinion. The RP signed the consent for DNR on 12/1/11. Further review of the residents record revealed there was no second physician that deemed the resident incompetent to make healthcare decisions. Review of the residents Admission Minimum Data assessment dated [DATE] under section C0500 Brief interview for mental status, Resident #12 scored a 14 which indicated the resident was cognitively intact. On 12/11/12 at 10:30 AM, during an interview with the Licensed Practical Nurse #7, s/he confirmed that Resident #12 did not have the required documentation from two physician's to determine the resident's decisional capacity on the medical chart. | 2016-12-01 |
| 7619 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2012-11-29 | 152 | D | 0 | 1 | IFSP11 | **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 correct information throughout the medical record for 1 of 13 residents reviewed for Advanced Care Directives.(Resident #8) The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Record review on 11/27/12 revealed on the inside flap of the chart that Resident #8 was a DNR (Do not resuscitate). A physician's orders [REDACTED]. Further review revealed a Declaration of a Desire for a Natural Death dated 1/28/10. An Advance Directive was signed on 11/9/12 by the responsible party which indicated a Full Code. The physician's cumulative orders for November 2012 revealed the resident was a Full Code. Two physicians signed the Advance Directive on 11/15/12 and 11/19/12 indicating the resident lacked the mental capacity to make decisions about current or future medical care. During an interview with the Unit Manager and ADON on 11/27/12, they confirmed that the code status(DNR) on the front of the chart was incorrect and Resident #8 should be a Full Code. | 2016-12-01 |
| 7724 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2012-10-03 | 152 | D | 0 | 1 | RGS411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on observations, record review and interviews the facility failed to provide evidence that 2 physicians had deemed resident #22 (1 of 22 residents reviewed for healthcare decision capability) incompetent to make his/her own healthcare decisions. The findings included: The facility admitted Resident #22 on 10/13/10 with a [DIAGNOSES REDACTED]. During the record review on 10/3/12 at 10:45 am a Do Not Resuscitate (DNR) form was noted on the front of the chart which had been signed by the residents spouse. After further record review, the healthcare decisional capacity form which is to be signed by 2 physicians and the forms for Power of Attorney, giving the residents spouse the ability to make healthcare decisions for the resident, could not be located. An interview on 10/3/12 at 10:49 am with Registered Nurse #1 revealed that she is aware of the healthcare decisional capacity and POA forms and that one of them should be on the residents chart. A request was made that he/she locate either the healthcare decisional capacity form signed by 2 physicians deeming Resident #22 incapable to make her own healthcare choices or provide the POA forms appointing the spouse to make healthcare decisions. RN #1 was unable to produce either form from the residents record, stating she could not locate them. | 2016-11-01 |
| 7941 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2012-09-05 | 152 | D | 0 | 1 | 201911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility failed to determine a resident was competent to complete his/her Advance Directive related to Do Not Resuscitate for 1 of 13 sampled residents reviewed. Resident #7 was not determined incompetent to sign her own Advance Directive with only 1 physician statement related to competency. The finding included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Record review on 9/04/12 reviewed an Admission Minimum (MDS) data set [DATE] and a Quarterly Minimum (MDS) data set [DATE] that indicated the resident was severely cognitively impaired. Further record review revealed a Resuscitation Designation form that indicated the resident had orders of Do Not Resuscitate signed by a family member. There was no documentation that 2 physicians had deemed the resident incompetent to sign her own Do Not Resuscitate/Advance Directive. Record review revealed the resident was listed as DNR since 5/15/12. Review of the resident's care plan dated 5/17/12 indicated the resident was Do Not Resuscitate without 2 physician's signature to determine the ability of the resident to make healthcare decisions. An interview on 9/04/12 at approximately 2:35 PM with Licensed Practical Nurse #1 confirmed the findings. An interview on 9/04/12 at approximately 3:30 PM with the Social Services Director confirmed the findings there was no documentation to indicate a second physician had deemed resident incompetent to sign her own Advance Directive. | 2016-10-01 |
| 8450 | SUMMIT HILLS SKILLED NURSING FACILITY | 425390 | 110 SUMMIT HILLS DRIVE | SPARTANBURG | SC | 29307 | 2012-08-02 | 152 | E | 0 | 1 | SQR511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Extended Survey, based on interview, record review, and review of the South Carolina Code of Laws, the facility failed to ensure that residents' Authorization of Do Not Resuscitate - Resident Without Decision Making Capacity was signed by 2 physicians in accordance with state laws for 3 of 5 residents reviewed for Decision Making Capacity, Residents #2, #4 and #10. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. On 7/30/12 at 2:45 PM, record review revealed that the Authorization of Do Not Resuscitate Resident Without Decision Making Capacity was signed by the attending physician. There was no signature for a concurring physician. During an interview on 8/1/12 at 7:48 AM, the Director of Nursing confirmed there was only 1 physician signature on the Authorization and that 2 signatures were required. The Social Worker was not available to interview. The facility admitted Resident #4 with [DIAGNOSES REDACTED]. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. On 7/31/2012 record review for Residents #4 and #10 revealed that the Authorization of Do Not Resuscitate Resident Without Decision Making Capacity was signed by the attending physician. There was no signature for a concurring physician. In an interview on 07/31/2012 the Director of Nurses confirmed that two signatures were required. Review of the Interpretive guidelines of CFR 483.10(a)(3) and (4) revealed that the facility may seek a health care decision (or any other decision or authorization) from a surrogate or representative only when the resident is unable to make the decision. Review of the South Carolina Code of Laws, Title 44 - Health, Chapter 66, Adult Health Care Consent Act, Section 44-66-10 #9 revealed A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient. | 2016-04-01 |
| 8532 | COUNTRYWOOD NURSING CENTER, LLC | 425370 | 1645 RIDGE ROAD | HOPKINS | SC | 29061 | 2012-02-22 | 152 | D | 0 | 1 | BQ7X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on record review, interview and review of South Carolina Code of Laws, Title 44 - Health, Chapter 66, Adult Health Care Consent Act, the facility failed to ensure that the Do Not Resuscitate (DNR) order was obtained in accordance with State law as required for Resident #4, 1 of 5 residents reviewed with DNR orders. The facility failed to ensure that 2 Physicians had examined and certified the inability to consent for Resident #4. The findings included: On [DATE] at 4:10 PM, record review revealed a South Carolina Emergency Medical Services (EMS) DO NOT RESUSCITATE ORDER signed by the resident's representative. Further review revealed a facility form, CPR (Cardiopulmonary Resuscitation) DIRECTIVE, signed by the representative and dated [DATE] indicating the representative had signed an EMS - No CPR Directive or Do Not Resuscitate (DNR) order. Record review also revealed an AUTHORIZATION OF DO NOT RESUSCITATE INCOMPETENT RESIDENT form for Resident #4. The form was signed by the Attending Physician [DATE] and the resident's representative on [DATE]. There was no signature for a Concurring Physician. During an interview on [DATE] at 11:50 AM, Licensed Practical Nurse (LPN) #2 was asked if the resident was a DNR or a Full Code. LPN #2 pulled the resident's record and stated she was a DNR. She confirmed the DNR order was signed by the resident's representative. She stated that a representative is allowed to sign for a resident only if the resident had been deemed incompetent to consent and stated that the inability to consent had to be certified by 2 physicians. LPN #2 confirmed that the AUTHORIZATION OF DO NOT RESUSCITATE INCOMPETENT RESIDENT was signed by only one physician and that the resident should be a full code until the second physician signature was obtained. She also confirmed that, when asked if the resident was a DNR or Full Code, she had gone to the DNR form and determined the resident was a DNR. Review of South Carolina Code of Laws, Title 44 - Health, Chapter 66, Adult Health Care Consent Act revealed the statement A patient's ability to consent must be certified by two licensed physicians, each of whom has examined the patient. | 2016-03-01 |
| 8611 | BETHEA BAPTIST HEALTHCARE CENTER | 425372 | 157 HOME AVENUE | DARLINGTON | SC | 29532 | 2012-04-04 | 152 | D | 0 | 1 | C3N311 | **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 ensure two physicians determined a resident lacked capacity prior to allowing a responsible party to make decisions for that resident Resident #1 was not judged to lack capacity by 2 physician's prior to the (RP) Responsible Party signing Advanced Care Directives. (1 of 13 sampled residents reviewed for resident rights.) The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4-3-12 at 11:25 AM record review revealed Resident #1's Advanced Care Directives code status as (DNR) Do Not Resuscitate, and was signed by the RP (responsible party) and a physician. The physician orders [REDACTED]. Further review of the social service notes again described the residents code status as DNR. On 4-3-12 at 1:55 PM during an interview with RN #1 it was revealed that there was not a Certification of Patient's Inability to Consent to Health Care Decisions completed by two physicians. RN # 1 verified that this should have been completed prior to the RP making any Advanced Care Decisions on behalf of the resident. On 4-4-12 at 2:30 PM during an interview the Director of Nursing provided a Certification of Patient's Inability to Consent to Health Care Decisions for Resident #1, it was signed and dated on 4-3-12 by one physician and voiced they were waiting for another physician to examine her. | 2016-02-01 |
| 8695 | LAUREL BAYE HEALTHCARE OF GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2011-10-19 | 152 | D | 0 | 1 | PK5911 | **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 allow 1 of 12 sampled resident's the opportunity to formulate his own advanced directive. Resident #22 was evaluated and it was documented by two physician's that the resident had the capacity to make health care decisions. A physician's orders [REDACTED]. The findings included: The facility admitted Resident #22 on [DATE] and readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 10:33 AM, review of the closed record for Resident #22 revealed a Physician's Certification dated [DATE] stated that the resident was able to make Health Care decisions and was signed by a physician on [DATE]. The Resident also had an Advanced Directives form completed and signed on [DATE] by the resident and his son which stated that he did not wish to discuss it which resulted in the resident being a Full Code. Further review of the Nurses' Notes indicated that on [DATE], Resident # 22 was readmitted to the facility a Category 4 with Hospice Care. Physician's Telephone Orders of [DATE] requested a Hospice evaluation. The resident was admitted to Hospice services on [DATE]. On [DATE] the NP (Nurse Practitioner) documentation indicated that the resident was alert and oriented times 3. Review of the Social Service notes dated [DATE] indicated that Resident #22 .now receives Hospice Care . On [DATE], [DATE] and [DATE] the Nurses' Notes contained documentation that the resident was alert and oriented times 3 (person, place and time) and could make needs known. On [DATE], [DATE] and [DATE] nursing documented the resident was alert and oriented times 2. No further documentation related to Resident #22's cognition was observed in the Nurses' Notes. On [DATE] at 10:33 AM, review of the closed record for Resident #22 revealed a Telephone Order (TO) for a DNR per family/pt. (patient) request dated [DATE] The resident expired. on [DATE]. During an interview with the Social Service worker, the surveyor asked if the resident had been evaluated for the capacity to consent following his re-admission and change to Hospice services. He stated that there was not one completed. He stated that the resident's family had spoken with the physician and the decision was made by the family to make the resident a DNR. When asked if there were Physician's Progress Notes to document the meeting /decision and the resident's cognitive status/participation in the decision at the time of the DNR order, he stated No. No further documentation was provided prior to the survey team exiting the facility. | 2015-12-01 |
| 8773 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2011-09-14 | 152 | D | 0 | 1 | 6MCR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification and Complaint Survey, based on interviews, record review and review of the facility's policy Policies and Procedures Social Services Manual Section Advance Directives and the South Carolina Code of Laws/ Title 44, Chapter 66, Adult Health Care Consent Act, the facility failed to ensure that two Physicians had examined and certified the inability to consent in accordance of State Law for Resident # 1, (1 of 14 sampled residents reviewed for advanced directives.) The findings included: The facility admitted Resident #1 on 4/14/11 with [DIAGNOSES REDACTED]. On 9/13/11 at 2:48 PM, record review revealed a letter stating This resident has been deemed without capacity by one medical physician whom is currently pending a second physician signature regarding the resident's choice of treatment preference as of . The family has elected the following code status per the resident's desire until the second physician signature is received, the resident desires : DNR (Do Not Resuscitate.) as of per (resident's daughter.) Also noted in the record were 2 Emergency Medical Services Do Not Resuscitate Orders dated 8/26/11; one also contained a note stating pending order per (MD). In addition, the Advance Directives / Medical Treatment Decisions Acknowledgement of Receipt stated that one of the resident's daughters was unaware of Advance Directives and directed the facility to check with another daughter. The second daughter was the daughter who elected a DNR Code Status for the resident. A Physician's Telephone Order was noted dated 8/30/11 for Do Not Resuscitate. Review of the care plan on 9/14/11 at approximately 2:30 PM revealed a care plan for Advanced Directives indicating the resident has elected a FULL CODE status r/t (related to) her choice of treatment preference which is in effect. No Power of Attorney or Living Will was located in the resident's record. Review of the resident's MDS (Minimal Data Set) revealed the resident to be severely cognitively impaired with a BIMS (Brief Interview of Mental Status) of score 4 on 7/25/11. During an interview at 4:13 PM on 9/13/11, the Social Services Director confirmed the resident had not been deemed incompetent to consent for DNR or other health care decisions by 2 physicians. She confirmed that she was aware that 2 physician signatures were required to determine the resident's ability to consent. She further reported that the facility has only 1 contracted Physician and that they have been having difficulty obtaining a second physician's signature to determine residents' capacity to consent to treatments. She also confirmed that the resident's daughter had not provided the facility with any paperwork that named her as the resident's Power of Attorney or a Living Will declaring the resident's desires related to DNR status. Review of the facility's policy revealed Chapter 1 of the Policies and Procedures Social Services Manual Section Advance Directives page 1-45 under Procedure stated the facility complies with applicable state and federal laws regarding advance directives . In addition, the policy stated If the resident has an advance directive, the social worker will request a copy of the directive so that it may become part of the medical record . The policy further stated Note: The advance directive copy should always remain in the resident's record, protected in a plastic cover, even if the record is thinned. During an interview on 9/14/11 at 2:50 PM, the Director of Nursing stated they clearly were not following the policy related to Advance Directives and confirmed the code status was very confusing and that the care plan indicated the resident was a Full Code despite other documentation. Review of the South Carolina Code of Laws, Title 44 - Health, Chapter 66, Adult Health Care Consent Act ,Section 44-66-20 revealed the statute stated, in part: (6) A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient. | 2015-12-01 |
| 9100 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2012-01-25 | 152 | D | 0 | 1 | IEP611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interviews and review of the facility's policy entitled "Advance Directives Protocol" and the "South Carolina Code of Laws/Title 44, Chapter 66, Adult Health Care Consent Act", the facility failed to ensure that two Physicians had examined and certified a resident's inability to make health care decisions in accordance with State Law for Resident #8. Resident # 7 had conflicting information related to Advanced Directives in the medical record. (2 of 10 residents reviewed for advanced directives.) The findings included: The facility admitted Resident #8 on 1/24/2008 with [DIAGNOSES REDACTED]. On 1/24/12 at 2:35 PM, record review revealed an Emergency Medical Services DNR (Do Not Resuscitate) form signed by the Resident's Health Care Medical Power of Attorney. Review of the resident's MDS (Minimal Data Set) revealed the resident to be severely cognitively impaired with a BIMS (Brief Interview of Mental Status) score of 4 on 5/24/11 and a score of 3 on 11/18/11. On further record review, an Inability to Consent form signed by two Physicians was unable to be located for Resident #8. During an interview on 1/24/12 at 3:30 PM, the ADON (Assistant Director of Nursing) confirmed that the resident was unable to make health care decisions for a DNR status and needed two Physicians to examine and certify her incompetent in accordance of State Law. Review of the "South Carolina Code of Laws, Title 44 - Health, Chapter 66, Adult Health Care Consent Act, Section 44 - 66 - 20" revealed the statute stated, in part: " (6) A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient." At 4:00 PM on 5/24/12, the ADON confirmed that she was unable to locate the Inability to Consent form in Resident #8's chart dating back to the admission date of [DATE]. The ADON stated, "They must not have done them in 2008." Review of the facility's policy entitled "Advance Directives Protocol" received from the DON (Director of Nursing) on 1/25/12 at 9:00 AM, revealed this policy did not address residents who are cognitively impaired. The facility admitted Resident #1 on 11/9/11 with [DIAGNOSES REDACTED]. Hypertension, and Dementia. Record review on 1/23/12 revealed a South Carolina Emergency Medical Services form for Do Not Resuscitate Order dated 11/9/11 and signed by Resident's POA (Power of Attorney). However, the physician had not signed the sheet, nor had two physicians deemed the resident incompetent to make own decisions. Continued review revealed on the Physician order [REDACTED]. Further down an order dated 11/09/11 Code Status/ Advanced Directives: DNR. The resident's Admission Sheet also specified DNR. During an interview with the DON (Director of Nursing) on 1/23/12 at 2:20 PM, the DON stated the physician had not signed the DNR so the resident was still full code. The DON reviewed the medical record and could not explain why there were discrepancies in the record about the resident's code status. She stated she would contact Social Services to make sure these were corrected and follow up on the Advance Directives to be placed on the medical record. The DON stated the nurses in case of a code would look on the binder for a red dot if code, then look at advanced Directives. They (the nurses) could look on the physician's orders [REDACTED]. The facility admitted Resident # 7 on 5/4/11 with [DIAGNOSES REDACTED]. Record review on 1/23/12 revealed a DNR Emergency Sheet signed by 1 physician (Only 1 physician signature required for Hospice). However, the Physician order [REDACTED]. The DON confirmed the information in the medical record was not accurate related to the code status. Interview with LPN #1 (Licensed Practical Nurse)and RN #2 (Registered Nurse) confirmed they would both look at the spine of the chart for the red dot, Advanced Directives, and the Physician order [REDACTED]. | 2015-08-01 |
| 9147 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2011-08-11 | 152 | D | 0 | 1 | 1EF811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of survey, based on record review and interview, the facility failed to demonstrate evidence that a Do Not Resuscitate (DNR) was signed by an appropriate legal representative for 1 of 25 residents reviewed for advance directives. (Resident #2) The findings included: Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review on 8/9/11 of the resident's face sheet revealed the listed responsible party as the niece. The South Carolina Emergency Medical Services Do Not Resescitate Order (DNR) was also signed by the niece on 3/25/11. Upon further review, the resident was deemed a DNR by physician's orders [REDACTED]. During an interview on 8/10/11, at 9:45am with Social Service staff members, both confirmed that the person who had signed the advance directive was the niece to Resident #2 and was the assumed primary contact family member. However, the Social Service assistant stated that the brother of the resident had always been the primary contact family member. The director reviewed the chart and was unable to locate a Healthcare Power of Attorney form that allowed for the niece to act as a representative in decisions for the resident. Record review of the "Initial Social Service History" form revealed that the resident also had two daughters, in addition to the brother and niece. | 2015-07-01 |
| 9314 | PRUITTHEALTH-ORANGEBURG | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2011-08-17 | 152 | D | 0 | 1 | CVJ911 | On the days of survey, based on record review and staff interviews, the facility failed to ensure that 1 of 16 sampled resident's (Resident #9, ) rights were exercised appropriately. Residents #9 was alert and oriented on admission, however advance directives were signed by a family member. The findings included: The facility admitted Resident #9 on 4-28-11 with multiple comorbidities following Left Above-Knee Amputation with Complications. Record review and interviews revealed that Resident #9 was not afforded the right to formulate her own advance directive. Record review on 8-16-11 at 9 AM revealed that a family member had signed the information on advance directives provided at the time of admission, though there were no physician certifications of the resident's inability to make her own health care decisions. The Advance Directives Checklist had "Full Code" written in with a request for additional information. Social Progress Notes dated 5-2-11 stated,"(Daughter) is RP (Responsible Party)-looking into POA (Power of Attorney). Desires DNR (Do Not Resuscitate)." Review of the 5-5-11 Admission Minimum Data Set Assessment on 8-16-11 at approximately 11 AM revealed that the resident was cognitively intact with a Brief Interview for Mental Status score of 15. During an interview on 8-16-11 at 6 PM and on 8-17-11 at 9 AM, the resident stated that she did not recall anyone talking to her about advance directives. The resident wanted her daughter to make decisions for her whenever she became unable to do so, "but right now I certainly can." During an interview on 8-17-11 at 11:10 AM, Social Services verified that the facility should have discussed advance directives with the resident as she was alert and oriented at the time of admission. | 2015-05-01 |
| 9372 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2012-01-25 | 152 | D | 1 | 0 | YR0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, interviews, and review of facility policies, the facility failed to ensure that two physicians examined and certified the resident's inability to formulate advanced directives and/or consent to a Do Not Resuscitate (DNR) order for 1 of 1 cognitively impaired resident reviewed with a DNR order authorized by another person (#11). The findings included: Resident #11 with [DIAGNOSES REDACTED]. On [DATE], the resident's wife authorized a DNR order. On [DATE], the physician gave the DNR order. Review of the medical record failed to show a determination by two physicians, who examined the resident, that he was incompetent to make health care decisions. A document was noted in the medical record dated [DATE], written on notepaper and allegedly signed by the resident, stating he desired no CPR (cardiopulmonary resuscitation). The names of two witnesses were on the form, both printed in the same handwriting. A note at the bottom of the page was dated [DATE] and said the resident appointed his wife as decision maker and his daughter as alternate. The resident's signature for the added notation was not witnessed. Review of the facility's policy and procedure for Advanced Directives revealed the following: "Incompetent - When a resident is incompetent, he/she is unable to make his or her own decisions. A resident should not be presumed incompetent unless two (2) physicians render an opinion of such ... " (page ,[DATE]) "Residents that are not competent may be judged to be without capacity by two (2) physicians that will evaluate the resident and select the Code Status that is in the best interest of the resident. The 'Advanced Directive - Choice of Treatment' form must be signed by both physicians. ..." (page ,[DATE]) Review of the facility's Admission, Transfer, & Discharge Procedures, Chapter 1, page ,[DATE], stated: "... The forms to document competency include: "Resident Capacity, which is determined by the attending physician and then "Choice of Treatment, which must be signed another (sic) physician as required by SC law which requires two (2) physicians to deem a resident 'without capacity.' ..." | 2015-05-01 |
| 9436 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2011-03-16 | 152 | D | 0 | 1 | R83211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, Resident # 13 current medical record contained a Do Not Resuscitate (DNR) order. ( 1 of 16 residents reviewed for advanced directives ) However, the record failed to document two physicians determined the resident as lacking capacity to make his own health care decisions. The findings included: The facility admitted Resident # 13 on 4/26/10 with [DIAGNOSES REDACTED]. Record review on 3/14/11 revealed a notation in the front of the record, on a red tag, indicating the resident's status was a DNR. There was also a physician's orders [REDACTED]. Further record review failed to reveal documentation which showed two physician's had deemed this resident to be unable to make his own health care decisions thus allowing another person to make his healthcare decisions, The MDS (Minimum Data Set) documented the resident to have a BIMS score of 5 which denoted a severely impaired cognitive skills for decision making. An interview with LPN #8 (Licensed Practical Nurse) on 3/14/11 at 5:40 PM confirmed there was no documentation in the record by two physicians deeming the resident as lacking capacity to make healthcare decisions. Medical Records staff also verified there was not a competency form in the resident's thinned records. At 6:00 PM the Social Service Director confirmed he could not find the required documentation that two physicians had evaluated the resident. | 2015-04-01 |
| 9818 | FOUNTAIN INN CONVALESCENT CENTER | 425168 | 501 GULLIVER ST | FOUNTAIN INN | SC | 29644 | 2011-07-13 | 152 | D | 0 | 1 | LEF611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review of a closed chart and interviews, the facility failed to obtain 2 physician signature to deem Resident #15 incompetent to sign her advance directive for Do Not Resuscitate (DNR). (1 of 15 sampled residents reviewed) The findings included: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 7/13/11 revealed Resident #15 was deemed competent to make her own health care decisions related to DNR (Do Not Resuscitate) by the facility's physician. Further record review revealed the Advanced Directive for DNR was not signed by the resident and there was no evidence the resident lacked the capacity to make health care decisions. Interview on 7/13/11 at approximately 9:20 AM with the Social Service Director, Medical Records Staff and Director of Nursing confirmed the findings. | 2014-11-01 |
| 9856 | THE COTTAGES AT BRUSHY CREEK | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2011-05-18 | 152 | D | 0 | 1 | B6NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey, based on interviews and record reviews, the facility failed to obtain two Physician's signatures for statements of competency in accordance with state law in the Health Care Consent Act of South Carolina for 2 of 14 residents reviewed. The findings included: The facility admitted Resident #1 on 2/26/10 and readmitted her on 5/10/11. Her [DIAGNOSES REDACTED]. Record Review on 5/16/10 at 3:50 PM revealed a Physician Certificate Ability or Inability to Consent to Admission or Treatment with only 1 Physician signature dated September 10, 2010. Review of the resident's MDS (Minimal Data Set) dated 3/2/10 revealed she had short and long term memory problems and required cueing for decision making. Review of the 2/10/11 MDS revealed a BIMS (Brief Interview for Mental Status) score of 6, indicating severely impaired cognition. The facility admitted Resident #8 on 6/24/09 with [DIAGNOSES REDACTED]. Record review on 5/16/11 at 2:35 PM revealed a Physician Certificate Ability or Inability to Consent to Admission or Treatment with only 1 Physician signature dated 12/16/10. Review of the 9/14/10 annual MDS revealed she had short and long term memory problems and required assistance for decision making. Review of the 3/10/11 MDS revealed a BIMS score of 7, severely impaired cognition. During an interview at 3:30 PM on 5/17/11, the Social Services Supervisor stated that the Physicians rely on the the Social Workers to assist with resident's cognitive assessment to determine competency. She further stated that the Social Workers rely on the Physicians to sign the competency certificates. She confirmed that the Physician Certificate Ability or Inability to Consent to Admission or treatment for [REDACTED]. In addition, the Social Services Supervisor confirmed that the facility had no process in place to ensure that the competency certificates were signed by two physicians. Review of the South Carolina Code of Laws, Chapter 66, Adult Health Care Consent Act, Section 44-66-20 (6) states "A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient." | 2014-10-01 |
| 9905 | THE RETREAT AT BRIGHTWATER | 425395 | 171 BRIGHTWATER DRIVE | MYRTLE BEACH | SC | 29579 | 2011-04-06 | 152 | D | 0 | 1 | TY5Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and record review, the facility failed to ensure that for 2 of 6 sampled Residents (Residents #2 and #6) reviewed for Advanced Directive status, that the rights of the Residents were exercised by the person appointed under State law to act on the resident's behalf. Neither resident had been deemed to lack capacity to make health care decisions which could enable others to make decisions on their behalf. The findings included: Resident #2, was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 4/5/11 at approximately 10:05am revealed a "Do Not Resuscitate Order" (DNR) dated 4/23/10 was signed by the resident's daughter (Power of Attorney). Further review of the record did not reveal evidence that two physician's declared the resident lacked the capacity to make health care decisions. Interview on 4/5/11 at approximately 2:15pm with Registered Nurse #1, after review of the record, confirmed that there was no documentation by two physicians declaring the resident incapable of making health care decisions. Resident #6 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 4/6/11 at approximately 10:30am revealed a "Do Not Resuscitate Order" dated 5/24/10 was signed by the resident's daughter. Further review of the record did not reveal documentation by two physicians' declaring the resident lacked the capacity to make health care decisions. Interview on 4/6/11 at approximately 3:10pm with the Director of Nursing confirmed that there was no documentation declaring the resident incapable of making health care decisions. | 2014-10-01 |
| 10119 | STILL HOPES EPISCOPAL RETIREMENT COMMUNITY | 425401 | 1 STILL HOPES DRIVE | WEST COLUMBIA | SC | 29169 | 2011-11-10 | 152 | D | 0 | 1 | HXLZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and record review, the facility failed to allow Resident #2 to exercise her right to sign the "Do Not Resuscitate Order". Resident #2 was 1 of 7 sampled residents, who had not been declared incapacitated by two Physicians, reviewed for advance directives. The findings included: Resident #2 was admitted with [DIAGNOSES REDACTED]. Record review on 11/8/11 at approximately 4:40pm revealed a "Do Not Resuscitate Order" was signed by the resident's Power of Attorney on 8/12/10. Further review revealed there was no documentation by two physicians stating the resident was incapacitated as required by State Law. Interview with the Administrator on 11/9/11 at approximately 4:30pm indicated that after review of the resident's records, a statement signed by two physicians of the resident's incapacity could not be found. | 2014-06-01 |
| 3876 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2017-10-23 | 153 | D | 1 | 0 | NRO811 | > Based on review of facility files and interview, the facility failed to ensure resident medical records were provided completely, in a timely manner, and cost-based fees were followed per facility policy. Resident #2's power of attorney requested a copy of the resident's medical record on 5/3/17. The facility faxed a bill for the fees for the copies on 6/6/17. Copies of the resident's medical record were emailed on 10/12/17. The request was sent for the resident's entire file and the facility did not submit the entire file. The facility did not provide Nurses' Notes, assessments, or medication/treatment administration orders. The facility fee form did not follow the facility's policy related to the fees for copies of medical records. One of three residents reviewed for record requests. The findings included: The Medical Records staff provided a handwritten list of resident medical record requests. The staff stated that there was no log to indicate when requests were received or when they were fulfilled. The medical records staff stated s/he keeps a copy of all the information that is sent in a file for each resident record request. Reviewed copies of the information requested that were provided in the file for Resident #2. Noted there were no nursing progress, assessments, or administration records notes in the file. There was a letter addressed to the owner of the facility dated 6/23/17 from an attorney's office that indicated the request for the entire chart and medical record for Resident #2 dated 5/3/17 had not been received. Review of the Medical Records Copy Charges form dated 6/6/17 revealed a record processing fee of $25.00, Pages 1-30 @ $.65 for a total of $19.50, Pages 31+ @ $.50 for a total of $26.00 with a total charge of $70.50. In an interview with the surveyor on 10/23/17 at approximately 3:05 PM, medical records staff stated s/he scanned the information in the request folder into his/her computer and then emailed the information to the email provided. That is all the information s/he provided for the medical record request. In an interview with the surveyor on 10/23/17 at approximately 3:30 PM, medical records staff stated s/he doesn't know when s/he received the request letter dated 5/3/17. S/he does not keep a log of when s/he receives request. They do not provide information on CDs per corporate policy. The copy of the letter dated 6/23/17 came in with another letter that was dated 9/6/17 to show where they sent it because the medical records staff never received the letter dated 6/23/17. That letter was addressed to the owner of the corporation. Medical records staff stated s/he does not know what happened to the original letter addressed to the owner of the company. Medical records staff stated s/he received the letter dated 5/3/17 and faxed the fee form on 6/6/17. The next information s/he received was the letter dated 9/6/17, which she received on 9/8/17. A staff member from the attorney's office called on 9/12/17 and said s/he did not receive the fee form. Medical records staff emailed the invoice on 9/12/17. The next email s/he received was 10/11/17 indicating payment was made 9/15/17 and the records had not been received. Medical records staff checked with the business office because s/he had not been informed about payment and was told the payment had been received. S/he emailed the records on 10/12/17. Medical records staff did not send Nurses' Notes, generally s/he doesn't send unless they specifically request the information. S/he also did not send medication administration records. Medical records staff confirmed s/he did not send a copy of the entire medical record. Medical records staff stated if records are emailed, they are still charged per sheet. Medical records staff also stated s/he did not send the resident's assessments. Medical records staff stated s/he figures they will contact him/her if they need additional information. Medical records staff confirmed Nurses' Notes and assessments are part of the resident's medical record and care. At approximately 4:15 PM, medical records staff stated s/he did not know about the 2 days to respond to record requests. S/he also stated the charge per the form s/he had is different than the policy. The Medical Records Copying Charges form was one that s/he was provided when s/he started in medical records. Review of the facility's Accessing Health Information Policy indicated the resident's legal representative may receive a copy of the clinical record within two working days after the request, at a photocopying charge not to exceed the amount specified in this manual. Further review revealed Charges for Releasing Information provided that a facility may collect a charge of $.25 per page for making and providing copies of clinical records. If the facility collects a retrieval charge as outlined in the section below, the facility may not charge for making and providing copies of the first 10 pages of a clinical record. A facility may collect a $15.00 retrieval charge in addition to the per page charge as outlined above. If the person requesting the copies asks that the copies be provided within 2 working days, and the facility provides the copies within 2 working days, the facility may collect a fee of $10.00 in addition to the other charges. | 2020-09-01 |
| 4842 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2015-07-16 | 153 | E | 0 | 1 | XW0O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide upon an oral or written request, access to all medical records pertaining to him/herself within 24 hours (excluding weekends and holidays) and after receipt of his or her records for inspection, to purchase at a cost not to exceed the community standards photocopies of the records or any portions of them upon request and 2 working days advance notice to the facility. Residents #22, #23, #24 and #25 did not receive medical records timely or the facility was unable to show when the medical records were received by the resident and/or legal representative, 4 of 6 residents sampled for the request of medical records. The findings included: Review of the closed medical record indicated that the facility admitted Resident #22 with [DIAGNOSES REDACTED]. Review of the Significant Change 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. The Significant Change and Quarterly MDS coded Resident #22 as requiring extensive to total assistance for all activities of daily living. During an onsite visit to the facility on [DATE], Resident #22 was sampled related to the release of medical records. Review of the facility records revealed communication to the facility medical records department dated (MONTH) 21/2015 from their legal department that stated, .You forwarded to us a request seeking the release of the medical/billing records for the above-named individual (Resident #22) who is/was a resident at your facility. This authorization is compliant. You may release a copy of Resident #22's records to . (requesting agent) upon receipt of payment for copies per state statute . Please remember to send all future requests for residents' charts to the Legal Department within 24 hours of receipt of the request. Do not release the chart until you receive approval from the Legal Department. The bottom of the form included information to be faxed back to the Legal Department showing when payment was received from the requestor, the amount, and the date the medical/billing records were sent. Resident #22's information was not filled out on the form. Attached to the communication was a facsimile cover sheet dated (MONTH) 22, (YEAR) requesting Resident #22's medical record with the following comments: Please provide a complete certified copy of the records for . (Resident #22), DOB (date of birth): . I have transmitted the POA for the authorization of this request . The facsimile cover sheet indicated that 8 pages including the cover sheet were faxed. The (MONTH) 22, (YEAR) fax to the facility requesting the medical records and attached to the communication showed pages 001, 002, 006/ , 007/008, 008/008. In an interview with the surveyor on 07/14/2015 at 3:00 PM the Administrator stated that the first request dated (MONTH) 22, (YEAR) for Resident #22's records did not contain a complete POA (power of attorney) and that the legal department had to get back in touch with the legal representative to get a complete POA. S/he stated that this was completed on (MONTH) 21, (YEAR), the check was received from the legal representative on 06/12/2015 and the records were mailed on 06/24/2015. Review of the closed medical record for Resident #24 indicated s/he was admitted with [DIAGNOSES REDACTED]. Review of the facility records related to medical/billing records request revealed communication to the facility medical records department dated (MONTH) 27, (YEAR) from their legal department that stated, .You forwarded to us a request seeking the release of the medical/billing records for the above-named individual (Resident #24) who is/was a resident at your facility. This authorization is compliant. You may release a copy of Resident #24's records to . (requesting agent) upon receipt of payment for copies per state statute . Please remember to send all future requests for residents' charts to the Legal Department within 24 hours of receipt of the request. Do not release the chart until you receive approval from the Legal Department. The bottom of the form included information to be faxed back to the Legal Department showing when payment was received from the requestor, the amount, and the date the medical/billing records were sent. Resident #24's information was not filled out on the form. Attached to the communication was a facsimile cover sheet dated and faxed (MONTH) 24, (YEAR) requesting Resident #24's medical record. The facility provided a letter mailed on 06/04/2015 to Resident #24's legal representative regarding the cost of the medical records, a check was received on 06/11/2015 and the records were mailed to the legal representative on 07/01/2015. The medical records were mailed more than two months after there were requested. Review of Resident #23's closed medical record indicated s/he was admitted with [DIAGNOSES REDACTED]. Review of the facility records related to medical/billing records request revealed communication to the facility medical records department dated (MONTH) 27, (YEAR) from their legal department that stated, .You forwarded to us a request seeking the release of the medical/billing records for the above-named individual (Resident #23) who is/was a resident at your facility. This authorization is compliant. You may release a copy of Resident #23's records to . (requesting agent) . Please remember to send all future requests for residents' charts to the Legal Department within 24 hours of receipt of the request. Do not release the chart until you receive approval from the Legal Department. The bottom of the form included information to be faxed back to the Legal Department showing when payment was received from the requester, the amount, and the date the medical/billing records were sent. Resident #23's information was not filled out on the form. Attached to the communication was a facsimile cover sheet dated and faxed (MONTH) 14, (YEAR) requesting Resident #23's medical record. In an interview with the surveyor on 07/14/2015 the Administrator stated s/he did not know when the medical records were picked up, but s/he was sure they had been picked up. Review of Resident #25's medical record indicated s/he was admitted with [DIAGNOSES REDACTED]. In an interview with the surveyor on 07/14/2015 the Administrator stated that a request form was filled out at the facility on 05/29/2015 and sent to the legal department by email. I think it was hand delivered to the family member who requested it, do not know when. The Administrator provided information from their legal department from Title 44 - Health, Section 44-7-325 highlighted in yellow, .(B) Except for those requests for medical records pursuant to Section 42-15-95: (1) A health care facility shall comply with a request for copies of a medical record; (a) no later than forty-five days after the patient has been discharged or forty-five days after the request is received, whichever is later . S/he stated that this was the information they were using regarding medical records. | 2019-07-01 |
| 6473 | LIFE CARE CENTER OF COLUMBIA | 425337 | 2514 FARAWAY DRIVE | COLUMBIA | SC | 29223 | 2015-02-10 | 153 | D | 1 | 0 | MY9R11 | Based on review of the facility files and interview, the facility failed to ensure each resident or his/her legal representative the right to purchase at a cost not to exceed the community standard photocopies of the records or any portions of them upon request. The photocopies of Resident #2 and #4 exceeded the cost noted in the facility's Health Information Management Policy and Procedure Manual. 2 of 2 residents reviewed for medical record requests. The findings included: Review of invoices for Resident #2 and Resident #4 revealed the facility charged $0.65 for the first 30 pages and $0.50 per page after for photocopies of their medical records. Resident #2 had 175 pages processed for a total cost of $92.00. Based on facility policy the cost should have been $62.25. Resident #4 had 310 pages processed for a total of $159.50. Based on facility policy the cost should have been $96.25. Review of the facility's Health Information Management Policy and Procedure Manual revised September 2013 revealed Life Care Centers of America's policy is for the facility to charge the rate of $1 per page for the first 25 pages and $0.25 per page thereafter for copying the medical record. The policy also indicated The facility is responsible for investigating any state regulations related to charges for photocopying and/or checking with local resources, such as copying services, to determine reasonable charges for the area and whether state law is more stringent in allowable charges. In an interview with the surveyor on 2/4/15 at approximately 4:05 PM, the Health Information Management staff stated s/he was trained to charge the price noted on the invoice. The person who trained him/her in 2007 gave him/her the breakdown of what to charge for copies of medical records. The Health Information Management staff stated that s/he receives the revisions to the Health Information Management Policy and Procedure Manual and places them in the manual. | 2018-02-01 |
| 6516 | MILLENNIUM POST ACUTE REHABILITATION | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2015-01-08 | 153 | D | 1 | 0 | LD4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility files and interview, the facility failed to ensure the resident or his/her legal representative had access to all records pertaining to him/herself including clinical records and to purchase photocopies of the records or any portions of them upon request and two working days advance notice to the facility. Resident #2's legal representative submitted multiple requests to the facility for a copy of the resident's medical record. The facility had no documentation of the request and had not released copies of the medical record. One of one resident's reviewed for medical record request. The findings included: Review of information provided to the State Agency revealed requests for Resident #2's medical record were sent to the facility on [DATE], 10/14/14 and 11/21/14. A copy of the Request and Authorization form signed by the resident was attached to each request. In an interview with the surveyor on 12/23/14 at approximately 2:50 PM, the medical records person stated that s/he had received only three requests for medical records since 7/1/14. The surveyor reviewed the three requests and noted the above requests were not included in the information provided. The medical records person stated that all record requests received by the facility should be forwarded to him/her. The medical records person keeps the request and what is copied together. At approximately 3:30 PM, the medical records person stated s/he does not keep a log of requests received or when the records are released. The medical records person also does not track if the records are mailed or picked up in person. In a telephone interview with the surveyor on 1/8/15 at approximately 1:35 PM, Resident #2 stated his/her legal representative requested a copy of his/her medical record from the facility but had not received it. | 2018-01-01 |
| 8349 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2013-05-01 | 153 | D | 1 | 0 | G3XH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on closed record review and interview, the facility failed to provide the legal representative for Resident #1 a copy of the resident's medical record. The facility failed to provide the copies of the medical record per the federal guidelines within 48 hours after a written request by the legal representative. The findings included: Review of the Agape Senior Authorization for Release of Protected Health Information revealed Resident #1's Power of Attorney completed the request on [DATE]. Review of the medical records request log revealed the request for Resident #1's medical record was received on [DATE]. Review of the Medical Record Copying Fee Sheet for Resident #1's medical record revealed it was completed [DATE]. Review of the Agape Nursing and Rehabilitation Center Contract signed by Resident #1's Power of Attorney on [DATE] revealed Section V (d) .Copies of medical records will be released to the Resident or Legal Representative within two (2) working days of the written request During interview on [DATE] the facility Administrator stated that Resident #1's Power of Attorney provided the written request for the medical record on [DATE] after Resident #1 expired. Review of Resident #'1's Daily Skilled Nurse's Note dated [DATE] revealed s/he expired at 6:55 PM. | 2016-05-01 |
| 8497 | MAGNOLIA MANOR - ROCK HILL | 425165 | 127 MURRAH DR | ROCK HILL | SC | 29732 | 2013-03-27 | 153 | D | 1 | 0 | X9KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on closed record review and interview, the facility failed to provide the legal representative for Resident #2 a copy of the residents's medical record on 2/8/13. The facility failed to provide the copies of the medical record per the federal guidelines within 48 hours after a written request by legal representative. The facility did not make the medical record available until 2/18/13. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the closed record on 3/27/13 revealed a form requesting a copy of the resident's medical records signed on 2/8/13 by the Legal Representative for the resident. During an interview with Medical Records Director, the Director confirmed that the records were requested on 2/8/13. The Director explained s/he then had to contact their home office to get clearance to copy. By the time the clearance came back and the records were copied it was 2/18/13. The Responsible Party was contacted on 2/18/13 and notified the records were ready. | 2016-03-01 |
| 9373 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2012-01-25 | 153 | G | 1 | 0 | YR0211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on medical record review, review of facility records, and interviews, the facility failed to ensure that a resident's legal representative was allowed to purchase copies of the resident's medical record with 2 working days advance notice for 2 of 2 requests made by family members (#1 and #2). The facility also failed to release copies of a medical record, requested by the resident, in a timely manner (#A). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was unable to communicate. His parents were deceased . For all his time at the facility, his sister was his responsible party and made all decisions for him. She signed authorization for Do Not Resuscitate (DNR)and for vaccinations. The facility staff notified the sister about any change in condition the resident experienced. The sister attended care plan meetings and actively participated in the ongoing plan of care for her brother. She was the one who signed discharge paperwork at the facility, and it was she who authorized release of information to the resident's new facility. Review of the available medical record revealed that on [DATE], two physicians signed a form titled Authorization of Do Not Resuscitate Incompetent Resident. The physicians certified that the resident did not have the capacity to make decisions and that DNR status was appropriate for him. Resident #1's sister signed consent for the DNR order. Review of the South Carolina Health Care Consent Act revealed that a residents inability to consent must be certified by two physicians. "... Persons who may make health care decisions for patient who is unable to consent; order of priority; exceptions. ...6 an adult sibling, grandparent, or adult grandchild of the patient ..." On [DATE], the resident's sister requested copies of his medical record for the period of [DATE] to [DATE]. On [DATE], the facility sent the requested copies of the medical record to their corporate legal office. On [DATE], the facility sent a letter to the resident's sister stating " ... (Resident) was deemed as 'Incompetent' as of his admission to our facility back in 2002 according to the documentation we have on file. ..." The facility continued to say: "Our legal team has indicated to me you will have to pursue legal 'Guardianship' through the Probate Courts in order to have any documentation related to (resident's) care at our facility released to you. ..." As of [DATE], the medical record copies still had not been released to Resident #1's sister. Resident #2 lived at the facility from [DATE] to [DATE]. Her [DIAGNOSES REDACTED]. Throughout most of her stay at the facility, the resident made her own decisions. She displayed impaired cognitive status in early 2011 (,[DATE] on the Brief Interview for Mental Status, assessment date of [DATE]) and had a decline in condition which became more pronounced in mid-[DATE]. At that time, the resident was included in the facility's Butterflies Are Free program for end of life comfort care. All diagnostics were discontinued. A physician's orders [REDACTED]. On [DATE], the resident vomited a large amount of brown emesis. Facility staff contacted the physician who instructed them to call the daughter and follow her wishes. The resident expired at the facility on [DATE]. On [DATE], the resident's daughter requested copies of the medical record. The facility sent copies of the record to their corporate legal department on [DATE]. As of [DATE], the copies had not been released to the resident's daughter. Resident #A requested copies of his medical record on [DATE]. The facility sent the copies to their corporate legal department on [DATE]. The copies were released to the resident on [DATE]. During an interview with the Administrator and the Health Care Information Management Director on [DATE] at 1:25 PM, they confirmed the information concerning the three medical records noted above. | 2015-05-01 |
| 9659 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2011-10-13 | 153 | D | 1 | 0 | BFJD11 | **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 provide requested medical records within 24 hours for 1 of 1 residents who requested their medical record. Resident #1 did not receive requested medical records in a timely manner. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. During record review on 10/11/2011, the resident was noted to have a BIMS (Brief Interview for Mental Status), score of 11 on her quarterly MDS (Minimum Data Set) of 9/24/2011. Her initial MDS of 7/13/201 coded her as 13. Review of her Social Service notes of 9/6/2011 revealed a note, "Family request pt (patient) info from chart. MSW (masters prepared social worker) fax request to Legal Services...." In an interview on 10/12/2011 at 12:45 PM, the resident's family member stated she received the requested information until, "last week". On 10/12/2011 the person responsible for medical records gave a statement regarding the requested medical records of resident #1. The resident's family requested the information on September 6, 2011. The resident signed to allow the release of the medical record on September 9, 2011. There was a meeting with the family member and the therapist. The facility thought the family had their questions answered and no longer needed the records. On September 29, 2011 the family member called and asked for the records. The facility had the records available on September 29, 2011. The family member picked up the records on October 3, 2011. The medical records should have been available with in 24 hours after the resident signed for the release of information. | 2015-02-01 |
| 10164 | UNIHEALTH POST-ACUTE CARE - NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2010-12-15 | 153 | G | Inf | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification, Complaint survey,and Extended Survey, based on record reviews, review of facility documents, and interviews, the facility failed to ensure that the resident's legal representative was provided with the opportunity to purchase copies of the medical record for 2 of 7 resident representative requests reviewed (Residents #23 and #39) and failed to provide copies of requested records in two working days for 3 of 7 resident representative requests approved to received them (Residents C, D, E). The findings included: During the Entrance Conference, the facility was asked to provide a list of requests made since [DATE] for copies of resident medical records. A list of nineteen names was provided. The facility was then asked to provide dated request forms and evidence the copies were provided as requested. Documents for eighteen residents were provided which included Authorization For Use & Disclosure Of Information, PHI (protected health information) Request Cover Sheet, written requests, Power of Attorney documentation, Certificates of Appointment, Fiduciary Letters, letters of denial, e-mail correspondence with the facility medical records person, "Goin Postal" receipts for certified letters, Medical Record Billing Invoices, and Certified Mail receipts. None of the resident information packets contained copies of all the above listed forms, usually two or three forms were provided for each resident. All of the resident representatives who requested copies of the medical record were identified by the facility as the resident's Responsible Party and were the individuals notified concerning changes in the resident's condition or treatment (protected health information). The denials all stated in part: "... As you may be aware, the Health Insurance Portability and accountability Act and the privacy regulations promulgated thereunder (collectively, "HIPAA") has imposed strict requirements on health care providers regarding the release of protected health information ("PHI") Under HIPAA, a provider may release PHI of an individual to a personal representative authorized under state law to act on behalf of the individual. See 45 CFR 164.502(g). Further, HIPAA requires that the provider verify the identity of the personal representative and that person's authority to access PHI as a personal representative. 164.514(h)(1)(i). Such a personal representative may be a durable power of attorney for health care or guardian of the person if the individual is living or the permanent administrator or executor of the estate if the individual is deceased . The center will not be able to release these records until it receives verification of the applicable representation. ..." Resident #23 arrived at the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the resident assessments of [DATE] and [DATE] showed no memory, decision making, or communication problems. On admission, the resident's brother was listed as the Responsible Party but this was changed to his son on an unknown date. The resident's son did start receiving the resident's Statement of Account by [DATE]. Resident #23's son began requesting copies of the medical record on [DATE]. The resident was transferred to the hospital on [DATE] and expired later that day. His son continued to make multiple requests for copies of the medical record and enlisted the aide of The Regional Ombudsman. His requests were repeatedly denied by the corporation legal staff. The Power of Attorney document provided by the son was deemed unacceptable. The probate court's certification of the son as the resident's personal representative was also deemed insufficient. Resident #23's son was directed to produce a fiduciary letter. During an interview with the Administrator on [DATE] at 8:35 AM, a representative from the corporate legal department was called and confirmed that copies of the resident's medical record had not been provided because the son failed to produce fiduciary letters. Resident #39 entered the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's daughter was listed as her Responsible Party. Review of the resident assessment of [DATE] revealed the facility was unable to assess the resident's memory and decision making ability due to her medical status. Communication was impaired. Resident #39 was found unresponsive on [DATE]. Cardiopulmonary resuscitation was initiated and the resident was sent to the hospital where she expired. The daughter was notified of all the events leading to discharge. On [DATE], the resident's daughter requested copies of her mother's medical record and was denied that same day. The corporate representative stated during the interview on [DATE] that it was because she did not have the resident's Healthcare Power of Attorney. Information provided by the facility revealed the following information concerning lack of timeliness in addressing requests for copies of the medical record made by resident representatives: The resident representative for Resident C requested copies of the medical record on [DATE] and was initially denied on [DATE] but documents provided by the facility showed this decision was reversed at a later date. The second request, made on [DATE], showed corporate approval on [DATE] and a posting bill dated [DATE]. Resident D's representative made a request for copies on [DATE] and did not receive approval for the copies until [DATE]. Resident E's representative requested copies of the record on [DATE] but did not receive approval for the copies until [DATE]. | 2014-04-01 | ||
| 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 requested copies of the medical record. Review of the current medical record indicated that on [DATE] the resident's wife signed a facility provided Authorization for Use & Disclosure of Information form requesting records for her husband (Resident #1) from "[DATE] - Present for personal purposes". On [DATE] Resident #1's wife received a letter from a representative of the facility, which stated, "...regarding your request for the above mentioned patients' medical records. As you are aware, the Health Insurance Portability and Accountability Act and the privacy regulations promulgated there under (collectively, "HIPPAA") has imposed strict requirements on health care providers regarding the release of protected health information ("PHI"). Under HIPPAA, a provider may disclose an individual's PHI to a personal representative who under state law has authority to act on behalf of the individual. See 45 CFR 164.502(g)(1), 164.514(h)(1)(i). Further, HIPPAA requires that the provider verify the identity of the personal representative and that person's authority to access PHI as a personal representative. See 45 CFR... Such a personal representative may be a durable power of attorney for health care or guardian of the person if the individual is living, or the permanent administrator or executor of the state if the individual is deceased . The Advance Directive provided to the facility does not provide the proper authority. The center will not be able to release these records until it receives verification of the applicable representation..." Information provided by the Ombudsman revealed a letter to Resident #1's wife dated [DATE] in which she was advised of her rights under the Health Care Consent Act (SC Code [DATE] et. esq.). A letter to the facility dated [DATE] from the Ombudsman was also provided, which included the following statement, "...I will meet with Resident #1's wife in the morning to visually inspect the medical record and from there will assist as needed in identifying the records she wants copied for her personal use." On [DATE] Resident #1's wife signed another Authorization for Use & Disclosure of Information form requesting records "from date of admission to present: nurses notes, skin asst. (assessments)/body audits, Soc (social) Services notes, all physical therapy, speech therapy, care plans" for personal use. Review of the Health Care Consent Act (SC Code [DATE] et. esq.) Section [DATE] states, "Persons who may make health care decisions for patient who is unable to consent; order of priority; exceptions. (A) Where a patient is unable to consent, decisions concerning his health care may be made by the following persons in the following order of priority: (1) a guardian appointed by the court pursuant to Article 5, Part 3 of the South Carolina Probate Code, it the decision is within the scope of the guardianship; (2) an attorney-in-fact appointed by the patient in a durable power of attorney executed pursuant to Section [DATE], if the decision is within the scope of his authority; (3) a person given priority to make health care decisions for the patient by another statutory provision; (4) a spouse of the patient..." Resident #1's spouse is his personal representative and per the Health Care Consent Act is the person who makes health care decisions for him. In a telephone interview with the facility on [DATE] the facility stated that this was a HIPPA concern and they would not release information to Resident #1's wife for "personal use" and that the wife would have to complete the request to list specific information and the purpose of the use of the information. In an interview with the surveyor on [DATE] the Ombudsman stated that she met with Resident #1's wife at the facility on [DATE] in order to review Resident #1's medical record during a care plan meeting. A verbal review was conducted of the medical record with the Administrator, Social Worker, Director of Health Services, Senior Care Partner and Speech Therapist present along with Resident #1's wife and the Ombudsman. Following the verbal review Resident #1's wife and the Ombudsman looked at the record page by page to determine what she wanted copied. When asked if the resident's wife filled out the authorization form, the Ombudsman stated that the facility staff completed the Authorization for Use & Disclosure of Information form and the resident's wife initialed and signed where needed. At no time did the facility staff give any instructions to the resident's wife regarding how to fill out the form. At the time of the survey Resident #1's wife had not received the requested copies of her husband's medical record. | 2014-03-01 | ||
| 2983 | ANCHOR REHAB AND HEALTHCARE CENTER OF AIKEN, LLC | 425311 | 550 EAST GATE DRIVE | AIKEN | SC | 29803 | 2017-01-25 | 154 | D | 0 | 1 | UJVQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide informed consent in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (#23) of 5 residents reviewed for unnecessary medications of 31 sample residents. The findings included: Specifically, the facility failed to provide consent for the use of an anti-psychotic medication for resident #23. Review of the medical record of Resident #23 on 01/24/17 at 3:41 PM revealed Resident #23 was admitted to facility on 07/20/16 after a hospitalization for [MEDICAL CONDITION] of the lower extremities. Review of the resident's hospital discharge summary dated 07/20/16 revealed Resident #23 had [DIAGNOSES REDACTED]. Further review of the medical record on 01/24/17 at 3:45 PM revealed Resident #23 was admitted to hospice services effective 09/30/16 for a [DIAGNOSES REDACTED]. Review of the medical record on 01/24/16 at 4:00 PM revealed the admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #23 had no behaviors, no mood issues, had [DIAGNOSES REDACTED]. The assessment further indicated the resident's medications during the assessment period included antianxiety(6), antidepressant(7), antibiotic (7) and diuretic (5) medications. A significant change MDS assessment dated [DATE] indicated Resident #23 was usually understood and usually was able to understand, had moderate cognitive impairment, [MEDICAL CONDITION], felt down, depressed or hopeless, tired and had little energy and had no behaviors. Review on 01/24/17 at 4:17 PM of the resident's current physician orders [REDACTED]. A physician's orders [REDACTED]. Review on 01/25/17 at 10:52 AM revealed the resident's (MONTH) (YEAR) monthly pharmacy review revealed the pharmacist identified agitation was not a qualifying [DIAGNOSES REDACTED]. The physician accepted the recommendation and added the [DIAGNOSES REDACTED]. Further review of the medical record revealed no documentation of consent from the resident and/or family for use of the [MEDICATION NAME]. Review on 01/25/17 at 8:37 AM revealed Hospice interdisciplinary (IDT) notes dated 10/24/16 at 10:15 (no AM or PM indicated) stated Resident #23 was seen for a routine visit and the resident was confused and oriented to self. The documentation stated the resident was having a lesser degree of paranoia. The Hospice certified nurse aide (CNA) notes dated 10/24/16 and untimed stated Resident #23 was very agitated and didn't want anything done. The CNA documented Delusions where very active today. Hospice notes dated 10/26/16 stated Resident #23 was resting very comfortably in bed and that the facility nurse requested [MEDICATION NAME] IM as the resident was refusing her medications. The notes stated the resident had no complaints of pain and was pleasant and cooperative. CNA hospice notes dated 10/26/16 stated the resident was very good that day. CNA hospice notes dated 10/28/16 stated Resident #23 was very agitated and CNA was told the resident was throwing stuff. Documented resident was afraid she would be murdered. Review of the resident's Medication Administration Record [REDACTED]. There was no documentation of any additional doses administered. Documentation in the nurse's notes at times of administration indicated the resident was having increased agitation and delusions and attempts at non-pharmacological interventions were ineffective. There was no documentation of the resident and/or family's consent for use of the [MEDICATION NAME]. Interview on 01/25/17 at 9:54 AM with the Director of Nursing (DON) verified there was no evidence of consent obtained from the resident and/or family for use of [MEDICATION NAME]. The DON further verified the resident last received a dose of the [MEDICATION NAME] on 11/27/16 and that it remained a current physician's orders [REDACTED].> | 2020-09-01 |
| 146 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2017-10-11 | 155 | D | 1 | 1 | SACF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and review of the facility policy, the facility failed to observe resident's Advanced Directive rights for 1 of 12 residents reviewed for Advanced Directives. The facility did not ensure the correct code status for Resident #67. The findings included: The facility admitted Resident #67 with a [DIAGNOSES REDACTED]. On [DATE] at 11:10 AM, during record review, a signed and notarized Advanced Directive dated (MONTH) 1, (YEAR), prior to the Resident's admission on [DATE], revealed the Resident requested DNR status. The Physician's admission documentation for Resident #67 stated the Resident did not want CPR and was discussed with the Resident's daughter who is also the Responsible Party. On [DATE] 1:36 PM an interview with the Social Services Director revealed s/he agrees with documentation in the chart stating Resident #67 should be a DNR. S/he also discovered a signed DNR order in the file cabinet in Social Services office for the Resident that was not in the chart. On [DATE] 1:48 PM The Social Services Director stated, I will be changing the code status to DNR immediately for this resident. S/he also stated, I should have caught it; I used to work for DHEC. This surveyor witnessed the Social Services Director remove the FULL CODE page and replace it with the DNR page in Resident #67's chart. On [DATE] 2:05 PM Review of Facility Policy, DO NOT RESUSCITATE- POLICY, Policy Interpretation and Implementation #5 states: If the decision has been made for a natural death, the physician shall be notified and a DNR (DO NOT RESUSCITATE) order will be obtained as well as documented in the clinical records. | 2020-09-01 |
| 246 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2016-09-22 | 155 | D | 0 | 1 | HKBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews Resident # 219 had a Do Not Resuscitate order written with only one physician's documentation of diminished capacity and unable to make advance directive decisions. ( 1 of 20 reviewed for Advance Directives.) The findings included: Chart review on 9/21/16 revealed a red DNR (No Not Resuscitate) sheet in the front of Resident # 219's chart. There was also copy of physician's orders [REDACTED]. Only one physician had signed and documented that the resident was not competent to make own decisions. Interview with Social Service Worker on 9/21/16 at 3:10 PM revealed that the facility only had declaration of incompetency from one physician, two Physician's documentation required. When asked where nurses would look first for resuscitation orders in case of an emergency, she/he stated They would go to the sheet in the front of the chart. Three nurses were interviewed on 9/21/16 at 3:23 PM related to where they would look first for code status in an emergency. Registered Nurse #4 and Licensed Practical Nurses #3 and # 4 each stated they would look in the front of the chart for the red sheet. The resident was admitted [DATE] and had been designated as a NO Code until 9/21/16. The resident's care plan also documented the resident as no code status. | 2020-09-01 |
| 289 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2017-05-11 | 155 | D | 1 | 1 | X7DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to allow resident #14 to formulate their own Advance Directive, 1 of 21 sampled residents reviewed for Advance Directives. Resident #14 was DNR (Do Not Resuscitate) on admission to the facility with no documentation to indicate that was his/her choice. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review of a telephone order, dated 4/18/2017, on 5/9/2017 at 2:01 PM, revealed an order that indicated Resident #14 is DNR status. Record review of a Advance Directive form, dated 4/18/2017, on 5/9/2017 at 2:01 PM, revealed that DNR status was chosen and signed for by the resident's family member. Record review of the Minimum Data Set 3.0 on 5/9/2017 at 3:03 PM, revealed that the resident had a BIMS (Brief Interview for Mental status) score of 14, indicating the resident was cognitively intact. Record review of a competency form on 5/9/2017 at 2:01 PM, revealed the physician documented that Resident #14 was unable to make health care decisions for himself/herself secondary to Dementia. This form was signed by the physician on 4/20/2017. There was no documentation from a second physician addressing the resident's ability to make his/her own healthcare decisions. Record review of the Social Worker notes on 5/9/2017 at 2:38 PM, revealed no documentation that Advance Directives or code status had been discussed with the resident. Record review of the Initial Social Service History, dated 4/18/2017, on 5/10/2017 at 3:45 PM, revealed that the resident had given family permission to sign all admission paper work for him/her. A section of the Initial Social Service History that addressed Advance Directives and code status was left blank. During an interview with the Admissions Coordinator and Director of Social Services on 5/10/2017 at 3:27 PM, the Director of Social Services confirmed that the facility did not have 2 physicians address the resident's decisional capacity. The Director of Social Services stated the facility had been waiting for the 2nd physician to evaluate the resident. The Director of Social Services confirmed that on 4/20/2017 one of the facility's physicians determined that the resident was unable to make his/her own health care decisions due to Dementia and the resident remained DNR status. The Admissions Coordinator stated that the resident had given family permission to sign all paperwork, including the Advance Directive. The Admissions Coordinator stated she was aware the resident had been evaluated by the physician on 4/20/2017 and that the physician determined that the resident was unable to make his/her own health care decisions. The Admissions Coordinator and Director of Social Services confirmed there was no documentation indicating a discussion had been had with the resident on 4/18/2017 regarding Advance Directives. | 2020-09-01 |
| 438 | PRUITTHEALTH-WALTERBORO | 425053 | 401 WITSELL STREET | WALTERBORO | SC | 29488 | 2016-10-13 | 155 | D | 0 | 1 | 6NBC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled Do Not Resuscitate Policy: South [NAME]ina, the facility failed to ensure that 2 of 17 residents reviewed for advance directives were afforded the opportunity to formulate their own advance directive.(Resident #97 & #116) The findings included: The facility admitted Resident #97 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed a facility form titled Authorization of Do Not Resuscitate Order Without Decision-Making Capacity. The form did not have any category marked, but was signed by two physicians and the Responsible Party. Further review of the record revealed there was no documentation two physician's signed a statement to indicate the resident lacked the capacity to sign his/her own advance directive. During the review of Resident #97''s medical record, a red DNR sticker was observed on the facesheet. Review of the physician's order dated [DATE] revealed the resident's code status was a DNR. Review of the 14-day Minimum Data Set, the Brief Interview for Mental Status was coded as an 11. The facility admitted Resident #116 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed a facility form titled Authorization of Do Not Resuscitate Order Without Decision-Making Capacity. The area marked stated The patient/resident is a person for whom Cardiopulmonary Resuscitation would be medically futile in that such resuscitation will likely be unsuccessful in restoring cardiac and respiratory function; or will only restore cardiac and respiratory function for a brief period of time so that the patient/resident will likely experience repeated need for (CPR) over a short period of time. The form was signed by two physicians and the Responsible Party. The form did not state why the resident was incapable of making healthcare decisions and no documentation was found that the resident had been deemed unable to make healthcare decisions by two physicians . A DNR order was implemented on [DATE]. Further review of Resident #116's medical record revealed a red DNR sticker on the face sheet. Review of the Quarterly Minimum (MDS) data set [DATE] revealed the Brief Interview for Mental Status score was scored as a 3. On [DATE] at 9:13 AM, during an interview with the Director of Nursing, he/she confirmed the forms did not reflect the resident was incapable of making healthcare decisions and did not list the [DIAGNOSES REDACTED]. Review of the facility policy titled Do Not Resuscitate Policy: South [NAME]ina under the Definitions Section #4 the following: Decision Making Capacity means the ability to understand and appreciate the nature and consequences of an order not to resuscitate, including the benefits and disadvantages of such an order, and to reach an informed decision regarding the order. Every adult is presumed to have Decision Making Capacity unless determined otherwise by a physician in writing in the patent/resident's medical record or pursuant to a court order. | 2020-09-01 |
| 618 | C M TUCKER JR NURSING CARE | 425074 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2017-06-01 | 155 | D | 0 | 1 | YBVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have 2 physicians evaluate the decisional capacity of Resident #99, 1 of 11 residents reviewed for Advance Directives. Resident #99 was made DNR (Do Not Resuscitate) Status after being evaluated by 1 physician who determined that the resident was not capable of making their own healthcare decisions. The findings included: The facility admitted Resident #99 with [DIAGNOSES REDACTED]. Record review of the Election of Code Status and Medical Intervention form on 5/31/2017 at 11:25 AM, revealed that DNR status was selected for the resident. The form was signed by a family member and Physician #1 on 5/17/2017. Review of a Certification Of Inability To Consent form on 5/31/2017 at 11:25 AM, revealed that Resident #99 was examined by Physician #1 on 5/18/2017. Physician #1 certified that resident #99 was unable to make healthcare decisions due to his/her cognitive status. There was an area on the form to be completed by a 2nd physician to indicate whether they concurred or did not concur with the previous physician's findings. This was not completed by a 2nd physician. During an interview with the Social Worker on 6/1/2017 at 10:22 AM, the Social Worker confirmed that Resident #99 had been made DNR status and was not evaluated by 2 physicians for decisional capacity. In addition, the Social Worker stated he/she was not aware that 2 physicians were required to determine decisional capacity for a resident when family members select Code status for a resident. | 2020-09-01 |
| 716 | RIVERSIDE HEALTH AND REHAB | 425082 | 2375 BAKER HOSP BLVD | CHARLESTON | SC | 29405 | 2017-09-22 | 155 | D | 1 | 0 | MJSH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the medical record, interview and review of the facility policy and procedure, the facility failed to ensure that Resident #217's family involvement related to Advance Directives was completed and available in the medical record upon admission for 1 of 21 residents reviewed for Advance Directives. The findings included: Resident #217 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 9/20/17 at approximately 9:30 AM reveals, a DNR (Do Not Resuscitate) sticker on the front sheet of the medical record. The sheet in the chart labeled, Progress Notes, with the Resident Name, Room # and Physician labeled on the bottom of the sheet, and there was no documentation/entries on the front or the back of the sheet. The page in the Medical Record titled Social Services Progress Notes has an entry which stated: LMSW (Licensed Medical Social Worker) introduced self to Resident #217. He was none responsive. LMSW and Unit Nurse (LPN #3) called RP (Responsible Party) to inquire about her wishes for Advanced Directives. RP stated that h/she wanted a DNR (when it's God's time let him go). LMSW and LPN #3 noted on the DNR form his/her wishes and both signed as witnesses The form titled, Emergency Medical Services Do Not Resuscitate Order, has the following information documented on the form.This 217 notice is to inform all emergency medical personnel who may be called to render assistance to Resident #217 that he/she has a terminal condition which has been diagnosed by me and has specifically requested that no resuscitative efforts including artificial stimulation of the cardiopulmonary system in the event of cardiopulmonary arrest. Date signed: 9/19/17 and written above the line labeled, Patient's signature (or prorogate or Agent), is written: RP (Responsible Party), Lillie Taste, wants a DNR. Two signatures: Medical social worker and LPN#3., dated 9/19/17. Two physician signatures on the form. The form titled: Physician Certification Regarding the Ability to Consent has the resident's name hand printed on the form, no other information is completed on the form and no signatures on the form for the Consulting Physician and the Consulting Physician. An interview with the Social Worker On 9/20/2017 at 11:26 PM, he/she stated: We are working on getting the physician signature. An interview with the Unit Manger, LPN #3 on 9/20/2017 at approximately 11:15 AM, he/she said she talked with the family so he/she would honor their wishes of DNR. LPN #3 verified that there was no RP signature in the medical record. An interview on 09/20/2017 at 11:26 AM, with the DON( Director of Nursing), he/she said to verify a DNR status that he/she would verify in the medical record for the DNR sticker and the second check would be to verify for the Physician order for [REDACTED]. The DON was able to locate an electronic note from the initial visit from the Nurse Practitioner dated 9/19/2017, electronically signed on 9/1917 at 9:51 PM. The DON said that electronic notes completed by the providers are placed in the medical record when the notes are received. Review of the electronic progress note titled, Progress Note, Sep 19.2017, Elite Patient Care (EPC) states, .Admit/discharge date : 9/18/2017, Supervising Provider: Medical Director #1, .Chief Complaint Reason for this Visit, New Admission to EPC services, HPI (History Physical Information) relating to this Visit, .He/She (Resident #217), does not follow commands today. He/She did not speak to me. He/She does have spastic movements with his R (Right) hand. Information was obtained by EMR (electronic medical record) notes from Vibra. He is DNR Assessment and Plan .Additional text,Mother (Resident#17 mother is named and phone number listed). Patient is DNR. The Progress note was Electronically signed by: ( Physician Assistant #1) on Sep 19, 2017 at 9:51 PM, CDT. A review of the facility policy and procedure titled, Social Services Policies and Procedures, Subject: Advance Directives, states the following: .2. Upon admission to the facility, the Admissions Coordinator will: A. Provide each patient/resident AND/OR their legal representative with a copy of the facility's policy and stare requirements for advanced directives AND each patient/representative AND/OR their legal representative will then sign an acknowledgement confirming receipt of this information . .3 1)Ensure the legal representative has the authority to make decisions regarding life sustaining treatments. 2) Notify the legal representative of their rights and responsibilities. 3) If the legal representative requests or consents to the withholding/withdrawal of life-sustaining treatments, steeps outlined in 3(A) 1-4 are followed AND written consent must be obtained from the legal representative. .4. B. 3) The attending physician must talk with the patient/resident regarding consequences and implications of their decision and the discussion must be documented in the progress note. | 2020-09-01 |
| 801 | MAGNOLIA MANOR - GREENVILLE | 425090 | 411 ANSEL ST | GREENVILLE | SC | 29601 | 2016-12-14 | 155 | D | 0 | 1 | 1MGH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents who were deemed unable to make health care decisions had two physician signatures to determine the resident's inability to make health care decisions. Resident #101 was coded for Do Not Resuscitate (DNR) with only one physician's signature for mental incapacity. (1 of 16 sampled residents reviewed for Advance Directives). The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. A review of the medical record on 12/13/16 at approximately 11:17 AM revealed Resident #101 was coded as a Do Not Resuscitate (DNR) on a tabbed sheet in medical record, a written physician's orders [REDACTED]. There was only one physician's statement in the medical record to indicate the resident did not have the mental capacity to make health care decisions. An interview on 12/13/16 at approximately 11:20 AM with Licensed Practical Nurse (LPN) #1 who reviewed the medical record and confirmed the resident was coded for DNR with only one physician's signature to indicate the resident did not have mental capacity to make health care decisions. An interview on 12/13/16 at approximately 1:39 PM with the Social Services Director (SSD) who reviewed the medical record and stated Resident #101 was coded for DNR. The SSD further confirmed there was no second physician statement to indicate the resident had no decisional capacity to make health care decisions. | 2020-09-01 |
| 1037 | HEARTLAND HEALTH CARE CENTER - GREENVILLE EAST | 425106 | 601 SULPHUR SPRINGS ROAD | GREENVILLE | SC | 29611 | 2017-06-14 | 155 | D | 0 | 1 | HYX211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that Resident #137 developed his/her own advance directive for Do Not Resuscitate (DNR) for 1 of 12 sampled residents reviewed. Resident #137's family member signed the facility's advance directive for DNR without two (2) physician's signatures of decisional capacity. The findings included: The facility admitted Resident #137 with [DIAGNOSES REDACTED]. A review of the medical record on 613/17 at approximately 2:05 PM revealed a physician's orders [REDACTED]. Review of the facility's Do Not Resuscitate form revealed a family member signed the DNR documentation for the resident. There was no documentation with two physician's signatures in the medical record to determine Resident #137 could not make health care decisions. Further record review revealed a social services note dated 4/20/17 that indicated Resident #137 was DNR with physician's orders [REDACTED]. An interview on 6/13/17 at approximately 2:11 PM with Registered Nurse (RN) #1 confirmed he/she could not locate the second physician's signature of decisional capacity. RN #1 stated he/she would take the medical record to the social services department for assistance. An interview on 6/13/17 at approximately 3:18 PM with RN #1 confirmed the facility's DNR was not signed by the resident and the second physician's signature related to decisional capacity was obtained 6/13/17. | 2020-09-01 |
| 1110 | MOUNT PLEASANT MANOR | 425110 | 921 BOWMAN ROAD | MT PLEASANT | SC | 29464 | 2016-11-03 | 155 | D | 0 | 1 | U4CH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the Adult Care Consent Act, Section 44-60-20 of the South [NAME]ina Code of Laws, the facility failed to afford 1 of 15 residents the opportunity to formulate his/her own Advance Directives. (Resident #110.) The findings included: The facility admitted Resident #110 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Do Not Resuscitate Request/Order form signed by the resident's family member indicating the resident's code status was Do Not Resuscitate. Review of the physician's orders [REDACTED]. Further review of the medical record indicated no documentation related to the resident's capacity to make his/her own healthcare decisions. The surveyor requested this information. During an interview on 11/03/16, the Director of Nursing (DON) reviewed the medical record and confirmed that there was no form attesting to the resident's capacity to make his/her own healthcare decisions. The DON stated that the DNR advance directive was done after admission, and the form with two physician's signatures was missing from the record. The DON stated that the Social Service department was responsible for getting the paperwork completed, and the form was overlooked. Review of the Adult Health Care Consent Act, Section 44-66-20 of the South [NAME]ina Code of Laws, indicates: (8) 'Unable to consent' means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner .A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient . | 2020-09-01 |
| 1384 | CONWAY MANOR | 425121 | 3300 4TH AVENUE | CONWAY | SC | 29527 | 2017-10-06 | 155 | D | 0 | 1 | BSC711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to maintain complete and accurate records as related to Code Status. The Advance Directive for Resident #244 included conflicting information as to what and when Resident #244 formulated an Advance Directive. Resident #244 was 1 of 1 resident sampled with concerns about code status. The findings included: Resident #244 was admitted with [DIAGNOSES REDACTED]. A record review on [DATE] at appproximately 10:30 AM revealed a red sticker on the interior cover of the medical record states, DNR (Do not resuscitate), The Face Sheet with the date and time listed states [DATE] 5:59 PM, admitted : [DATE] and under the section titled Additional Information, Code Status DNR. The form titled,[NAME]Manor .Medical Intervention Guideline states that .I. In the event of [MEDICAL CONDITION], I wish the following measures to be taken: The form has a box and a check is placed in the box beside the statement which reads: No, I do not desire Cardiopulmonary Resuscitation (CPR) to be initiated in the event of a witnessed [MEDICAL CONDITION]. The form has the following information: Responsible Party: Name listed[NAME][NAME] [NAME]-[NAME] Date: [DATE], Witness: Name listed, Date: [DATE], and, a states, I am the attending Physician and I have reviewed the Resident's desires Physician : Name, Date: [DATE]. The form titled: Physician's Telephone Order, states: Date ordered: [DATE], Time Ordered: 6:30 and Orders: DNR. The form titled: Physician Orders, for the Month of (MONTH) (YEAR),[NAME]Manor LLC, states on page 3 of 3, Order date: [DATE], Start Date: [DATE], .Orders: Full Code. Review of the Care Plan for Resident #244 states: Problem Onset [DATE]: Resident #244 poses at risk for irregular heart beat d/T history of CAD ([MEDICAL CONDITION]),[MEDICAL CONDITION](Hypertension), A Fib ([MEDICAL CONDITION] Fibrillation) with pacemaker in use, Approach: DNR status per family and resident request. During an interview on [DATE] at 11:20:07 AM with the Assistant Administrator verified that the Electronic Medical Record has a physician order for [REDACTED]. H/She said, if the resident goes to the hospital we would print off the Face Sheet that would go to the hospital with the resident. A review of the Departmental Notes, for Social Services entries in the electronic medical record was verified by the Assistant Administrator reveals the following entries: [DATE] at 11:08 AM: . HE IS FULL CODE. , [DATE] at 3 :02 PM: This SW spoke with resident RP (niece). Wants a full code to continue. Does not want DNR .,[DATE] at 4:28 PM, HE IS FULL CODE. AND ON [DATE] AT 8:49 PM .niece made him a DNR A review of the facility Policy Statement titled: Resident Right-Advance Directives, states, .Policy Interpretation and Implementation .4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. On [DATE] the Assistant Administrator said that on [DATE] all the resident's electronic and paper medical records were reviewed to verify that both the Electronic Medical Record and paper medical records for each resident had accurate and matching documentation regarding the Advance Directives. H/She provided an updated copy of Resident #244's Physician Orders For the month of (MONTH) (YEAR) on page 3 of 3, now shows the following entries: Order Date [DATE], Start Date: [DATE]: Orders: FULL CODE, Discontinue Date: [DATE], and Order Date: [DATE], Start Date: [DATE], Orders: DNR. | 2020-09-01 |
| 1415 | INMAN HEALTHCARE | 425122 | 51 N MAIN ST | INMAN | SC | 29349 | 2017-02-09 | 155 | D | 0 | 1 | 6GNK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's Advance directives policy, the facility failed to obtain 2 physicians to address the decisional capacity of Resident # 36, 1 of 18 sampled residents reviewed for Advance Directives. Resident #36 was coded as Do Not Resuscitate (DNR) per the family's request and was not deemed to be non-decisional by 2 physicians. The findings included: The facility admitted Resident #36 with [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED].#36 was DNR status. Record review of a physician's Progress Note on 2/9/2017 at 11:06 AM, revealed that the resident was Without capacity and DNR per family. Record review of the Minimum Data Set 3.0 (MDS) on 2/9/2017 at 11:34 AM, revealed the resident had a Brief Interview of Mental Status (BIMS) score of 00, indicating severe cognitive impairment. There were no other physician's notes or orders addressing decisional capacity for Advance Directives. Review of the facility's Advance Directives policy on 2/9/2017 at 2:02 PM, revealed that if a resident does not have capacity to execute an Advance Directive, then the facility must follow state law to determine who has authority to make health care decisions on behalf of the resident. During an interview with the Social Services Manager (SSM) on 2/9/2017 at 2:09 PM, the SSM stated that DNR status was chosen for Resident #36 by the family. The SSM also stated that state law requires 2 physicians determine the resident's decisional capacity if the resident is unable to create their own Advance Directive. The SSM confirmed that the facility did not have 2 physicians determine the decisional capacity of Resident #36. | 2020-09-01 |
| 1533 | BRIAN CENTER NURSING CARE - ST ANDREWS | 425129 | 3514 SIDNEY ROAD | COLUMBIA | SC | 29210 | 2017-07-13 | 155 | D | 1 | 1 | ZIE111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that resident records were updated to include current information on residents' advance directives for 1 of 17 sampled residents reviewed for code status. Resident #48 did not have current information available on the Medication Administration Record (MAR), thus jeopardizing the staff's ability to follow the resident's/family's choices regarding advance directives. The findings included: The facility admitted Resident #48 with [DIAGNOSES REDACTED]. Record review on 07/11/2017 at 2:05 PM revealed a DNR (Do Not Resuscitate) sticker in the front of the medical record (paper chart). A No Code Agreement was signed by the family and two physicians. Further review on 7-12-17 at 10 AM revealed that the 6-17 and 7-17 Medication Administration Records (MARs) noted CODE STATUS: FULL CODE. During an interview on 7/13/17 at 9:50 AM, when asked what s/he would do if a resident coded while s/he was passing medication, Licensed Practical Nurse (LPN) #11 stated s/he would check the MAR for code status and follow that guidance. LPN #11 verified the code status as documented on the MAR. When the discrepancy in the medical record was brought to her/his attention, s/he then stated s/he would check the chart at the nursing station. | 2020-09-01 |
| 2080 | OAKBROOK HEALTH AND REHABILITATION CENTER | 425156 | 920 TRAVELERS BOULEVARD | SUMMERVILLE | SC | 29485 | 2017-06-29 | 155 | D | 0 | 1 | 4QY511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure accuracy of medical records for Code Status and the Advance Directives Notification Worksheet in the medical record for 1 of 21 residents reviewed. Resident #141's Advance Directive was not complete in the clinical record and was in conflict with the record maintained by Social Services. The findings included: Resident #141 was admitted on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 9:09 AM a review of the Advance Directives Section of the Medical Record kept on the nursing unit revealed that the form titled; Advance Directives Notification and Work Sheet was signed by Resident #141 and no date completed. On the same form, the section that states: Please Choose One: ___I do want CPR: Attempt Cardio [MEDICAL CONDITION] Resuscitation (CPR) Choosing CPR means that all medical treatments will be done to prolong life when the heart stops or breathing stops. ___I do not want CPR: Do not Attempt Resuscitation (Allow Natural Death) This means no attempts will be made to restart the heart or breathing if either stops allowing for a natural death. No election was made for CPR as there was no election checked by the resident. The form shows a signature on the Social Service line and dated [DATE]. [DATE] at 2:43 PM, LPN#1 verified that no selection was checked on the Advance Directives Notification Worksheet located in the medical record kept on the nursing unit. On [DATE] at 2:53 PM, Social Worker #2 verified that the date should have been included beside the Resident #141's signature and form should have had an election made for CPR. On [DATE] at 3:30PM Social Worker #2 presented a copy of the Advance Directives Notification Worksheet that h/she keeps in a file in his/her office that has checkmark by I do not want CPR and stated: I keep the original copy in a file in my office. On [DATE] 9:44AM the Administrator verified that the copy of Advance Directives Notification Worksheet in Resident #141's medical record does not match the copy that Social Worker #2 keeps in her office. The Policy and Procedure titled: Social Services Policies and Procedures, Subject: Advance Directives states, Procedures: 4. B. Once it has been determined that the patient/resident wishes to be a DNR patient/resident, the following procedures must be followed IN ADDITION to those outlined in the Policies of Practice for Advance Directives 1) The patient/resident's decision must be CLEARLY AND CONCISELY documented in their chart AND on the patient's/resident's care plan .2) The properly executed Do Not Resuscitate consent from must be provided to the attending physician AND a Do Not Resuscitate order must be provided in the current orders the patient's/resident's medical record. | 2020-09-01 |
| 2601 | WESTMINSTER HEALTH & REHAB CENTER | 425291 | 831 MCDOW DRIVE | ROCK HILL | SC | 29732 | 2017-11-15 | 155 | D | 0 | 1 | G4YM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were afforded the opportunity to formulate their own Advance Directives for 1 of 11 residents reviewed for Advance Directives. (Resident #79) In addition, the facility failed to have a signed physician's orders [REDACTED].#41) The findings included: The facility admitted Resident #79 with [DIAGNOSES REDACTED]. On 11/14/17 at 11:00 AM, a review of Resident #79's medical record revealed that on Resident #79's Resuscitation Status Consent Form there was a check on the line that stated, DO NOT Resuscitate Status, and the form was not signed by Resident #79. Review of Resident #79's Minimum Data Set ((MDS) dated [DATE] revealed under section AC-500 a score of 13 indicating Resident #79 was independently able to make decisions. On 11/14/17 at 3:00 PM during an interview with the Director of Social Services, s/he verified Resident #79s Resuscitation Status Consent Form was not signed by the resident, and s/he indicated that Resident #79 was able to make decisions independently. The facility admitted Resident #41 with [DIAGNOSES REDACTED]. Review of the medical record on 11/14/17 revealed a Resuscitation Status Consent Form dated 7/27/17 which indicated Resident #41 wanted to be a DNR. Further review of the medical record revealed there was no valid physician's orders [REDACTED]. During an interview on 11/14/17 at approximately 2:45 PM, the surveyor requested documentation from the Social Services department related to the resident's code status. On 11/14/17 at approximately 3:30 PM, the Social Services Director informed the surveyor that nursing staff reviewed the medical record and determined that there was no order for DNR status. The Social Services Director stated that staff would obtain a clarification order 11/14/17. On 11/14/17 at approximately 4:00 PM, the Director of Nursing (DON) reviewed the Advance Directive paperwork and stated the he/she would obtain the physician's orders [REDACTED].>On 11/15/17 at approximately 10:00 AM, the Social Services Director stated that the facility had recently begun using a Do Not Resuscitate Order form as part of the Advance Directive paperwork. The Social Services Director had no explanation for why Resident #41's record did not have a valid MD order upon review on 11/14/17. | 2020-09-01 |
| 2786 | CHESTERFIELD CONVALESCENT CENTER | 425302 | 1150 STATE ROAD | CHERAW | SC | 29520 | 2017-06-16 | 155 | D | 0 | 1 | BF3E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility policy titled, Advanced Directives, the facility failed to ensure Resident #165 and #9 were afforded the right to formulate an advance directive for 2 of 4 residents reviewed. The findings included: The facility admitted Resident #165 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 10:40 AM of the medical record for Resident #165 revealed a form titled, No Code Request, signed by the family of Resident #165 deeming the resident a DNR (Do Not Resuscitate) status. Further review on [DATE] at approximately 10:45 AM of the medical record for Resident #165 indicated that Resident #165 has not been deemed unable to make his/her own health care decisions by 2 physicians. Review on [DATE] at approximately 10:50 AM of the monthly physician's orders for the month of (MONTH) (YEAR) revealed an order for [REDACTED]. An interview on [DATE] at approximately 12:00 Noon with the Director of Nurses (DON) confirmed the physician's order was not signed, and stated, this resident should be a full code until the resident makes the decision for a DNR or 2 physicians deem him/her unable to make own health care decisions and a responsible party makes the decision for him/her. Review on [DATE] at approximately 12:15 PM of the facility policy titled, Advance Directives, under Policy: states, The facility AND company will recognize each patient's/resident's right to self-determination AND their right to accept or refuse medical or surgical treatment, the right to choose to receive cardiopulmonary resuscitation (CPR), and the right to execute (or not execute) advanced medical directives such as Living Wills, agent designations, do-not-resuscitate directives, etc. The purpose of this Policy of Practice is to provide instruction to the facility for obtaining, honoring and implementing advance directives to the fullest extent of the law. The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed an Admission Minimum Data Set which listed the resident's Brief Interview for Mental Status as 14. Further record review on [DATE] revealed a document on Resident #9's chart titled Resuscitative Directive For Resident Who Is Unable To Give Consent To And Cannot Make Or Communicate A Reasoned Decision Concerning His/Her Healthcare. Per the physician documentation on the form-Able to consent. A(Alert) +O(Oriented) x(times) 3. Further review of the form revealed Resident #9's daughter signed the resident's name and placed her initials behind the resident's name for a No Code Request dated [DATE]. During an interview with the Admissions Coordinator on [DATE] at 3:24 PM, he/she stated the daughter had informed him/her that Resident #9 liked her to sign paperwork for him/her. There was no documentation in the medical record of Resident #9's permission for the daughter to sign nor was there any documentation that a Do Not Resuscitate was Resident #9's wish. Upon further interview, the Admissions Coordinator stated he/she did not confirm with Resident #9 that this was his/her wishes. He/she stated he/she was trusting what the daughter stated. During an interview with the Assistant Director of Nursing, he/she stated the facility did not know there was a problem with Advance Directives until the surveyor had brought it to the facility's attention. Review of the facility policy titled Social Services Policies and Procedures-Advance Directives revealed the following: E. If a patient/resident has NOT executed an advance directive AND would like to do so(and he or she has the ability to do so), the Social Service Director shall obtain the necessary forms and assist the patient/resident with completing the forms . F. The facility will review the residents existing choices with resident or responsible party periodically and with significant decline or improvement. | 2020-09-01 |
| 3840 | COMPASS POST ACUTE REHABILITATION | 425391 | 2320 HIGHWAY 378 | CONWAY | SC | 29527 | 2017-02-17 | 155 | D | 0 | 1 | FLED11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, review of facility policies, and review of the South [NAME]ina Adult Health Care Consent Act, the facility failed to ensure residents were afforded the opportunity to exercise choices for 2 of 22 residents reviewed for advance directives. Resident #101 and Resident #86 were not afforded the opportunity to formulate their own advance directives. The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Emergency Medical Services Do Not Resuscitate Order form dated 10/27/16 signed by the physician and Resident #101's representative. The medical record did not contain documentation signed by 2 physician's indicating that Resident #101 lacked the capacity to make his/her own healthcare decisions. The medical record contained no further documentation related to the resident's advance directives except for an order dated 10/27/16 which indicated the resident was a Full Code. During an interview on 2/15/17, the surveyor asked the Assistant Director of Nursing (ADON) for more documentation related to Resident #101's advance directives, information related to the resident's healthcare decision-making capacity, and informed the ADON the surveyor was unable to locate any physician's orders [REDACTED]. The ADON provided a copy of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an interview on 2/16/17 at approximately 9:15 AM, the ADON informed the surveyor that 1 physician had signed the paperwork related to Resident #101's decision-making capacity, and the second physician would sign the paperwork today. On 2/16/17 at approximately 4:00 PM, the ADON provided the surveyor with a copy of a Do Not Resuscitate order signed by the resident's physician dated 2/16/17. The ADON also provided a copy of a form entitled Authorization for Allow Natural Death Patient WITHOUT Ability to Consent signed by Resident #101's representative and 2 physicians related to the resident being incapable to making his/her own medical decisions. Review of the South [NAME]ina Adult Health Care Consent Act, Section 44-66-20 indicates in section (8), .A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient .If a patient unable to consent is being admitted to hospice care pursuant to a physician certification of a terminal illness required by Medicare, that certification meets the certification requirements of this item. The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Review on 2/17/2017 at approximately 8:03 AM of the medical record for Resident #101 revealed a physician's orders [REDACTED]. No documentation could be found in the medical record to ensure the code status had been discussed with the resident nor his/her responsible party of a possible DNR status. During further review of the medical record on 2/17/2017 at approximately 8:03 AM revealed no 2 physician signatures to determine that Resident #101 was unable to make his/her own health care decisions. Review on 2/17/2017 at approximately 9:20 AM of the facility policy titled, Code Status Listing, under Resident Rights states, It is the policy of this facility to assure that advanced directives are honored as written. Number one under procedures states, All residents will be informed of their opportunity to file advanced directives upon admission and at least annually. | 2020-09-01 |
| 4019 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 155 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews, review of the facility policy titled Do Not Resuscitate Policy: [STATE], and review of the [STATE] Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act, the facility failed to initiate cardiopulmonary resuscitation (CPR) as required for 2 of 3 sampled residents reviewed for death in the facility. Residents #205 and #210 had advance directives signed by family/responsible party without two physicians' determinations of inability to make health care decisions completed. The facility failed to establish and implement policies and procedures consistent with State law regarding health care decisions/formulation of advance directives. The facility transferred decision-making responsibility to the legal representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. It was determined on [DATE] at 11:45 AM that Immediate Jeopardy existed as of [DATE] for Resident #205 and on [DATE] for Resident #210 for F-155 which was identified at a scope and severity level of (J). The findings included: Cross Refer to CFR 4[AGE].25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). Cross Refer CFR 4[AGE].[AGE] F-490 Administration was identified at a scope and severity level of (J). The facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation. The failure of the facility to ensure policies and procedures were established and implemented according to State law regarding Advanced Directives placed all residents at risk for serious harm/death. Cross Refer CFR 4[AGE].[AGE](o)(1) F-520 Quality Assurance was identified at a scope and severity level of (J). The facility failed to ensure the Quality Assurance process was utilized to identify, and implement a plan of action regarding adherence to legally executed Advanced Directives. The facility admitted Resident #205 with past medical history of [REDACTED]. S/he was treated at the hospital for a Subcapital Right Femoral Neck Fracture resulting from a fall at the Assisted Living Facility (ALF) where s/he resided. According to Social Services Progress Notes, the discharge plan was to return to the ALF. Review of the [DATE] Admission and [DATE] 14 Day Minimum Data Set assessments revealed that the resident scored a 0 on the Brief Interview for Mental Status (BI[CONDITION]), indicating severe cognitive impairment. Review of Nurse's Notes at 10:07 AM on [DATE] revealed that Resident #205 was participating in therapy daily. On [DATE] at 8:20 AM, a staff member called the nurse to the resident's room. S/he stated when s/he assisted the patient out of bed to the chair, s/he did not respond to his/her name. At this time, the resident had no blood pressure (BP) and oxygen (O2)saturation (sat) was 82%. Oxygen was administered at 2 liters/minute. The physician was notified and gave orders to hold medication and notify the family. When notified of the resident's decline in condition, the daughter-in-law stated they did not want the resident hospitalized and to just keep him/her comfortable. According to the notes, the family arrived at 9:45 AM and left at 10:00 AM. At 10 AM, O2 sat 87(%). Pulse 37 (beats per minute). Extremities cool to touch. Patient with some upper extremity movement. At 10:50 AM, the Registered Nurse (RN) Weekend Supervisor noted, Called to room by (Licensed Practical Nurse (LPN) #8) stating resident not breathing. Resident found unresponsive, in bed, no respirations, no pulse, no heart or breath sounds auscultated. No code called per advance directives and signed DNR order in chart. Record review at 8:31 AM on [DATE] revealed a red DNR (Do Not Resuscitate) sticker on the face sheet in the front of the medical record. There was also a [DATE] Physician's Interim Order for DNR. Review of the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity revealed it was signed, but not dated, by the physician. There was no second physician signature to indicate that the resident had been assessed for ability to make health care decisions. The form was signed by a family member to indicate consent to the order and witnessed by Social Services. In addition, there was a DNR order on a Florida Department of Health form indicating that Resident #205 had a durable power of attorney. Multiple requests (on [DATE] at 9 AM, 12:45 PM, and 2 PM) were made to the Administrator to review the power of attorney and on [DATE] at 5:30 PM, s/he stated they were unable to locate the document. During an interview at 9:20 AM on [DATE],Social Services #2 stated that advance directives were discussed on admission. If the resident had an advance directive or durable power of attorney for health care, a copy was requested at that time and placed in the medical record. When asked to describe the process for obtaining an advance directive such as a DNR, s/he stated that Social Work would discuss it with the resident and responsible party, get the forms signed and put them in the doctor's box for his/her signature upon next visit. If the resident was able to make his/her own decisions, the resident would sign the Authorization of Do Not Resuscitate Order With Decision Making Capacity form. If the resident was unable to make health care decisions, the family/responsible party would sign the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity form. The forms were then put into the doctor's box. Social Services #2 reviewed Resident #205's Authorization of Do Not Resuscitate Order Without Decision-Making Capacity form and verified that there was only 1 physician's signature determining the resident's inability to make health care decisions. The surveyor asked, In this case, if the resident had been found without vital signs, should s/he have been resuscitated? Social Services #2 stated,Yes. During an interview at 9:45 AM on [DATE], the attending physician/Medical Director confirmed that a second physician needed to assess a cognitively impaired resident and sign that s/he was unable to make health care decisions before the resident could be considered a DNR and the next of kin could make the advance directive decision for him/her. The physician verified his/her signature on the form and confirmed there was no second physician's signature. S/he stated,They (the facility) used to fax or take the form to (physician) to review and sign as the second physician. I don't know what has happened to that. During an interview on [DATE] at 11:08 AM, the Director of Nurses (DON) reviewed the medical record. When asked how the nurse knew what to do in the event the resident was found without vital signs, the DON stated,They have the DNR sticker. Nurses don't go by the sticker. They go by the doctor's order. After reviewing the record, s/he further stated, They needed the second doctor's signature before the order was written and put on the chart. S/he confirmed that, in these circumstances, CPR should have been initiated. During an interview at 11:38 AM on [DATE], LPN #8 stated s/he could not recall all the details of the incident. S/he reviewed and confirmed the entries in the record. At 1:15 PM, when asked how s/he determined when to initiate CPR, LPN #8 stated s/he would look for the physician's order in the chart. Review of the Care Plan at 1:28 PM on [DATE] revealed no reference to advance directives being in place or resident/family participation in the plan of care. During an interview at approximately 2 PM, with the Administrator present, a corporate representative stated s/he thought advance directives were portable from state to state. The facility admitted Resident #210 with [DIAGNOSES REDACTED]. Closed record review at 9:22 AM on [DATE] revealed that the resident was initially admitted on [DATE], was hospitalized for [REDACTED]. Review of Skilled Daily Nurse's Notes at 11:17 AM revealed that at 11:20 AM on [DATE], Resident #210 was alert (with) confusion.denied pain/discomfort.has been OOB (out of bed) -> (to) chair. The next note at 5 AM on [DATE] stated, Resident in bed resting with eyes closed. No complaints of pain or discomfort. No signs of distress noted. At 6:50 AM, the Certified Nursing Assistant (CNA) requested the nurse to come to the resident's room. The LPN noted, There was no movement at this time. There was no pulse, respiration. The RN on duty noted no vital signs and no response to tactile stimuli. Resident is DNR, Resident expired at present time. Closed record review at approximately 9:30 AM revealed a red DNR (Do Not Resuscitate) sticker on a [DATE] Physician's Interim Do Not Resuscitate Order in the front of the medical record. Review of the Authorization of Do Not Resuscitate Order Without Decision-Making Capacity revealed it was signed by one physician on [DATE]. There was no second physician signature to indicate that the resident had been assessed for ability to make health care decisions. The form was signed by a family member to indicate consent to the order. The [DATE] Multidisciplinary Care Conference Meeting form noted: DNR signed during meeting. Review of the ,[DATE] cumulative monthly Physician's Orders at 11:06 AM revealed that they also included a DNR order. Review of the Care Plan at 10:50 AM on [DATE] revealed no reference to advance directives being in place or resident/family participation in the plan of care. During an interview at 10:30 AM on [DATE], the Administrator reviewed the medical record. S/he verified that, although the family had signed for a DNR order, and a physician's order had been written, there was only one physician's signature determining the resident's inability to make health care decisions. The [STATE] Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act notes persons who may make health care decisions for a patient who is unable to consent in order of priority. SECTION [DATE]. Definitions states: (8) Unable to consent means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner. A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient. Review of the facility policy titled Do Not Resuscitate Policy: [STATE] and the [STATE] Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act revealed the policy was not in conformance with State law. The [DATE] policy stated: Definitions: 4. Decision Making Capacity.Every adult is presumed to have decision making capacity unless determined otherwise by a physician in writing.Procedure: I. Receiving a DNR Order from Another Healthcare Provider: A. Any written order issued by any attending physician using the term 'do not resuscitate', 'DNR',.or substantially similar language, and that is contained in the patient's medical record shall constitute a sufficient order.C. If an adult patient/resident does not have decision-making capacity and is a candidate for non-resuscitation a physician may issue a DNR with the consent of the patient/resident's representative. Based on full and/or limited record reviews, interviews, and review of the facility policies, it was determined on [DATE] at 11:45 AM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 4[AGE].10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 12:40 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable and implemented on [DATE]. The Immediate Jeopardy at F-155, F-309, F-490, and F-520 was removed on [DATE] but the citations remained at a lower scope and severity of D. The AOC included the following: (1) The residents with the alleged deficient practice are no longer residing in the facility. (2) The Director of Health Services will complete a review of all residents in the facility to ensure that do not resuscitate orders have been obtained per policy and state regulations. The Social Worker will also ensure where appropriate two physician signatures have been obtained. (3) All new residents' code status will be included on the 24 hour chart check daily and then reviewed during the daily morning meeting for compliance. (4) The DNR policy is as follows: Prior to, or upon Admission, the patient/resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directives Checklist, which is in the South Carolina Admission Packet, will be completed. Should the patient/resident indicate on the Advance Directive Checklist that he/she has issued advanced directives about his/her treatment, the healthcare center will require that copies of such advance directives be given to the healthcare center for inclusion in the patient/resident's medical record. A copy of the advance directive shall become a permanent part of the patient/resident medical record. The Director of Health Services will notify the attending physician of advance directives and document such notification in the medical record. Should the patient/resident indicate on the Advance Directive Checklist that he/she does not currently have an advance directive, but would like further information on advance directives; the patient/resident shall be provided with legal forms located on the [STATE]'s Office on Aging website. If upon admission, or any time thereafter a patient/resident or his Representative requests a DNR order, the Social Worker/Case Mix Director or Director of Health Services shall be responsible for completing the process. If an adult patient/resident HAS decision making capacity, he/she may consent to an order not to resuscitate. If an adult patient/resident does not have decision making capacity and is a candidate for non- resuscitation and the attending physician may decide to withhold life-prolonging measures or discontinue life prolonging measures by initiating a without decision making capacity form and having a concurring physician signature along with the authorized person signature. All resident will be a full code until this procedure is complete (5) The facility Admission Director will review advance directive checklist with resident and or responsible party. If there resident is confused and BI[CONDITION] (Brief Interview for Mental Status) score is 9 or below, a decision making capacity form will be completed with two physician signatures. The BI[CONDITION] score will be completed on the day of admission for all new residents. (6) Social service was educated on the process for obtaining Advance Directive upon admission and change of condition per policy and by regulation, by the Regional Nurse Consultant. All future hires for the department will be trained during the orientation and all of the Social Workers in the facility will be reeducated annually with their evaluation. (7) The Regional Nurse Consultant has educated both physicians at the facility on the DNR and requirements for the second signature. (8) The Clinical Competency Coordinator will educate all of the licensed nursing personnel on the DNR orders and requirements for DNR orders to be valid before the start of their next work shift. | 2020-09-01 |
| 4287 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2016-12-15 | 155 | D | 0 | 1 | N3QC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the South [NAME]ina Adult Health Care Consent Act, the facility failed to ensure residents had the right to formulate an advance directive for 1 of 11 residents reviewed for advance directives. Resident #43 was not afforded the opportunity to formulate his/her own advance directive. The findings included: The facility admitted Resident #43 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #43 signed an Advance Directive/Medical Treatment Decisions form dated 12/1/15 which indicated he/she did not choose to formulate or issue any Advance Directives at this time. I want efforts made to prolong my life and want life-sustaining treatment to be provided. Review of the cumulative physician's orders [REDACTED]. Further record review revealed the Nurses' Notes dated 6/20/16 indicated, (family member) confirmed pt (patient) will go on Hospice today. Review of the Physician's Progress Notes dated 6/20/16 indicated that Resident #43 was DNR (Do Not Resuscitate). Review of the Initial Hospice MD Plan of Care dated 6/20/16 indicated under Treatment Plans / Orders that Resident #43 had a DNR Order. Review of the South [NAME]ina Emergency Medical Services Do Not Resuscitate Order form in the medical record indicated the physician and the resident's family member signed the form dated 6/19/16. During an interview on 12/15/16 at approximately 3:45 PM, the surveyor requested additional documentation concerning Resident #43's advance directive and documentation related to the resident's decision-making capacity. On 12/15/16 at approximately 5:15 PM, the Director of Nursing and the Administrator reviewed the information in the medical record. Both confirmed at that time that there was no documentation indicating physician determination of the resident's capacity to make healthcare decisions. Review of the South [NAME]ina Adult Health Care Consent Act, Section 44-66-20 indicates in section (8), .A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient .If a patient unable to consent is being admitted to hospice care pursuant to a physician certification of a terminal illness required by Medicare, that certification meets the certification requirements of this item. Review of the facility policies entitled Advance Directives and Do Not Resuscitate Order revealed neither policy addressed physician documentation related to a resident's decision-making capacity when healthcare decision-making, including advance directives, was made by someone other than the resident. | 2020-04-01 |
| 4407 | CHESTERFIELD CONVALESCENT CENTER | 425302 | 1150 STATE ROAD | CHERAW | SC | 29520 | 2017-02-15 | 155 | D | 1 | 0 | GU9M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to honor resident rights for 1 of 5 residents reviewed. Resident # 4 requested to go to the hospital and was denied. The findings included: The facility admitted resident #4 with [DIAGNOSES REDACTED]. Review of the medical record revealed Nurses Notes that stated, the resident's skin was noted to be macerated on her/his back, buttocks and thighs. The resident was frequently educated on the need for being cleaned, changed and turned. On 10/21/16 at 1:50 PM the resident requested to go to the hospital. There was no medical reason for resident to be transferred. 10/24/16 at 3:05 PM, Resident told Certified Nursing Assistant, (CNA) s/he was not going to be changed until sent to hospital. 7:30 PM Allowed staff to wash and change her/him. While changing resident became aware of multiple open [MEDICAL CONDITION] on back. Resident washed with soap and water. Res (Resident) crying the whole time saying s/he needed to go to hospital. MD and wound nurse made aware. 11/11/16 8:45 AM Resident found shaking, Altered Mental Status, unable to obtain accurate vital signs (v/s) because of shaking. SAT's 95%. Resident constantly removing oxygen. Dr. notified with orders to send out. ER called and report given. Included resident's food seeking, mutilation of skin and non-compliance with bathing and being changed. Family was aware of her non-compliance with bathing and changing. Review of the physician progress notes [REDACTED]. Physician Notes .Need increase hygiene. 10/18/16 Finally up in geri chair. 10/25/16: Wound on left thigh healed. pt wants to go out to hospital due to (d/t) excoriations, will do in house wound care for now. 11/1/16 Staff reports been getting snacks and asking for more water and wanted to go to wound center, wounds on back still bleed.requested to go to the wound center for care, but nurses report, excoriations on back are extensive but stable . During an interview with Licensed Practical Nurse #1, S/he stated resident #4 had places on her backside. S/he wanted to go to hospital. Doctor said, no medical reason. | 2020-02-01 |
| 4554 | OAKBROOK HEALTH AND REHABILITATION CENTER | 425156 | 920 TRAVELERS BOULEVARD | SUMMERVILLE | SC | 29485 | 2016-09-09 | 155 | D | 0 | 1 | 706J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the Adult Care Consent Act, Section [DATE] of the South [NAME]ina Code of Laws, the facility failed to afford 2 of 25 residents the opportunity to formulate their own Advance Directives. (Resident #59 and Resident #113.) The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Review of the medical record revealed an Advance Directives Notification & Work Sheet signed by the resident's family member indicating the resident's code status was Do Not Resuscitate. The Physician Certification of Inability to Consent form was signed by the resident's physician and indicated the resident was unable to make his/her own healthcare decisions. Further review of this form indicated a second physician did not sign the form indicating the resident lacked the ability to make his/her own healthcare decisions until more than one month after the resident expired. During an interview on [DATE] at approximately 11:30 AM, the facility's Social Worker stated that the medical director first signs the Physician Certification of Inability to Consent forms. The Social Worker stated that he/she reviews the forms for those needing a second physician's signature. The Social Worker stated that this form was overlooked. Review of the Adult Health Care Consent Act, Section [DATE] of the South [NAME]ina Code of Laws, indicates: (8) 'Unable to consent' means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner .A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient . Resident #59 was admitted on [DATE] with a [DIAGNOSES REDACTED]. (The Advance Directives Notification & Worksheet) states Full Code and was signed by Easther Billy(NAME)( the residents niece) on [DATE] although the (Physicians Certification Of Inability to Consent) form states Resident able to make healthcare decisions. During an interview with the Social Worker on [DATE] at 1:10 PM, when asked if s/he could find paperwork where two doctors deemed the resident as unable to make her/his own healthcare decisions the Social Worker stated there is no documentation deeming Resident #59 as not capable of making her/his own decisions. The Social Worker stated, The resident was drowsy from the hospital and was unable to sign on [DATE] so his/her niece signed his/her advance directives. | 2019-11-01 |
| 4657 | LIFE CARE CENTER OF HILTON HEAD | 425147 | 120 LAMOTTE DRIVE | HILTON HEAD ISLAND | SC | 29926 | 2015-07-17 | 155 | D | 0 | 1 | RD4V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 1 of 10 residents reviewed for Advance Directives were afforded the opportunity to formulate their own Advance Directive. (Resident #11) The findings included: The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Record review on 7/16/15 revealed the resident had an order written [REDACTED]. Further review of the medical record revealed the resident had not been deemed incapable of making health care decisions by two physicians. During an interview with the Admissions Coordinator on 7/17/15, he/she stated there was no Health Care Power of Attorney or Living Will in the resident's admission file. At that time, the Administrator confirmed the findings and stated the resident should be a full code until all the proper paperwork had been completed. | 2019-09-01 |
| 4782 | GRAND STRAND REHAB AND NURSING CENTER, LLC | 425323 | 4452 SOCASTEE BLVD | MYRTLE BEACH | SC | 29588 | 2016-02-11 | 155 | J | 0 | 1 | 0L9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's Admission packet and policies titled Advance Directive Protocol and Advance Directive Policy, the facility failed to provide the opportunity to formulate an Advance Directive for 3 of 31 residents reviewed for Advance Directives. Resident #125 identified as having a decline in healthcare status, had no documentation available related to advance directives, and Residents #70 and #98 were not afforded the opportunity to formulate their own Advance Directive. It was determined on 1/29/16 at 10:45 PM Immediate Jeopardy existed for F-155 which was identified at a scope and severity level of (J). The findings included: The facility admitted Resident #125 with [DIAGNOSES REDACTED]. Review of the closed medical record indicated Resident #125 was hospitalized prior to admission to the facility. Review of the Hospital History and Physical dated 9/24/15 indicated in the section under Assessment and Plan #7 that the resident was a full code. Review of the Hospital Consultation Report dated 10/02/15 indicated in the section entitled Code Status that the resident was a full code. Review of the facility Physician's admission orders [REDACTED]. Review of the Physician's Progress Notes and Social Services progress notes revealed there was no documentation indicating the resident's code status or that this had been addressed upon admission with either the resident or resident's responsible party. On 1/29/16 at approximately 8:00 PM, the surveyor informed staff that the surveyor was unable to find any documentation in the medical record related to Resident #125's code status. The surveyor asked staff to review the medical record and provide documentation related to advance directives. On 1/29/16 at approximately 9:50 PM, the Assistant Director of Nursing (ADON) returned the medical record and informed the surveyor that the medical record contained no documentation related to advance directives. During an interview on 1/30/16 at approximately 4:30 PM, Social Services staff #1 reviewed the medical record. At that time, Social Services staff #1 confirmed that the Social Services Notes did not address advance directives, the record did not contain any documentation related to advance directives, and there was no documentation related to the resident or resident's responsible party being afforded the opportunity to formulate advance directives. Review of the facility's Admissions packet indicated under the section f, Each resident has the right to make an informed decision concerning his/her medical care, including his/her right .to formulate advance directives .Copies of any advance directives made by the resident should be presented upon admission and will be maintained in the Business Office and on the medical record. Information included under the section entitled Medical Records, indicated, Records are maintained uniformly for all residents For each resident admitted to the facility, admission records will be completed including but not limited to: .#13 Advance directives . Review of the facility's Advance Directive Protocol indicated bullet #1 stated, Inform each resident/family/responsible party/legal representative of his/her right .to formulate Advance Directives or not, and the facility's policies and procedures regarding these rights. Each resident must be given the opportunity to formulate an Advance Directive if they wish to do so. Information under bullet #3 indicated, Advance Directives concerning an individual resident's medical care should be documented on the resident's chart . Review of the facility's policy entitled, Advance Directive Policy indicated under section 1, .Each resident will be given an opportunity to formulate an Advance Directive if they wish to do so. The facility admitted Resident #98 with [DIAGNOSES REDACTED]. Record review on 1/28/16 revealed a Do Not Resuscitate(DNR) Order and a red dot on the outside of the chart indicating the resident was a DNR. No paperwork was observed on the chart indicating the resident and/or family had signed for a DNR or that the resident had been deemed incapable of making health care decisions by two physicians. During an interview with Social Services on 1/28/16, he/she confirmed there was no paperwork on the resident's chart nor could he/she find paperwork signed by the two physicians. Further interview with Social Services on 1/29/16 at 2:52 PM revealed on 1/28/16 Resident #98 had been deemed a Full Code and paperwork related to the resident being a DNR had been removed from the chart until all paperwork was completed for a DNR. The facility admitted Resident #70 with [DIAGNOSES REDACTED]. Review on 1/30/2016 at approximately 11:43 AM of Resident #70's medical record revealed a physician order [REDACTED]. Further review on 1/30/2016 at approximately 11:43 AM of the medical record for Resident #70 revealed that he/she had not been afforded the opportunity to formulate his/her own Advanced Directive. Resident #70 did not have documentation on the medical record in which 2 physician's had indicated that he/she was not able to make his/her own health care decisions. Review on 1/30/2016 at approximately 12:00 Noon of the facility's protocol titled, Grand Strand Healthcare, Inc., Advance Directive Protocol, states under the second * A resident is considered competent to make medical decisions for themselves unless two licensed physicians, one of which is the attending physician, have examined the resident and determined in writing, that the resident is incompetent/incapacitated and unable to make such decisions; or the resident has been declared incompetent/incapacitated by a lawful court of competent jurisdiction. Further review on 1/30/2016 at approximately 12:15 PM of the facility policy titled, Grand Strand Healthcare, Inc. Advance Directive Policy, under 1. states: Grand Strand Healthcare, Inc., recognizes that under South [NAME]ina Law, every person, age 18 or older, has the right to make decisions concerning his/her medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives, which may include a Do Not Resuscitate (DNR) Directive. An Advance Directive is intended as a way for the resident to tell us how they want to be treated, and also to name an agent to make health care decisions for them if they are unable to make medical decisions for themselves. The resident and or the family/legal representative is to be informed of our policy at the time of admission. We will gladly discuss it and answer any questions they may have. However, we do not provide legal advice, make decisions for the resident, or interfere with or influence a resident's decision. Each resident will be given an opportunity to formulate an Advance Directive if they wish to do so. During an interview on 1/30/2016 at approximately 5:02 PM with the Director of Nurses, he/she verified and confirmed that 2 physicians had not deemed Resident #70 unable to make his/he own health care decisions before obtaining a No Code status. And he/she had not been able to formulate his/her own Advance Directive. Based on record review, interviews, and review of facility policies, it was determined on 1/29/16 at approximately 10:45 PM Immediate Jeopardy existed in the following area: CFR 483.10(b)(4) F-155 Right to formulate an Advance Directive was identified at a scope and severity level of (J). The facility failed to afford all residents the right to formulate an Advanced Directive. The facility Administrator, Director of Nursing (DON), and ADON were informed of the Immediate Jeopardy on 1/29/16 at approximately 10:45 PM. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable on 1/30/16 at approximately 3:40 PM, and the Immediate Jeopardy at F-157 was removed and lowered in scope and severity to a D. The A[NAME] included the following: 1. Resident #125 no longer resides in the facility. All other residents are at risk. 2. We have reviewed our policy and procedure/protocol concerning Advance Directives and made the following revisions: (1) added language to make it clear that we do not provide legal advice, make decisions for residents or interfere or influence a resident's decision; and (2) if a do not resuscitate directive is desired, a doctor's order should be documented on the chart and a red sticker placed on the chart next to the resident's name for easy identification. 3. An audit of all current residents' charts was conducted on 1/30/16 by the DON, ADON, Unit Manager, MDS Coordinator, and Staff Development Coordinator (SDC) to ensure that all residents who wish to have an Advance Directive have the Advance Directive documented on their chart; that a doctor's order for DNR is present on the chart; and the chart is labeled with a red sticker next to the resident's name for easy identification. All other residents will be treated as a full code. The resident, resident's family/RP, and attending physician will be notified of each resident's desire for a DNR. The family/RP and attending physician will be notified of any change of condition. 4. All licensed nurses and CNAs were in-serviced by the DON, ADON, and SDC on 1/30/16 on our revised policies; properly identifying each resident's code status and ensuring that it is documented on the resident's chart if the resident is a DNR; on assessing the resident and documenting any change in condition; on documenting that the doctor and family/RP were notified. All licensed nurses and CNAs who were not available will be in-serviced as soon as they are available prior to being able to work. All newly-hired licensed nurses, agency nurses, CNAs and agency CNAs will be in-serviced during the orientation process. The DON and SDC will provide annual training for all licensed nurses. The DON will be responsible for all Advance Directives, obtaining a DNR where appropriate, and obtaining the signatures of two physicians when the resident is incapacitated. The ADON will be responsible in the absence of the DON. 5. The Unit Managers will monitor weekly x4, then monthly x3, and quarterly thereafter to ensure this deficiency does not recur. | 2019-08-01 |
| 4854 | PRUITTHEALTH- DILLON | 425113 | 413 LAKESIDE COURT | DILLON | SC | 29536 | 2016-01-22 | 155 | D | 0 | 1 | QNZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled Advance Directives & Do Not Resuscitate Orders, the facility failed to ensure Resident #101 was afforded the opportunity to form Advance Directives for Code Status. Resident #101 was not deemed to lack capacity to make healthcare decisions by two physicians. (1 of 22 residents reviewed for advanced directives) The findings included: The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Record review on 1/21/16 revealed a physician's order dated 1/11/16 for a Do Not Resuscitate(DNR). Review of the Admission Nursing assessment dated [DATE] stated the resident was alert and oriented. Further record review of the Ability to Consent to Health Care Decisions revealed the physician had signed in the wrong area and only one physician had signed the form. During an interview with Registered Nurse #1 on 1/22/16, he/she confirmed the paperwork was not completed and stated the resident's code status remained a DNR. Review of the facility policy Advance Directives & Do Not Resuscitate Orders revealed the following: As long as you are competent and able to communicate, you make your own decisions. | 2019-07-01 |
| 4921 | SAVANNAH GRACE AT THE PALMS OF MT PLEASANT | 425404 | 1010 LAKE HUNTER CIRCLE | MOUNT PLEASANT | SC | 29464 | 2016-02-10 | 155 | E | 0 | 1 | 2S3A11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were given the opportunity to formulate Advance Directives for Code Status for 6 of 19 residents reviewed for Advance Directives. Residents #8, #31, #36 & #122 all had physician orders [REDACTED]. The signed forms were Emergency Transport forms only. Residents #123 & #125, both deemed to have capacity to make their own healthcare decisions, had forms signed requesting to be a Full Code, but the forms were signed by the Responsible Party and not the residents involved. The findings included: The facility admitted Resident #122 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed Resident #122 had been deemed with capacity. A physician's orders [REDACTED]. An Emergency Medical Services Form indicated the resident was a DNR during transport. Information about Cardiopulmonary Resuscitation(CPR)/DNR form and the Emergency Medical Services Form was signed by someone other than the resident. No Advance Directive form was noted in the resident's record to direct the facility of the resident's wishes if he/she resident were to have a code situation. The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed Resident #31 had been deemed without capacity. A physician's orders [REDACTED]. An Emergency Medical Services Form indicated the resident was a DNR during transport. No Advance Directive form was noted in the resident's record to direct the facility in the event a code situation should arise. The facility admitted Resident #36 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed Resident #36 had been deemed with capacity. A physician's orders [REDACTED]. An Emergency Medical Services Form indicated the resident was a DNR during transport. No Advance Directive form was noted in the resident's record to direct the facility of the resident's wishes if he/she were to have a code situation. Review of the facility's Code Status Audit completed [DATE] revealed the facility reviewed for the code status in chart, medical decisional capacity, resident deemed incompetent by two doctors, capacity form completed, DNR signed by physician and DNR/Full Code Order written. During an interview with the Administrator on [DATE], he/she stated there was no other form the facility utilized related to code status. - The facility admitted Resident #123 with [DIAGNOSES REDACTED]. Review of the Advance Directives section of the medical record revealed the resident's Responsible Party (RP) signed a form indicating the resident's code status was Full Code. A Physician's Telephone Order dated [DATE] indicated Resident #123 was a Full Code. The Advance Directives section contained no documentation signed by the resident indicating the resident was afforded the opportunity to formulate his/her own Advance Directive. Review of the Physician's Determination of Capacity form signed by the physician indicated After examining the above named resident ., I, as the attending physician, believe the above named resident is: With Capacity. Further review of the document indicated, Resident with capacity is one who is able to understand reasonably the nature of his/her illness and is able to make informed decisions regarding treatment in medical care. A physician's telephone order dated [DATE] also indicated, resident (with) capacity. The facility admitted Resident #125 with [DIAGNOSES REDACTED]. Review of the Advance Directives section of the medical record revealed the resident's Responsible Party (RP) signed a form indicating the resident's code status was Do Not Resuscitate. A physician's orders [REDACTED]. The Advance Directives section contained no paperwork signed by the resident indicating the resident was afforded the opportunity to formulate his/her own Advance Directive. Review of the Physician's Determination of Capacity form revealed the physician indicated After examining the above named resident ., I, as the attending physician, believe the above named resident is: With Capacity. Further review of the document indicated, Resident with capacity is one who is able to understand reasonably the nature of his/her illness and is able to make informed decisions regarding treatment in medical care. A Physician's Telephone Order dated [DATE] also indicated, resident (with) capacity. Review of the Adult Health Care Consent Act, Section [DATE] of the South Carolina Code of Laws, indicates: (8) 'Unable to consent' means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner .A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient . On [DATE] at approximately 2:15 PM, the Administrator and Social Services Director reviewed the above documentation related to the Advance Directives for Resident #123 and Resident #125 and confirmed the surveyor's findings at that time. The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Review of the medical record on [DATE] at approximately 10:19 AM for Resident #8 revealed a form titled, Emergency Medical Services, Do Not Resuscitate Order, and was signed by Resident #8's responsible party on [DATE]. This form was for EMS transport only. Further review of Resident #8's medical record on [DATE] at approximately 10:19 AM revealed a physician's orders [REDACTED]. There was no 2 physician signed, capacity form which would deem Resident #8 unable to make his/her own healthcare decisions in the medical record. No other forms were found in the medical record for Resident #8, signed by him/herself nor the responsible party indicating that Resident #8 had or requested a Do Not Resuscitate (DNR) status. Review on [DATE] at approximately 1:40 PM of the facility policy titled, Health Care Directives, states under, 1.0 Purpose: Each competent resident or patient has the right to determine the future course of his or her medical care and treatment and to document those wishes in case he or she becomes unable to make informed decisions or to articulate his or her desires. Some of the residents and patients at Five Star communities and facilities are incapable of making informed healthcare and financial decisions. As a result, they have someone else making those decisions for them. All Five Star communities and facilities must honor a validly executed document regarding a resident's or patient's health care wishes, provided that (1) the community or facility receives a valid written copy of the document, and (2) the document meets the requirements set forth in both state and federal laws. An interview on [DATE] at approximately 2:00 PM with the Administrator revealed the the Emergency Medical Services (EMS) form for code status was the only form that the facility is using and had been using for code status. | 2019-07-01 |
| 4932 | VIBRA HOSPITAL OF CHARLESTON -TCU | 425405 | 1200 HOSPITAL DR 2ND FL | MOUNT PLEASANT | SC | 29464 | 2016-04-28 | 155 | D | 0 | 1 | YC7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy entitled Advance Directives, the facility failed to incorporate choices regarding advance directives into treatment, care and services for 1 of 1 sampled resident reviewed for choices. Resident #119 had discrepancies in advance directives on the medical record. The findings included: The facility admitted Resident #119 with [DIAGNOSES REDACTED]. Review of the [DATE] admission History and Physical on [DATE] at 3:06 PM revealed that the resident was alert and say he (she) would not want CPR (cardiopulmonary resuscitation). Review of the Admission Body of Orders at 3:20 PM on [DATE] revealed the Code Status: Full Code. A [DATE] 3:10 PM Social Services Interdisciplinary Note reviewed at 4:40 PM stated, The resident is a DNR (Do Not Resuscitate) by his (her) choice. At 4:45 PM, review of the Medication Administration Record [REDACTED]. No Physician's Order could be located to reflect the resident's choice in advance directives. During an interview at 6:09 PM on [DATE], when asked about the code status of Resident #119, Registered Nurse #1 referred to the physician's orders and stated, full code. When the resident's request documented on the History and Physical was brought to her/his attention, s/he confirmed the information and reviewed the record for an updated order. The nurse was unable to locate a physician's order for DNR status. Social Services stated s/he had spoken with the resident and that s/he wanted to be a DNR. S/he had placed the completed form in the physician's box to be signed. The facility policy entitled Advance Directives states: On Admission, the attending Physician will discuss the desired code status with the resident and include this information in his History and Physical. If resident desires to have No CPR, MD will write order for this. During an interview on [DATE], the attending physician stated, I should have written the order. | 2019-07-01 |
| 4997 | EDISTO POST ACUTE | 425116 | 575 STONEWALL JACKSON BOULEVARD | ORANGEBURG | SC | 29115 | 2015-09-15 | 155 | D | 0 | 1 | 56XY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the facility policy titled, Advance Directives, the facility failed to provide 2 of 2 residents out of a total of 35 reviewed for Advanced Directives the opportunity to make their own health care decisions. Resident #146 and #147 had been deemed able to make their own healthcare decisions, including Advance Directives, by their physician. Resident #146 and #147 had Advance Directives signed by a family member and not the resident. The findings included: The facility admitted Resident #146 with [DIAGNOSES REDACTED]. Review of Resident #146's medical record on 9/11/2015 at approximately 8:50 AM revealed a form signed by the resident's physician that stated Resident #146 is able to make own health care decisions. Further review of Resident #146's medical record on 9/11/2015 at approximately 8:50 AM revealed a form titled, Acknowledgement of Patient Information on Advance Directives, states, I have received written information on state law, and the facility's written policy, advising me of my right to make decisions concerning my medical care, including the right to accept or refuse medical or surgical treatment, and formulate advance directives (declaration and/or durable power of attorney for health care decisions). The form was signed by a family member, not the resident. Review on 9/11/15 at approximately 8:50 AM of another form titled, Resident/Family Consent for Cardiopulmonary Resuscitation, revealed the statement, I understand that Cardiopulmonary Resuscitation constitutes an extraordinary measure and SHOULD NOT be done , this form was signed by a family member. The facility admitted Resident #147 with [DIAGNOSES REDACTED]. Review of Resident #147's medical record on 9/11/2015 at approximately 9:46 AM revealed a form signed by the resident's physician that stated Resident #147 is able to make own health care decisions. Further review of Resident #147's medical record on 9/11/2015 at approximately 9:46 AM revealed a form titled, Acknowledgement of Patient Information on Advance Directives, stated, I have received written information on state law, and the facility's written policy, advising me of my right to make decisions concerning my medical care, including the right to accept or refuse medical or surgical treatment, and formulate advance directives (declaration and/or durable power of attorney for health care decisions. The form was signed by a family member, not the resident. Review on 9/11/15 at approximately 9:46 AM of another form titled, Resident/Family Consent for Cardiopulmonary Resuscitation, revealed the statement, I understand that Cardiopulmonary Resuscitation constitutes an extraordinary measure and SHOULD NOT be done , this form was signed by a family member. Review of the facility's policy titled, Advance Directives, on 9/11/2015 at approximately 11:12 AM stated, Our facility respects your right to make own medical treatment decisions. Medical treatment decisions are a matter of personal choice. At the time of admission, we will provide to resident's information concerning: An adult individual's right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to give advance directives and our facility's policies relating to implementation of these rights. During an interview with the Social Service Director on 9/11/2015 at approximately 11:30 AM, he/she stated, these forms are completed on admission. He/she went on to say that if the resident is deemed able to make own health care decisions that they should sign the code status themselves. | 2019-06-01 |
| 5109 | MUSC HEALTH MULLINS NURSNG HOME | 425312 | 518 S MAIN STREET | MULLINS | SC | 29574 | 2016-01-07 | 155 | D | 0 | 1 | CQI811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of Adult Healthcare Consent Act the facility failed to ensure 1 of 17 residents reviewed for Advanced Directives was afforded the opportunity to formulate his/her own Advanced Directive. Resident #95 was not deemed unable to make own healthcare decisions by 2 physicians. A Do Not Resuscitate (DNR) form was signed by a family member for Resident #95 and staff identified Resident #95's code status as DNR, but physician orders [REDACTED]. The findings included: The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Review of Resident #95's medical record on 1/8/2016 at approximately 11:44 AM revealed a form titled, Consent for Do Not Resuscitate, (No Code/DNR), signed by a family member. Further review of Resident #95's medical record revealed a form titled Medical Condition Certification, which states, I certify that I have examined the above named resident and it is my opinion that this resident is unable to understand Resident's Rights and is unable to make Health Care decisions related to the following reason. The form was signed by only one physician. Review of the Adult Healthcare Consent Act revealed 2 physician signatures were required to deem a resident unable to make own healthcare decisions. An interview on 1/8/2016 at approximately 11:55 AM with Registered Nurse #1,Unit Manager of the 300 Hall, verified that the DNR code status, was signed by a family member and 2 physicians had not deemed resident #95 unable to make his/her own health care decisions. The nurse manager went on to say that this resident is a no code/DNR. Review of the cumulative orders on 1/8/2016 at approximately 12:05 PM dated 12/1/2015 through 12/31/2015 listed Resident #95 as a Full Code. Further review of the cumulative orders for 10/26/2015 through 10/31/2015 revealed resident #95 as a Full Code. A physician's orders [REDACTED].#95 as a Full Code. | 2019-05-01 |
| 5169 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2016-04-01 | 155 | J | 0 | 1 | HRWQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility's admission information, the Resident Bill of Rights, and Wildewood Downs Policy for Advanced Directives, the facility failed to provide the opportunity to formulate an Advance Directive for 2 of 22 residents reviewed for Advance Directives. The facility failed to document Resident #87's choice to be a full code and communicate this choice to the Interdisciplinary Team and failed to ensure orders and treatment reflected this choice. The facility failed to document why a Do Not Resuscitate (DNR) order was obtained for Resident #50 or that family or the resident was consulted prior to obtaining the order. It was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed as of [DATE] for F-155 which was identified at a scope and severity level of J. The findings included: The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Review of the Advance Directives section of the closed medical record revealed a form signed by the physician indicating Resident #87 was able to consent to health care decisions . Further record review revealed a form entitled Advanced Directives. The bottom section of the form was signed by the resident upon admission indicating Yes related to having a Living Will and Yes related to having a Healthcare Power of Attorney. In the middle of the form, information indicated in bold type,DO NOT CHECK 'YES' UNLESS YOU HAVE THE PAPERS ON YOUR PERSON WHILE YOU ARE COMPLETING THIS FORM!!!!!!!!! A copy of a Durable Power of Attorney (for financial decisions), ending with page 8, was included in the record; however, the record did not contain a copy of a Living Will or Healthcare Power of Attorney. Handwritten documentation on the bottom half of the form indicated, Resident wishes to be a DNR. The handwritten notation was not dated nor signed to indicate who wrote the documentation. In addition, there was no documentation that this was the resident's choice or how/when this information was obtained. During an interview on [DATE], the Director of Admissions reviewed the Advance Directive paperwork and stated that he/she handwrote the notation Resident wishes to be a DNR on the form entitled Advanced Directives. He/she stated that no other paperwork related to Advance Directives is completed by the Admissions Department. He/she stated that after completing paperwork for newly admitted residents, the information is given to the Social Services Director for completion. During an interview on [DATE] at approximately 12:33 PM, the Admissions Director was asked to clarify the process after completion of the admissions paperwork related to Advance Directives. The Admissions Director indicated that there was no process because the social worker and the doctor come behind me and ask the resident . The Admissions Director indicated that the social worker will place Advance Directive information related to needed orders in a book for the physician to review. Review of the Social Service notes on the day of admission indicated, Pt (patient) has chosen to be a full code. The documentation was signed by the Director of Social Services. During an interview on [DATE] at approximately 3:20 PM, the Social Services Director reviewed the record with the surveyor. The Social Services Director confirmed that he/she documented the Social Services notation dated the day of Resident #87's admission. The Social Services Director stated that he/she talked with Resident #87 about code status, explained the meaning of full code status, and Resident #87 indicated that he/she wanted to be a full code. The Social Services Director stated that he/she always talks with residents about code status, and that the physician does not always address code status with new admissions. During the interview, the Social Services Director stated that paperwork concerning Advance Directives used to be under social services years ago and then got added to the admission paperwork. The Social Services director stated that he/she reviews the paperwork from admissions prior to speaking with newly admitted residents. Review of the physician's orders revealed an order dated [DATE] at 11:25 PM for a DNR order which was received by Licensed Practical Nurse (LPN) #1. Review of the 24 Hour Report dated [DATE] indicated Resident #87 expired at 11:25 PM. Review of the Nurse's Notes dated [DATE] indicated the resident was noted at 11:25p with no vital signs. During an interview on [DATE] at approximately 4:30 PM, LPN #1 stated that he/she checked the medical record when Resident #87 was found with no vital signs, and the record indicated the resident was a full code. LPN #1 stated that he/she called the resident's family member to check to see if he/she still wanted the resident to be a full code or sent out to the hospital. In a facility-obtained, signed statement dated [DATE], LPN #1 wrote that, I perused (resident's) chart for a DNR order, checked (his/her) advanced directive noted that it stated, 'I do not want CPR.' I placed a call to the responsible party (resident's family member) to notify of ceased respirations & inquire if (resident's family member) wanted CPR instituted. During an interview on [DATE] at approximately 8:59 AM, the Medical Director reviewed the policies entitled Wildewood Downs Policy for Advanced Directives, Resident Bill of Rights, and the closed medical record with the surveyor. The Medical Director confirmed that there were no physician's orders related to code status written upon admission. The Medical Director confirmed that the medical record contained documentation in the social services notes indicating the resident wanted to be a full code and a handwritten notation on paperwork completed upon admission indicating the resident wanted to be a DNR. The Medical Director stated, A procedure gap here is definitely a problem .I have concerns over making sure we follow procedures and better documentation. We need to .make sure everyone is aware of the policy and make sure the documentation is in place. The Medical Director indicated that social services is to make sure all paper work is done, and sometimes it takes a while depending on when we get here to actually sign. The Medical Director stated that it needs to be more clear as to what the resident actually wants and makes their own decision. During the interview, the Medical Director indicated he/she had recently signed several DNR forms to help correct this issue. As part of the facility's Allegation of Compliance, staff conducted a Code Status Audit of all resident charts on [DATE]. Review of the audit revealed that corrections related to code status were identified as needed on 5 out of 25 resident records reviewed by staff. During an interview on [DATE] at approximately 12:42 PM, Resident #87's physician of record reviewed the closed medical record with the surveyor. After review of the Advance Directive paperwork, physician's orders, Nurse's Notes, and 24 Hour Report/Change of Condition Report, the physician agreed there was no physician's order related to Resident #87's code status written until the time that the resident expired and staff obtained an order for [REDACTED]. The physician stated that when staff called him/her for the DNR order on [DATE], he was told the resident wanted to be a DNR, and the nurse had spoken with the family. The physician reviewed the form indicating the resident was deemed capable of making healthcare decisions and the social services documentation indicating the resident wanted to be a full code. The physician stated he/she had been unaware of the social services documentation indicating the resident wanted to be a full code. The physician indicated that he/she relies on staff to provide capacity forms and information for orders related to Advance Directives that need to be signed when he/she makes rounds. The physician indicated he/she should talk with the resident and not rely on the staff for information, the resident may change their minds. Review of the Resident Bill of Rights indicated, Residents have the right to have an advanced directive or a living will executed on their behalf. This document, if already executed prior to admission or thereafter, should be given to the Social Services Director and attending physician to (sic) it can be included in the medical record. Review of the Wildewood Downs Policy for Advanced Directives revealed #2 indicated, MD will discuss Advanced Directives (Full Code or DNR) with the resident and/or representative to determine code status. If MD is not present at time of admission and resident/POA has stated that they wish to be DNR, MD will be called for orders. Information under #4 indicated, If resident is made a DNR, a doctor's order .will be completed and placed in chart. The facility admitted Resident #50 with [DIAGNOSES REDACTED]. Review of the closed medical record indicated Resident #50 expired on the fifth day following admission. Review of the Advanced Directives form completed upon admission indicated the resident's responsible party signed the form. Further review of the form revealed a handwritten notation which indicated, resident wants to remain a full code. The notation was not signed nor dated. A form dated [DATE] was signed by one physician indicating the resident lacked the ability to consent to healthcare decisions. Information located at the top of the form stated, According to the South Carolina Adult Health Care Consent Act, Section [DATE], a patient's inability to consent must be certified by two licensed physicians. Review of the Nurse's Notes dated [DATE] on the ,[DATE] PM shift indicated staff attempted unsuccessfully to contact Resident #50's family regarding a skin tear. Documentation dated [DATE] on the ,[DATE] PM shift indicated new orders were written on that date related to giving medications. Review of the physician's orders revealed an order dated [DATE] which indicated the resident's code status was DNR. Record review revealed no social services documentation was located in the medical record. Review of the Nurse's Notes revealed there was no documentation as to why the DNR order was obtained on [DATE], who requested the order, or that the family or resident was consulted prior to obtaining the order. Review of the 24 Hour Report/Change of Condition Report dated [DATE] revealed that Resident #50 expired at 3:35 AM. Review of the Nurse's Notes dated [DATE] revealed the Assistant Director of Nursing documented that staff was unable to reach the resident's family member until 6:15 AM. Based on record review, interviews, and review of facility policies, it was determined on [DATE] at approximately 5:50 PM Immediate Jeopardy existed in the following area: CFR 483.10 (b)(4) F-155 Right to formulate an Advance Directive was identified at a scope and severity level of J. The facility failed to afford all residents the right to formulate an Advance Directive. The facility Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at approximately 5:50 PM. The facility provided an Allegation of Compliance (A[NAME]) that was acceptable on [DATE] at approximately 5:45 PM, and the Immediate Jeopardy at F-155 was removed and lowered in scope and severity to a D. The A[NAME] included the following: 1. The Advanced Directives Policy and the CPR Policy have been reviewed by the Medical Director and the DON. No changes have been made at this time. 2. All residents in the Nursing and Rehabilitation Unit have been interviewed and have had their code status confirmed. If residents were unable to confirm their code status, due to dementia, altered mental status, etc., or have been deemed unable to make medical decisions by the physician, their responsible parties (person with legal rights to make decisions for the resident), have been completed as of [DATE] and code statuses on all residents are current. 3. A complete chart audit has been conducted to confirm that the resident's wishes correspond with what is written on the chart. For example, if a resident states that he/she wishes to have a DNR order, it has been confirmed that there is an MD order and a signed DNR form on the chart. Any discrepancies have been corrected. An audit trail is attached to show the changes to any discrepancies. 4. All nurses and CNAs present on the unit from the time of the allegation until the current time on all shifts have been instructed by formal in-services on the Advanced Directive and CPR policies to understand that CPR is to be started on any resident who does not have an order for [REDACTED]. Signed statements have been obtained from all nurses and CNAs that they have received the training, and that they understand the content and have had an opportunity to ask questions. 5. The Administrator, DON, ADON, and attending physician and Medical Director have received in-service training by the RN nurse consult (sic) for The Hollinger Group regarding the Advanced Directive and CPR Policies. 6. The LPN who was working the night that the alleged non-compliance occurred has been counseled and also attended the mandatory in-service for Advance Directive and CPR. Her written statement of the alleged events is attached. She also attended the mandatory in-service, as evidenced by her signature on the master sign in sheet which is attached, and the signed statement that she received the policy, understands the content, and had an opportunity to ask questions. 7. The Administrator or Director of Nursing or Assistant Director of Nursing will check each shift to ensure that all staff scheduled to work have received the in-service until all facility staff have received the in-service. The in-service may be conducted by the Administrator, DON, ADON, or Staff Development nurse. This in-service will be provided to all new CNA and licensed nurse hires at Wildewood Downs. Wildewood Downs does not use any agency staff. 8. This practice will be prevented in the future by having all admissions checked for code status and the appropriate information (DNR order and DNR sheet if ordered) at the time of admission. This will be done by the DON or the ADON, or the Staff Development nurse in their absence. If the appropriate information is not present, the DON, ADON, or Administrator will get the appropriate orders or information on the chart, and notify the physician and the nurse assigned to the new resident admission that the information was not obtained per policy. These findings will be presented at the monthly QA meeting. 9. All department heads attend a daily morning meeting to go over any issues in the facility at 9 am. After this meeting, managers, including the Administrator, DON, ADON, MDS Coordinator, Admissions Nurse, Social Services Director, and Therapy Program Director attend an additional stand up nursing meeting daily to go over the 24 hour report. Each resident is discussed and any issues are brought up at this time. Any issues that require follow up are assigned at this time to the appropriate manager. Copies of all new orders are placed in the folder of the ADON for review. There is an RN on call 24 hours a days 7 days a week to address any nursing issue that requires immediate attention. | 2019-04-01 |
| 5346 | WESTMINSTER HEALTH & REHAB CENTER | 425291 | 831 MCDOW DRIVE | ROCK HILL | SC | 29732 | 2016-01-21 | 155 | D | 0 | 1 | ZBI211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that 1 of 10 sampled residents reviewed for Advance Directives were given the opportunity complete/sign their own Advance Directive. Resident #29 Advance Directive for Do Not Resuscitate (DNR) was signed by a family member without two physician's signatures to determine competency. The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. A review of the medical record on 1/20/16 at approximately 10:44 AM revealed a physician's orders [REDACTED].#29 was on a 72 hour Do Not Resuscitate (DNR) order. Further record review revealed there was a RESUSCITATION STATUS CONSENT FORM in the chart that indicated the resident's DNR was signed by a family member with one physician's signature that indicated the resident could not make health care decisions. An interview on 1/20/16 at approximately 11:47 AM with the Social Services/Admission Staff confirmed the findings that only one physician signature was noted on the form and two physician signatures were required. An interview on 1/20/16 at approximately 11:55 AM with the Assistant Director of Nursing (ADON) revealed another 72 hours DNR physician's orders [REDACTED]. | 2019-01-01 |
| 5360 | NHC HEALTHCARE - MAULDIN | 425359 | 850 E. BUTLER RD. | GREENVILLE | SC | 29607 | 2015-06-10 | 155 | D | 0 | 1 | X50X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents who were deemed competent signed his/her own Advance Directive for Do Not Resuscitate for 1 of 16 sampled residents reviewed. Resident #338 Advance Directive Do Not Resuscitate form was signed by a family member. The findings included: The facility admitted Resident #338 with [DIAGNOSES REDACTED]. A record review on 6/10/15 at approximately 9:38 AM revealed an ADVANCE DIRECTIVE/DNR D[NAME]UMENTATION NOTES form dated 3/18/15 signed by the resident's daughter. There was no documentation in the chart; signed by two physicians to determine the resident could not make his/her own health care decisions. Further record review revealed a statement form for CERTIFICATION OF PATIENT'S INABILITY TO CONSENT TO HEALTH CARE DECISIONS signed by a physician on 5/11/15 that indicated Pt (patient) able to consent to medical procedures. In an interview on 6/10/15 at approximately 10:09 AM LPN (Licensed Practical Nurse) #1 confirmed the findings that there was no documentation in the chart to indicate the resident could not sign his/her own Advance Directive. LPN #1 then referred the surveyor to the SSD (Social Services Director). An interview on 6/10/15 at approximately 10:17 AM with the SSD revealed there was no documentation of two physician's signatures to indicate the resident could not make health care decisions. The SSD then stated he/she will have the resident sign the Advance Directive form. | 2019-01-01 |
| 5415 | FRASER HEALTH CENTER | 425150 | 300 WOOD HAVEN DRIVE | HILTON HEAD ISLAND | SC | 29928 | 2015-11-11 | 155 | D | 0 | 1 | GFDV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to offer Resident #5 the opportunity to formulate an Advance Directive. Resident #5 was 1 of 10 residents reviewed for Advance Directives. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. At 12:39 PM on 11/10/2015 record review of the monthly Physician order [REDACTED]. Further review revealed the DNR form was signed by someone other than the resident although the name was not legible. Additional review revealed no documentation of the resident's inability to consent. Review of the admission face sheet revealed an Advance Directive Acknowledgement signed by the resident that did not indicate any advance directive. Registered Nurse #3 (RN#3) on 11/10/15 at 12:44 PM confirmed Resident #5 signed the Advance Directive Acknowledgement form on admission and made no decision on the form. RN #3 stated I don't think (the resident) has been declared incompetent by 2 physician's to make his/her own healthcare decisions. | 2018-12-01 |
| 5436 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2015-12-17 | 155 | D | 0 | 1 | R72X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to allow the resident to formulate an advance directive. There was no evidence of certification by two physicians of the resident's inability to make health care decisions. Resident #147 was 1 of 17 residents reviewed for Advance Directives. The findings included: The facility admitted Resident #147 with [DIAGNOSES REDACTED]. During the record review on 12-17-15 at approximately 12:30PM, there was a signature by one attending physician by the statement, Form Reviewed (Complete only if no inabilities noted): I have reviewed the resident for his/her inability to consent to the categories listed below and find no limitations signed and dated on 15 (MONTH) (Jan.) 2014. On the back of the Certification of Inability To Consent his/her daughter signed as the Substitute Decision Maker, if the resident is unable to give informed consent. During an interview with the Social Worker on 12-17-15 at approximately 12:38PM, s/he stated that the resident had threatening behavior towards others, hostile, unable to care for self with decubitus on his/her bilateral heels when he/she entered the facility. The Social Worker stated, The resident's family was very involved in his/her care. I have spoken to the daughter many times in reference to his/her care. During an interview with his current Physician on 12-17-15 at approximately 12:45PM, s/he stated that the resident was not able to make decisions about his/her health care. The Physician stated, I am in the process of updating the Advance Directives since the previous Physician is no longer here at the facility. The previous physician signed the document on admission of 2014. | 2018-12-01 |
| 5461 | OPUS POST ACUTE REHABILITATION | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2015-05-06 | 155 | D | 0 | 1 | 10H311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to comply with requirements related to the resident's right to formulate an advance directive for 1 of 11 residents reviewed for advanced directives. Resident #10's medical record contained conflicting information that indicated the resident was both a full code and a do not resuscitate (DNR). The findings included: Resident #10 was admitted to the facility on [DATE]. review of the resident's medical record revealed [REDACTED]. There was no additional paperwork located in the Advance Directives section of Resident #10's medical record. Review of Resident #10's admission Monthly physician's orders [REDACTED]. Review of Resident #10's (MONTH) (YEAR) Monthly Physician order [REDACTED]. Review of the Physician's Telephone Orders revealed there were no orders to change the resident from a Full Code to a DNR. Review of Resident #10's (MONTH) and (MONTH) (YEAR) Medication Records revealed DNR orders are in place with an order date of 4/25/15 signed off by nursing twice daily through 5/6/15. Review of Resident #10's Care Plan completed 4/22/15 revealed the resident's code status was a full code. In an interview with the surveyor on 5/6/15 at approximately 1:10 PM, RN (Registered Nurse) #5 stated that if a resident was unresponsive s/he would have someone check the resident's medical record. RN #5 stated that the resident's advance directive was located in one of the first sections of the medical record. RN #5 stated that for residents who have a full code status there was a green sheet of paper that stated Full Code. In an interview with the surveyor on 5/6/15 at approximately 1:30 PM, the Nurse Consultant stated that a DNR was signed for Resident #10 on 4/22/15 by the responsible party. The facility completed the paperwork for a resident with the ability to consent. The Nurse Consultant stated that the DNR status was in effect on 4/22/15. The Nurse Consultant stated that they had completed the wrong form for Resident #10 and needed to complete the paperwork for a resident without the ability to consent. The paperwork for residents without the ability to consent required two physician signatures. That form was completed by the resident's responsible party on 5/5/15 and signed by one physician on 5/5/15 and by the second physician on 5/6/15. The Nurse Consultant provided both consent forms to the surveyor on 5/6/15. The Nurse Consultant also provided a copy of a Physician's Telephone Order dated 5/6/15 that indicated Resident #10 was a DNR. The Nurse Consultant stated that if something had happened they would honor the family's wishes and would call for a 24 hour DNR order. In an interview with the surveyor on 5/6/15 at approximately 1:45 PM, the Nurse Consultant stated that nursing would check facility paperwork and if the family wish was for a DNR they would call and get a 24 hour DNR. When asked how staff would know they needed to call and get a 24 hour DNR order for Resident #10 the Nurse Consultant stated that information would be reported shift to shift. The Nurse Consultant stated s/he could not provide any documentation that staff knew they should call and get a 24 hour DNR for Resident #10 if needed prior to the order on 5/6/15. | 2018-12-01 |
| 5497 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2015-01-23 | 155 | D | 0 | 1 | 1EGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy entitled Advance Directives, the facility failed to afford 1 of 19 sampled residents reviewed for advanced directives the right to formulate his/her own advanced directive. Although Resident #12 was able to make her/his own health care decisions, the spouse signed the advance directive. In addition, the facility failed to clarify the Code status of Resident #72, 1 of 1 resident with a request to make a change in an advance directive. The findings included: The facility admitted Resident #12 with [DIAGNOSES REDACTED]. Review of the [DATE] through [DATE] Physician's Cumulative Orders on [DATE] at approximately 12:00 PM revealed an order for [REDACTED].#12 had been examined by the physician and was competent to make health care decisions. Review of the Request Concerning Life-Prolonging Procedures for Resident #12 revealed the resident's spouse had signed the form on [DATE] requesting no .Cardiopulmonary Resuscitation (CPR), Use of respirators or ventilators, Blood transfusion, Administration of medications other than those necessary to prevent infection, provide comfort or alleviate pain, and Transfer to an acute care hospital. During an interview on [DATE] at approximately 4:30 PM, Licensed Practical Nurse #2 reviewed the record and confirmed the above finding. S/he stated, Social Services assists the family in these matters. During an interview on [DATE] at approximately 12:05 PM, Social Service Staff #1 reviewed the record and confirmed that Resident #12 had not signed the Request for Life-Prolonging Procedures although the physician had deemed him/her capable of making his/her own health care decisions. The facility admitted Resident #72 with [DIAGNOSES REDACTED]. Record review on [DATE] at approximately 3:30 PM revealed the ,[DATE] Physician's Order Recapitulation that noted the resident as a Full Code. Further review of the resident's medical record revealed [REDACTED].#72 was a Full Code. Record review on [DATE] at approximately 4:00 PM revealed a Nurses Note that Resident #72 had expired. The following was noted in Resident #72's Nurses Notes: [DATE] 5:05 PM Resident's condition remains unchanged. Wife at bedside. Both pupils in eyes are fixed .Doctor comes in facility and made aware of resident condition and wife wanting to make resident a DNR (Do Not Resuscitate) Code Status. [DATE] 6:15 PM Code Status DNR, new order [MEDICATION NAME] . [DATE] 7:50 PM Called into room via nurse. Witness resident taking last 2 breaths faint pulse noted, carotid pulse present faint. [DATE] 7:52 PM Call to resident room by Nurse, assess resident for pulse, no pulse, assess b/p (blood pressure) no b/p, look for rise and fall of chest for 1 min(ute) no movement. Auscultate lung, no sound, used stimuli, no response. Assess pupils no reaction fixed and dilated. [DATE] 8:15 PM Medical Director (MD) made aware. Review of the Advanced Directives Notification and worksheet signed and dated on [DATE] stated I do not want CPR: Do Not Attempt Resuscitation (Allow Natural Death). Review of the Resident's Durable Power of Attorney did not include health care decision making. Record review on [DATE] at approximately 4:45 PM revealed that staff had failed to record the Physician's Telephone Order for the change from a Full Code to DNR status for Resident #72. During an interview on [DATE] at approximately 5:23 PM, Licensed Practical Nurse (LPN) #4 stated that the resident's spouse came to them crying and stating s/he wanted Resident #72 to be a DNR because of her/his condition. LPN #4 stated s/he paged the resident's attending physician. However, s/he never responded. S/he notified another physician in the building and the resident's spouse told the physician that s/he wanted Resident #72 to be a DNR. LPN #4 stated s/he could not remember if a physician's order was signed at the time. During an interview on [DATE] at approximately 9:11 AM, the Medical Director confirmed there was no DNR order in the resident's medical record. The Medical Director stated, The resident should not have been resuscitated as a verbal order. However, the nurse did fail to document and write a DNR order for the physician to sign. The MD further stated that the nurse did not follow through with his/her responsibility in writing the order. The Director of Nursing needs to talk with nurses and discuss the importance, but I feel the nurse did her job by not resuscitating the resident. , Review of the policy entitled Initiation of Cardio-Pulmonary Resuscitation stated: The nursing home acknowledges its responsibility to provide basic life support, including initiation of Cardio-Pulmonary Resuscitation (CPR), to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directives, or in the absence of advance directives or a DNR order. Section 3 Procedures: B.CPR shall be initiated by qualified staff to a resident or patient that has experienced [MEDICAL CONDITION] unless: 1.) a valid DNR order is in place . | 2018-11-01 |
| 5575 | SANDPIPER REHAB & NURSING | 425146 | 1049 ANNA KNAPP BOULEVARD | MOUNT PLEASANT | SC | 29464 | 2015-04-01 | 155 | D | 0 | 1 | RGIM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record review and interview the facility failed to ensure that rights were protected regarding advanced directives for 2 out of 38 residents reviewed for advanced directives. Resident #189 did not have two physicians signatures to determine the resident's capacity to make health care decisions and Resident #165's medical decisional capacity form had not been signed by the next of kin. The findings included: Record review of Resident 165's medical decisional capacity revealed that it had been signed by her/his grandson. The physician signature on this form was 5/1/13. Review of the Durable Power of Attorney (POA) paperwork named Resident #165's son as power of attorney on 1/22/13. Resident #165's son is also the resident's next of kin. In an interview on 4/1/15 at 10:07 AM the facility Administrator confirmed that the POA or the resident would sign for a do not resuscitate order. The facility admitted Resident #189 with [DIAGNOSES REDACTED]. Review of Resident #189's medical record on 3/31/2015 at approximately 10:30 AM revealed a form titled, Medical Decisional Capacity. The form read, According to the Adult Health Care Consent Act, all health care decisions will be made in order of priority by: and contained the spouse's name. Resident #189 had not been deemed unable to make his/her healthcare decisions by 2 physicians. Further review of the medical record for Resident #189 on 3/31/2015 at approximately 10:30 AM revealed a Power of Attorney giving his/her spouse the right to make all healthcare decisions once he/she was deemed unable to make health care decisions for him/herself. Another form was found in medical record titled, Emergency Medical Services, Do Not Resuscitate Order, signed by his/her physician and his/her spouse. This form was notice to emergency medical services personnel only if he/she were transported out of the facility by medical transport. During an interview on 3/31/2015 at approximately 10:45 AM with Registered Nurse #1, he/she stated, the EMS form for medical transport is the form this facility uses for the code status. At this time he/she confirmed that 2 physicians had not deemed Resident #189 unable to make his/her own health care decisions. On 3/31/2015 a Medical Decisional Capacity form was signed by 2 physicians. | 2018-11-01 |
| 5621 | PRINCE GEORGE HEALTHCARE CENTER | 425295 | 901 MAPLE STREET | GEORGETOWN | SC | 29440 | 2015-01-15 | 155 | D | 0 | 1 | JQ1711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were afforded the opportunity to formulate an Advance Directive for 1 of 18 residents reviewed for Advance Directives. (Resident #9) The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the Advance Directives section of the medical record revealed that the Medical Intervention Guideline form was not signed by the resident. Information on this form indicated, It is your right to make important decisions regarding life-sustaining treatment. This Medical Intervention Guideline Form provides you the opportunity to inform us of your desires regarding treatment. Further record review revealed there was no determination by two physicians to indicate that Resident #9 was unable to make his/her own healthcare decisions as required under Section 44-66-20 of the Adult Health Care Consent Act. During an interview on 1/15/15 at approximately 2:15 PM, the facility's Social Worker stated that it was his/her process to interview residents to determine their ability to sign an Advance Directive; and if unable to sign, two physicians would certify that the resident was unable to make healthcare decisions, and a representative would sign the Advance Directive. The Social Worker reviewed Resident #9's record and verified that the form attesting to Resident #9's decision-making capacity was missing from the record. The Social Worker stated that he/she would provide the form when located. On 1/15/15 at approximately 3:26 PM, the surveyor was informed that the form had not been located. No form was provided prior to exit from the facility. | 2018-11-01 |
| 5622 | PRUITTHEALTH- NORTH AUGUSTA | 425296 | 1200 TALISMAN DRIVE | NORTH AUGUSTA | SC | 29841 | 2015-04-17 | 155 | D | 0 | 1 | 7XNV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to afford the opportunity to formulate an Advance Directive for 1 of 27 residents reviewed for Advance Directives (Resident #129). The findings included: The facility admitted Resident #129 with [DIAGNOSES REDACTED]. Review of the Advance Directives section of the medical record revealed a South Carolina Emergency Medical Services form for a Do Not Resuscitate Order signed by Resident #129's Responsible Party upon admission. Further record review indicated the resident's Responsible Party also signed an Advance Directives Checklist and a DNR Authorization Form for Patient/Resident Without Decision-Making Capacity: Florida, North Carolina & South Carolina upon admission. Further record review revealed there was no form signed by two physicians indicating Resident #129 did not have decision-making capacity and was unable to make his/her own healthcare decisions as required under Section 44-66-20 of the Adult Health Care Consent Act. On 4/16/14 at approximately 4:00 PM, the facility's Admissions Director reviewed the paperwork related to the Advance Directives and confirmed that the form signed by two physician's attesting to Resident #129's decision-making capacity was missing from the record. | 2018-11-01 |
| 5759 | COVENANT TOWERS HEALTHCARE CENTER | 425382 | 5001 LITTLE RIVER ROAD | MYRTLE BEACH | SC | 29577 | 2015-01-29 | 155 | D | 0 | 1 | EI2O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of the Resident Handbook, the facility failed to afford 1 of 6 residents the right to formulate an Advance Directive. Resident #56 had not been deemed unable to make own healthcare decisions concerning his/her Advance Directive/health care decisions by 2 physicians. The findings included: The facility admitted Resident #56 with [DIAGNOSES REDACTED]. Review of Resident #56's medical record on 1/27/2015 at approximately 12:04 PM revealed a form titled, Certification of Patient's Inability to Consent to Health Care Decisions, signed by only 1 physician and not the required 2 physicians. Further review of the medical record revealed a form titled, Do Not Resuscitate (DNR) Consent, signed by Resident #56's daughter on 1/23/2015. Resident #56 has the authority to make his/her own health care decisions until deemed unable to make own health care decisions by 2 physicians. During an interview on 1/27/2015 at approximately 12:10 PM with the Assistant Director of Nursing, he/she confirmed, after chart review, the Certification of Patient's Inability to Consent to Health Care Decisions, had been signed by only 1 physician and the not the required 2 physicians. Review on 1/27/2015 at approximately 12:30 PM of the Resident Handbook, page 14, Section titled, Code Status Request, states, A code status request is a physician's orders [REDACTED]. The resident's wishes will be made known through the signing of a code status request by the resident or a legally designated representative. The code status request will be signed by the attending physician and one other physician and will become part of the medical record at Covenant Towers. and the following section titled, Absence of an Advanced Directive, states, Competent residents will have the right to make all decisions regarding their health care. If an individual is deemed incompetent by the designation of the attending physician and one other physician or a legal entity and has not performed an advanced directive of any form, the resident may still have health care decisions made on his or her behalf through a court appointed guardian, typically a family member. | 2018-10-01 |
| 5871 | GOLDEN AGE - INMAN | 425316 | 82 N MAIN STREET | INMAN | SC | 29349 | 2015-03-05 | 155 | D | 0 | 1 | YNC111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of the facility policy entitled Advance Directives, and review of the South Carolina Adult Healthcare Consent Act, the facility failed to ensure that 1 of 15 sampled residents reviewed had the opportunity to develop their own advance directive. There was no documentation in the record to indicate Resident #23 desired a Do Not Resuscitate DNR status. An Emergency Medical Services EMS order for DNR was signed by the resident's Responsible Party. Two physicians had not determined that Resident #23 was unable to make his/her own healthcare decisions. The findings included: The facility admitted Resident #23 with [DIAGNOSES REDACTED]. Record review on 3/4/15 at 3:18 PM revealed current Physician's Orders for a DNR code status for Resident #23. Further review revealed a Physician's Telephone Order dated 8/13/13 stating Res(ident) is DNR since 8-8-13. A Progress Note Addressing Decisional Capacity dated 8/15/13 revealed one physician had signed that the resident was not able to make healthcare decisions for him/herself. A Nurse Practitioner's Progress Note dated 7/31/13 documented This patient lacks decision-making capacity. There was no documentation noted that a second physician had certified that the resident lacked decisional capacity. There was nothing noted in the record to indicate that facility staff had spoken with the resident about his/her code status and that a DNR status was what the resident desired. There was nothing noted in the record to indicate the resident was on hospice. During an interview on 3/4/15 at 3:40 PM, the Director of Nursing (DON) reviewed the documentation in the medical record and verified there was no evidence that 2 physicians had determined that Resident #23 was unable to make his/her own healthcare decisions. The DON stated s/he would check the thinned records to see if additional documentation could be found. During an interview on 3/5/15 at 11:27 AM, the Social Services Director (SSD) stated they could find no additional information. The SSD verified that 2 physicians had not determined that Resident #23 was unable to make his/her own healthcare decisions. When asked, the SSD stated s/he could not find documentation that the DNR was the resident's wishes. A review of the policy provided by the facility entitled Advance Directives revealed The resident has a right to .formulate an advance directive in accordance with state and federal law . According to the policy, on admission, .If a resident has not executed an advance directive and the resident has the capacity to make health care decisions, the social services department should contact the resident to determine whether the resident wishes to make an advance directive . Review of the South Carolina Adult Healthcare Consent Act Section 44-66-20 revealed that Unable to consent means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner . A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient. However, in an emergency the patient's inability to consent may be certified by a health care professional responsible for the care of the patient if the health care professional states in writing in the patient's record that the delay occasioned by obtaining certification from two licensed physicians would be detrimental to the patient's health. A certifying physician or other health care professional shall give an opinion regarding the cause and nature of the inability to consent, its extent, and its probable duration | 2018-08-01 |
| 5972 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2015-02-05 | 155 | D | 0 | 1 | SO3Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to afford 2 of 17 sampled residents the opportunity to formulate their own advance directives. A review of Physician order [REDACTED].#38 revealed orders for a Do Not Resuscitate (DNR) status. The documentation in the records indicated that the residents' Responsible Parties/family members had made the advance directive decisions, but there was no evidence that (2) physicians had determined that the residents were unable to make healthcare decisions at the time the orders were written. The findings included: The facility admitted Resident #38 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed A Physician's Telephone Order dated [DATE] for RESIDENT CODE STATUS IS DNR. A review of the facility's Advance Directives Checklist revealed the resident's Responsible Party had signed the form on [DATE]. There was a check next to the entry stating the resident had executed an advance directive and would provide a copy to the healthcare center. The resident had not signed this form. There was a blank in the space for the resident's signature. A review of the facility's Authorization of Do Not Resuscitate Order With Decision-Making Capacity revealed that the resident's Power of Attorney/Responsible Party had signed the form in the spot for the Patient/Resident's Signature on [DATE], stating s/he had been informed of and understood the risks and benefits of Cardiopulmonary Resuscitation (CPR) and did not want CPR (cardiopulmonary resuscitation) administered. There was no evidence in the physician progress notes [REDACTED]. Further review revealed no evidence that (2) physicians had determined the resident was unable to make healthcare decisions. During an interview on [DATE] at 1:32 PM, the Social Worker (SW) reviewed the code status documentation in the record. S/he verified the authorization form for the DNR status indicated Resident #38 had decision making capacity at that time though the form had not been signed by the resident. The Social Worker stated s/he would check to see if s/he had additional documentation. During an interview on [DATE] at 2:25 PM, the SW stated they had documentation from a prior facility showing the resident had been a DNR code status there, and that the resident had [DIAGNOSES REDACTED]. The Social Worker was unable to provide documentation that (2) physicians had determined the resident had been without decisional capacity at the time the DNR order had been written. When asked if there were any notes documenting the resident had requested a DNR status, the SW stated s/he had none at this time. The facility admitted Resident #35 with [DIAGNOSES REDACTED]. Record review on [DATE] at 1:23 PM revealed a Physician's Telephone Order dated [DATE] for DNR. A review of the facility's Advance Directives Checklist signed by Resident #35's spouse revealed that s/he had been given written materials on the resident's right to formulate advance directives on admission to the facility on [DATE]. DNR had been handwritten onto the form and underlined. There was a space for the resident's signature which had been left blank. A review of physician progress notes [REDACTED].#35 about his/her code status. There was no evidence in the current record that two physicians had determined the resident was unable to make healthcare decisions. On [DATE] at approximately 2:00 PM, the Director of Health Services (DHS) was informed of the concern that the resident had not been given the opportunity to formulate his/her own advance directive and requested any further information the facility might have. Upon checking for additional information, the DHS stated that a staff member was going to talk with the resident to determine the resident's wishes. On [DATE] at 4:00 PM, the Social Worker provided an Emergency Medical Services Do Not Resuscitate Order which had been signed by the resident on [DATE]. | 2018-07-01 |
| 6004 | PALMETTO HEALTH TUOMEY SUBACUTE SKILLED CARE | 425346 | 129 N WASHINGTON ST | SUMTER | SC | 29150 | 2016-02-19 | 155 | D | 0 | 1 | UXVO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Advance Directives/Advance Health Care Planning Documents, and General guidelines for Do Not Resuscitate Orders, Futility and Decisions to Forego or Withdraw Life-Sustaining Services, the facility failed to ensure 1 of 16 residents reviewed for Advance Directives were afforded the opportunity to formulate their own Advance Directives. No documentation could be found in the medical records to ensure Resident #78's repsonsible party was afforded the opportunity to formulate advanced directives. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Review on 2/18/2016 at approximately 4:00 PM of the medical record for Resident # 78 revealed a form titled, Certification of Patient's Inability to Consent to Health Care Decisions. The form was signed by two physicians and stated he/she did not have the ability to make his/her own health care decisions. Further review of the medical record on 2/18/2016 at approximately 4:00 PM revealed a physician's order for a DNR status dated 2/15/2016. Review on 2/19/2016 at approximately 8:15 AM of a,Palliative Care Narrative Note, (no signature) dated 2/15/2016 at 10:45 AM states, asked pt (patient) if he/she would want to be resuscitated if his/her heart stopped and he/she was not breathing. Pt said he/she would NOT want to be brought back, he/she requested DNR. NP (Nurse Practitioner) notified, order for DNR written. No documentation/signatures could be found in Resident #78's medical record to ensure these were the wishes of resident #78 and his/her Responsible Party/Family. No documentation could be found in Resident #78's medical record that the physician had discussed the code status with the Responsible Party/Family. Review on 2/19/2015 at approximately 9:20 AM of the facility policy titled, Advance Directives/Advance Health Care Planning Documents, states under section X11, Definition, under C. states, Advance Directives, means a written document used to record and communicate a person's wishes regarding future medical care. Review on 2/19/2016 at approximately 9:30 AM of the facility policy titled, General Guidelines for Do Not Resuscitate Orders, Futility and Decisions to Forego or Withdraw Life-Sustaining Services, under Section III, C. states, DNR Discussion:, Initiation of discussions concerning DNR status is appropriate and standard medical practice when the attending physician, with a reasonable degree of medical certainty, has determined that the patient has a terminal condition , is irreversibly comatose or in the process of dying for which resuscitation measures would probably be unsuccessful and would only serve to prolong the process of dying or promote suffering. Number 1. The attending physician plays the major role in discussing DNR decisions with the patient or the patient's surrogate decision maker. When a patient is unable to consent, the name of the surrogate decision maker is documented in the medical record . Number 2. states, The attending physician and patient (or surrogate decision makers) should have a discussion concerning [DIAGNOSES REDACTED]. | 2018-07-01 |
| 6016 | EMERITUS AT GREENVILLE | 425373 | 1306 PELHAM RD | GREENVILLE | SC | 29615 | 2014-12-18 | 155 | D | 0 | 1 | MXTQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the Do Not Resuscitate (DNR) Order was written by the physician for 1 of 5 sampled residents reviewed for advanced directives without evidence of discussion with the resident or the legal representative. Prior to the DNR order being written for Resident #10, there was no evidence of certification by two physicians of the resident's inability to make health care decisions or of involvement of the resident/legal representative in decision-making related to this order. There were also discrepancies in chart documents related to the resident's code status. The findings included: The facility admitted Resident #10, with current [DIAGNOSES REDACTED]. Record review on [DATE] revealed an Emergency Medical Services Do Not Resuscitate Order (not for use in the facility) signed by a family member on [DATE], the day after admission. The Care Plan initiated the same date noted Code Status is DNR. The hospital Discharge Summary stated: Husband requests full code. Record review on [DATE] at approximately 4:00 PM revealed discrepancies with the DNR order and the History and Physical Notes/Progress Note History by the physician. The DNR order was written on [DATE]. The History and Physical of the same date ([DATE]) noted: Code Status: Full Scope of Treatment. The Progress Note History by the Nurse Practitioner dated [DATE] and [DATE] stated: Code Status: Full Scope of Treatment. Review of the [DATE] Admission Minimum Data Set Assessment revealed a Brief Interview for Mental Status score of 99 indicating the resident was unable to complete the interview. S/he was noted with both long- and short-term memory problems and with moderately impaired cognitive skills for daily decision-making. There was no documentation found in the record related to resident or legal representative involvement in decision making regarding the DNR order. On the [DATE] Physician's Progress Notes, the physician wrote, Agree pt (patient) lacks decisional capacity re: (reference) CPR but no evidence was found in the record of another physician's initial evaluation of the resident's ability to make health care decisions. During an interview with the Medical Records Coordinator on [DATE] at approximately 4:15 PM, s/he stated that the facility did not use a form for determination of health care decision making capacity or for the resident or legal representative to sign to make decisions about health care. Also, s/he was unaware that two physicians were required to evaluate and determine the resident's inability to make health care decisions. | 2018-07-01 |
| 6121 | RIDGELAND NURSING CENTER INC | 425132 | 1516 GRAYS HIGHWAY | RIDGELAND | SC | 29936 | 2014-04-17 | 155 | D | 0 | 1 | 0N2F11 | **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 assess Resident #47 to determine decision-making capacity for health care decisions. (1 of 20 sampled residents reviewed for the ability to make health care decisions.) Resident # 47's decision related to advanced directives were signed for by a family member without first determining the resident's ability to make his/her own healthcare decisions. The findings included: The facility admitted Resident #47 with the [DIAGNOSES REDACTED]. Review of the resident's medical record on 4/15/14 at approximately 3:26 PM, revealed Resident #47 had a Do Not Resuscitate (DNR) order as an Advance Directive. Further review of the medical record revealed there was no documentation the resident had been assessed for decision-making capacity for health care decisions. Review of the Request Concerning Life-Prolonging Procedures form noted that the resident was a DNR and it had been signed by the resident's daughter During an interview on Interview on 4/16/14 at approximately 10:13 AM with the Social Services Director, s/he stated that Resident #47's son (not the daughter) was the designated Health Care Power of Attorney and additionally verified that the resident had not been assessed for decision-making capacity. | 2018-05-01 |
| 6232 | PRESBYTERIAN COMMUNITIES OF SOUTH CAROLINA- CLINTO | 425393 | 801 MUSGROVE STREET | CLINTON | SC | 29325 | 2015-02-19 | 155 | D | 0 | 1 | UWQF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and a review of the facility policy entitled Advance Directives, the facility failed to provide 1 of 6 sampled residents the opportunity to formulate his/her own advance directive. A Do Not Resuscitate (DNR) order was written for Resident #30 at the direction of the resident's Responsible Party (RP) without documentation that 2 physicians had determined the resident was unable to make healthcare decisions or that this was the resident's wishes. The findings included: The facility admitted Resident #30 with [DIAGNOSES REDACTED]. Record review on [DATE] at 4:10 PM revealed a [DATE] Physician order for [REDACTED]. Further review revealed the resident's RP had signed a request on [DATE] for Resident #30 to not have CPR performed under any circumstances. The RP had signed this request in the space designated for the Power of Attorney/RP for a resident certified as unable to sign. The space designated for a competent resident to sign had been left blank. Review of the facility form Attachment F, Certification of Patient's Inability to Consent to Health Care Decisions, revealed the following: According to the South Carolina Adult Health Care Consent Act, Section [DATE], a patient's inability to consent must be certified by two licensed physicians . According to the document, 2 physicians were to verify that a patient was considered unable to consent to healthcare procedures. The form contained only 1 physician signature dated [DATE]. A review of Progress Notes revealed a Social Services note dated [DATE] at 8:43 AM which documented the resident was a DNR with durable Power of Attorney (POA) for healthcare provisions. During an interview on [DATE] at 4:38 PM, when asked about the resident's code status, Licensed Practical Nurse (LPN) #1 reviewed the chart and stated the resident was a DNR. LPN #1 verified the documentation that the resident's RP had signed for the DNR status and that only 1 physician had signed the inability to consent form. The nurse thought that a copy of the form was in the physician's folder awaiting his/her signature as the 2nd physician. According to the nurse, the 2nd physician did not come to the facility as often as the attending physician did. During an interview on [DATE] at approximately 4:45 PM, the Director of Health Services (DHS) verified the Physician Orders conflicted with the resident's code status of DNR. The DHS stated that when the resident had been in Assisted Living, s/he had been a full code. During an interview on [DATE] at 5:01 PM, the Social Services Director (SSD) stated Resident #30 would not be coded if his/her heart stopped based on the RP's wishes for the DNR status. According to the SSD, s/he had attempted to speak with the resident about his/her code status but the resident did not or was not able to give a response. A review of the policy provided by the facility on [DATE] at 7:55 AM entitled Advance Directives revised [DATE], revealed that Advance directives will be respected in accordance with state law and facility policy .8. If a resident or health care designee chooses to have a DNR order, the resident or health care designee will sign the appropriate documents. The resident will always sign his or her DNR sheet unless they have been determined unable to make health care decisions by two physicians. | 2018-05-01 |
| 6235 | PRESBYTERIAN HOME OF SOUTH CAROLINA-COLUMBIA | 425396 | 700 DAVEGA DRIVE | LEXINGTON | SC | 29073 | 2015-07-29 | 155 | D | 0 | 1 | 79QP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not have all required paperwork for advanced directives for Resident #13 (1 of 10 residents reviewed for advance directives). The findings included: The facility admitted the resident with [DIAGNOSES REDACTED]. Record review on 7/28/15 revealed the resident had a physician order [REDACTED]. The resident was transported to the hospital the day after admission. On return to the facility, the resident's cognitive level had changed. No new documents had been filled out by the facility. During an interview on 7/28/15 with the Social Service Director, he/she stated if residents were not able to make their own decisions, the facility did not have 2 physicians on staff nor any way to be able to have 2 physicians to determine if residents were able to make their own health care decisions. At the time of readmission, the resident had confusion and a BIMS (Brief Interview for Mental Status) score of 7. Interview with the Director of Nurses and LPN (Licensed Practical Nurse) #1 revealed both nurses would look at the physician's orders [REDACTED]. The resident was still noted as DNR without proper documents being present. | 2018-05-01 |
| 6292 | MAGNOLIA MANOR - ROCK HILL | 425165 | 127 MURRAH DR | ROCK HILL | SC | 29732 | 2015-02-12 | 155 | D | 0 | 1 | 8QX711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to offer the opportunity to determine whether or not they wished to formulate an advance directive for Residents #6 and #12, 2 of 17 residents reviewed for advance directives. The findings included: Resident #6 was admitted to the facility with [DIAGNOSES REDACTED]. On 2/9/15 at 4:12 PM, record review revealed the resident's daughter had signed the Advance Directive Acknowledgment electing not to execute an advance directive at the time of admission on 4/18/13. Further review revealed that two physicians had determined that the resident was not able to make their own healthcare decisions at this time at the time of admission. Continued review revealed that on 7/31/13 and on 4/30/14, the attending physician had determined that the resident was able to make their own healthcare decisions at this time. Review of the Initial Social Service History dated 4/18/13 and the Social Service Review dated 4/26/13 indicated the resident was a Full Code. Social Service Reviews dated 7/25/13 and 4/8/14 indicated the resident was a DNR. Review of the Social Services Progress Notes revealed a note dated 5/15/13 that Code status was (changed) to DNR (Do Not Resuscitate) per family request on 5/11/13. Further review revealed no documentation in the Social Service Progress Notes that anyone had discussed with the resident the opportunity to formulate an advance directive after being determined to be able to make her/his own healthcare decisions. During an interview on 2/11/15 at approximately 2:50 PM, the Social Services Director (SSD) confirmed the resident's responsible party, the daughter, had requested the DNR in May when the resident was not able to make healthcare decisions. The SSD also confirmed that no paperwork was obtained from the resident related to an advance directive. The SSD stated s/he had discussed it with the resident but just didn't document the discussion or the resident's wishes. The facility admitted Resident #12 with [DIAGNOSES REDACTED]. On 2/9/15 at 4:35 PM, record review revealed an Advance Directive Acknowledgment signed by the resident's spouse on admission. Further review revealed a Health Care Decision Form signed by the physician and dated 2/4/15 that stated the resident was able to make their own healthcare decisions at this time. Review of the Social Service Review dated 2/4/15 and Social Service Progress Notes revealed no documentation that advance directives were discussed with the resident. During an interview on 2/10/15 at 12:55 PM the Social Services Director (SSD) confirmed the decision to not formulate an advance directive was signed by the spouse. The SSD also confirmed the physician had documented the resident was capable of making her/his own healthcare decisions. The SSD further confirmed there was no documentation that the opportunity to make the decision was offered to the resident. | 2018-04-01 |
| 6303 | CARLYLE SENIOR CARE OF FOUNTAIN INN | 425168 | 501 GULLIVER ST | FOUNTAIN INN | SC | 29644 | 2014-10-28 | 155 | D | 0 | 1 | GU8V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and the facility's Do Not Resuscitate Policy, the facility failed to ensure 2 of 6 sampled residents reviewed for rights to formulate an advance directive were afforded the opportunity to sign their own advance directive. There was no documentation by two physician's to determine that Residents #82 and #58 lacked the capacity make their own health care decisions related DNR (Do Not Resuscitate). The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. Record review on 10/28/14 at approximately 10:37 AM revealed Resident #82 Code Status was DNR (Do not Resuscitate). Further record review revealed a Certification of Resident Inability to Consent statement in the medical record with one physician's signature. However,the ability to consent or not consent box was unchecked. During an interview on 10/28/14 at approximately 3:45 PM with the DON (Director of Nursing), the information was verified. On 10/27/2014 2:34 PM, record review of the monthly physician's orders [REDACTED]. The medical record for Resident #58 had a form stating that the resident lacked capacity to make health care decisions. The Certification of Resident's inability to consent form was signed by the same physician in two areas that required two different physician's to verify the lack of capacity to make health care decisions. In an interview with the Director of Nursing (DON) at approximately 2:50 PM on 10/27/14, the DON verified that the signatures were from the same physician. Review of the facility provided policy for Do Not Resuscitate policy provided by the Director of Nursing revealed under #3. If a resident is unable to comprehend their rights as well as make healthcare decisions for themselves, documentation supporting this inability shall be made by two physicians. | 2018-04-01 |
| 6347 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2014-11-25 | 155 | D | 0 | 1 | YE6D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and the facility's document titled Understanding CPR the facility failed to ensure 1 of 12 sampled residents reviewed for rights to formulate an advance directive were given the opportunity to sign their own advance directive. There was no documentation of two physician's signatures to determine that Resident #163 could not make their own health care decisions related to Do Not Resuscitate (DNR). The findings include: The facility admitted Resident #163 with the [DIAGNOSES REDACTED]. Review of Resident #163's medical record on [DATE] at approximately 4:11 PM revealed the resident was a Do Not Resuscitate (DNR). Further review of the medical record revealed the resident's advanced directives. Review of the facility document titled Code Status noted there will be no heroic measures provided in emergency situations. The resident will remain at the facility and kept comfortable. Oxygen would be provided and comfort measures will be provided as ordered by the physician. CPR would not be provided. This document was signed by the resident's responsible party along with 2 witnesses and one physician. Further review of Resident #163's medical record on [DATE] revealed a form titled Understanding CPR that noted CPR is emergency medical procedure used in an attempt to restore circulation and respiration, which have ceased. The section under Limited Treatment Policy stated the policy is that all residents will be provided health care unless the attending physician enters a contrary order in the resident's medical record. Incompetent Resident: Law permits decisions to be made on behalf of a resident who lacks decisional capacity in several ways .If when competent, the resident has executed a declaration of desire for a natural death in accordance with State law, then life-prolonging treatment can be withheld in accordance with the resident's instructions set forth in the living will. Resident #163's medical record revealed no living will specifying the resident's desire for a natural death, nor two physician's signature deeming the resident incompetent to make health care decisions. During an interview with Director of Nursing on [DATE] at approximately 10:04 AM, s/he confirmed the resident did not sign his/her advanced directives and that the resident had not been deemed incompetent by two physicians. During an interview with the Social Services Director on [DATE] at approximately 11:25 AM: s/he confirmed that the facility does not get two physician signatures deeming residents incompetent if they do not sign their advance directives. S/he further stated residents normally come in confused and do not want to sign forms. Advanced directives are discussed during admission and whenever the family or residents want it changed. | 2018-04-01 |
| 6361 | THE RETREAT AT BRIGHTWATER | 425395 | 171 BRIGHTWATER DRIVE | MYRTLE BEACH | SC | 29579 | 2014-09-12 | 155 | D | 0 | 1 | TYTC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and review of the facility policy titled Health Care Decision Making, the facility failed to provide 2 of 9 residents out of a total sample of 28 reviewed for Advanced Directives the opportunity to make Health Care Decisions. Resident #14 and Resident #73 had been deemed able to comprehend and have the capacity to make Health Care Decisions (including Advance Directives) by their Attending Physician. Resident #14 and Resident #73 had Advance Directives signed by a family member and not the residents. The findings included: The facility admitted Resident #14 with [DIAGNOSES REDACTED]. Record review on 09-11-14 at approximately 9:15 AM of the Face Sheet revealed Resident #14's Advanced Directives were noted as Durable Power of Attorney, Do Not Resuscitate (DNR). Additional record review on 09-11-14 at approximately 9:15 AM of the Physician's Telephone Orders revealed an undated Physician's Order of Do Not Resuscitate (DNR). Review of the Cumulative Physician's Orders dated 09-01-14 through 09-30-14, 08-01-14 through 08-31-14, and 07-11-14 through 07-31-14 revealed the following, Code Status: Full Code. Further record review on 09-11-14 at approximately 9:20 AM of the Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07-18-14 noted a Brief Interview for Mental Status (BIMS) score of 13 out of a possible total score of 15. Record review on 09-11-14 at approximately 9:20 AM of The Retreat at Brightwater Advanced Directive Checklist for Resident #14 revealed the following, I have executed an Advance Directive and will provide a copy to the facility or services. I understand that the staff of the Retreat at Brightwater will not be able to follow the terms of my Advance Directive until I provide a copy of it to the staff. It had been signed by Resident #14's family member on 07-11-14. Additional record review on 09-11-14 at approximately 9:20 AM of the Brightwater Level of Comprehension signed by the Attending Physician for Resident #14 revealed the following, We certify that Resident #14 is able to comprehend the Resident's rights and responsibilities of this facility and is able to make Health Care Decisions (including Advance Directives). During an interview on 09-11-14 at approximately 10:22 AM with Social Service Worker #1, he/she, after record review, stated, the resident may have been groggy when he/she came in and the family signed for him/her. He/she is a DNR. During an interview on 09-11-14 at approximately 10:30 AM with Registered Nurse (RN) #3, he/she revealed Resident #14 was a DNR. During an interview on 09-11-14 at approximately 10:30 AM with Social Service Worker #2, he/she stated, the Facility Admission Packet with Advanced Directives is given and explained to the resident's family upon admission because normally the family member processes the admission paperwork as residents are often admitted from the hospital. Resident #14's family member signed the paperwork. I might have gone in to see him/her and to know what his/her wishes were related to Advanced Directives. The resident is a Full Code until the physician signs the DNR orders. Review on 09-11-14 of the facility policy titled, Health Care Decision Making, revealed the following: i.e Purpose: To provide residents the opportunity and knowledge necessary to make their health care decisions known. The facility admitted Resident #73 with the [DIAGNOSES REDACTED]. Review of the Minimum Data Set with the assessment reference date of 9/1/14 specified the resident had cognitive impairment. Review of Resident #73's medical record on 9/10/14 at approximately 4:11 PM revealed the resident was a Do Not Resuscitate (DNR). Further review of the medical record revealed the residents advanced directives.Review of the facility document titled Level of Comprehension noted the resident is able to comprehend the residents rights and responsibilities of the facility and is able to make health care decisions including advanced directives. This document was signed by the physician on 3/23/14. Another Level of Comprehension was completed for the resident with the date of 7/17/14 that noted the resident is able to comprehend the residents rights and responsibilites and is able to make health care decisions. There was no documentation in place that had the resident's signature or notation that they agreed with being a DNR. During an interview with Director of Nursing on 9/11/14 at approximately 10:04 AM, s/he confirmed the resident did not sign his/her advanced directives and that the resident had not been deemed incompetent by two physicians. During an interview with the Social Worker on 9/11/14 at approximately 2:00 PM s/he stated that that hospice does not use the level of comprehension form as it is a facility form. The Social Worker further stated that the resident was able to make decisions, but had a decline and was admitted to hospice. The Social Worker confirmed the facility failed to obtain a physician assessment on Resident #73's abiltiy to make health care decisions. | 2018-04-01 |
| 6396 | MOUNT PLEASANT MANOR | 425110 | 921 BOWMAN ROAD | MT PLEASANT | SC | 29464 | 2014-06-30 | 155 | D | 0 | 1 | QRXS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews, and review of the facility policy titled, Do Not Resuscitate , the facility failed to afford 2 of 19 sampled residents reviewed for Code Status the right to formulate their own Advanced Directives. Resident #52 and Resident #76 had not been deemed to lack capacity by 2 Physicians to make their own Advanced Directives/healthcare decisions. The findings included: The facility admitted Resident #52 with [DIAGNOSES REDACTED]. Record review on 06-25-14 at approximately 4:30 PM of the Physician's Telephone Orders dated 04-15-14 revealed the following order, .i.e .Do Not Resuscitate (DNR). Further record review on 06-25-14 of the Medical Decision Capacity for Resident #52 revealed only one Physician had determined Resident #52 to have all medical decisions made by others , not the required 2 Physicians. The resident's daughter had signed the Resuscitation designation form instead of the resident. During an interview on 06-25-14 at approximately 4:37 PM with the Director of Social Services, h/she, after chart review, verified the Medical Decision Capacity for Resident #52 had been signed by 1 Physician, not the required 2 Physicians. Review of the facility policy titled Do Not Resuscitate revealed in Section III. Basic requirements for facility Do Not Resuscitate order policy the following, (f.) Incompetent Patient- An adult who is unable to appreciate the nature and implications of his condition, to make reasoned decisions concerning his care, or to communicate decisions concerning his care. This incapacity must be verified by clinical assessment of the patient by 2 physicians, unless the individual was previously declared legally incompetent by court order. The facility admitted Resident #76 for Short-Term Rehab following hospitalization with [DIAGNOSES REDACTED]. Review of the Advance Directives section of the medical record revealed the resident's daughter signed the Resuscitation Designation form indicating the resident's code status was DNR. The physician had signed this form as well. Review of the Medical Decision Capacity form indicated one physician had signed this form indicating the resident lacked decision-making capacity. The section of the form reserved for a second physician's signature attesting to the resident's capacity contained documentation which stated, See H & P (History and Physical) & D/C (discharge) summary dated 2/18/14. Review of the hospital Discharge Summary indicated that the resident's granddaughter was the Healthcare Power of Attorney. Review of the facility's Social Services Evaluation form upon admission indicated , Resident's daughter is her RP and HCPOA (Healthcare Power of Attorney.) A DNR was signed by daughter and MD. Further record review indicated the resident signed a Durable Power of Attorney prior to admission designating his/her daughter as the Durable Power of Attorney. Review of the document indicated it did not address the right to make health-care decisions for the resident. Additional documentation was requested related to the family member signing the Advance Directive form without two physician's attesting to the resident's capacity to make healthcare decisions. The Director of Nursing reviewed the medical record and confirmed that the record contained only the Durable Power of Attorney. | 2018-03-01 |
| 6525 | THE RIDGE REHABILITATION AND HEALTHCARE CENTER, LL | 425293 | 226 WA REEL DRIVE | EDGEFIELD | SC | 29824 | 2017-05-10 | 155 | E | 1 | 1 | T7X811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility record review, the facility failed to honor residents rights regarding refusal of medications for 3 of 6 residents reviewed for behaviors. Residents #86, #112 and #71 were administered medications against their will. The findings included: In response to facility reported incidents of resident's given medications against their will an investigation was conducted during the Recertification Survey. Residents #86 and #112 had a history of [REDACTED]. The facility admitted resident #112 with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS) of 12/6/16 and Annual MDS of 3/3/17 revealed the resident was severely cognitively impaired with Brief Interview for Mental Status (BIMS) score of 2 and 3 out of 15. Review of the Resident's care plan revealed a problem with behaviors. History of verbal and physical aggression with staff and others, refusal to take meds, refusal to allow staff to assist with ADL's care and mobility tasks r/t [DIAGNOSES REDACTED], and [MEDICATION NAME] Hemorrhage. 4/24/17 4:20 PM The Surveyor attempted to interview the resident. The resident was sitting in Rock-n-go with alarm at the nurses station. Don't want you around. My name is -------. The resident's speech was slurred and difficult to understand. The resident was agitated and not able to answer questions. The facility admitted resident #71 with [DIAGNOSES REDACTED]. Review of Nurses Notes revealed resident had behaviors of hitting staff, cursing and refusing therapy treatments and refused to allow staff to assist. 4/24/2017 3:40 PM Resident observed lying in bed on back. TV on in room. Alert verbal. Doesn't remember anything about getting a shot through her clothes. Doesn't remember refusing to take [MEDICATION NAME] injection. I take shots all the time. On 4/24/17 at approximately 5:45 PM, Licensed Practical Nurse (LPN) #7 was interviewed by the surveyor. The LPN stated resident #112 reported to me, that the nurse forced him to take his/her medication, her/his name was -----(LPN #8). S/he asked the Certified Nursing Assistants (CNA's) to hold him/her down while s/he gave him/her an injection. I saw him/her do it. S/He was out in the lobby area acting out. I watched the CNA's hold him/her down. They did what they were told to do. I heard him/her say s/he did not want the shot. I reported it to the Director of Nursing (DON). Resident #86 was admitted to the facility with [DIAGNOSES REDACTED]. On 4/24/2017 at approximately 3:50 PM the resident was observed, up in wheel chair, propelling self in hallways. The surveyor attempted to speak to resident. Resident glaring at surveyor, no verbal response to attempts at conversation. On 4/25/17 at approximately 11:30 AM the surveyor attempted to interview the resident s/he continued to glare when surveyor attempted to talk with resident. Attempts to interview, unsuccessful. Review of the medical record revealed an Annual MDS of 1/23/17. The resident's BIMS score was 3 out of 15. Behaviors were coded of delusions with no behaviors. A Quarterly MDS of 3/20/17 revealed the resident was not coded for delusions. Review of the care plan revealed an identified problem history of physical and verbal aggression toward staff and other residents. History of refusing medications, history of refusing staff assistance with ADL's and mobility tasks, hygiene and bathing. Interventions included to administer medication. Divert attention when possible and attempt to refocus behavior on something else. Review of the Nurses Notes from August 2016 through 4/24/17 revealed the resident frequently refused medications. Review of the facility investigation revealed a statement from LPN #10. The LPN observed LPN #9 give the resident a [MEDICATION NAME] injection through the resident's clothes, after the resident refused the medication. LPN #9 was interviewed by phone on 5/5/17 at 11:30 AM. The LPN stated the resident never refused medication from him/her. I had no problem giving him/her medication. S/he would put his/her arm out. I never had a problem with him/her. On 5/10/17 at approximately 10:30 AM LPN #10 was interviewed by the surveyor. I saw her/him (resident #86) get a [MEDICATION NAME] shot by LPN # 9, given straight to the resident through his/her clothes. I was told the resident refused his/her meds. The last time I saw it the resident was bleeding. I think it was his/her right arm. I witnessed LPN #9 several times around May or June of last year give the resident injections when the resident had refused. I had reported to the DON (Director of Nursing). Resident #71 was held down in her/his bed and given a shot. The resident said s/he did not want the [MEDICATION NAME] shot. It made her feel funny and gave him/her knots in his/her arms. I saw the resident be given the [MEDICATION NAME] two times. Based on Based on Based on | 2018-01-01 |
| 6579 | FLORENCE REHAB & NURSING CENTER | 425163 | 133 WEST CLARKE ROAD | FLORENCE | SC | 29501 | 2014-06-19 | 155 | D | 0 | 1 | T4HW11 | **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 afford one of 22 sampled residents reviewed the right to formulate his/her own advance directive. Resident #122 was not informed of nor afforded the right to formulate his/her own advance directive. The findings included: During multiple observations throughout the survey (on 6-16-14 at 3:24 PM and 4 PM; on 6-17-14 at 8:55 AM and 3 PM; on 6-18-14 at 9 AM, 11:45 AM; and on 6-19-14 at 8:40 AM), and during the Resident Interview during Stage 1 of the survey (6-17-14 at 9:48 AM), Resident #122 was able to respond reasonably to all questions posed. Record review on 6-17-14 at 3:45 PM revealed no [DIAGNOSES REDACTED]. Admission Nursing Assessments dated 6-3, 6-9, and 6-14-14 revealed no documented confusion or memory problems. Further review of the medical record revealed that the resident's family member signed the Advance Directives-Acknowledgement of Receipt form on 6-3-14, indicating the resident has chosen to formulate and issue an Advance Directive of Do Not Resuscitate (DNR). A physician's orders [REDACTED]. During an interview on 6-18-14 at 2:30 PM, Social Services verified that the resident's family had signed the advance directive instead of the resident. S/he stated that, since admission, Resident #122 had been able to answer questions appropriately and was a '12' on the BIMS (Brief Interview for Mental Status), indicating minimal cognitive impairment. Social Services stated s/he was confused about the middle category of BIMS being interviewable. | 2017-12-01 |