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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10266 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 281 | D | THIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, interviews and review of acceptable standards of practice for licensed staff , the facility failed to assure for 1 of 2 residents reviewed for accurate documentation related to a [MEDICAL TREATMENT] site that the documentation was thorough and accurate as entered. Resident #4 had documentation of thrill and bruit checks after the shunt site was changed and the physician discontinued the order. The findings included: The facility admitted Resident #4 on 6/26/09 with the following Diagnoses: [REDACTED]. The record review on 4/12/10 revealed a physician's orders [REDACTED]. Further review revealed another order written on 11/5/09 for removal of infected [MEDICAL TREATMENT] catheter and replacement of [MEDICAL TREATMENT] catheter- a tummeled catheter due to permanent placement access. During an interview with Registered Nurse (RN) #1 on 4/12/10 he/she stated " a thrill and bruit is not checked because the resident has a catheter in her right chest, the other site was removed." The nurse's notes revealed that Licensed Practical Nurse (LPN) # 2 documented in the notes "thrill felt and bruit heard" on the following dates 3/11/10, 3/13/10, 3/27/10 and 4/10/10. LPN #1 documented in the nurse's notes on 3/13/10 "bruit and thrill felt". LPN #3 documented in the nurse notes on 3/30/10 "thrill felt and bruit heard". During an interview with LPN #1 on 4/12/10 at 4 PM, when asked how he/she checked for a thrill and bruit, he/she stated "I just put the stethoscope above the catheter and hear a "LUB-DUB". During an interview with LPN #2 on 4/12/10 at 4:15 PM when asked how he/she checked for a thrill and bruit, he/she stated " you have to check that in the arm, but hers is in the chest". When ask why he/she documented that the thrill and bruit was checked, the LPN stated "I don't know". | 2014-01-01 | ||
| 10267 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 315 | D | THIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of facility policy and procedure, the facility failed to provide appropriate catheter care for one of one catheter treatments observed. The Registered Nurse (RN) failed to properly anchor the catheter tubing during Resident # 3's catheter care. The findings included: The facility admitted Resident #3 on 7/27/09 with the following Diagnoses: [REDACTED]. During the catheter care observation on 4/13/10 at 9:15 AM RN #2 failed to secure the tubing to prevent pressure from tugging of the suprapubic catheter while cleaning, then drying the tube. At 9:20 AM on 4/13/10 during an interview with RN #2 he/she stated when ask about anchoring the tube "I didn't anchor it because its in the stomach." The facility policy titled Catheter Care, Suprapubic, stated under Procedure #11 "Gently grasp the catheter with non-dominant hand and use clean wash cloth to work down the tubing approximately 6 inches" | 2014-01-01 | ||
| 10268 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2010-04-14 | 323 | E | THIH11 | On the days of the survey, based on observations and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible. Three bathrooms in the common area observed to be used by residents had no call light system in place. The findings included: A random observation on 4/12/10 revealed a female resident in a wheelchair coming out of the bathroom unsupervised directly across from the main dining room. Another random observation on 4/13/10 revealed a male resident in a wheelchair coming out of the bathroom unsupervised directly across from the main dining room. An inspection of the bathrooms 1. located on the back hall next to the main dining room, 2. the bathroom directly across from the main dining room and 3. the bathroom located between the beauty shop and the activity room, all revealed no call light system in place. During an interview with the Director of Nursing (DON) on 4/13/10 at 11:40 AM, he/she confirmed that "these bathrooms are used by everyone, staff, visitors and residents". The DON stated that "the residents are assisted". When he/she was informed of the observations of residents using the bathroom alone, he/she stated "well we do have some that can go by themselves." | 2014-01-01 | ||
| 9914 | AZALEAWOODS REHAB & NURSING CENTER | 425014 | 123 DUPONT DR | AIKEN | SC | 29801 | 2010-07-07 | 246 | D | 0 | 1 | 56KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interviews, the facility failed to use appropriate methods to accommodate 1 of 1 sampled resident's need for a bed that would be the correct length. The findings included: The facility admitted Resident #2 on 9/21/09 with [DIAGNOSES REDACTED]. During the initial tour on 7/6/10 at approximately 11:30 AM, the resident was observed in bed with his feet extended over the foot of the bed. During all days of the survey, the resident was observed in bed in the same situation , either with a folded towel or pillow under his feet. In an interview with a family member on 7/6/10 at 8:25 PM, he/she stated that when visiting, he/she would try to pull the resident up in order to be more comfortable. In an interview with the Administrator, Director of Nursing and Nursing Consultant on 7/7/10 at 10:35 AM, they stated that the resident would slip down in the bed. A later observation revealed a blue foam wedge between the end of the mattress and the foot of the bed. with the resident's feet on the wedge. | 2014-09-01 |
| 9915 | AZALEAWOODS REHAB & NURSING CENTER | 425014 | 123 DUPONT DR | AIKEN | SC | 29801 | 2010-07-07 | 281 | E | 0 | 1 | 56KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility nursing staff failed to provide care that met professional standards of practice for one of four sampled resident's reviewed with sliding scale insulin. The nursing staff failed to clarify incomplete sliding scale insulin orders and failed to transcribe the correct sliding scale insulin to the Diabetic Flow Chart for Resident # 9. Furthermore, the nurses failed to identify the discrepancy between the MAR (Medication Administration Record) and the Diabetic Flow Chart for Resident # 9 . In addition, the nursing staff failed to correctly reconcile Physician orders [REDACTED]. The findings included: The facility admitted Resident # 9 on 3/25/09 with [DIAGNOSES REDACTED]. On 7/6/10 review of the resident's clinical record revealed that the resident had returned to the facility on [DATE] with readmission orders [REDACTED]= 2 units, 201-250 = 4 units, 251- 300 = 6 units, 301-350 = 8 units. There were no additional orders for what to administer if the resident's blood sugars were above 350. Review of the June MAR (Medication Administration Record) revealed that the new sliding scale insulin order had been correctly transcribed to the MAR and nine different nurses had initialed that the sliding scale had been administered twice a day. Review of the Diabetic Flow Chart revealed that the nursing staff had failed to update the chart to reflect the new sliding scale parameters and the nurses had administered the insulin following the old parameters. Further review of the chart revealed that there were no additional orders written related to sliding scale insulin. Interview with LPN # 1 on 7/6/10 at approximately 2:45 PM revealed that he/she had written the readmission orders [REDACTED]. When questioned related to the sliding scale parameters stopping at 350, he/she stated that he/she did not clarify the order and that if the blood sugar was above 400, the nurse should call the Physician. When questioned what the nurse should do if the blood sugar was above 350 since there were no guidelines, LPN # 1 stated call the Physician. LPN # 1 confirmed that the facility nurses' had failed to update the Diabetic Flow Chart to reflect the new sliding scale parameters and should have. LPN # 1 confirmed that multiple nurses' had signed the MAR and not identified the discrepancy between the MAR and Diabetic Flow Chart. LPN # 1 was questioned if the facility had any system in place to identify this type of error and responded that a facility nurse checks that the resident is receiving the correct dose of insulin on a weekly basis. Interview with the facility DON (Director of Nurses) on 7/6/10 at 3 PM, revealed that the facility had standing orders for sliding scale insulin however confirmed that not all resident's at the facility received insulin per this scale. The DON stated that the nurse receiving the readmission orders [REDACTED]. The DON confirmed that the facility nurses' had failed to update the Diabetic Flow Chart and failed to identified the discrepancy. The DON confirmed that no additional orders had been received related to the resident receiving insulin per the facility standing sliding scale insulin. On 7/7/10 additional review of the record revealed that the July monthly Physician orders [REDACTED]. Review of the July MAR and Diabetic Flow Chart revealed that the orders were not updated to reflect the change in the sliding scale insulin. The DON confirmed this. LPN # 2 stated that he/she had reconciled the orders on 6/30/10. When questioned if he/she had compared the printed orders and MAR with the chart to confirm that they were correct, he/she stated yes. LPN # 2 confirmed that the July monthly orders and MAR did not reflect the correct updated sliding scale and confirmed that he/she had not identified this during the monthly change over. | 2014-09-01 |
| 10142 | GLORIFIED HEALTH AND REHAB OF GREENVILLE, LLC | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2010-07-07 | 309 | D | KOJZ11 | **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 provide care and services as ordered by the physician. One of fourteen residents reviewed for care and services, Resident # 8, did not receive a follow-up with the oncologist to get biopsy results as ordered. The findings included: The facility admitted Resident # 8 on 6/14/10 with [DIAGNOSES REDACTED]. Record review on 7/6/10 at 2:30 PM of the accumulative physician's orders [REDACTED]. ___ (1) wk (week) for biopsy results". Review of the Physician Discharge Summary dated 6/14/10 on 7/6/10 at 2:37 PM revealed under "Hospital Course", that Resident # 8 was admitted with AMS (Altered Mental Status) s/p (status [REDACTED]. [MEDICATION NAME] on 6/10 with ROSE (Rapid On-Site cytopathologic Examinations) revealing malignancy...Heme/Onc (Hematology/Oncology) was consulted and recommended breast mass biopsy. This was performed on 6/14 by general surgery and final pathology/results pending. (Resident #8) is scheduled to follow up with Dr. ___ in 1 week for these results and to initiate plan of care... (She/He)does need quick follow up for biopsy results with Heme/Onc as this looks like [MEDICAL CONDITION] from preliminary results. (She/He) may be a possible Hospice candidate given her PMH (Primary Medical History) of dementia and other co-morbid conditions". Review of the Physician's Progress Notes, Nurses Notes, and Laboratory results on 7/6/10 revealed no mention of the breast mass biopsy results or an office visit. During an interview on 7/7/10 at 9:15 AM, RN (Registered Nurse) #1 reviewed the June 2010 accumulative physician's orders [REDACTED]. During an interview on 7/7/10 at 11:20 AM, Unit Clerk #1 was asked if they used an appointment calendar to keep track of residents' appointments. She/He stated that Resident #8's appointment was not on her calendar. When asked about how Resident #8 would have been transported to the appointment, she/he stated that EMS (Emergency Medical Systems) would transport Resident #8 to her/his appointment. She/He could not provide documentation that an ambulance was requested and stated that sometimes the ambulance service doesn't leave documentation. During an interview on 7/7/10 at 11:25 AM, RN #1 stated that Unit Clerk #1 had called the physician's office and that Resident #8 was in the system, but did not have an appointment. When asked about the process of how appointments are made for residents when they return from the hospital, RN #1 stated that the nurse takes off the orders and leaves a posting for the secretary to make an appointment for the resident. RN #1 stated that sometimes the secretary reads the notes from the hospital and goes ahead and makes the appointment. On 7/7/10 at 11:45 AM, when asked how the facility prevents appointments from being missed, RN #1 stated that the night nurse checks to make sure all orders are carried out. On 7/7/10 at 11:56 AM, RN #1 verified the breast mass biopsy results were not in the chart. | 2014-04-01 | ||
| 9982 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 371 | E | 0 | 1 | 2B2D11 | On the days of the survey, based on observation and interview, the facility failed to prepare, distribute, and serve food under sanitary conditions as evidenced by dietary staff not wearing hair restraints appropriately. The findings included: Observations on 7/19/10 at approximately 10:45am revealed 1 dietary aide whose hair restraint did not cover the front third of the head. Observations on 7/20/10 at approximately 12:05pm revealed the dietary aide, who was plating food on the trayline, the hair restraint did not cover the front half of the head. An aide who was placing the plates of food on the trays, the hair restraint did not cover the front third of the head. An aide who was a runner between the trayline in the main kitchen and the main dining room, the hair restraint did not cover the braids on the sides of the face. Interview with the Dietary Manager on 7/20/10 at approximately 12:25pm confirmed that the Aides were not wearing the hair restraints so that the restraints covered all the hair. | 2014-08-01 |
| 9983 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 221 | D | 0 | 1 | 2B2D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, and interviews, the facility failed to assure that one of two sampled residents reviewed for restraints was free from any physical restraint not required to treat the resident's medical symptoms. Resident # 20 was observed using a concave mattress. There was no evidence provided that a restraint assessment was completed, nor consent obtained for the use of the mattress. The findings included: The facility admitted Resident # 3 with [DIAGNOSES REDACTED]. During the initial tour of the building on 7/19/10, Resident # 3 was identified as using a concave mattress. A mattress with elevated sides was observed on the resident's bed. Record review conducted on 7/21/10 revealed a physician order [REDACTED]." An Occupation Screen dated 7/6/09 stated: "Resident suffered fall attempting to tx(transfer) out of bed. Res. (Resident) has low bed c (with) rails. Pt. (patient) would benefit from concave mattress as reminder to not attempt to tx. unassisted,..." The Director of Rehabilitation also stated the resident fell again on 7/15, proving that the mattress did not "prevent" the resident from getting out of bed. However, s/he verified that the facility had not considered the concept that a concave mattress could meet the definition of a restraint and no initial or subsequent restraint evaluation or consent had been obtained for its use. After the resident fell on [DATE], no subsequent evaluation was conducted related to the safety of continuing the device. A general review of the resident's physical capabilities from 7/09- 7/10 revealed the resident's ability to transfer and ambulate had fluctuated during the past year. The resident's ambulation capability reached approximately 150 feet with minimum assist and rolling walker and the ability to transfer with minimum assist with contact guarding (8/22/09 therapy discharge notes). On 7/21/10 at 9:30AM, an interview with Certified Nursing Assistant (CNA) # 1 was conducted. The CNA verified s/he was assigned to the resident. The CNA stated s/he was a "floater" and did not always work the same unit but had cared for the resident previously. The CNA stated the resident stood and pivoted to transfer from the bed to the chair and was able to ambulate with a rolling walker. When asked if the resident napped in the afternoon, the CNA stated the resident usually "stayed up." S/he further explained if the resident was put back to bed and was not tired, s/he "would attempt to get out of bed." Review of the medical record revealed no restraint assessment nor consent for the use of the mattress. On 7/21/10 when the facility was asked for the policy and procedure for the use of restraints, the Director of Nursing stated there was no policy - "We follow the regulation." A copy of the last in-service on restraints was requested and revealed the staff was educated on 2/4/10 that the definition of a restraint was "...any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body." | 2014-08-01 |
| 9984 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 441 | D | 0 | 1 | 2B2D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and review of facility provided infection control policy for hand hygiene (8/7/09), a facility staff member was observed to not follow facility standards related to handwashing/gloves use during the completion of a tube flush for Resident # 3. The staff member donned gloves at the start of the procedure and contaminated clean areas by failing to change gloves and/or wash hands. (One of seven treatments observed for infection control compliance.) The findings included: The facility admitted Resident # 3 on 9/27/08 with [DIAGNOSES REDACTED]. Resident # 3 was located in a room with three additional resident beds, with one community sink. On 7/19/10 at 2:45PM, an observation was conducted of Licensed Practical Nurse (LPN) # 2 performing a gastric tube flush for Resident # 3. The LPN was observed to wash his/her hands and turn on the light above the resident's bed, partially pull the bedside curtain, and apply gloves. While wearing gloves, the LPN turned the faucet on/off three times to measure the water to be used for the flush. He/she pulled the bedside curtain closed, exposed the gastric tube site, raised the head of the bed, and checked for gastric tube residual. The LPN opened the bedside curtain, returned to the sink, still wearing the same pair of glove. He/she turned on the water and rinsed the syringe. Continuing to wear the same gloves, the bedside curtain was opened, and the nurse administered the tube flush via gravity. The resident was re-draped, the bedside curtain opened, and the syringe/plunger washed and returned to storage. The LPN then removed the gloves worn during the process and washed his/her hands. On 7/21/10, the observation was shared with the Director of Nursing and the concerns not disputed. Facility policy for infection control (8/7/09) stated: "Gloves or the use of baby wipes are not a substitute for hand hygiene." | 2014-08-01 |
| 9985 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 253 | E | 0 | 1 | 2B2D11 | On the days of the survey, based on observations and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary and comfortable interior. Throughout the facility there were observations of multiple wheelchairs and gerichairs with cracked and/or torn arm pads unable to be adequately cleaned or sanitized. On 3 of 5 units there were shower chairs coated with a reddish-brown and/or black filmy substance. The findings included: During general dining observations in the main dining room on 7/19/10 at 12:28 PM, three wheelchairs were noted with cracked or torn arm pads. Observations in the small dining room next to the 400 Unit Nurses Station on 7/19/10 at approximately 12:35 PM revealed 1 gerichair and 3 wheelchairs with cracked/torn arm pads. Based on these observations, a general tour of the facility was conducted on 7/20/10 beginning at 3:45 PM. Eight wheelchairs/gerichairs were noted with cracked/torn arm pads. - Outside Room 305 (Geri-chair with both arms torn). - In the small dining room next to the 300 Unit Nurses Station (3 residents sitting in wheelchairs with one or both arm pads cracked). - Between the Business Office and Room 501 (2 wheelchairs with torn arm pads) - Between the water fountain and Room 503 (1 wheelchair with cracked arm pads). - In Room 407 (1 resident sitting in a wheelchair with a cracked arm pad). During a walking tour of the facility on 7/21/10 between 8:37 AM and 9:15 AM, the following observations of wheelchairs and gerichairs with cracked or torn arm pads were verified by the Maintenance Supervisor, Housekeeping Supervisor, and the Regional Supervisor for the contracted Housekeeping Service: - There were 2 wheelchairs and 1 gerichair in the 300 Unit hall with cracked/torn arm pads. - In the small dining room next to the 400 Unit Nurses Station there were residents sitting in 2 wheelchairs with cracked/ torn arm pads. - There was one wheelchair outside room 408 and one wheelchair in room 505 with cracked/torn arm pads. - In the 500 Unit hall there were 2 wheelchairs with cracks in the arm pads, 1 wheelchair arm with exposed green stuffing, and 1 gerichair with torn arm pads. During a general tour of the facility on 7/20/10 at 3:50 PM, the following housekeeping concerns were noted: - A shower chair in the 100 Hall Shower Room was observed with a black filmy substance on the rear side of the back support and on the underside of the seat. The legs of the chair were coated with a reddish-brown substance. - Peeling paint was observed on the Grab Bars in 2 toilet areas and the sink and shower areas in the Men's shower room located across from Room 200. Inside the shower was a shower chair with a black substance on the back side of the chair and a brown-gray substance on the chair legs. - In the shower room across from room 304 a shower chair was observed with worn and torn netting on the back. On the chassis of the chair was a yellow substance. The above observations were verified by the Housekeeping Supervisor, Maintenance Supervisor, and the Regional Supervisor for the contracted Housekeeping Service during a walking tour of the facility on 7/21/10 starting at 8:37 AM. During an interview on 7/21/10 at 11:15 AM, the Director of Nursing (DON) stated that the Certified Nursing Assistants (CNAs) were responsible for cleaning the 'touch' surfaces of the shower chairs in between uses and that housekeeping was responsible for cleaning the chairs regularly on a set schedule. During an interview on 7/21/10 at 11:50 AM, the Housekeeping Supervisor stated shower chairs were cleaned weekly on Saturday by housekeeping staff based on the copy of the cleaning schedule provided on. When asked if he/she thought the shower chairs observed were cleaned the previous Saturday, the Housekeeping Supervisor stated that the schedule had not been followed. On 07/20/10 at 1:30 PM a Quality of Life Group Interview was conducted with 13 Interviewable residents in attendance. It was noted by the surveyor during the interview that 4 of the residents present had wheelchairs with cracked and torn armrests. | 2014-08-01 |
| 9986 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 356 | C | 0 | 1 | 2B2D11 | On the days of the survey, based on observation and interview, the facility failed to post complete staffing data. The facility failed to post the number of Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) and the actual hours worked by category for each shift on the Staff Posting forms. The facility also failed to post the data in a prominent location readily accessible to visitors and residents as required. The findings included: Observation on 7/19/10 at approximately 5:20 PM and on 7/20/10 at approximately 10:50 AM revealed the number of RNs and LPNs and the actual hours worked by category were not posted on the Staff Posting forms for the 7:00 AM - 3:00 PM shift, the 3:00 PM - 11:00 PM shift or the 11:00 PM - 7:00 AM shift on those dates but were posted as "Licensed Nurses." During observations throughout the survey, the Staff Posting forms were posted behind the nursing stations and not displayed in a prominent location readily accessible to visitors and residents. Copies of the Staff Posting forms for the last 30 days were requested on 7/20/10. Review of these forms revealed the number of RNs and LPNs and the actual hours worked by category were not posted on the Staff Posting form on any of these dates as required but were posted as "Licensed Nurses." Review of the Staff Posting forms for the last 31 days revealed that on all of the last 31 days, the Staff Posting forms indicated 6 nurses for the 3:00 PM - 11:00 PM shift. Review of the 24 Hour Assignment sheets revealed that on 22 of the last 31 days, 6 nurses worked from 3:00 PM - 7:00 PM but only 5 nurses worked from 7:00 PM - 11:00 PM. During an interview on 7/21/10 at approximately 11:30 AM, the Director of Nursing (DON) confirmed that the posting did not list the Licensed Nurses by category or include the actual hours worked. The DON also confirmed that the Licensed Nurses worked 12 hour shifts and that the number of nurses that worked between 3:00 PM - 7:00 PM and 7:00 PM - 11:00 PM was different and was not reflected on the Staff Posting form. She/He also verified that the Staff Posting form was posted behind each of the nursing stations but not in a prominent area accessible to visitors and residents. | 2014-08-01 |
| 9987 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 167 | C | 0 | 1 | 2B2D11 | On the days of the survey, based on observations and interview, the facility failed to place the most recent state survey results in a location readily accessible to residents and visitors, and there were no notices posted regarding the availability of the survey results. The findings included: Observation on 7/19/10 at approximately 12:45 PM revealed a white binder entitled "DHEC (Department of Health and Environmental Control) Survey" sitting on the receptionist's desk back behind a lamp. The survey results were not readily accessible to residents or visitors. Observation on 7/20/10 at 11:35 AM revealed the receptionist sitting at a desk near the entrance of the facility. The Director of Nursing (DON) was standing next to her/him. A white binder entitled "DHEC Survey" was sitting on the desk behind a lamp a couple feet away to the right and behind where the receptionist was sitting. When questioned by the surveyor if anyone had asked to see the survey results, the receptionist stated that sometimes residents or visitors would ask to see them. When questioned if the survey results were readily accessible where they were located if someone had to ask to see them, the DON moved the survey results to the front of the desk below the countertop. During a general tour of the facility on 7/20/10 from 3:45 PM to 4:45 PM, observations revealed there were no notices posted regarding availability of the most recent state survey results. | 2014-08-01 |
| 9988 | LAUREL BAYE HEALTHCARE GREENVILLE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2010-07-21 | 468 | E | 0 | 1 | 2B2D11 | On the days of the survey, based on observation and interview, the facility failed to equip corridors with firmly secured handrails on each side. The findings included: During a walk through of the facility on 7/20/10 beginning at 3:45 PM and during a tour with the Maintenance Supervisor on 7/21/10 at 8:37 AM, loose and/or missing handrails were observed and confirmed in the following areas: - Between the lobby and the 100 Hall Nursing Station there were no handrails on one side. The handrails on the other side were loose. The hall exiting to the courtyard had no handrails on either side. - Between Room 111 and the exit door, there was approximately 6 feet of handrail missing. - Between the Men and Women's Shower Room across from Room 200, there was a handrail missing. - There was a loose handrail outside of Room 208. - There was a loose handrail between the Men/Women's Restroom and Shower on the 300 Hall. - There was an 11 foot section of handrail that was missing in the breezeway near the 400 Hall Nursing Station. - There were several sections of handrail missing in the hall leading to the dining area between the 400 and 500 Halls (7 feet on one side, 4 feet on the other, and one full section of 11 feet on one side). - There were no handrails for approximately 3 feet outside the Social Services Office on the 500 Hall. - There were no handrails between Room 504 and the fire door for approximately 2 feet. | 2014-08-01 |
| 10278 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 425 | E | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the pharmacy, supplying medications to the facility, failed to assure the accurate administration of all drugs for 1 of 6 residents observed during medication pass. Resident A with a physician's orders [REDACTED]. The findings included: On 7/27/10 at 8:50 AM during observation of medication pass for Resident A, Licensed Practical Nurse (LPN) #4 was observed to measure Miralax Powder to the 15 milliliter mark in a medication cup used to measure liquid medications. The Miralax Powder was dissolved in 7 ounces of water and administered to the resident along with 8 other medications. Reconciliation of medication pass for Resident A revealed a current physician's orders [REDACTED]. DX (diagnosis) CONSTIPATION". The identical physician's orders [REDACTED]. All of the orders were signed by the physician without clarifying the ambiguous dosage. Further review revealed that the Physician's admission orders [REDACTED]. Dx Constipation". During an interview on 7/28/10 at 8:40 AM, the pharmacist at the pharmacy supplying the medications to the facility, stated that the pharmacy did not have the original order for the Miralax Powers (written 1/20/04) on hand. She/he stated that, on the pharmacy side, they have 17 Gms in 8 ounces of water as the standard (manufacturer's recommended) dose for Miralax and confirmed that the dosage on the monthly orders, printed by the pharmacy, was not clear. She/he further stated that, if there was an error, it was the pharmacy's fault. During an interview on 7/28/10 at 8:47 AM, LPN #4 stated that the pharmacist came to the facility yesterday (7/27/10) at about 5 PM, after the observation of medication by this surveyor the morning of the same day, and changed the dose for the Miralax on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. | 2014-01-01 | ||
| 10279 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 314 | D | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview and review of the product insert sheet for Santyl/facility policy for the application of a [MEDICATION NAME] product, the facility failed to assure that one of two sampled resident's reviewed for pressure ulcer care received appropriate treatment and services. During observation of the pressure ulcer treatment for [REDACTED]. Facility staff was unaware if the pressure relieving mattress in use was appropriately set for the resident's use. The findings included: The facility last admitted Resident # 3 on 7/24/10. The resident's [DIAGNOSES REDACTED]. On 7/27/10 at 9:10am, an observation of the resident's pressure ulcer treatment was conducted. During the the procedure, the wound care nurse was observed to clean the outside raised edge of the pressure ulcer but not clean the wound bed itself. The wound bed was noted to contain slough and tunneling was noted. Following the treatment, the wound care nurse was questioned as to why the wound bed was not cleaned. S/he stated s/he did not want the spray the "collect" where the wound was undermined and did not want to injure the wound bed by having to pat it dry. S/he also stated s/he felt the use of Santyl cleaned the wound bed when the previous dressing was removed. Review of the product insert sheet from Santyl revealed the manufacturers recommendation stated to clean the wound bed prior to the application of Santyl. The instructions stated the wound bed should be cleansed prior to application.. remove as much loose debris as possible, gently cleanse the wound bed with saline or wound cleanser followed by saline each time the dressing is changed. Additionally, the facility policy also stated the wound bed should be cleansed prior to the application of a [MEDICATION NAME] product. Also following the completion of the treatment, the facility wound care nurse was questioned related to the use of the pressure relieving mattress which was in place on the resident's bed. The head, foot and middle areas were all set at the same maximum level - 5. When asked how s/he knew the setting was appropriate for the resident, s/he stated maintenance department set up the bed and s/he did not know. During an interview with the Maintenance Supervisor on 7/28/10, s/he stated Maintenance did set up the bed and s/he could tell by "looking at it" if the setting was appropriate. The Maintenance supervisor confirmed the instructions for determining the appropriate setting for resident use were not used by the maintenance department. | 2014-01-01 | ||
| 10280 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 373 | D | 1BYP11 | On the days of the survey, based on observation, interview and record review, the facility failed to identify the use of a paid feeding assistant program and failed to implement the approved program consistent with State law. The findings included: On 7/26/10, upon entrance to the facility, the Administrator stated the facility did not utilize a paid feeding assistant program. On 7/27/10, at approximately 1:30pm, the Administrator and Nurse Consultant again stated the facility did not have or use a paid feeding assistant program. During random observations during the evening meal on 7/26/10, two activity staff members were observed feeding residents in the "B" building. One resident was being fed in a small alcove in the "B" building and another resident was being fed in his/her room. Both staff members stated they were not Certified Nursing Assistants. During the noon meal on 7/27/10, the activity members were again observed feeding residents either in their rooms (building "B") or dining room (main building). Further investigation revealed the facility did have an state approved feeding assistant program. On 7/27/10 at 2PM, during an interview with the Staff Development Coordinator (SDC) , s/he stated s/he had not taught the feeding assistant program since her return to the facility 12/09 but s/he previously had taught it at the facility. S/he stated an awareness that both activity personnel had previously completed the feeding assistant program. When asked which residents a staff member who had completed the program could feed, the SDC stated they would feed "easier" residents. S/he further stated one particular activity staff member would feed "anyone she felt comfortable with...s/he would not step out of her comfort zone." A review of personnel files revealed both staff members had completed the paid feeding assistant program at the facility (in 2005 and 2007). On 7/28/10, during an interview with the Administrator it was verified that the facility was not cognizant that using trained staff members to feed residents constituted use of a paid feeding program. Additionally, the facility had not been following the stated mandated guideline for the paid feeding program by assuring a record was maintained of all individuals used as feeding assistants; assuring coordination of the program under the general supervision of a nurse; assuring a nurse was readily available for the supervision of feeding assistants while feeding; and identifying and assessing residents who could be fed by feeding assistants based on a charge nurse's assessment. | 2014-01-01 | ||
| 10281 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 441 | E | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. Interview and observation of the Laundry Department revealed a lack of knowledge of appropriate infection control practice. Personal Laundry was not being sanitized. Following observation of catheter care for Resident # 3, handwashing concerns were identified. The findings included: On 7/27/10 at 11AM, an observation of the facility laundry department was conducted. Laundry worker # 1 was observed placing soiled laundry into a washing machine. After the soiled laundry was placed, s/he was observed to remove the protective gown by pulling it over his/her head when unable to untie the strings. The same laundry worker was asked to explain the process on how to handle laundry from an infected resident. Both Laundry worker # 1 and # 2 stated they would wear two pair of gloves and put on two gowns for protection. When asked how the two gowns would be applied, they stated one frontward and one backward. A box containing 3 pillows (1 cloth and 2 vinyl covered) was observed in the soiled area. When asked how the pillows would be cleaned, Laundry worker # 1 stated one pillow would be discarded because it was torn. The other two pillows would would be cleaned the same by spraying and wiping off with a disinfectant cleaner and then dried with a towel. Review of the label of the product indicated would be used stated it was to be used for non-porous surfaces. Further interview revealed that no bleach or other disinfecting chemical was used when washing the resident's personal laundry. The facility water temperature for personal laundry was identified as cold/warm. Appropriate chemical sanitization was used for bedding and other linens when washed. On 7/27/10 at 11:25AM, an interview was conducted with the Maintenance Supervisor, identified as in charge of the laundry. S/he also stated that s/he would "guarantee" that s/he would wear two gowns and two pairs of gloves if handling known infectious laundry. During an interview with the Staff Development Coordinator who also was in charge of the facility infection control program, s/he stated laundry staff was in-serviced on hire related to infection control. Thereafter, (annually) staff completed a self study program. Laundry staff was not asked to demonstrate knowledge on how to apply/remove personal protective equipment. The facility last admitted Resident # 3 on 7/24/10. The resident's [DIAGNOSES REDACTED]. On 7/28/10 , an observation of the resident' s catheter care was conducted. After cleaning the residents catheter, the nurse removed his/her gloves, applied the resident's brief, covered the resident, discarded the overbed covering, bagged soiled supplies, raised the resident's head of bed, lowered the bed height, returned an unused brief to the resident's closet, opened the bedside curtain, walked down the hallway and opened the room door prior to discarding used supplies and then sanitized his/her hands. The Facility policy for hand hygiene stated that hands should be washed "after removing gloves." | 2014-01-01 | ||
| 10282 | WHITE OAK MANOR - YORK | 425089 | 111 SOUTH CONGRESS STREET | YORK | SC | 29745 | 2010-07-28 | 156 | D | 1BYP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure a Resident's responsible party's stated interest in a Do Not Resuscitate order was acted upon timely. Resident # 11's responsible party expressed interest in formulating an Advanced Directive. After the Resident was determined to lack capacity for healthcare decisions, the facility took no further action. (1 of 13 sampled resident's reviewed for Advanced Directives) The findings included: The facility last admitted Resident # 11 on 7/7/10. The resident's [DIAGNOSES REDACTED]. On 7/26/10 a review of the current medical record revealed a Social progress note dated 7/8/10 which stated: "Res (resident) has POA (Power of Attorney) copy placed on chart and no living will. RP (Responsible party) is interested in DNR (Do not Resuscitate)." On 7/14/10 two physicians documented the resident lacked capacity to make healthcare decisions. Additional Social progress notes were documented on 7/16 and 7/19/10 noting resident behaviors and family visits/contacts. However, there was no further documentation related to the resident's advanced directive status. On 7/26/10 at 4:10pm, during an interview with the nurse consultant, s/he stated the resident was a "full code." On 7/27/10 at 11am, during an interview with social services employee # 1, s/he stated once a resident's capacity has been determined, appropriate action related to the residents/responsible party stated wishes for advanced directives should "happen quickly". S/he verified no action had been taken by the facility after the resident's capacity has been determined. S/he further stated the RP had been contacted and would be coming to the facility "today" to sign the paperwork for the resident's Do Not Resuscitate status. | 2014-01-01 | ||
| 10004 | WHITE OAK MANOR - ROCK HILL | 425088 | 1915 EBENEZER RD | ROCK HILL | SC | 29732 | 2010-08-04 | 441 | E | 0 | 1 | 3N7711 | On the days of the survey, based on observation and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. Observations of processing resident's personal laundry and interview with staff of the Laundry Department revealed failure to ensure personal laundry was sanitized appropriately per infection control guidelines. The findings included: On 8/4/10 at 10AM, an observation of the facility laundry department was conducted. Upon entering, observations revealed 2 of the 3 washing machines in the process of washing clothes. The washing machines had a display that identified various functions while running. One of the functions allowed display of the current water temperature. Observations of the temperature of the washing machine used for colored clothes displayed a temperature of the water at 53 degrees Farenheit . The temperature continued to read 53 degrees Farenheit on two additional reviews of the washing machine's water. Further interview revealed that no bleach or other disinfecting chemical was used when washing the resident's personal laundry. On 8/4/10 at 10 :03 AM, an interview was conducted with the Housekeeping Supervisor, identified as in charge of the laundry. He/She confirmed the water temperature and stated no other disinfecting chemicals were used for resident's laundry. | 2014-08-01 |
| 10181 | HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER | 425362 | 1137 SAM RITTENBURG BLVD | CHARLESTON | SC | 29407 | 2010-08-11 | 441 | F | 58Y911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on interviews, the facility staff failed to demonstrate appropriate knowledge related to infection control issues. The findings included: On 8/11/10 at approximately 9:30 AM during an interview with LPN # 1 when questioned what he/she would tell visitor's prior to entering a resident's room who had an order for [REDACTED]. On 8/11/10 at approximately 9:45 AM interview with Housekeeper # 1, who was responsible for cleaning a room with a "Stop See the Nurse Prior to Entering." sign was questioned what the sign meant. Housekeeper # 1 was unable to tell the surveyor why the sign was posted. When questioned if he/she would utilize any special cleaning procedures for a resident who was on contact isolation for Clostridium Difficile, he/she failed to identify to use any chemical to clean the room. On 8/11/10 at approximately 10:15 AM RN # 4 was questioned what he/she would tell a visitor prior to entering a resident's room who was on contact precautions. He/She stated that he/she was unsure what to tell a visitor. On 8/11/10 at approximately 11:00 AM, Housekeeper # 2 was questioned if he/she would use any special procedure to clean a resident's room who was on contact isolation for Clostridium Difficile, and he/she stated no. When questioned if he/she had been trained on cleaning procedures for rooms that had resident's with infection control precautions, he/she said no. | 2014-04-01 | ||
| 10182 | HEARTLAND OF WEST ASHLEY REHAB AND NURSING CENTER | 425362 | 1137 SAM RITTENBURG BLVD | CHARLESTON | SC | 29407 | 2010-08-11 | 425 | F | 58Y911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to follow a procedure to ensure that expired medications were not stored with other medications in 2 of 4 medication rooms. The finding included: On 8/9/10 at approximately 11:15AM, inspection of the 1 South Medication Room revealed one orange colored Emergency Box sealed with a red integrity seal and bearing an outside label which read Meclizine expired 7-27-10. The box was opened and revealed the following: -One vial of Lidocaine HCl (Hydrochloride) Injection 10 mg (milligram)/ml (milliliter), 50 ml. by Hospira, Lot 68-435-DK, expired 1 [DATE] (August 1, 2010). -One Extended Phenytoin Sodium 100mg capsule lot 39 expired 8-5-10 (packaged by NCS Healthcare of SC) -Two Ciprofloxacin 500mg tablets lot BEM51B LC expired 7-2-10 (packaged by NCS Healthcare of SC) -Five Meclizine HCl 25mg tablets lot 601 EH expired 7-27-10 (packaged by NCS Healthcare of SC) These findings were verified by RN (Registered Nurse) # 1 (Floor Manager) on 8/9/10 at approximately 11:25AM who stated that the Consultant Pharmacist is supposed to check for out- of-date medications during monthly visits and was unsure whether the nurse was also responsible for checking on an ongoing basis. RN # 1 a lso confirmed that this emergency box was used to supply medications to all residents on the first floor. On 8/9/10 at approximately 1:40PM, inspection of the 2 North Medication Room revealed one orange colored Emergency Box sealed with a green integrity seal. The box was opened and revealed the following: -One vial of Lidocaine HCl (Hydrochloride) Injection 10 mg/ml, 50 ml. by Hospira, Lot 68-434-DK, expired 1 [DATE] (August 1, 2010) This finding was verified by LPN (Licensed Practical Nurse) # 1 on 8/9/10 at approximately 1:50PM. LPN # 1 stated that the box had been delivered on 8/6/10 by the Pharmacy and that the green integrity seal indicated that it had not been opened since delivery. This finding was also verified by RN # 2 (Floor Manager) on 8/9/10 at approximately 2:10PM who stated that the green seal meant that it had been unopened since delivery by the pharmacy and that if it had been opened it would have been resealed with a red integrity seal. RN # 2 also confirmed that this emergency box was used to supply medications to all residents on the second floor. On 8/9/10 at approximately 4:40PM the Facility Administrator provided a copy of the most recent "Quality Improvement: Consultant Pharmacy Summary" which covered 7/27/2010 to 7/28/2010 and had been signed 7/28/10. This summary showed on page 2 of 3 that out-of-date medications had been checked, but did not identify any of the expired medications found during the survey. The summary also showed that the emergency supply on "1N, 1S and 2N needs to have e-box returned to pharmacy." | 2014-04-01 | ||
| 10035 | LAUREL BAYE HEALTHCARE OF ORANGEBURG | 425116 | 575 STONEWALL JACKSON BOULEVARD | ORANGEBURG | SC | 29115 | 2010-08-18 | 156 | C | 0 | 1 | G5LE11 | On the days of the survey, based on record reviews and interview, the facility failed to complete 3 of 3 mandated Liability Notices. The findings included: During review of resident funds on 8/18/10, three of three mandated Liability Notices were not completed by the business office. During an interview following the review, the Business Manager confirmed that the Liability Notices were not completed. | 2014-07-01 |
| 10036 | LAUREL BAYE HEALTHCARE OF ORANGEBURG | 425116 | 575 STONEWALL JACKSON BOULEVARD | ORANGEBURG | SC | 29115 | 2010-08-18 | 315 | D | 0 | 1 | G5LE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, facility policy, and interview, the facility failed to provide appropriate catheter care for 1 of 3 sampled residents with observed catheter care. Resident #3 received catheter care without appropriate cleansing of the area surrounding the meatus and releasing the labia between attempts to clean the perineal area. The findings included: The facility admitted Resident #3 on 11/14/08 with [DIAGNOSES REDACTED]. Observation of catheter care on 8/17/10 at 3:40 PM revealed that after donning gloves, Certified Nursing Assistant(CNA)#2 attempted to spread the resident's labia and with a peri-wipe cleansed down the center. Releasing the labia, CNA #2 obtained a second wipe and placing her right hand on the mons pubis, cleansed down the center of the perineal area. Resident #3 was turned to his/her right side and using different periwipes, cleansed down the left buttock, cleansed down the right buttock, and cleansed the rectal area in an upward motion. Resident #3 was turned onto his/her back. CNA #2 removed his/her gloves, washed his/her hands, and donned gloves. The catheter was grasped at the insertion site and cleansed approximately four inches down the catheter tubing. CNA #2 removed his/her gloves, washed his/her hands, gathered the trash and disposed of the trash in an appropriate container. Review of the facility policy titled "Urinary Catheter Care", states in section IIb - 'Cleanse area of catheter insertion well using soap and water or peri-wipes and being careful not to pull on catheter or advance it further into the urethra. The facility had conducted several inservice trainings on Urinary Tract Infections during the month of March 2010 in which CNA #2 attended at least one inservice. The above observation was shared with the Director of Nursing on 8/18/10. | 2014-07-01 |
| 10037 | LAUREL BAYE HEALTHCARE OF ORANGEBURG | 425116 | 575 STONEWALL JACKSON BOULEVARD | ORANGEBURG | SC | 29115 | 2010-08-18 | 441 | D | 0 | 1 | G5LE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations and interviews, the facility presented with a soiled utility room on the North hall with the hand washing sink unaccessible due to a box of trash can liners placed on the sink and multiple over filled barrels of soiled linen which crowded the room. Soiled gloves were used to complete supra pubic catheter care for Resident #5 which was one of four catheter treatments observed. The findings include: The facility admitted Resident #5 on 03/19/09 with [DIAGNOSES REDACTED]. On 08/17/2010 at 11:30 AM Certified Nurses Assistant (CNA) #1 completed peri care and, with the same gloves on, completed supra pubic catheter care for Resident #5. After CNA #1 removed the soiled gloves and was washing her/his hands, she/he confirmed that normally the soiled gloves are removed and hands are washed, then the catheter care completed with clean gloves. During an interview with the Staff Development staff, they indicated that the catheter care and the peri-care was fine. She/ He verbalized that the gloves needed to be removed and the hands washed between peri-care and the supra pubic catheter care. After performing pressure sore treatment on 8/17/10 at 12:10 PM, Licensed Practical Nurse(LPN)#4 disposed of trash/linen in the North soiled utility room. Observation of the utility room revealed multiple barrels crowded into the room with three barrels not completely covered. LPN #4 left the soiled utility room and entered an employees' only room which appeared to be a nourishment area. After performing a tube flush on 8/17/10 at 12:57 PM, LPN #2 disposed of trash in the North soiled utility room. Observation of the utility room revealed multiple barrels crowded into room with several barrels partially covered. LPN #2 leaned over a barrel to reach the handwash sink. After performing pressure sore treatment on 8/17/10 at 4:42 PM, LPN #3 disposed of trash in the North soiled utility room. A box of trash liners was noted on the sink. LPN #3 entered an employees' only room which appeared to be a nourishment area. On 3/18/10 at 3:15 PM, the North soiled utility room was observed with LPN #1. He/she confirmed that two red barrels were partially covered and a box of trash liners on the handwash sink. | 2014-07-01 |
| 10079 | LILA DOYLE AT OCONEE MEDICAL CENTER | 425075 | 101 LILA DOYLE DRIVE | SENECA | SC | 29672 | 2010-08-18 | 431 | E | 0 | 1 | SNPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility provided policies for Oral Medication Administration, Controlled Medications (both policies undated) and Event Reporting (last reviewed 7/10), the facility failed to maintain records of receipt and disposition of all controlled drugs in sufficient detail to ensure a determination that drug records were accurate and periodically reconciled for 3 of 7 sampled residents reviewed for the administration of controlled substances. Resident # 4 received an incorrect dose (less than what was ordered) of a controlled medication. The medical record documented the medication was administered, but not removed from the controlled supply. Concerns were identified related to the reconciliation of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident # 17 was documented as having received a medication which was not documented as removed from the controlled supply. In addition the facility failed to provide a separately locked, permanently affixed compartment for storage of discontinued controlled drugs (Schedule II and other drugs subject to abuse) which limited access to authorized personnel, in the First Floor Medication Room. (One of 2 medication rooms reviewed for medication storage). The findings included: On 8/18/10 at 8:53 AM, observation of the First Floor Medication Room revealed a locked cabinet used for storage of discontinued narcotics and other controlled medications (per the Consultant Pharmacist). The cabinet was locked but a hole was observed in the cabinet door. The hole was measured to be 20 inches from the bottom of the cabinet. The hole was large enough for this surveyor to insert a hand through the hole and inside the locked cabinet. Observation of the contents of the cabinet revealed the following multidose containers: 1 pack OxyContin CR (Controlled Release) 10 mg - 4 tablets remaining 1 pack Morphine ER (Extended Release) 15 mg - 4 tablets remaining 1 pack Temazepam 30 mg Capsules - 2 capsules remaining 1 pack Diazepam 5 mg Tablets - 30 tablets 1 pack Ambien 10 mg Tablets - 9 tablets remaining 1 pack Ambien 10 mg Tablets - 28 tablets remaining 1 pack Lortab 5/500 mg Tablets - 70 tablets remaining 1 pack Roxicet 5/325 mg Tablets - 50 tablets remaining. In addition to those listed above, there were 45 other (partial and full) containers of controlled medications stored in the cabinet. During an interview on 8/18/10 at 8:58 AM, the Consultant Pharmacist verified that the hole in the cabinet door was a possible means of access to the discontinued controlled medications by unauthorized personnel and that the discontinued controlled medications were in containers that would fit through the hole in the cabinet door. The facility last admitted Resident # 4 on 7/9/10. The resident's [DIAGNOSES REDACTED]. On 8/17/10 at 10:15AM, review of the current medical record revealed the resident was ordered by the physician to receive liquid Lortab 7.5/15 milliliters (ml)- 20 ml every four hours for pain. A review of the Narcotic Sign Out Record revealed on 7/28/10 at 1800 15 ml was signed out as administered with a notation of "bottle completed". The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the physician orders, physician progress notes [REDACTED]. After the concern had been brought to the attention of the facility, the nurse responsible for the administration of the medication was sent to speak to this surveyor, accompanied by the Director of Nursing and the Consulting Pharmacist. The nurse stated s/he was aware that the full dose had not been administered. S/he stated it had brought it to the attention of the supervisor, and s/he had reassessed the resident. S/he stated 15 ml had been administered because that was all that was left in the bottle and an additional supply was not available at that time. When asked if s/he understood the surveyors concerns and that there was no documentation in the medical record, s/he stated "yes." The facility last admitted Resident # 17 on 8/14/10. The resident's [DIAGNOSES REDACTED]. On 8/18/10 at 9:20AM record review revealed the resident was ordered by the physician to receive Ativan .5 milligrams daily at 2PM. Review of the July 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Narcotic Sign out Record indicated the medication was not removed from the controlled supply on 7/23 and 7/26/10. On 10:10AM, the Unit Manager stated the initial in the box for 7/23 and 7/26/10 was an "R" meaning that the medication was refused. The Unit Manager verified the initial was not circled and there was no further documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On 7/6/10 Ativan 0.5 milligrams was documented as administered to Resident # 17 at 1400. However, the Narcotic Sign out record did not document the medication was removed for administration and the quantity of medication remained the same from 7/5-7/7/10. On 8/18/10 at 9:20AM record review revealed the resident was ordered by the physician to receive Ativan .5 milligrams daily at 2PM. Review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s refusal. The Ativan quantity available for administration on the narcotic sign out record remained the same from 8/7 (28 doses) to 8/12/10 (27 doses) . On 8/18/10 at 10:10AM the Unit Manager stated s/he was unable to find additional information to explain the doses which were not administered. A review of the facility provided policies revealed under Event Reporting that the "following medication incidents should be reported; Any error or omission in providing a medication such as: 1. Per physician's written order 2. At the time and date prescribed 3. With the correct drug 4. In the correct quantity...." The facility policy for Controlled Medications stated...: "2. A declining inventory record is to be maintained for all controlled drugs. This "Narcotic Sign Out Record" is to account for each dose of medication given to a resident. Each line of the Narcotic Sign Out Record is to represent one dose.... 5. If a dose is removed from the container for administration but refused by the resident or not given for any reason, it is to be documented on the Narcotic Sign out record on the line representing that dose. The controlled medication should be placed in a small envelope that is stamped with the resident's name, prescription number, and name of controlled medication. This medication is to be given to the supervisor or DON (Director of Nursing) for proper destruction by the pharmacist. If unable to follow above procedure, two nurses may flush refused dose in the sewer system with appropriate documentation on the Narcotic Sign Out Record. 7. Any discrepancy in the count of controlled substances is to be reported immediately to the responsible supervisor and a signed entry shall be recorded on the page where the discrepancy is found...." The facility policy for Oral Medication Administration Procedure stated: "14. If a resident refuses medication, indicate on MAR by placing the letter "R". a. Note refusal or ingestion of less than 100% of dose in the "Nurse's Medication Notes" on the back of the MAR." The facility admitted Resident #19 on 5/10/2006 with [DIAGNOSES REDACTED]. During review of the resident's medical chart on 8/17/2010 and 8/18/2010, records revealed multiple entries, for the month of July, on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No witnesses were documented. Resident #19 received Xanax 0.25 milligrams (mg) 1 tablet twice a day at 0900 (9:00 AM) and 1700 (5:00 PM). She/he also received Lortab 2.5/500 tablet 1-twice a day at 9:00 AM and 5:00 PM. There were also entries that indicated the medications were given on the MAR but were not signed out on the Narcotic Record. Xanax 0.25 mg tablets were signed out on the resident's Narcotic Record on 7/5 at 0900 and 7/14 at 0900, 7/25 at 0900. The MAR indicated [REDACTED]. Each entry stated that the resident had refused the medication with no second nurses' signature to witness the wasted narcotic. On 7/24 and 7/27/2010 the Xanax 0.25 mg tablet was signed as given on the MAR but was not signed on the Narcotic record as being removed from the supply. Resident #19 also received Lortab 2.5/500 at 9:00 AM and 5:00 PM. On 7/13, 7/14 at 9:00 AM, 7/23 at 5:00 PM, 7/25 at 9:00 AM , 7/28 at 9:00 AM and 7/30/2010 at 5:00 PM the Lortab was signed as removed from the narcotic supply to administer. The MAR indicated [REDACTED]. The records indicated that there had not been an additional nurses' signature verifying that the medications had been wasted properly. Review of Resident #19's Nurses' Notes revealed one entry on 7/25/10 that the resident had refused her/his medications. This entry contained no information related to a witness to the disposal of the controlled medications. On 8/18/2010 at 10:30 AM, during an interview with Registered Nurse #1, she/he verified that there had been no witnesses to the disposal of the Xanax and the Lortab documented. She/he also agreed that there should be two nurses that witness the disposal of any controlled medication. Cross refer to F281 related to facility policies for Medication Administration, Controlled Medications and Event Reporting. | 2014-06-01 |
| 10080 | LILA DOYLE AT OCONEE MEDICAL CENTER | 425075 | 101 LILA DOYLE DRIVE | SENECA | SC | 29672 | 2010-08-18 | 281 | E | 0 | 1 | SNPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview and review of the facility provided policies for Oral Medication Administration, Controlled Medications (both policies undated) and Event Reporting (last reviewed 7/10), the facility failed to maintain professional standards for the administration of controlled medications. Resident # 4 received an incorrect dose (less than what was ordered) of a controlled medication. Resident # 4's medical record documented medication was administered, but not removed from the controlled supply. Concerns were identified related to the reconciliation of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Concerns were identified related to the disposal of controlled medications which were dispensed but refused by Resident # 19. Resident # 17 was documented as having refused his/her controlled medications without further explanation. Resident # 17 was documented as having received a medication which was not documented as removed from the controlled supply. (3 of 7 sampled residents reviewed for the administration of controlled substances.) The findings included: The facility last admitted Resident # 4 on 7/9/10. The resident's [DIAGNOSES REDACTED]. On 8/17/10 at 10:15AM, review of the current medical record revealed the resident was ordered by the physician to receive liquid [MEDICATION NAME] 7.5/15 milliliters (ml)- 20 ml every four hours for pain. A review of the Narcotic Sign Out Record revealed on 7/28/10 at 1800 15 ml was signed out as administered with a notation of "bottle completed". The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the physician orders, physician progress notes [REDACTED]. After the concern had been brought to the attention of the facility, the nurse responsible for the administration of the medication was sent to speak to this surveyor, accompanied by the Director of Nursing and the Consulting Pharmacist. The nurse stated s/he was aware that the full dose had not been administered. S/he stated it had brought it to the attention of the supervisor, and s/he had reassessed the resident. S/he stated 15 ml had been administered because that was all that was left in the bottle and an additional supply was not available at that time. When asked if s/he understood the surveyors concerns and that there was no documentation in the medical record, s/he stated "yes." The facility last admitted Resident # 17 on 8/14/10. The resident's [DIAGNOSES REDACTED]. On 8/18/10 at 9:20AM record review revealed the resident was ordered by the physician to receive [MEDICATION NAME] .5 milligrams daily at 2PM. Review of the July 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Narcotic Sign out Record indicated the medication was not removed from the controlled supply on 7/23 and 7/26/10. On 10:10AM, the Unit Manager stated the initial in the box for 7/23 and 7/26/10 was an "R" meaning that the medication was refused. The Unit Manager verified the initial was not circled and there was no further documentation on the back of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On 7/6/10 [MEDICATION NAME] 0.5 milligrams was documented as administered to Resident # 17 at 1400. However, the Narcotic Sign out record did not document the medication was removed for administration and the quantity of medication remained the same from 7/5-7/7/10. A review of the facility provided policies revealed under Event Reporting that the "following medication incidents should be reported; Any error or omission in providing a medication such as: 1. Per physician's written order 2. At the time and date prescribed 3. With the correct drug 4. In the correct quantity...." The facility policy for Controlled Medications stated...: "2. A declining inventory record is to be maintained for all controlled drugs. This "Narcotic Sign Out Record" is to account for each dose of medication given to a resident. Each line of the Narcotic Sign Out Record is to represent one dose.... 5. If a dose is removed from the container for administration but refused by the resident or not given for any reason, it is to be documented on the Narcotic Sign out record on the line representing that dose. The controlled medication should be placed in a small envelope that is stamped with the resident's name, prescription number, and name of controlled medication. This medication is to be given to the supervisor or DON (Director of Nursing) for proper destruction by the pharmacist. If unable to follow above procedure, two nurses may flush refused dose in the sewer system with appropriate documentation on the Narcotic Sign Out Record. 7. Any discrepancy in the count of controlled substances is to be reported immediately to the responsible supervisor and a signed entry shall be recorded on the page where the discrepancy is found...." The facility policy for Oral Medication Administration Procedure stated: "14. If a resident refuses medication, indicate on MAR by placing the letter "R". a. Note refusal or ingestion of less than 100% of dose in the "Nurse's Medication Notes" on the back of the MAR." The facility admitted Resident #19 on 5/10/2006 with [DIAGNOSES REDACTED]. During review of the resident's medical chart on 8/17/2010 and 8/18/2010, records revealed multiple entries, for the month of July, on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. No witnesses were documented. Resident #19 received [MEDICATION NAME] 0.25 milligrams (mg) 1 tablet twice a day at 0900 (9:00 AM) and 1700 (5:00 PM). She/he also received [MEDICATION NAME] 2.5/500 tablet 1-twice a day at 9:00 AM and 5:00 PM. There were also entries that indicated the medications were given on the MAR but were not signed out on the Narcotic Record. [MEDICATION NAME] 0.25 mg tablets were signed out on the resident's Narcotic Record on 7/5 at 0900 and 7/14 at 0900, 7/25 at 0900. The MAR indicated [REDACTED]. Each entry stated that the resident had refused the medication with no second nurses' signature to witness the wasted narcotic. On 7/24 and 7/27/2010 the [MEDICATION NAME] 0.25 mg tablet was signed as given on the MAR but was not signed on the Narcotic record as being removed from the supply. Resident #19 also received [MEDICATION NAME] 2.5/500 at 9:00 AM and 5:00 PM. On 7/13, 7/14 at 9:00 AM, 7/23 at 5:00 PM, 7/25 at 9:00 AM , 7/28 at 9:00 AM and 7/30/2010 at 5:00 PM the [MEDICATION NAME] was signed as removed from the narcotic supply to administer. The MAR indicated [REDACTED]. The records indicated that there had not been an additional nurses' signature verifying that the medications had been wasted properly. Review of Resident #19's Nurses' Notes revealed one entry on 7/25/10 that the resident had refused her/his medications. This entry contained no information related to a witness to the disposal of the controlled medications. On 8/18/2010 at 10:30 AM, during an interview with Registered Nurse #1, she/he verified that there had been no witnesses to the disposal of the [MEDICATION NAME] and the [MEDICATION NAME] documented. She/he also agreed that there should be two nurses that witness the disposal of any controlled medication. | 2014-06-01 |
| 10081 | LILA DOYLE AT OCONEE MEDICAL CENTER | 425075 | 101 LILA DOYLE DRIVE | SENECA | SC | 29672 | 2010-08-18 | 441 | E | 0 | 1 | SNPY11 | On the days of the survey, based on observation and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. Interview and observation of the Laundry Department revealed a lack of knowledge of appropriate infection control practice. Personal Laundry was not being sanitized. The findings included: On 8/17/10 a review of the facility laundry system was completed. It was revealed that only personal laundry was processed within the facility. On 8/17/10 an interview with Laundry staff member # 2, who stated s/he was the primary person responsible for personal laundry was conducted. S/he stated that personal laundry was processed using cold water. Laundry worker # 2 stated that if a resident was on isolation, s/he would use hot water. However, s/he was unaware of the water temperatures available for use within the laundry. When asked if any bleach/sanitizing type product was used for processing personal laundry, s/he stated "no". S/he also stated s/he processed the cloth napkins used by residents using hot water (unknown temperature) and no bleach. A follow-up interview with the Laundry supervisor confirmed the process used. At 12 noon, a written statement was given the surveyor stating the water temperature was not 160 degrees. On 8/18/10 at 11AM, a meeting was conducted with the Administrator at his/her request and representatives from the Laundry Supply Company responsible for processing other linens used by the facility and processed at the hospital; hospital/facility laundry representatives, facility engineers, Maintenance, and the survey team. During the meeting it was stated that the Administrator was not aware until August 2010 of the changes in the regulation. Due a personal concern, s/he had sent the information to the Director of Nursing who then sent the information to the person in charge of the laundry. However, no action had been taken until the concern was identified by the survey team. | 2014-06-01 |
| 10082 | LILA DOYLE AT OCONEE MEDICAL CENTER | 425075 | 101 LILA DOYLE DRIVE | SENECA | SC | 29672 | 2010-08-18 | 280 | D | 0 | 1 | SNPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to review and revise Resident # 15's care plan to accurately reflect the location and type of access port to receive [MEDICAL TREATMENT]. ( 1 of 1 [MEDICAL TREATMENT] resident reviewed for accuracy of care plan.) The findings included: The facility admitted Resident # 15 on 2/04/10 with [DIAGNOSES REDACTED]. Record review on 8/17/10 revealed this resident to be receiving [MEDICAL TREATMENT] on Tuesday, Thursday, and Friday. Further review also revealed the resident to have a shunt in the right arm and a [MEDICATION NAME] site. The first nurse thought the resident was receiving [MEDICAL TREATMENT] in a shunt in the left arm. RN #2 (Registered Nurse), when asked about sites, did not know location of site but went to ask another nurse, who stated the resident had a porta cath in the left shoulder where e/he received [MEDICAL TREATMENT]. The physician's history and physical dated 02/24/10 documented " several attempts were made at an AV fistula, all failed and e/he had a left [MEDICAL TREATMENT] [MEDICATION NAME] catheter placed. RN # 2 did not know what care was to be done for the [MEDICAL TREATMENT] resident. S/.he stated the resident did his/her own bath and dressing. The nurses would just look to make sure there was no blood on the dressing on [MEDICAL TREATMENT] days. Nurses notes for April, May,and June did document dressing checks after returning from [MEDICAL TREATMENT]. However, for July and August there was no documentation in the medical record related to any dressing checks. Continued record review on 8/18/10 revealed care plan #7 for Potential for Complications related to [MEDICAL TREATMENT]. Listed under approaches was the following: 1. Monitor/report/record to MD (Medical Doctor) prn (as necessary) [MEDICAL TREATMENT] complications such as air embolism, bleeding, decreased cardiac output, local or systemic infection. 2. check [MEDICATION NAME] site for s/s (signs/symptoms) infection. (Marked D/C-discontinued). 3. Check shunt site for s/s of infection, pain, or bleeding daily and prn. Check for bruit, thrill. During an interview with RN #3, the care plan person, she stated she had updated the care plan in April when the resident had surgery to place a shunt and thought the resident was receiving [MEDICAL TREATMENT] through the shunt. LPN #1 checked documentation in the medical record and stated, "The resident did not have a shunt placed in April." Therefore, the care plan did not accurately reflect care necessary for this resident related to [MEDICAL TREATMENT]. | 2014-06-01 |
| 10083 | LILA DOYLE AT OCONEE MEDICAL CENTER | 425075 | 101 LILA DOYLE DRIVE | SENECA | SC | 29672 | 2010-08-18 | 309 | D | 0 | 1 | SNPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interviews, the facility had no Policies/Procedures related to Caring for the [MEDICAL TREATMENT] Resident , had no education for staff on care of [MEDICAL TREATMENT] resident in 2009 nor 2010, and had no documentation of any assessment of the resident after [MEDICAL TREATMENT] visits or coordination of care with the [MEDICAL TREATMENT] clinic. Resident #15 was 1 of 1 resident reviewed receiving [MEDICAL TREATMENT]. The findings included: The facility admitted Resident # 15 on 2/04/10 with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Hypertension, End Stage [MEDICAL CONDITION], Chronic Pain, Adult Failure to Thrive, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], Debility, [MEDICAL CONDITION], and [MEDICAL CONDITION] with [MEDICAL CONDITION]. Record review on 8/17/10 revealed this resident to be receiving [MEDICAL TREATMENT] on Tuesday, Thursday, and Friday. Further review also revealed the resident to have a shunt in the right arm and a [MEDICATION NAME] site. The first nurse thought the resident was receiving [MEDICAL TREATMENT] in a shunt in the left arm. RN #2 (Registered Nurse), when asked about sites, did not know location of site but went to ask another nurse, who stated the resident had a porta cath in the left shoulder where s/he received [MEDICAL TREATMENT]. The physician's history and physical dated 02/24/10 documented " several attempts were made at an AV fistula, all failed and s/he had a left [MEDICAL TREATMENT] [MEDICATION NAME] catheter placed. RN # 2 did not know what care was to be done for the [MEDICAL TREATMENT] resident. S/.he stated the resident did his/her own bath and dressing. The nurses would just look to make sure there was no blood on the dressing on [MEDICAL TREATMENT] days. Nurses notes for April, May,and June did document dressing checks after returning from [MEDICAL TREATMENT]. However, for July and August there was no documentation in the medical record related to any dressing checks. Continued record review on 8/18/10 revealed care plan #7 for Potential for Complications related to [MEDICAL TREATMENT]. Listed under approaches was the following: 1. Monitor/report/record to MD(Medical Doctor) prn(as necessary) [MEDICAL TREATMENT] complications such as air embolism, bleeding, decreased cardiac output, local or systemic infection. 2. check [MEDICATION NAME] site for s/s (signs/symptoms) infection. (Marked D/C-discontinued). 3. Check shunt site for s/s of infection, pain, or bleeding daily and prn. Check for bruit, thrill. During an interview with RN #3, the care plan person, she stated she had updated the care plan in April when the resident had surgery to place a shunt and thought the resident was receiving [MEDICAL TREATMENT] through the shunt. LPN #1 checked documentation in the medical record and stated, "The resident did not have a shunt placed in April." RN #4 and LPN #1 confirmed the facility did not have a Policy and Procedure for Care for the [MEDICAL TREATMENT] Resident. Resident # 15 did not have physician's order in the current medical record for [MEDICAL TREATMENT] nor any orders for the care for the site. This was confirmed by both nurses. Later, an order was found in a closed chart. An interview with the Education Director revealed no inservices had been done in 2009 nor thus far in 2010 related to care for the [MEDICAL TREATMENT] Resident. She stated the staff would know what to do for the resident by the physician's orders and the resident's care plan. There were no physician's orders related to care of the [MEDICAL TREATMENT] site. Nor was the care plan correct as to the site or care of. | 2014-06-01 |
| 10128 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 250 | D | 8F5E11 | **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 provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 of 14 residents reviewed for social services. Resident #16 failed to receive medically related social services for discharge planning and lost personal items. The findings included: The facility admitted Resident #16 on 06/07/10 with the following [DIAGNOSES REDACTED]. He/she was coded on the Minimum Data Set (MDS) as having no short or long term memory problems and as having modified independence with cognitive skills for daily decision making with new situations only. The resident was noted in the Resident Assessment Profile as being a short term rehabilitation resident, planning to return to home. The social service note dated 6/7/10 (admitted ) stated that the resident was living in an apartment alone at Pickens County disability prior to hospitalization and that" the goal is to d/c (discharge) home on 31st day. " Social service notes stated, "will visit on reg. 1:1 basis to observe moods and adjustment to placement." The social service notes contained 5 more entries -6/14/10, 6/21/10, 6/24/10, 7/6/10, and 8/3/10. None of the entries addressed discharge planning or assessment for the resident's plan to return home. There was no indication in the documentation that the social services director had talked with the resident regarding the plans to return home and no documentation that he/she had helped the resident with planning for the discharge to home. The information in the social services notes addressed areas,such as; the resident's mood, appetite, weight, and activities. There was no mention of the arrangements to prepare for a move back home, although the 31st day had passed on July 1, 2010. There was no documentation as to why the resident's discharge date had been extended. In review of the resident's current Care Plan dated 6/24/10, there was no mention of the resident's upcoming discharge under social services or nursing sections of the plan. In an interview with the Social Services Director (SSD) on 8/25/10 at 9:00 AM he/she was unsure of the agencies involved with the resident and stated there was a man and a nurse who visited him/ her (the resident) , but was unsure of who they were, the agency they represented, or the role they played in the resident's discharge plan. The SSD did indicate he/she thought the delayed discharge was related to the resident's inability to bear weight. The SSD was unable to provide any additional evidence of social services involvement related to discharge planning with the resident and stated that his/her careplan for the resident was included on the overall careplan in the patient's record. In an interview with Resident #16 on 8/25/10 at 10:15 AM, the resident appeared upset about his/her missing purse and Playstation. He/she thought the items went missing in late July, but was unsure of the exact date. Resident #16 continued to complain about the missing items during the interview and stated he/she had notified the facility and his/her sister about this concern. When questioned about the plan to return to his/her apartment, he/she stated that he/she knew he/she needed a "rail put up in the bathroom" before he/she could return to the apartment, but did not know how it would be paid for. Resident #16 also informed this surveyor that he/she had been employed in the local Disability Board's Day Program(workshop) and was unsure if he/she could ever return to this work. The resident expressed he/she wanted to return to the apartment provided by the Disability Board and was upset that his/her purse was missing because his/her only keys for the apartment were in that purse. In an interview with Licensed Practical Nurse(LPN) #1 on 8/25/10 at 11:05 AM , he/she stated he/she overheard the resident complaining about the loss of his/her Playstation , but could not recall the date this occurred. He/she stated he/she told the Social Services Director and he/she was to talk with the resident's sister regarding the lost Playstation . LPN #1 did not recall hearing the resident complain about a lost purse. In an interview with the Social Services Director on 8/25/10 at 11:10 AM related to the lost items, he/she presented a Grievance/Complaint which documented the resident's complaint that a black purse and Playstation was missing and that a search was conducted of the resident's room and staff were questioned with no results.. There was no date or signature on the copy presented. There was no documentation in the social service notes related to the resident's lost items and concerns the resident expressed about the missing keys in relation to his/her return to the apartment. | 2014-04-01 | ||
| 10129 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 514 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, observations, and interviews the facility failed to maintain accurately documented records for 3 of 18 records reviewed for accuracy of records. Resident #7 had inaccurate documentation related to the application of a sling, Resident #13 had inaccurate documentation related to the application of ted hose, and Resident #16 had inaccurate documentation of a Grievance/Complaint Report. The findings included: The facility admitted Resident #16 on 06/07/10 with the following [DIAGNOSES REDACTED]. He/she was coded on the Minimum Data Set (MDS) as having no short or long term memory problems and as having modified independence with cognitive skills for daily decision making with new situations only. In an interview with Resident #16 on 8/25/10 at 10:15 AM, the resident appeared upset about his/her missing purse and Playstation. He/she thought the items went missing in late July, but was unsure of the exact date. He/she continued to complain about the missing items during the interview and stated he/she had notified the facility and his/her sister about this concern. In an interview with Licensed Practical Nurse(LPN) #1 on 8/25/10 at 11:05 AM , he/she stated he/she overheard the resident complaining about the loss of his/her Playstation , but could not recall the date this occurred. He/she stated he/she told the Social Services Director (SSD) and the SSD was to talk with the resident's sister regarding the lost Playstation . LPN #1 did not recall hearing the resident complain about a lost purse In an interview with the Social Services Director on 8/25/10 at 11:10 AM related to the lost items, he/she presented a Grievance/Complaint which documented the resident's complaint that a black purse and Playstation was missing and that a search was conducted of the resident's room and staff were questioned with no results.. There was no date or signature on the copy presented. The Social Services Director informed that the form should had been dated 8/16/10 and offered to date the form for the surveyor. This Surveyor requested a copy of the original document as received with no date. When the copy was provided at 12 noon, the copy was dated 8/16/10 and signed by the Social Services Director. Resident #7 was originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. There were multiple observations on all days of the survey of the resident without a sling, however, the Treatment Record documented the resident had worn the sling on all 3 days of the survey. Record Review on 8/23/10 at 3:48 PM revealed cumulative physician's orders [REDACTED].D. (Medical Doctor). O.K. to remove orthopedic device to left arm for ADL (Activities of Daily Living) Care". The following observations were made in which Resident #7 was not wearing the ordered sling. - On 8/23/10 at 1:52 PM. Resident sitting in the doorway of the therapy office. at 2:59 PM. Resident sitting in wheelchair in her room. at 6:22 PM. Resident sitting in wheelchair in her room eating dinner. - On 8/24/10 at 8:55 AM. Resident lying in bed. at 10:00 AM. Resident lying in bed. at 12:32 PM. Resident eating lunch in her room. -On 8/25/10 at 9:12 AM. Resident sitting in wheelchair in room. During an interview on 8/24/10 at 10:00 AM, Resident #7 was asked about the sling and why it wasn't being worn. The resident stated that at her/his last appointment, the orthopedic doctor told her/him that she/he could take it off. She/He stated that if the doctor wanted her to wear it, she/he would. When asked if staff encourage her/him to wear the sling, the resident stated that staff members haven't instructed her/him to wear it. Review of the consult section of the chart on 8/24/10 revealed no orthopedic notes. Review of the Nurses Notes on 8/25/10 revealed no mention of the use of a sling for 8/23/10 through 8/25/10. During an interview on 8/25/10 at 10:30 AM, Licensed Practical Nurse #3 was asked about Resident #7's last orthopedic visit. The nurse checked the appointment calendar and stated the last orthopedic visit for Resident #7 was in July. When asked about any orthopedic progress notes, the nurse stated the physician only sent a note if there were any changes and verified there were no orthopedic notes in the chart. LPN #4 joined the interview and both nurses were told that Resident #7 had been observed on all days of the survey without her/his sling having been worn. The cumulative physician's orders [REDACTED]. Upon review of the Treatment Record for Resident #7 for August 2010, documentation for the dates of the survey were brought to the nurses attention. For August 23rd and 24th, the Orthopedic Device Sling To Left Arm had been initialed as having been worn for the 11-7, 7-3, and 3-11 shifts. For August 25th, the Orthopedic Device Sling To Left Arm had been initialed as having been worn for the 11-7 and 7-3 shifts. LPN #4 verified she/he was the nurse that documented on the Treatment Record regarding the use of the sling. When asked about the discrepancy between the surveyor observations and documentation on the Treatment Record, LPN #4 stated that she/he had been asking Physical Therapy (PT) if Resident #7 had been wearing her/his sling. LPN #4 stated she/he thought that PT had supplied the sling for the resident. The surveyor and LPN #4 then went to see Resident #7, who was not wearing the ordered sling. Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. There were multiple observations on 8/24/10 of the resident without her/his ordered TED Hose, however, the Treatment Record documented the resident had worn the TED Hose that day. Record review on 8/24/10 at 9:05 AM revealed cumulative physician's orders [REDACTED].M. OFF IN P.M. R/T (Related To) [MEDICAL CONDITION]". Review of the Care Plan on 8/24/10 at 11:24 AM revealed "TED hose as ordered" as an approach for resident being "At risk for complications r/t (related to) [MEDICAL CONDITION]". Review of the 8/9/10 "Easley Living Center" progress note (signed by the Nurse Practitioner) on 8/24/10 at 9:30 AM revealed "Her/His [MEDICATION NAME] was recently increased to 40 mg (milligrams) because she/he was having [MEDICAL CONDITION]". Review of the 8/6/10 "Easley Living Center" progress note signed by the Physician revealed "She does complain of some increased [MEDICAL CONDITION] in her left lower extremity, however. Nursing staff reports no major issues with this patient including any skin breakdown...Extremities: She does have 1+ [MEDICAL CONDITION] in that left lower extremity primarily in the dorsum of her left foot. Trace lower extremity [MEDICAL CONDITION] on the right...Regarding the lower extremity [MEDICAL CONDITION], we will increase her [MEDICATION NAME] up to 40 mg a day". Review of the August 2010 Treatment Record on 8/24/10 at 10:20 AM revealed an entry for "Ted Hose: On in A.M. Off in P.M. R/T [MEDICAL CONDITION], 7-3 On, 3-11 Off" that had been initialed for the 7-3 shift for August 24th. Observations on 8/24/10 at 10:25 AM, 11:48 AM, 12:27 PM, 1:52 PM, 4:00 PM, and 4:38 PM revealed Resident #13 sitting in her/his wheelchair wearing socks, but no TED hose. During an interview on 8/25/10 at approximately 10:20 AM, Licensed Practical Nurse (LPN) # 3 was told that there were observations made of Resident #13 without her/his TED hose on. LPN #3 reviewed and verified the cumulative Physician"s Orders for August 2010 and the resident's Care Plan which indicated the resident was to wear the Ted Hose. She/He also verified the Physician's progress notes that indicated the resident had [MEDICAL CONDITION]. LPN #4 joined the interview and was told that the resident had been observed without the ordered TED Hose. LPN #4 verified that she/he was the nurse that documented on the Treatment Record regarding the application of the TED Hose. The surveyor, LPN #3 and LPN #4 reviewed the Treatment Record documentation for August 2010 in which the TED hose had been initialed as having been worn on 8/24/10 and 8/25/10 for the 7-3 shift. When asked about the discrepancy between the Treatment Record documentation and the observations of the resident without her/his TED Hose, the nurse stated that she/he reminded the Certified Nursing Assistants (CNAs) to apply the TED Hose. When asked to go to check and see if the resident was currently wearing the TED Hose, LPN #4 stated that she/he was new and didn't know the residents well, and if the resident was not in her/his room then LPN #3 would have to point the resident out to her/him. Upon entry to the room, Resident #13 was lying on her/his bed. The nurse stated the resident would not be wearing TED Hose in bed, and staff usually kept the TED Hose on her/his wheelchair. There were no TED Hose on the wheelchair, and, while checking the bedside table and closet, the nurse stated the TED Hose was probably in the laundry being washed. When asked if the resident only had one pair of TED Hose, the nurse answered "yes". | 2014-04-01 | ||
| 10130 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 164 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility policies entitled "Competency Catheter Care- Female" (undated) and "Competency Catheter Care-Male" ([DATE]), the facility failed to provide adequate personal privacy for 2 of 2 sampled residents observed for catheter care. Appropriate clothing/draping was not provided for Residents #6 and #8 to prevent unnecessary exposure of body parts during catheter care. Also, based on random observation and interviews, the facility failed to provide privacy/confidentiality during medical/financial communication with Resident #13 in a common area of the facility. The findings included: The facility admitted Resident #6 on [DATE] with [DIAGNOSES REDACTED]. Prior to beginning catheter care on [DATE] at 2:40 PM, Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA) #1 closed the corridor door and pulled the privacy curtain around the resident's bed. Observation revealed the resident lying in bed with a house dress pulled up to the epigastric area. A towel was positioned across the abdomen and perineal area. The resident's legs were bare to her/his ankles except for the disposable brief which was pulled down to the knees. Prior to the treatment, the CNA removed the towel drape and placed it below the resident's feet on the bed, exposing the resident from the epigastric area to the ankles. Resident #6 remained thusly exposed throughout the catheter care, perineal care, positioning on her/his left side, and cleansing of the buttocks and anal areas. The resident was then instructed to "lie back" which she/he did without assistance. Both staff then left the bedside with the resident exposed to wash their hands. They returned to the bedside and assisted the resident to replace the brief and pull down and snap the housedress in readiness to get out of bed. Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #8 had not been draped appropriately during catheter care. During observation of catheter care on [DATE] at 3:32 PM, Licensed Practical Nurse (LPN) #1 removed the towel covering Resident #8's perineum leaving him exposed while she/he raised the bed to a workable height. Certified Nursing Assistant (CNA) #3 then performed catheter care. After removing her/his gloves and discarding them in the trash bag, CNA #3 left the bedside to wash her/his hands leaving the resident's perineum exposed. LPN #1 followed and observed while CNA #3 washed her/his hands. Upon returning to the bedside, CNA #3 said "I am going to place the towel back over you" and redraped the resident. During an interview on [DATE] at 9:18 AM, LPN #1 and CNA #3 verified Resident #8 had been left exposed while the bed was being raised and during handwashing. LPN #1 stated that she/he thought privacy had been afforded since the privacy curtain had been closed. Review of the policy provided by the facility entitled "Competency, Catheter Care- Male" on [DATE] at 3:42 PM revealed that once catheter care was completed, the procedure would be to "...Remove gloves. Reposition residents clothing and cover. Wash hands". Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #13 had been asked by a staff member to sign paper work allowing the facility to collect funds for room and board in a common area. During a random observation on [DATE] from 4:35 PM to approximately 4:45 PM, Resident #13 was observed in the dining room of Unit 1 sitting across from a staff member. The staff member was attempting to get her/him to sign a paper. The resident loudly exclaimed, "I'm not going to sign any papers!" Resident #13 was visibly agitated and upset and stated that she/he did not want to talk to him/her and that she/he had not spoken to a (man/woman) since her/his (spouse) had died . The staff member reminded the resident that they had talked yesterday and went on to compliment the resident on the clothing she/he was wearing. The resident exclaimed, "Don't touch me!" The staff member continued to ask her/him to sign the paper work with the resident tearfully yelling out "No!" Another surveyor working in the chart room behind the Unit 1 Nurses Station overheard the incident. A Certified Nursing Assistant (CNA) identified the staff member as someone who worked in the therapy department. During an interview on [DATE] at 5:45 PM, the Occupational Therapist (OT) and Director of Rehabilitative Services were present. The OT stated that he/she had been asked by Social Services to have the resident sign paperwork to allow the facility to collect funds from her/his account for room and board. He/She stated that therapy had a good working relationship with the resident before, but that today the resident was not in a good mood. The OT stated that the resident would not sign the paper so, "We thought it best to stop". During an interview on [DATE] at 3:35 PM, the Social Services Director (SSD) and the Director of Nursing (DON) were present. The SSD stated that Resident #13 had exhausted her/his Medicare benefits and the facility needed funds in order for the resident to stay there. She/He stated that the resident's son needed a letter signed by the resident in order to have the bank release her/his funds. She/He stated that the resident had refused to sign the paper work for her/him, so therapy was asked to get the paper work signed since the resident was more comfortable with the therapy staff. The SSD stated that Resident #13 had "Sundowners in the afternoon" and that she/he discussed the funds matter with the resident this morning. They did not have the resident sign any papers. Instead, she/he stated they had the resident call the bank herself/himself in order to get the funds released. The SSD and DON were informed of concerns that the OT attempted to get Resident #13 to sign paper work related to her/his financial affairs in the dining room and did not provide privacy. The SSD verified that she/he had brought the resident to her/his office that morning to discuss the resident's financial matters and stated this was the usual practice. | 2014-04-01 | ||
| 10131 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 241 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation and interview, the facility failed to promote care in a manner that maintained or enhanced dignity and respect. Staff failed to respect Resident #13's wishes to refuse to sign paperwork and terminate a conversation in a common area which resulted in increased agitation. The findings included: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. During a random observation on [DATE] from 4:35 PM to approximately 4:45 PM, Resident #13 was observed in the dining room of Unit 1 sitting across from a staff member. The staff member was attempting to get her/him to sign a paper. The resident loudly exclaimed, "I'm not going to sign any papers!" Resident #13 was visibly agitated and upset and stated that she/he did not want to talk to him/her and that she/he had not spoken to a (man/woman) since her/his (spouse) had died . The staff member reminded the resident that they had talked yesterday and went on to compliment the resident on the clothing she/he was wearing. The resident exclaimed, "Don't touch me!" The staff member continued to ask her/him to sign the paperwork with the resident tearfully yelling out "No!" After the staff member left, Certified Nursing Assistant (CNA) #2 came and sat down next to the resident to talk to her/him. Another surveyor working in the chart room behind the Unit 1 Nurses Station overheard the incident. A CNA identified the staff member as someone who worked in the therapy department. During an interview on [DATE] at 5:45 PM the Occupational Therapist (OT) and Director of Rehabilitative Services were present. The OT stated that he/she had been asked by Social Services to have the resident sign paperwork to allow the facility to collect funds from her/his account for room and board. He/She stated that therapy had a good working relationship with the resident before, but that today she/he was not in a good mood. The OT stated that the resident would not sign the paper so, "We thought it best to stop". During an interview on [DATE] at 3:35 PM, the Social Services Director (SSD) and the Director of Nursing (DON) were present. The SSD stated that Resident #13 had exhausted her Medicare benefits and the facility needed funds in order for the resident to stay there. She/He stated that the resident's son needed a letter signed by the resident in order to have the bank release her/his funds. She/He stated that the resident had refused to sign the paper work for her/him, so therapy was asked to get the paper work signed since the resident was more comfortable with the therapy staff. The SSD stated that Resident #13 had "Sundowners in the afternoon" and that she/he discussed the funds matter with the resident this morning. They did not have the resident sign any papers. Instead, she/he stated they had the resident call the bank herself/himself in order to get the funds released. The SSD and DON were informed of concerns about the OT's continued attempts to get Resident #13 to sign the paper work after the resident clearly indicated she/he was not going to sign them and became increasingly agitated and upset. During an interview on [DATE] at 4:02 PM, the surveyor asked CNA #2 what she/he knew about the incident since she/he had been observed going in and out of the dining room the day before while the therapist was speaking with Resident #13. CNA #2 stated she/he had heard Resident #13 fussing with the therapist about signing papers. The CNA stated that the resident had been thinking that people are trying to steal her/his money. The CNA stated the resident's demeanor is usually pretty quiet during the day, but in the afternoon the resident gets upset and cries when approached. When asked about how long this had lasted yesterday afternoon, CNA #2 stated that the resident had been agitated for about ,[DATE] minutes before she/he calmed down. Cross Refer to F164 as it relates to failure of the facility to address personal issues with | 2014-04-01 | ||
| 10132 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 157 | D | 8F5E11 | **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 notify the responsible party (RP) of changes. For one of five residents reviewed for falls, Resident #3 had a family member who was not notified of a fall with injury. The findings included: Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 8/23/10 at 1:45 PM revealed Resident #3 sitting on her/his bed. She/He had a dark swollen area on her/his forehead along with yellow/black discolorations under her/his eyes. Record Review on 8/24/10 at 11:52 AM revealed Nurse's Notes dated "8/11/10 5P(M) Resident asleep in high back chair + rolled onto floor. Has aprox(imately) 9 cm (centimeter) bruise to forehead. BP (Blood Pressure) 158/84, P(ulse)- 76, R(espirations)- 20, T(emperature)- 97.8. ROM (Range of Motion) (without) difficulty. Assisted to chair. Neuro (checks) WNL (within normal limits). No distress noted". "8/11/10 6 P(M) (Family member) called + notified of fall + injury." "8/11/10 6:15 P(M) Dr.__ notified on voice mail of fall + injury." Review of the Incident/Accident Report on 8/24/10 revealed the following: "Date of Incident/Accident: 8-11-10, Time of Incident/Accident: 5 PM, ...Name of Physician Notified: Dr. __, Date: 8/11/10, Time of Notification: 6:15 PM, Name and Relationship of Family Member/Resident Representative Notified: (Family Member), Date: 8/11/10, Time of Notification: 6 PM". During a phone interview on 8/25/10 at 9:00 AM, Resident #3's family member stated that she/he would be the person who would be notified if the resident's condition changed. The family member went on to state that she/he came in to visit her/his family member one afternoon and found bruises on Resident #3's face. She/He had asked the staff what had happened, but they didn't know. She/He stated that there was a big fuss made because nothing had been documented about it, but that she/he was told that Resident #3 had fallen the night before. The family member stated she/he later received a call from the nurse who had been taking care of Resident #3 at the time of the incident, and was told that Resident #3 went to sleep in a chair without arms and had fallen out of the chair. She/He was unable to recall the date she/he had visited and found her/his family member with the injury. During an interview on 8/25/10 at 10:10 AM, Licensed Practical Nurse (LPN) # 3 stated she/he was aware of the incident and that the Assistant Director of Nursing (ADON) had been called to talk to the family member and had handled the situation. During an interview on 8/25/10 at 10:48 AM, the ADON stated she/he had spoken with the family member regarding the incident and verified that the family member had not been notified of the fall with injury. The ADON could not recall the date she/he had spoken with the family member about the incident. The ADON stated that she/he had called the nurse who had been on duty the evening of the incident and the nurse had stated she/he had been so busy that she/he didn't notify the family. | 2014-04-01 | ||
| 10133 | MAJESTY HEALTH & REHAB OF EASLEY, LLC | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2010-08-25 | 309 | D | 8F5E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interviews, the facility failed to provide care and services as ordered by the Physician for 2 of 18 sampled residents reviewed. The facility failed to ensure that Resident #13, on anticoagulant therapy, did not receive [MEDICATION NAME] after the Physician ordered the medication held due to an elevated PT/INR ([MEDICATION NAME]/International Normalization Ratio). In addition, Resident #13 did not have Ted Hose applied as ordered. Resident #7 did not have a sling applied as ordered by the physician. The findings included: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 8/24/10 at 9:36 AM revealed a laboratory (lab) report dated 5/17/10. The PT was 37.2 H(igh). The reference range was listed as 9.4-10.8 sec(onds). The INR was 3.9 H(igh). The reference range was listed as .9-1.2 with the suggested therapeutic INR range for venous [MEDICAL CONDITION] and [MEDICAL CONDITION] listed as 2.0-3.0. A handwritten note to the right of the page stated "Dr. __: Hold [MEDICATION NAME]. Redraw PT/INR Thursday 5/20/10 and call to Dr. __during business hrs (hours) Thursday". Review of the Physician's Telephone Orders on 8/24/10 at 12:42 revealed an order to "Hold [MEDICATION NAME], Check PT/INR Thursday 5/20/10, Call results to Dr. __ during business hours Thursday". The Physician's Telephone Order had been dated 5/17/10 and the time next to "Signature of Nurse Receiving Order" was 6:45 PM. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 5 mg (milligrams) (1) PO (By Mouth) (at) HS (Bedtime) 9P(M)". The [MEDICATION NAME] had been initialed as having been given on 5/15/10, 5/16/10, and 5/17/10. The [MEDICATION NAME] had been held from 5/18/10 through 5/22/10 and had been discontinued on 5/23/10 according to the MAR indicated [REDACTED] During an interview on 8/24/10 at 3:45 PM, the Director of Nursing (DON) reviewed and verified the 5/17/10 PT/INR results, the Physician's Telephone Order dated 5/17/10 at 6:45 PM, and the MAR indicated [REDACTED]. Review of the laboratory reports and additional physician orders [REDACTED]. At that time the physician ordered Vitamin K to be given and a follow-up PT/INR to be drawn on 5/22/10, continue to "hold [MEDICATION NAME], d/c (discontinue [MEDICATION NAME])". The lab work on 5/22/10 was INR 3.19. Record review on 8/24/10 at 9:05 AM revealed cumulative physician's orders [REDACTED].M. OFF IN P.M. R/T (Related To) [MEDICAL CONDITION]". Review of the Care Plan on 8/24/10 at 11:24 AM revealed "TED hose as ordered" as an approach for resident being "At risk for complications r/t (related to) [MEDICAL CONDITION]". Review of the 8/9/10 "Easley Living Center" progress note (signed by the Nurse Practitioner) on 8/24/10 at 9:30 AM revealed "Her/His [MEDICATION NAME] was recently increased to 40 mg (milligrams) because she/he was having [MEDICAL CONDITION]". Review of the 8/6/10 "Easley Living Center" progress note signed by the Physician revealed "She does complain of some increased [MEDICAL CONDITION] in her left lower extremity, however. Nursing staff reports no major issues with this patient including any skin breakdown...Extremities: She does have 1+ [MEDICAL CONDITION] in that left lower extremity primarily in the dorsum of her left foot. Trace lower extremity [MEDICAL CONDITION] on the right...Regarding the lower extremity [MEDICAL CONDITION], we will increase her [MEDICATION NAME] up to 40 mg a day". Observations on 8/24/10 at 10:25 AM, 11:48 AM, 12:27 PM, 1:52 PM, 4:00 PM, and 4:38 PM revealed Resident #13 sitting in her/his wheelchair wearing socks, but no TED hose. During an interview on 8/25/10 at approximately 10:20 AM, Licensed Practical Nurse (LPN) # 3 was told that there were observations made of Resident #13 without her/his TED hose on. LPN #3 reviewed and verified the cumulative Physician"s Orders for August 2010 and the resident's Care Plan which indicated the resident was to wear the Ted Hose. She/He also verified the Physician's progress notes that indicated the resident had [MEDICAL CONDITION]. LPN #4 joined the interview and was told that the resident had been observed without the ordered TED Hose. LPN #4 verified that she/he was the nurse that documented on the Treatment Record regarding the application of the TED Hose. The surveyor, LPN #3, and LPN #4 then reviewed the Treatment Record documentation for August 2010 in which the TED Hose had been initialed as having been worn on 8/24/10 and 8/25/10 for the 7-3 shift. When asked about the discrepancy between the Treatment Record documentation and the observations of the resident without her/his TED Hose, the nurse stated that she/he reminded the Certified Nursing Assistants (CNAs) to apply the TED Hose. When asked to go to check and see if the resident was currently wearing the TED Hose, LPN #4 stated that she/he was new and didn't know the residents well. She/He went on to say that if the resident was not in her/his room, then LPN #3 would have to point the resident out to her/him. Upon entry to the room, Resident #13 was lying on her/his bed. The nurse stated the resident would not be wearing TED Hose in bed, and staff usually kept the TED Hose on her/his wheelchair. There were no TED Hose on the wheelchair, and, while checking the bedside table and closet, the nurse stated the TED Hose was probably in the laundry being washed. When asked if the resident only had one pair of TED Hose, the nurse answered "yes". Resident #7 was originally admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #7 had not worn a sling as ordered for all the days of the survey. Record Review on 8/23/10 at 3:48 PM revealed cumulative physician's orders [REDACTED].D. (Medical Doctor). O.K. to remove orthopedic device to left arm for ADL (Activities of Daily Living) Care". Review of the Care Plan on 8/23/10 at 4:33 PM revealed "Orthopedic device as ordered 7/13/10" as an approach to impaired mobility. The following observations were made in which Resident #7 was not wearing the ordered sling. - On 8/23/10 at 1:52 PM. Resident sitting in the doorway of the therapy office. at 2:59 PM. Resident sitting in wheelchair in her room. at 6:22 PM. Resident sitting in wheelchair in her room eating dinner. - On 8/24/10 at 8:55 AM. Resident lying in bed. at 10:00 AM. Resident lying in bed participating in interview with surveyor. at 12:32 PM. Resident eating lunch in her room. -On 8/25/10 at 9:12 AM. Resident sitting in wheelchair in room. During an interview on 8/24/10 at 10:00 AM, Resident #7 was asked about the sling and why it wasn't being worn. The resident stated that at her/his last appointment, the orthopedic doctor told her/him that she/he could take it off. She/He stated that if the doctor wanted her to wear it, she/he would. When asked if staff encourage her/him to wear the sling, the resident stated that staff members haven't instructed her/him to wear it. Review of the consult section of the chart on 8/24/10 revealed no orthopedic notes. During an interview on 8/25/10 at 10:30 AM, Licensed Practical Nurse (LPN) #3 was asked about Resident #7's last orthopedic visit. The nurse checked the appointment calendar and stated the last orthopedic visit for Resident #7 was in July. When asked about any orthopedic progress notes, the nurse stated the physician only sent a note if there were any changes and verified there were no orthopedic notes in the chart. LPN #4 joined the interview and both nurses were told that Resident #7 had been observed on all days of the survey without her/his sling having been worn. The cumulative physician's orders [REDACTED]. Upon review of the Treatment Record for Resident #7 for August 2010, documentation for the dates of the survey were brought to the nurses attention. For August 23rd and 24th, the Orthopedic Device Sling To Left Arm had been initialed as having been worn for the 11-7, 7-3, and 3-11 shifts. For August 25th, the Orthopedic Device Sling To Left Arm had been initialed as having been worn for the 11-7 and 7-3 shifts. LPN #4 verified she/he was the nurse that documented on the Treatment Record regarding the use of the sling. When asked about the discrepancy between the surveyor observations and documentation on the Treatment Record, LPN #4 stated that she/he had been asking Physical Therapy (PT) if Resident #7 had been wearing her/his sling. LPN #4 stated she/he thought that PT had supplied the sling for the resident. The surveyor and LPN #4 then went to see Resident #7, who was not wearing the ordered sling. | 2014-04-01 | ||
| 10051 | NHC HEALTH CARE, CHARLESTON | 425381 | 2230 ASHLEY CROSSING DRIVE | CHARLESTON | SC | 29414 | 2010-08-31 | 371 | E | 0 | 1 | SJ8211 | On the days of the survey, based on observation and interview, the facility failed to prepare food under sanitary conditions as evidenced by food service equipment and the floor with a build up of grease, dried food stains, and/or food debris on it. The findings included: Observations on 8/30/10 at approximately 6:15am revealed lids to the steam table had a build up of grease and food stains; drawers to the left of the sugar/flour bins had a build up of grease on the fronts and drawer pulls; a reach-in refrigerator to the right of the sugar/flour bins had dried spills on the front of the door; bakers racks at the end of the trayline had grease build up, dried spills, and food debris on the rails and uprights; a switch box at the prep sink had grease and dust on the top of the box; there was a wide strip of built up grime around the electric boxes on the floor under the prep and steam tables; and in the baking prep area there was a build up of grime at the juncture were the floor met the wall. Observations on 8/31/10 at approximately 10:55am with the Director of Food Service (DFS) confirmed that the above conditions were present. Interview at that time indicated that the kitchen had been pressure washed on 8/17/10 but had not cleaned closely around the electric boxes. S/he further indicated that there was a daily, weekly, and monthly cleaning schedule for the kitchen. Review of the daily cleaning schedule revealed "Baking Prep area, both tables top and bottom shelves, Dry bins, inside drawers, refrigerator inside and out, cart cleaned, all items dated and labeled. COOKS AREA ALL AREAS USED BY COOKS WILL BE CLEANED DAILY. . . " When surveyor asked to review the past week's completed daily cleaning schedule, the most recent completed schedule provided was 8/26/10. The DFS indicated that more recent completed schedules could not be found at that time. | 2014-07-01 |
| 10183 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 279 | D | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to develop, review and revise the resident's comprehensive plan of care for 2 of 9 resident care plans reviewed. No Care Plan for Resident #7 was developed for [MEDICATION NAME] Therapy and Resident #9 had no Care Plan related to allergies [REDACTED]. The findings included: The facility admitted Resident #9 on 1/25/2008 with [DIAGNOSES REDACTED]. On 9/7/2010 at 3:20 PM, review of the medical chart for Resident #9 revealed that the resident had multiple medication allergies [REDACTED]. ([MEDICATION NAME]), E-Mycin ([MEDICATION NAME]), [MEDICATION NAME], Keflex, Beta Blockers and TAO (Triple Antibiotic Ointment) (adverse reaction) as well as *No sleeping pills*, OpSite Dsds (dressings), Tapes and Band-Aids. The Cumulative Orders for August and September 2010 listed Sulfa (Sulfonamide Antibiotics), [MEDICATION NAME], Ambien, [MEDICATION NAME] and [MEDICATION NAME]. The facility's Nursing Home History and Physical dated 8/5/2010 listed the resident's allergies [REDACTED]. A Nursing Home Admission History and Physical dated 8/25/2010 listed her/his allergies [REDACTED]. A hand written note was included which stated Tapes, OPsite, *No sleeping Pills Per POA (Power Of Attorney). Further review indicated that there was no Care Plan in the record related to Resident #9's numerous allergies [REDACTED].#9 had no Care Plan for allergies [REDACTED]. The facility admitted Resident # 7 on 7/26/10 with [DIAGNOSES REDACTED]. Record review on 9/7/10 revealed this resident to be receiving [MEDICATION NAME] 5 mg(milligrams) every night. Lab studies were done per physician's orders [REDACTED]. Continued review revealed no care plan had been developed related to anticoagulant therapy and the [MEDICATION NAME] usage since the resident was admitted . In an interview with the DON (Director of Nursing) on 9/8/10, s/he confirmed there was no care plan related to the [MEDICATION NAME] use. S/he also stated s/he would have expected a care plan to have been developed. | 2014-04-01 | ||
| 10184 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 281 | G | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, record reviews and review of the facility's protocol for Care Of Skin Abrasions, the facility failed to provide services for the residents which met the professional standards of quality for 1 of 9 residents sampled for professional standards and random observations during medication pass. Resident #9 had documented allergies [REDACTED]. The findings included: The facility admitted Resident #9 on 1/25/2008 with [DIAGNOSES REDACTED]. Review of the resident's medical chart on 9/7/2010 at 3:20 PM revealed that the resident had multiple allergy inconsistencies documented. The allergy sticker on the inside of the chart listed [MEDICATION NAME], Sulfa, [MEDICATION NAME], Amox. ([MEDICATION NAME]), E-Mycin ([MEDICATION NAME]), [MEDICATION NAME], Keflex, Beta Blockers and TAO (Triple Antibiotic Ointment) (adverse reaction) as well as *No sleeping pills*, OpSite Dsds (dressings), Tapes and Band-Aids. The Cumulative Orders for August and September 2010 listed Sulfa (Sulfonamide Antibiotics), [MEDICATION NAME], Ambien, [MEDICATION NAME] and [MEDICATION NAME]. The facility's Nursing Home History and Physical dated 8/5/2010 listed the resident's allergies [REDACTED]. A Nursing Home Admission History and Physical dated 8/25/2010 listed her/his allergies [REDACTED]. A hand written note was included which stated Tapes, OpSite, *No sleeping Pills Per POA (Power Of Attorney). Review of the Nurses' Notes dated 8/2/2010 at 0630 (6:30 AM), indicated that the resident had rubbed a scab off of the right side of her/his face. The nurse cleaned the area and applied "TAO (Triple Antibiotic Ointment) and a band-aid". At 5:00 PM, the Nurses' Notes revealed that the area on the right side of the resident's face was "red & (and) irritated. Res. (resident) states is painful to touch. On MD (physician) book for eval. (evaluation)." No other entries related to the resident's face were noted until 8/10/2010 at 4:40 PM which indicated that the physician had seen the resident and written new orders related to the "area on side of face." Review of the Treatment Administration Record (TAR) for Resident #9 for the month of August 2010 contained no documentation of the TAO being administered prior to the new order on 8/11/2010. On 9/7/2010 at 6:00 PM, during an interview with Licensed Practical Nurse (LPN) #4, she/he stated that a Telephone Order (TO) for the TAO should have been written and the TAO should have been documented on the TAR. Review of the TO dated 8/2/2010 stated per protocol apply TAO ointment to R (right) cheek abrasion and cover with dressing until healed. A TO dated 8/10/2010 indicated that the TAO had been discontinued on 8/10/2010. Review of the facility's protocol for Care Of Skin Abrasions revealed "...Preparation: 1. Verify that there is a physician's order for this procedure. (Note: This may be generated from a facility protocol) 2. Review the resident's care plan, current orders and [DIAGNOSES REDACTED]. 3. Check the Treatment Record...." Review of a Physician's Progress Note dated as dictated on 8/10/2010 contained documentation indicating ..."Allergic Reaction"...and to stop the topical antibiotics. On 9/8/2010 at 8:30 AM, during an interview with the Director Of Nursing (DON) and the Assistant Director Of Nursing (ADON), both verified the allergy information. The DON and ADON also verified the Nurses' Notes stating that the resident had received the TAO and that it was not documented as to how long and how often the resident received the treatment. On 9/8/2010 at 11:50 AM, during an interview with Resident #9, the resident's daughter, the Nurse Practitioner (NP) and the ADON present, the resident and her/his daughter stated that the resident had received the TAO for 3 days that they were sure of stating maybe 4 days. The NP stated that she/he was reviewing the resident's allergies [REDACTED]. During a random observation of the Medication Pass on 9/7/10 at 3:30PM, Licensed Practical Nurse # 6 was observed to leave a bottle of [MEDICATION NAME] on top of the medication cart when s/he entered the room to administer medications. The medication cart was not able to be seen from the resident's bedside. After entering the resident's room, the nurse was observed to leave the medication filled syringe on the bedside table as s/he left the room the wash his/her hands. After checking the resident's blood sugar and determining the need to call the physician for further direction, the nurse returned to the medication cart where s/he left both the bottle of insulin and the medication filled syringe on top of the cart unattended as s/he returned to the bathroom to wash his/her hands. On 9/8/10 at approximately 7:40AM, during observation of medication pass, Licensed Practical Nurse # 7 was observed to enter a resident's room and leave a medication cup containing nine medications and a bottle of [MEDICATION NAME] Nasal Spray on the bedside table when s/he left the room to wash his/her hands. The medications were not visible to the nurse as s/he washed his/her hands. On 9/8/10 at 10:30AM, the findings were shared with the Director of Nursing, who verified it was not facility policy to leave medications unattended. | 2014-04-01 | ||
| 10185 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 371 | F | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations and interview, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. Four of 4 ovens were observed to have dried, baked on spills on the interior walls, racks and floors of the ovens which extended to the exterior surfaces of the oven doors. The resident refrigerators on 2 of 3 units contained 16 [MEDICATION NAME] Extra nutritional supplements which had expired. The findings included: On 9/7/2010, during initial tour of the facility's kitchen, 4 ovens were observed to have a build up of food spills which were baked onto the oven doors and interiors. On 9/8/2010 at 8:40 AM, during an additional tour of the kitchen the ovens remained unchanged. On 8:45 AM, Dietary Staff worker #1 verified the ovens with the build up. At 9:20 AM, the Dietary Manager stated that the ovens were on a cleaning schedule but there was not a check of to ensure the staff had completed the task. A cleaning check off was initiated and provided on 9/8/10. During initial observation of the resident refrigerator on the Orchard View unit, 13- 8 ounce (oz) (237 milliliter (ml) containers on [MEDICATION NAME] Extra for Wounds with an expiration date of 20 July 2010 were noted. The location of the supplements and expiration date was verified by the Director Of Nursing. At 10:35 AM, Licensed Practical Nurse (LPN) #1 stated that the unit had 1 resident receiving the [MEDICATION NAME]. The resident refrigerator on the Overlook Point Unit contained 3-8 ounce (oz) (237 milliliter (ml) containers on [MEDICATION NAME] Extra for Wounds with an expiration date of 20 July 2010. The location of the supplements and expiration date was verified by Certified Nursing Assistant (CNA) #3. | 2014-04-01 | ||
| 10186 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 492 | E | 9VMS11 | On the days of the survey, based on review of personnel files, the facility failed to verify 2 of 3 LPN's (Licensed Practical Nurses) license were in good standing with the State Board of Nursing prior to hiring. The facility also failed to verify the criminal back ground for 1 of 3 LPNs prior to the hire date.The findings included:On 9/7/10 review of LPN #7's personnel file revealed that LPN # 7 started work on 6/16/10, however the facility failed to verify that his/her license was in good standing with the State Board of Nursing until 6/30/10. Review of LPN #8's personnel file revealed that LPN #8 started work on 7/7/10, the facility failed to verify that his/her license was in good standing with the State Board of Nursing until 7/20/10. The facility also failed to complete a criminal background check for LPN #8 until 7/20/10. LPN #9's hire date was 7/7/10 and the facility completed the license verification on 7/20/10. An interview with the Minimum Date Set (MDS) Nurse and the Staffing Coordinator on 9/7/10 at 3:00 PM confirmed that the license/criminal background check was not verified prior to hiring the nurses. On 9/8/10 at 9:00 AM, the NHA stated the he/she was not aware of the license and criminal background verifications not being done prior to hire until it was discovered by the surveyor. He/she also stated that a plan to resolve the issue had been started. | 2014-04-01 | ||
| 10187 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 496 | E | 9VMS11 | On the days of the survey, based on employee personnel record reviews and interviews, the facility failed to verify certification checks and/or criminal background checks prior to beginning work for 3 of 2 Certified Nursing Assistant's reviewed for certification verification and criminal background checks.The findings included:On 9/7/10 review of employee personnel records revealed that the facility failed to verify certification for 2 of 2 CNAs (Certified Nursing Assistants) prior to beginning work. On 9/7/10, review of the CNA personnel records revealed:CNA # 1 began work on 6/9/10 with verification completed 8/11/10.CNA # 2 began work on 6/16/10 with her/his criminal background check completed on 6/17/10 and verification completed 7/31/10. An interview with the Minimum Date Set (MDS) Nurse and the Staffing Coordinator on 9/7/10 at 3:00 PM confirmed that the license/criminal background check was not verified prior to hiring the CNA's. On 9/8/10 at 9:00 AM, the NHA stated the he/she was not aware of the license and criminal background verifications not being done prior to hire until it was discovered by the surveyor. He/she also stated that a plan to resolve the issue had been started. | 2014-04-01 | ||
| 10188 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 160 | B | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of resident funds for conveyance upon death, the facility failed to convey one fund within 30 days of death, and failed to have proper authorization to convey 2 other resident funds. The findings included: An interview with the Business Office Manager on [DATE] related to conveyance of funds upon death revealed 3 of 4 accounts reviewed were refunded improperly. Account of Resident A, who expired on [DATE], was refunded by check written on [DATE]. The manager explained that corporate had recently found several accounts that had not been refunded, and she made out the check this day. Resident B had expired on [DATE] and a check had been made out to Colonial Trust on [DATE]. No legal authorization had been obtained to make the check out to this entity. Resident C expired on [DATE], and a check was made out on [DATE] to a son who had not been appointed as an administrator of the estate. | 2014-04-01 | ||
| 10189 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 167 | C | 9VMS11 | On the days of the survey, based on observation and interview, the facility failed to post for resident review the Certification Survey for 8/20/09. The findings included: During a random observation on 9/7/10, the facility survey book, located upstairs in the skilled unit, was reviewed and found it contained last year's Licensure Survey, a Complaint Survey, and a Certification Survey dated 2008. The Certification Survey results for 8/20/09 were not included. The Director of Nursing (DON) reviewed the book and confirmed the survey was not included. The DON reviewed the survey book posted downstairs at the entrance and confirmed that book also did not have the 2009 Certification Survey included. | 2014-04-01 | ||
| 10190 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 441 | F | 9VMS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on review of facility Infection Control Policies, Logs, and interviews, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection related to cleaning/non cleaning of glucometers, not making documented compliance rounds of all departments, and not keeping accurate infection control logs for trending and tracking of infections. There were also expired supplies in 2 of 3 medication rooms. The findings included: Review of the monthly infection control logs on [DATE] and [DATE] revealed list of x-rays done each month and pharmacy printouts for residents on antibiotics for each month with listings of residents, tests done, organisms identified, antibiotics started. However, these listings were not in order by date. When the DON (Director of Nursing) and ADON (Assistant Director of Nursing) were interviewed regarding their infection control program, they stated the ADON filled out the log weekly or bi-weekly. They received the printouts from X-Rays and Pharmacy the next month so those were added to the logs then. The logs were not current. When asked how they did their tracking or trending for infections, they stated they had weekly meetings where infections were discussed. If they saw more infections were occurring, they would check to see which unit. No line listing of MDRO's ( Multi Drug Resistant Organisms) in the facility were being kept. The Admission's Coordinator would have to call someone in Nursing before placing a new resident. The ADON did not do compliance rounds to other departments for infection control. She stated she supposed the department heads did their own rounds. She did not receive any written reports for these. She did not do compliance rounds in nursing, but did competency checks on staff yearly. During observation of medication pass on [DATE] at 3:30PM, Licensed Practical Nurse #6 was observed to use a multi-resident glucometer to check a resident's blood sugar. The glucometer was not observed to be cleaned by the nurse either before or following its use. Random interviews related to cleaning of glucometers on [DATE] at 1:40PM and [DATE] at 4PM (two different units and two different shifts) revealed that both nurses stated they would use Alcohol to clean the glucometer. On [DATE] two boxes of Stat Let lancets with a manufacturers expiration date of ,[DATE] were observed stored in the Overlook Pointe medication room as verified by Licensed Practical Nurse #8. In the Orchard Medication Room, (2) IV 3000 Standard dressings with a manufacture's expiration date of ,[DATE] and (2) Allevyn thin dressings with a manufacturers expiration date of ,[DATE] were stored as verified by Licensed Practical Nurse # 1 at 5:45PM. Both nurses stated it was the responsibility of the third shift to check for outdated supplies. | 2014-04-01 | ||
| 10191 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2010-09-08 | 309 | D | 9VMS11 | **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 follow a physician's order to monitor Resident # 14's blood pressure before administering a medication. Resident #14 was one of four sampled resident's receiving medications with physician ordered parameters for administration. The findings included: Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged home on[DATE]. On 9/8/10, a review of the closed medical record revealed a physician's order for "[MEDICATION NAME] 60 milligrams, hold if pulse is less than 40" and notify the physician. A review of the July and August 2010 Medication Administration Records revealed there was no documentation that the resident's pulse was obtained/documented prior to the medication administration given daily at 6AM, 12P, 6P, or 12AM. The findings were verified and not disputed when shared with the Director of Nursing on 7/8/10 at 10:30 AM. | 2014-04-01 | ||
| 10269 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 279 | D | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record review, observations and interviews, the facility failed to develop and implement care plans with interventions to prevent aspiration for Residents #1, #2, #3 and #4 prescribed mechanically altered diets with nectar thick liquids and assessed as at risk for aspiration. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Observation on 09/13/2010 at approximately 3:00 PM of Resident #1's room revealed a white Styrofoam cup dated 09/11/2010 filled with water. In an interview with the surveyor on 09/13/2010 at 3:30 PM Licensed Practical Nurse #1 confirmed the date on the cup and the liquid. LPN #1 stated that a Speech Therapist had been working with Resident #1 and she was to have thickened liquids only. "The cup must have been left by the weekend staff." Record review on 09/13/2010 revealed a hospital transfer summary dated 08/23/2010 with discharge [DIAGNOSES REDACTED]. The physician ordered on [DATE] Speech-Language Pathology 5 days per week daily with precaution listed as aspiration; a pureed diet with nectar thick liquids was prescribed. Review of Resident #1's care plan revised 08/31/2010 listed as a focus area "Alteration in nutritional status r/t (related to) therapeutic mechanically altered diet with thicken liquids. Has severe dysphagia with high aspiration risk, family declines feeding tube." Interventions listed "will provided diet/snacks as ordered, will report hypo/hyper glycemia, will honor food preferences, will provide OHA's (oral hypoglycemic agents) as ordered". The facility admitted Resident #2 on 03/10/2008 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed physician's orders [REDACTED]. Review of Resident #2's care plan revised 09/13/2010 listed as a focus area "History of weight loss r/t receives daily diuretic and has dx (diagnosis) of dysphagia..." Interventions included "will provide honey thick liquids as ordered". The facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a telephone order dated 08/26/2010 for a pureed diet with nectar-like thick liquids. Review of Resident #3's care plan revised 08/26/2010 listed as a focus area "Nutrition: potential for weight loss related to dementia is also a diabetic; therapeutic mech (mechanically) alt (altered) diet with nectar thicken liquids..." Interventions included "encourage and assist as needed to consume all foods and/or supplements and fluids offered at and between meals. 8-26-2010 now to receive nectar thick liquids..." The facility admitted Resident #4 on 05/19/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Review of Resident #4 care plan initiated 08/12/2010 listed as a focus area "Feeding tube use with potential for complications also received ordered liquids and PO (by mouth) diet..." Interventions included "elevated head 30-45 degrees at all times... monitor for and report any signs of aspiration or intolerance of feeding..." Review of the Certified Nurse Aide (CNA) Kardex failed to list Resident #1 as at risk for aspiration; Residents #2, #3 and #4 were noted on the CNA Kardex as at risk for aspiration. The PIW (patient intervention worksheet) used by the CNAs did not include aspiration precautions for Residents #1, #2, #3 and #4. In a face-to-face interview with the surveyor on 09/14/2010 at 1:00 PM Speech Therapist #1 stated that any resident receiving nectar thick liquids should be on aspiration precautions, that she taught the CNA individually about aspiration precautions when she worked with the residents. When asked if she taught every shift she stated, "No." The Speech Therapist stated she was concerned about posting information at the bedside due to it being personal information about the resident. In face-to-face interviews with the surveyor on 09/14/2010 CNAs #1, #2 and #3 stated they would position the resident upright and give them small bites. The CNAs could not recall an inservice related to aspiration precautions. In reviewing the CNA Kardex monitor with the surveyor CNA #3 was not sure if the CNA Kardex addressed aspiration precautions, until she saw aspiration precautions on the monitor. | 2014-01-01 | ||
| 10270 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 315 | G | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection based on record review and interviews the facility failed to provide appropriate treatment and services to prevent urinary tract infections for 2 of 3 residents reviewed for urinary tract infections. On 08/13/2010 the physician ordered a STAT urinalysis and culture/sensitivity for Resident #1 to be done on 08/14/2010; the urine obtained by an in and out catheterization was left in the refrigerator, the test was not performed and treatment was delayed. Resident #1 was admitted to the hospital on [DATE] with a urinary tract infection. Resident #3's with increased blood sugars and a low grade temperature had a urinalysis and culture/sensitivity done on 08/05/2010, which was carried to the wrong lab, treatment was delayed for 4 days. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, "Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS state in AM; pt tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP. RP would like for resident to be evaluated. MD notified. Resident sent to hospital..." Record review on 09/13/2010 of the hospital admission history and physical dated 08/16/2010 at 3:33 PM revealed an admission assessment and plan that stated, "Urinary tract infection. We will initiate [MEDICATION NAME]. The last two urine cultures had produced fluoroquinolone resistant species. The patient was given [MEDICATION NAME] in the ER, although these were both acceptable [MEDICATION NAME] given the patient's unspecified [MEDICATION NAME] history, we will refrain cephalosporins and initiate carbapenem therapy pending final culture. 2. Altered mental status secondary to problem 1..." On 09/13/2010 a review of the laboratory studies revealed no results for the UA/CS ordered by the physician STAT in the AM on 08/13/2010. In an interview with the surveyor on 09/14/2010 the Director of Care Delivery for 1 Front stated that she had discovered that the urinalysis had not been done when she came in to work on Monday morning, 08/16/2010; that the urine was left in the refrigerator. The facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of the Lexington Medical Center urinalysis results dated 08/05/2010 had a note that stated, "wait for C and S". The culture and sensitivity results were available on 08/07/2010 but not obtained by the facility until 08/09/2010, treatment was started 2 days after the test results were available. In an interview with the surveyor on 09/14/2010 the Director of Care Delivery for 1 Front stated that she discovered that the hospice nurse carried the urine to the wrong lab and as soon as this was discovered the resident was treated. | 2014-01-01 | ||
| 10271 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2010-09-14 | 281 | G | 916711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observations, record review and interviews, the facility failed to provide care that met professional standards of practice for 2 of 3 sampled residents reviewed for standards of practice related to urinary tract infections and for 4 of 4 sampled residents reviewed for standards of practice related to aspiration precautions. The findings included: The facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Record review on 09/13/2010 revealed the following Nurse's Note: 08/13/2010 at 6:00 PM that stated, "Speech only slightly garbled today. Hx (history) UTI (urinary tract infection) in the past. New order received for UA/CS (urinalysis/culture and sensitivity) Stat in AM.... 08/14/201 at 6:50 AM In and out cath (catheterization) to obtain urine specimen for UA and CS STAT in AM; pt (patient) tolerated procedure well... 08/15/2010 at 2:00 PM Pt with garble speech appears confused unable to coordinate hands to mouth. Placing hands in plate rather than spoon to eat with. Chest congested. BP (blood pressure) 114/63 p (pulse) 68 R (respirations) 18 unlabored. MD (medical doctor) notified ordered [MEDICATION NAME] Bid (twice a day) and chest x-ray given. Schedule CT (computerized tomography) of head at hospital... Late entry for 08/15/2010 12:30 AM MD here to see resident... 08/16/2010 11:40 AM Resident unable to coordinate hand movement. Garbled like speech. Tongue hanging out of mouth. Resident not herself call RP (responsible party). RP would like for resident to be evaluated. MD notified. Resident sent to hospital..." Record review on 09/13/2010 of the hospital admission history and physical dated 08/16/2010 at 3:33 PM revealed an admission assessment and plan that stated, "Urinary tract infection..." On 09/13/2010 a review of the laboratory studies revealed no results for the STAT UA/CS ordered by the physician for the AM of 08/14/2010. In an interview with the surveyor on 09/14/2010 the Director of Care Delivery (DCD) for 1 Front stated that she had discovered that the urinalysis had not been done when she came in to work on Monday morning, 08/16/2010; that the urine was left in the refrigerator. The nursing staff failed to assure that the lab picked up the urine on 08/14/2010. The facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Continued review of the physician's orders [REDACTED]. Review of the Lexington Medical Center urinalysis results dated 08/05/2010 had a note that stated, "wait for C and S". The culture and sensitivity results were available on 08/07/2010 but not obtained by the facility until 08/09/2010, treatment was started 2 days after the test results were available. In an interview with the surveyor on 09/14/2010 the DCD for 1 Front stated that she discovered that the hospice nurse carried the urine to the wrong lab and as soon as this was discovered the resident was treated. The DCD stated that the urinalysis results were usually received within 24 hours of the collection date and the culture/sensitivity results was received within 48 hours of the collection date. The nursing staff failed to followup on a urinalysis done on 08/05/2010 until 08/09/2010, four days after the urine was sent to the lab. As stated in paragraph one, the facility admitted Resident #1 on 08/20/2008 with [DIAGNOSES REDACTED]. Observation on 09/13/2010 at approximately 3:00 PM of Resident #1's room revealed a white Styrofoam cup dated 09/11/2010 filled with water. In an interview with the surveyor on 09/13/2010 at 3:30 PM Licensed Practical Nurse #1 confirmed the date on the cup and the liquid. LPN #1 stated that a Speech Therapist had been working with Resident #1 and she was to have thickened liquids only. "The cup must have been left by the weekend staff." Record review on 09/13/2010 revealed a hospital transfer summary dated 08/23/2010 with discharge [DIAGNOSES REDACTED]. The physician ordered on [DATE] Speech-Language Pathology 5 days per week daily with precaution listed as aspiration; a pureed diet with nectar thick liquids was prescribed. Review of Resident #1's care plan revised 08/31/2010 listed as a focus area "Alteration in nutritional status r/t (related to) therapeutic mechanically altered diet with thicken liquids. On 09/14/2010 at 8:15 AM Resident #1 was observed in the dining room independently eating a pureed breakfast and drinking thicken water. The facility admitted Resident #2 on 03/10/2008 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed physician's orders [REDACTED]. Review of Resident #2's care plan revised 09/13/2010 listed as a focus area "History of weight loss r/t receives daily diuretic and has dx (diagnosis) of dysphagia..." On 09/14/2010 at 8:20 AM Resident #2 was observed in the dining room independently drinking thicken juice at breakfast. Additional review revealed the facility admitted Resident #3 on 07/31/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a telephone order dated 08/26/2010 for a pureed diet with nectar-like thick liquids. Review of Resident #3's care plan revised 08/26/2010 listed as a focus area "Nutrition: potential for weight loss related to dementia is also a diabetic; therapeutic mech (mechanically) alt (altered) diet with nectar thicken liquids..." On 09/13/2010 at approximately 3:15 PM Resident #3's granddaughter stated that her grandmother was unable to drink unassisted. The facility admitted Resident #4 on 05/19/2009 with [DIAGNOSES REDACTED]. Record review on 09/14/2010 revealed a physician's orders [REDACTED]. Review of Resident #4 care plan initiated 08/12/2010 listed as a focus area "Feeding tube use with potential for complications also received ordered liquids and PO (by mouth) diet..." On 09/14/2010 at 10:00 AM Resident #4 stated that he needed help with drinking and eating. Aspiration precautions were not care planned as a focus area for Residents #1, #2, #3 and #4 and observations on 09/13/2010 and 09/14/2010 revealed no system to identify residents who were at risk for aspiration. Review of the Certified Nurse Aide (CNA) Kardex failed to list Resident #1 as at risk for aspiration; Residents #2, #3 and #4 were noted on the CNA Kardex as at risk for aspiration. The PIW (patient intervention worksheet) used by the CNAs did not include aspiration precautions for Residents #1, #2, #3 and #4. In a face-to-face interview with the surveyor on 09/14/2010 at 1:00 PM Speech Therapist #1 stated that any resident receiving nectar thick liquids should be on aspiration precautions, that she taught the CNA individually about aspiration precautions when she worked with the residents. When asked if she taught every shift she stated, "No." The Speech Therapist stated she was concerned about posting information at the bedside due to it being personal information about the resident. In face-to-face interviews with the surveyor on 09/14/2010 CNAs #1, #2 and #3 stated they would position the resident upright and give them small bites. The CNAs could not recall an inservice related to aspiration precautions. In reviewing the CNA Kardex monitor with the surveyor CNA #3 was not sure if the CNA Kardex addressed aspiration precautions, until she saw aspiration precautions on the monitor. | 2014-01-01 | ||
| 10296 | AGAPE NURSING & REHAB CENTER | 425379 | 300 AGAPE DRIVE | WEST COLUMBIA | SC | 29169 | 2010-09-14 | 328 | E | DZ1T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure that residents received treatments as ordered by the physician for 1 of 2 residents reviewed who had nebulizer treatments ordered (#2). Resident #2 did not receive the nebulizer treatments ordered on [DATE] until 8/17/10. The findings included: Resident #2 with [DIAGNOSES REDACTED]. Review of the Daily Skilled Nurses Notes revealed a note on 8/12/10 at 10:15 PM stating: "Resident noted to have cough (with) congestion. Notified MD." The physician saw the resident on 8/13/10 and wrote in his progress note that the resident was "... quite short of breath and feeling terrible. ..." A treatment plan was documented in the progress note including "Start [MEDICATION NAME] solution 2.5 mg/3mL (2.5 milligrams per 3 milliliters), (0.083%), 3 mL, Q 4 hrs. (every four hours) while awake x (times) 5 days, then prn (as needed for) wheeze. ..." Antibiotics, nasal oxygen, a chest x-ray, and a speech therapy consult were also ordered for suspected aspiration pneumonia. The 8/13/10 Daily Skilled Nurses Note at 6 PM documented that the resident was coughing but had no complaint of pain. He was resting in bed. The nurse's note documented that the physician wrote new orders for oxygen, nebulizer treatments, and a chest x-ray. The chest x-ray was done and no infiltrates were noted. Speech Therapy evaluated the resident and changed his diet. A swallow study was scheduled for 8/16/10. The nurse's note ended with "... No distress when eating supper. Will monitor." Review of the physician's orders [REDACTED]. "Chest x-ray Re: poss (possible) aspiration pneumonia "[MEDICATION NAME] 100 mg PO (by mouth) BID (two times a day) x 10 days, 1st dose STAT "[MEDICATION NAME] 500 mg PO BID x 10 days, 1st dose STAT "[MEDICATION NAME] 2.5mg/3mL via neb q 4 (hours) while awake x 1 week, then PRN "Oxygen 2 L/min (liters per minute) via nasal cannula" This order was signed by the physician and signed by the same nurse who documented the information in the 6 PM nurse's note on 8/13/10. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nebulizer treatment was to start on 8/13/10 at 10 PM. Continued review of the MAR indicated [REDACTED]. A notation on the back of the MAR indicated [REDACTED]. Another entry in the resident's MAR for [MEDICATION NAME] showed a date of 8/14/10. It specified the same dose and schedule as the order on 8/13/10. Administration of the [MEDICATION NAME] nebulizer treatments began with the 10 AM dose on 8/17/10 and ended with the 6 AM dose on 8/24/10. Review of a list of nurses assigned to the resident from 8/13/10 to 8/17/10 showed the resident had six different nurses taking care of him on those dates. Review of the medical record showed no evidence the physician was notified of the missed nebulizer treatments. Review of the Daily Skilled Nurses Notes revealed the physician was notified of an elevated temperature of 100.6 degrees on 8/15/10. A urine culture was ordered. The documentation in the nurses' notes did not show evidence of any acute distress suffered by the resident during the period of the missed nebulizer treatments. The physician visited the resident on 8/16/10 and documented in his progress note that the resident's breathing was the same. "... He does not feel clinically improved there. ... " No respiratory distress was assessed. The resident's respiratory rate was regular with normal air movement. Bibasilar crackles were noted. "... His inactivity is the cause of his crackles, based on clinical eval and xray result. Will order an incentive spirometer to the bedside and have him do that Q (every) 2H while awake. ..." There was no new order related to starting the nebulizer treatments on 8/17/10. During an interview with the Director of Nurses (DON)on 9/14/10, she stated there was no reason for the nebulizer treatment omissions. The facility had plenty of nebulizer machines on hand (three machines were observed in the respiratory supply closet) and if one was not available, the facility's supply company was available at all times to obtain needed equipment. The DON said three staff members were counseled related to the omissions and an inservice program was planned for later in the month of September 2010 to review this and other issues. | 2014-01-01 | ||
| 10194 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 441 | E | A4CW11 | On the days of the survey, based on observation and interview, the facility failed to sanitize residents' personal laundry. The findings included: During observation on 9/14/10 at approximately 1:36 PM, Laundry Aid #1 loaded multiple residents' personal laundry into the washer and set the cleaning solution pump on "F1." The sign posted on the wall stated F1 solution was without bleach. During an interview at that time, the laundry aid stated she always used setting 1 for residents' personal clothes so they wouldn't be damaged. At 1:46 PM, during an interview, the Area Mechanic stated the water in the washer was between 115 and 120 degrees. He further stated the water used to be at 180 degrees but, after changing chemicals, they had been told the water temperature didn't need to be that high. At approximately 3:08 PM on 9/14/10, the Director of Environmental Services confirmed that the F1 setting did not include bleach and stated the (solution) pump should have been set on the F2 setting which added bleach after five minutes. Review of the detergent container did not reveal that the detergent contained any sanitizer. The Director of Environmental Services did not provide any additional information that the detergent had any bateriocidal properties. | 2014-03-01 | ||
| 10195 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 333 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure that one of 20 residents reviewed for medication assessment was free of significant medication errors. Potassium was not administered as ordered to Resident #6 for a period of 5 days. The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Prognosis was "nil" at the time of admission. Record review on 9-14-10 at 1:55 PM revealed 7-19-10 physician's orders [REDACTED]. Review of the 7-19-10 Basic Metabolic Profile revealed the following results: Sodium = 130 LOW (reference 135-145 mmol/L); Potassium = 4.9 (reference 3.6-5.0 mmol/L); Chloride = 95 LOW (reference 101-111 mmol/L); Blood Urea Nitrogen = 52 HIGH (reference 6-20 mg/dl); Creatinine = 1.8 HIGH (reference 0.5-1.2 mg/dl). Review of the 7-10 Documentation Record (Medication Administration Record/MAR) revealed that the medication was held as ordered and that the [MEDICATION NAME] was resumed on 7-27-10. The Potassium (20 milliEquivalents daily) was not initialed on the MAR indicated [REDACTED]. During an interview on 9-15-10 at 9:40 AM, the Director of Nurses verified that the medication had not been initialed as given for the five day period as noted. She stated she had been unaware of the omissions, no medication error report had been completed, and the physician had not been notified. She reviewed the record and verified that no recent Potassium level had been drawn. | 2014-03-01 | ||
| 10196 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 315 | E | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, interview, and review of the policy provided by the facility entitled "Skills Checklist for Suprapubic Catheter Care", the facility failed to ensure appropriate treatment and services for residents with catheters. The Certified Nursing Assistant (CNA) failed to properly anchor the suprapubic catheter tubing during catheter care for Resident #2, one of three residents observed with catheter care. Also, the facility failed to assess oral intake and urinary output as indicated by residents' medical condition for one of two sampled residents reviewed with an indwelling Foley catheter and Care Plan for intake and output monitoring. Resident #6, with a history of fluid imbalance and [MEDICAL CONDITION], had incomplete intake and output documentation. The findings included: The facility admitted Resident #2 on 10/22/09 with [DIAGNOSES REDACTED]. Observation of catheter care on 9/14/10 at 12:23 PM revealed CNA(Certified Nursing Assistant) #2 cleaning, rinsing, and drying the catheter tubing. She held the tubing between her index finger and thumb, approximately 4 inches from the insertion site, and anchored it to the resident's thigh while wiping down the tubing. The CNA cleansed from the insertion site distally toward where she held the catheter, causing undo tension on the catheter tubing. During an interview on 9/15/10 at 11:25 AM, CNA #2 verified she had anchored the catheter tubing at the resident's thigh instead of at the insertion site while performing catheter care. She stated she thought she was supposed to anchor the tubing to the thigh. Review of the policy entitled "Skills Checklist for Suprapubic Catheter Care" on 9/15/10 revealed "...6. Apply soap to one wet cloth, 7. Hold tubing (Without pulling) in other hand, 8. Wash around one side of tubing with soapy cloth-, 9. Using a different, clean part of cloth- wash around the other side of the Tubing, 10. Hold the tubing closest to the body to anchor it and prevent it from being pulled, 11. Using a different, clean part of cloth- wrap cloth around tubing (while holding with other hand) and wash tubing at least 4 inches away from body...14. Rinse one side of the insertion site ___/other side of tubing ___/the tube at least 4 inches___(while anchoring the tubing)___...16. Dry with clean cloth- one side of insertion site ___/other side of insertion site __/ around tubing and out 4 inches ___/ while anchoring tubing___." The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Prognosis was "nil" at the time of admission. Record review on 9-14-10 at 1:55 PM revealed significant weight loss noted on both the 11-16-09 Admission and 7-22-10 Quarterly Minimum Data Set Assessments. Weight records revealed an admission weight of 242 pounds and a 7-10 weight of 129.3 pounds. Further review revealed stabilization after the most recent assessment. The resident was admitted with and continued to have an indwelling Foley catheter. During an interview on 9-15-10 at 9:40 AM, the Director of Nurses (DON) attributed the majority of the weight loss to a dramatic decrease in [MEDICAL CONDITION] after admission (related to the [DIAGNOSES REDACTED]. Review of the current Care Plan revealed approaches including monitoring for [MEDICAL CONDITION] and recording intake and output every shift. Review of Intake and Output (I&O) Records revealed that urinary output was inconsistently monitored. For the month of 7-10, 31 of 31 days had omissions of recorded output. For 8-10, 30 of 31 days were incomplete. 13 of 13 days were incomplete in 9-10, through the dates of the survey. There was no output recorded for 7-31-10 7AM-3PM shift through 8-1-10 11PM-7AM shift (6 consecutive shifts), from 8-28-10 7AM-3PM shift through 8-31-10 7AM-3PM shift (10 consecutive shifts), and from 8-31-10 11PM-7AM shift through 9-3-10 7AM-3PM shift (8 consecutive shifts). Review of the diet card on 9-14-10 at 12:05 PM indicated that the resident was on a 1500 ml (milliliter) fluid restriction. As the tray was delivered, Certified Nursing Assistant (CNA) #4 stated she would "go get the coffee" as per the resident's request. During an interview at this time, CNA #4 reviewed the diet card and stated that she thought the resident was on a fluid restriction. The CNA verified that the diet card noted and that the resident received only 5 ounces of soup and 1/2 cup of iced tea as fluids for that meal. CNA #4 also verified that the resident had a water-filled pitcher at the bedside. A water pitcher had also been observed at the residents bedside on 9-13-10 at 9:35 PM and on 9-14-10 at 10:15 AM. At 12:30 PM on 9-14-10, Licensed Practical Nurse (LPN) #2 verified that a resident on fluid restriction should not have a water pitcher at the bedside and that intake and output should be monitored. I&O records were reviewed and 23 of 31 days in 7-10, 27 of 31 days in 8-10, and 11 of 13 days in 9-10, through the dates of the survey, were recorded with intakes of greater than 1500 ml. No current physician's orders [REDACTED]. During an interview on 9-15-10 at 9:35 AM, LPN #5 verified that Resident #6 should have had her intake and output monitored every shift. She stated that nurses wrote this information on the daily assignment sheet. CNAs were to record the intake and output at the end of their shifts. The Ward Secretary was responsible to "get the I&O and record it" on the Intake and Output Records. During the interview on 9-15-10 at 9:40 AM, the DON confirmed that Resident #6 had not been on a fluid restriction "for quite some time...She was on a restriction when first admitted due to [MEDICAL CONDITION] (skin) all over her body..." The DON stated that the diet card had been corrected. She verified the Care Plan to monitor the intake and output and confirmed that the reports were incomplete. | 2014-03-01 | ||
| 10197 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 332 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interviews and the Drug Facts and Comparisons book (updated monthly), the facility failed to ensure that it was free of medication error rates of five percent or greater. The medication error rate was 6.5 %. There were 3 errors out of 46 opportunities for error. The findings included: Error #1: On 9/13/10 at 8:36 PM, during observation of medication pass, Registered Nurse (RN) #5 was observed to administer two Klor-Con 10 (Potassium Chloride Extended Release) tablets and 7 other medications to Resident #10. During an interview on 9/13/10 at 8:48 PM, RN #5 revealed that supper trays arrived on the unit at about 6 PM and that Resident #10 had eaten in his room (approximately 2 and one-half hours before the potassium was administered). The Drug Facts and Comparisons book, page 49 (Potassium Replacement Products), states (under "Patient Information"): "May cause GI (gastro-intestinal) upset; take after meals or with food and with a full glass of water." Error #2: On 9/13/10 at 9 PM, during observation of medication pass, RN #2 was observed to administer one drop of [MEDICATION NAME] Ophthalmic Solution and one drop of [MEDICATION NAME] Ophthalmic Solution to the right eye of Resident A with one minute and 56 seconds between the two drops. RN #2 then administered one drop of the same two eye drops to the resident's left eye with 2 minutes and 4 seconds between the 2 drops. The Drug Facts and Comparisons book, page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "Because of rapid lacrimal drainage and limited eye capacity, if multiple drop therapy is indicated, the best interval between drops is 5 minutes. This ensures that the first drop is not flushed away by the second or that the second drop is not diluted by the first.". Error #3: On 9/14/10 at 7:47 AM, during observation of medication pass, RN #1 was observed to instill one drop of [MEDICATION NAME] Ophthalmic Suspension into each eye of Resident B without shaking the bottle before instillation. The Drug Facts and Comparisons book, page 1725, states (under "General Considerations in Topical Ophthalmic Drug Therapy"): "Resuspend suspensions (notably, many ocular steroids) by shaking to provide an accurate dosage of drug.". During an interview on 9/14/10 at 9:53 AM, RN #1 confirmed she did not shake the [MEDICATION NAME] Ophthalmic Suspension before instillation into the resident's eyes. Observation of the [MEDICATION NAME] Ophthalmic Suspension bottle revealed that there was no auxiliary "Shake Well" label attached to the bottle. During an interview on 9/14/10 at 10:43 AM, the facility's Consultant Pharmacist stated that she doesn't supply medications to the facility but agreed that there should be a "Shake Well" auxiliary label attached to the [MEDICATION NAME] bottle. | 2014-03-01 | ||
| 10198 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 225 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of the policy provided by the facility entitled "Alleged Violations of Mistreatment, Neglect and Abuse Including Injuries of Unknown Origin and Misappropriation of Property" dated 2/09, the facility failed to complete a thorough investigation for one of one reportable incidents reviewed for misappropriation of funds. The findings included: One of three reportable incidents reviewed on 9/15/10 revealed that a resident reported $44.00 missing from his room on 9/7/10. According to the DHEC (Department of Health and Environmental Control) Five-Day Follow-Up Report dated 9/13/10, "He had noticed this the week prior to the report". Under "Witnesses and other Staff on duty at time of/or prior to Reportable Incident:", there was nothing written. According to the report, the missing money had been reported by the facility to the Union County Sheriff's Office on 9/8/10. The "Summary Report of Facility Investigation:" stated "(Resident) keeps various items in the basket where he reported the money had been stored. (Numerous pieces of mail, straws, playing cards, and various other items). He has been reminded again to lock up any large amounts of money." Attached to the Five-Day Follow-Up Report was a letter dated May 4, 2010 from the Administrator addressed to residents and their families reminding them that the facility could store valuables and that residents are encouraged to not keep any items of personal or monetary value in their room. The letter went on to state that "The facility will take every precaution to protect belongings but cannot be accountable for valuables left in resident rooms". There were no resident or staff statements attached or evidence of a thorough investigation being completed. During an interview on 9/15/10 at approximately 12:30 PM, the Social Services Director (SSD) stated the resident had a history of [REDACTED]. After reviewing the Five-Day Follow-Up Report, she verified there were no resident or staff statements included. When asked if she had asked any of the staff about the missing money, she said "We felt like, they know to report. We thought it would be ineffective to ask each one." She went on to state that they had thought it best if the Sheriff's Department handled it. The SSD stated staff receive inservices on misappropriation. She then stated they did ask staff present at the time of the report if anyone knew about missing money, however, they did not get any statements and did not check to see which staff may have been on duty at the time of the alleged incident. The SSD had questions about where to draw the line as far as who to interview during an investigation. Review of the policy entitled "Alleged Violations of Mistreatment, Neglect and Abuse Including Injuries of Unknown Origin and Misappropriation of Property" on 9/15/10 revealed "Investigation procedures for allegations of misappropriation of resident property are as follows: ...The individual assigned to conduct the investigation will conduct a thorough investigation of the allegation. Areas/items that may be included as appropriate in the investigation include: a. An interview with the person reporting the missing items, b. A search of the resident's room for the missing items, c. an interview with the resident, as medically appropriate, e. An interview with the alleged individual accused of taking the residents' property, if known, f. Interviews with staff members, g. Interviews with the resident's roommate, family members, and visitors as appropriate...". | 2014-03-01 | ||
| 10199 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 323 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on observations, record reviews, and interviews, the facility failed to ensure that the resident environment remained free of accident hazards as was possible and that each resident received assistance devices to prevent accidents. Random observations were made of unattended paint thinner accessible to cognitively impaired, mobile residents and of bottles of Hydrogen Peroxide (H2O2) stored unsecured in Resident #3's bathroom. The facility also failed to provide interventions as required to minimize injury for one (1 )of 6 sampled residents reviewed for falls. Resident # 6 who was assessed at high risk for falls did not have a low bed and mats provided as per the plan of care. The findings included: On 9/14/10 at 10:50 AM a random observation was made by two surveyors on Unit 1 Maple Lane in the patient shower area of an unattended 1 gallon container of Paint Thinner on the window sill and 2 paint cans without covers containing paint thinner, soaked brushes, and rags soaked in paint thinner. There was a strong odor of the chemical in the shower area and in the Maple Lane Hall. The label on the Paint Thinner read, "DANGER: COMBUSTIBLE LIQUID, FLAMMABLE--HARMFUL OR FATAL IF SWALLOWED". The Material Safety Data Sheet (MSDS) provided by the Administrator on 9/14/10 read : "RISK STATEMENTS-Irritating to eyes, respiratory system, and skin. Harmful by inhalation, may cause lung damage if swallowed. Harmful in contact with skin. Vapors may cause drowsiness and dizziness". SAFETY STATEMENTS on the MSDS read: "Avoid contact with skin and eyes, Keep container tightly closed. Do not breathe gas, fumes, vapor, or spray, Keep away from sources of ignition. Take precautionary measures against static discharges." HANDLING AND STORAGE SECTIONS of the MSDS stated, "STORAGE : Vapors may ignite explosively and spread long distances. Prevent vapor build up. Keep cool and keep in the dark. Do not store above 49 C/120 F(Fahrenheit). Keep container lightly closed and upright when not in use to prevent leakage." "HANDLING: Use only with adequate ventilation. Avoid breathing of vapor of spray mist. Avoid contact with skin and eyes. Wear OSHA standard goggle or face shield. Wear gloves, apron, and footwear impervious to this material. Wash clothing before reuse. Avoid free fall of liquid. Empty container very hazardous!" Residents in nearby rooms #17 and #15 were using oxygen at the time of the random observation and a fan was blowing in the hall by the shower room with the observed Paint Thinner. In an interview on 9/14/10 at 11:00 AM with the Administrator and Environmental Services Manager they recognized the paint thinner as a hazardous chemical and removed if from the premises promptly. The Administrator stated they had contracted painters to repaint the facility halls and the Paint Thinner was left by the painters who were currently using the product. He stated that he had informed them prior to the start of the painting of the halls to remove unattended hazardous chemicals while painting the facility. He did not have a formal, written contract with the paint company, or evidence of this instruction. Following completion of tracheal suctioning and care on 9-14-10, Registered Nurse (RN) #1 removed the two-tiered wired basket cart containing all tracheostomy suctioning and care supplies from Resident #3's room. She stated that it was routinely stored in the resident's bathroom. The cart contained two 16 ounce bottles of Hydrogen Peroxide which were labeled, "Harmful if swallowed. Keep out of the reach of children." On 9-15-10 at 10:45 AM, Licensed Practical Nurse (LPN) #4, while preparing to perform tracheostomy care for Resident #3, stated that she had obtained the cart containing the H2O2 and other supplies from the unlocked resident bathroom. The facility admitted Resident #6 with [DIAGNOSES REDACTED]. Record review on 9-14-10 at 1:55 PM revealed that resident was assessed at high risk for falls on the most recent Fall Risk Assessment completed on 7-20-10. The 7-22-10 Care Plan noted that the resident was to have a "Low bed with mats". The 7-22-10 Quarterly Minimum Data Set Assessment noted the resident with both short- and long-term memory problems and varying mental function. On 9-13-10 at 9:35 PM, the resident was observed in a low bed, but without mats in place. The resident was observed in a regular height bed without mats on 9-14-10 at 9 AM, 10:15 AM, 12:05 PM, 1:30 PM, and 3:50 PM. During an interview on 9-14-10 at 4 PM, Certified Nursing Assistant (CNA) #1 stated that she did not know how long the resident had not had the low bed/mats. She was aware that the resident was supposed to have them "because it's on the Basic Care Sheet (CNA Care Plan)." During an interview on 9-14-10 at 3:50 PM, RN #2 checked the Documentation Record and verified that it indicated that the resident was to have a low bed with mats. The form noted "FYI" next to the intervention which RN #2 stated meant that the nurse was to check to assure the item was in place. She went to the resident's room and verified that the resident was in a regular height bed without mats. The nurse was unable to lower the bed and was unable to locate mats in the room for the resident. | 2014-03-01 | ||
| 10200 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 309 | E | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews and record review, the facility failed to follow physician's orders for application of Knee High TED (antiembolism stockings) Hose for Resident # 11, 1 of 4 residents reviewed with orders for TED Hose. The facility also failed to include provision of Services from a Chaplain and Social Services in the care plan and no documentation of visits from these disciplines were found in the record for Resident #18, 1 of 2 resident's reviewed receiving Hospice Services . The findings included: The facility admitted Resident #11 on 4/26/04 with [DIAGNOSES REDACTED]. Record Review on 9/14/10 at approximately 6:15 PM revealed a Physician's Order for "Knee high TED hose on in the morning before getting out of bed & (and) remove at bedtime ([MEDICAL CONDITION])" with a start date of 9/16/08. Observation of the resident at 6:25 PM on 9/14/10 revealed the resident was not wearing TED Hose. During an interview on 9/15/10 at 1:15 PM, the resident stated she had never had any stockings and that she did have swelling in her feet "sometimes." Review of the resident's Minimal Data Set revealed the resident was coded as not having any short or long term memory problems. The resident was named on the list provided by the facility of Interviewable Residents and she was a member of the Resident Council. Record Review on 9/15/10 at approximately 1:30 PM revealed that the TED Hose had been signed off daily for August and September, including being signed off for being applied the morning of 9/15/10. During an interview on 9/15/10 at approximately 2:15 PM, Registered Nurse (RN) #4 stated she had just received a new pair of TED Hose for the resident the previous week. Upon observation of the resident, RN #4 confirmed the resident was not wearing TED Hose. RN #4 was unable to locate any TED Hose in the resident's drawers. When informed of the resident's statement that she had never had any stockings, RN #4 stated: "She's usually pretty with it." During an interview on 9/15/10 at approximately 2:45 PM, Physical Therapy Assistant #1 stated Resident #11 was being seen 3 times per week by Physical Therapy and the treatment included leg exercises. She further stated that she had not observed the resident wearing TED Hose for at least the last month. The facility admitted Resident #18 on 7/6/10 with [DIAGNOSES REDACTED]. She was placed on Hospice Services on 7/30/10 for [DIAGNOSES REDACTED]. Review of Resident #18's record on 9/15/10, revealed no documentation of Chaplain or Social Service visits since the resident was admitted to Hospice. Review of the resident's facility and Hospice care plans revealed no care plan for Chaplain or Social Services. During an interview with RN #4 at approximately 12:00 PM, she stated she knew of no other place there would be any documentation from the Hospice staff other than in the chart. At approximately 12:30 PM on 9/15/10, the Director of Nursing stated she had spoken to the Hospice provider in the past regarding keeping information in the residents' charts in the facility and not just in the Hospice office. She stated the Director of Social Services might know if there was any documentation located anywhere else. During an interview on 9/15/10 at 1:22 PM, the Social Services Director stated she did not know of any documentation other than what was located in the chart and confirmed there was no documentation in the record of Chaplain or Social Service visits. Review of the Hospice Contract revealed the Hospice Provider was responsible for providing medical social services and counseling services (including bereavement,...and spiritual counseling.) It further stated that "Hospice shall furnish Nursing Facility with a copy of the Hospice Plan of Care" and any modifications to the plan of care. | 2014-03-01 | ||
| 10201 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 322 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interviews, and review of the facility's policies entitled "Gastrostomy Tube Check List" and "Procedure for Cleaning 60 cc (cubic centimeters) Syringes Used for Resident Feeding", the facility failed to utilize universal precautions and clean technique when flushing the Gastrostomy (G-) Tube and when cleaning and storing the piston syringes and gravity set for 2 of 3 residents observed for Gastrostomy Tube flushes. The findings included: The facility admitted Resident #5 on 7/17/09 with [DIAGNOSES REDACTED]. On 9/14/10 at approximately 12:33 PM, Licensed Practical Nurse (LPN) #6 was observed by two surveyors providing a Gastrostomy Tube flush before and after medication administration without washing her hands prior to initiating the procedure. LPN #6 opened the Medication cart, retrieved a bottle of liquid Tylenol from the drawer and poured 20 milliliters (ml) of Tylenol into a medication cup. LPN #6 proceeded to the resident's room, knocked, entered the room and filled the 2 empty medicine cups with 30 ml of water from the sink and placed all 3 medicine cups on the over-bed table. She then closed the door, opened a plastic bag and placed it on the foot of the bed and donned a pair of non-sterile gloves. LPN #6 proceeded to check for and replace residual, checked for placement of the [DEVICE], and administered the 30 ml flush, the medication and ended with another 30 ml flush. Upon completion of the procedure, the piston syringe was rinsed and placed wet, back into the bag. Review of the "Gastrostomy Tube Check List" provided by the facility on 9-14-10 revealed "2. Placement check: Check placement before flushes,...Gather supplies..., Explain procedure to Resident, Provide Privacy, Wash Hands, (apply) Non-sterile gloves, ..." The facility admitted Resident #3 on 4-8-01 with [DIAGNOSES REDACTED]. Prior to observation of a Gastrostomy (G-) feeding and flush on 9-14-10 beginning at 9:55 AM, two Certified Nursing Assistants exited the resident's room after completing AM care, including incontinent care. Registered Nurse (RN) #1 proceeded to prepare the resident for a gravity feeding. She checked placement using a 60 cc (cubic centimeter) piston syringe and then infused 30 cc of water via gravity through the barrel of the syringe. The RN then connected the gravity feeding tubing to the [DEVICE] and set the clamp so as to infuse it slowly. She then took apart the piston syringe and placed it in the sink. She removed the gloves she had used during the procedure, rinsed the syringe with water, placed the piston in the barrel of the syringe, and stored it together, wet, in its original packaging. At 10:30 AM, RN #1 disconnected the gravity feeding set and hung the capped tubing on the feeding pole. She neglected to rinse out the feeding set, allowing feeding to remain in the tubing and bottom of the bag. When asked if this was how the set was stored until the next feeding, the RN replied, "Yes." The nurse completed the water flush via gravity using the barrel of the feeding syringe. After completing the procedure, RN #1 again placed the piston and barrel of the feeding syringe into the sink. She removed the gloves she had used during the procedure, rinsed the syringe with water, placed the piston in the barrel of the syringe, and stored it together, wet, in its original packaging. RN #1 verified that this was the procedure she always followed. During an interview on 9-15-10 at 10 AM, the Director of Nurses stated that the facility policy did not address handling of the piston syringe or gravity feeding set. She stated that the syringe should not have been placed in the sink and that the feeding should have been rinsed out of the gravity set and not allowed to remain until the next feeding time. On 9-15-10 at 1 PM, RN #1 verified the procedure as above noted. During an interview on 9-15-10 at 12:05 PM, the Administrator stated there was no evidence on file that RN #1 had been trained on the proper procedure for [DEVICE] feeding/flush. Review of the facility's policy entitled "Gastrostomy Tube Checklist" on 9-15-10 revealed no reference to cleansing or storage of the piston syringe or gravity feeding set. Review of the Infection Control Manual on 9-15-10 revealed a policy entitled "Procedure for Cleaning 60 cc Syringes Used for Resident Feeding" which stated: "...3. The syringe is washed and cleaned thoroughly with dispenser soap and water and rinsed well in hot water subsequent to use. Be sure not to place the syringe in the sink. 4. The syringe is stored separate (barrel and syringe) on a clean paper towel and covered with a clean towel and allowed to air dry...7. Syringes used for tube feeding are cared for in the same manner as described above..." | 2014-03-01 | ||
| 10202 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 328 | D | A4CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to follow the Physician's Orders for the administration of oxygen for 1 of 4 sampled residents reviewed with oxygen. Resident # 18 oxygen rate was observed above the stated physician's order. The findings included: The facility admitted Resident #18 on 7/6/10 with [DIAGNOSES REDACTED]. She was placed on Hospice Services on 7/30/10 for [DIAGNOSES REDACTED]. Review of the record on 9/15/10 at approximately 11:00 AM revealed a Physician's order for O2 (oxygen) at 2 liter per minute (lpm) via NC (nasal cannula.) Review of the Hospice Nursing Visit Note revealed the Hospice nurse had documented the oxygen at 3 lpm via NC on 9/15/10, 9/8/10 and on 8/23/10. Review of the Documentation Record (MAR) revealed facility nursing staff was signing off the O2 at 2 lpm via NC each shift including the days of the survey. Observation on 9/15/10 at approximately 11:30 revealed the oxygen was flowing at approximately 3 1/2 lpm via NC. At approximately 1:00 PM on 9/15/10, Registered Nurse (RN) # 4, verified the oxygen was flowing at 3 1/2 lpm via NC. Upon questioning, she stated "I'd have to check the MAR (Documentation Record) but I'm pretty sure it's supposed to be at 2 (lpm)." RN #4 also reviewed the record and confirmed the Physician's Orders and the MAR indicated and could not locate any new order to increase the flow rate. During an interview on 9/15/10 at 2:28 PM, the Hospice Nurse stated the oxygen was supposed to be at 2 lpm and had been since admission to Hospice. She stated she thought the oxygen flow rate had inadvertently been changed on 9/15/10 when the Certified Nursing Assistant had reached to turn the oxygen back on after the resident's AM care had been completed. She stated the 3 lpm documented on the Nursing Visit Note for 9/15/10 had been a documentation error only. The Hospice Nurse later changed the documentation on the 9/8/10 Nursing Visit Note from 3 lpm to 2 lpm and did not date the change. | 2014-03-01 | ||
| 10203 | ELLEN SAGAR NURSING HOME | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2010-09-15 | 468 | E | A4CW11 | On the days of the survey, based on observation and interview, the facility failed to equip multiples areas in the corridors with handrails. The findings included: On 9/15/10 at approximately 1:55 PM, multiple areas leading into or on corridors were observed without handrails affixed to the walls. Areas included, but were not limited to: -an area approximately 3 1/2 feet at the entrance to Rocky Road Hall on the left and right sides of the hall -an area approximately 3 1/2 feet at the entrance to Rainbow Row Hall on the right side of the hall -approximately 5 feet across from the Unit I Nurses Station -a section approximately 8 feet long in a corridor behind the Unit I Nurses Station -the entire length of the corridor connecting Unit I and Unit II on both sides of the hallway -two 5 foot sections and two 3 1/2 foot sections on Unit II at the Nurses Station and several other areas leading into the 3 halls from the nurses station. During an interview on 9/14/10 at approximately 4:15 PM, the Maintenance Director verified multiple areas were without handrails and stated that the corridor between Units I and II had never had handrails as far as he knew. He also stated that the area behind the Unit I Nurses Station "looks like there used to be one there." | 2014-03-01 | ||
| 10272 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-09-16 | 328 | D | UGRJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection based on observations, interviews and record review the facility failed to ensure residents received timely foot care. The physician saw resident #2 and prescribed an antibiotic and cleaning to the right toenail bed until seen by the podiatrist related to redness of the toenail bed; resident #2 had a history of [REDACTED]. The findings included: The facility admitted Resident #2 on 08/21/2009 with [DIAGNOSES REDACTED]. Resident #2 was sampled as a result of a complaint related to skin care. Review of the current medical record on 09/16/2010 revealed the most recent Podiatry visit as 01/20/2010. A review of the nurse's notes revealed documentation that the podiatrist on 01/10/2010 for routine care saw Resident #2. On 03/10/2010 the physician saw Resident #2 due to pain in the left great toe and ordered triple antibiotic ointment for 7 days and Keflex 250 milligrams for 10 days. Nurse's notes from 03/11, 03/12, and 03/13/2010 documented a purulent yellow discharge from the left great toe. The Nurse's notes on 03/14/2010 at 3:45 PM stated, "CNA (certified nurse aide) reported to me Res (resident) in need of toenail trim. Removed bil (bilateral) bunny boots and both feet extremely dry and cracked no open areas noted. Velcro closure of top of (L) foot has rubbed reddened area to skin but intact. Attempted to trim toenail of (L) great ft (foot) and pus actively comin (sic) out. Toenail fell off. Trimmed all toenails and all came off either whole or crumbled. Skin underneath old nail pink and very healthy in appearance. Cleansed feet multiple times with warm water at bedside... Has had trx (treatment) ongoing to (L) great toes for inf (infection) with TAO. Had foul odor and purulent pus before cleaning. At present no active bleeding. Continued review of the nurse's notes revealed the physician was not notified about the drainage on 03/11, 03/12 and 03/13/2010 or that during care the toenails came off on 03/14/2010. The physician examined Resident #2's toes on 03/16/2010 and continued the previous orders. The antibiotic was completed on 03/19/2010. Review of the nurse's notes from 03/19/2010 thru 08/18/2010 revealed no documentation related to the resident's toenails. A nurse's note dated 08/19/2010 at 2:00 PM stated, "Brought to this nurse's attention; Resident's daughter went to nurse from station 4 to show her resident's (R) great toenail very thick and crusty in some areas. Nurse able to pull back some of crustation (sic) revealing some redness along cuticle line no puss or secretions of any kind noted. Resident denies any discomfort. Resident seen by covering NP (nurse practitioner) orders rcd (received) for Keflex 500 PO (by mouth) TID (three times a day) x 7 days and cleanse (R) great toe nail bed with NSS (normal saline solution) BID (twice a day) until seen by foot MD (medical doctor)...Resident has been added to podiatry list." Review of the Weekly Skin Assessment's from 04/2010 thru 08/13/2010 showed no documentation related to Resident #2's toenails. An observation with the surveyor on 09/16/2010 at 2:10 PM with Licensed Practical Nurse (LPN) #1 revealed Resident #2 wearing bunny boots on both feet; the great toe nails on both feet appeared fragile, rough, thickened and yellow; there was very little nail seen on all toes. Resident #2 stated that she had no pain when asked if the toenails were painful. LPN #1 stated that the resident was on the list to be seen by the podiatrist. In an interview with the surveyor on 09/16/2010 at approximately 4:20 PM the Director of Nurses provided a list of residents who were to been see by the podiatrist at his next visit. When asked when that would be she stated that she did not know, that it was difficult to get the podiatrist to come to the facility. She stated that the RN (registered nurses) cut the toenails for the residents as needed. The DON added that the ward clerk who kept up with the podiatrist appointments was on vacation and she would return next week. The facility was unable to provide a written nail care policy. In an interview with the surveyor on 09/22/2010 at 10:50 AM the Ward Clerk responsible for making the podiatry appointments stated that the podiatrist was in the facility on 01/20/2010, 02/08/2010, 03/25/2010, 04/02/2010, 05/05/2010, 06/23/2010, 07/12/2010 and 08/09/2010. When asked when he would be there again she stated she had not called to ask him to return, that she usually waited two weeks after his visit, then called and schedule him to come to another station; the facility had 4 nursing stations. The Ward Clerk said that she collected the names of the residents who needed to be seen by the podiatrist from each station and then scheduled the residents; she confirmed that Residents #2 was on the list to be seen on the next podiatry visit. When asked if she had been told that Resident #2 had an order for [REDACTED]. | 2014-01-01 | ||
| 10273 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2010-09-16 | 157 | D | UGRJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record review the facility failed to notify the physician of changes for one of five residents reviewed for foot care. Resident #2 with prescribed antibiotics for an infection of the left great toe developed "a purlent (sic) yellow discharge" that was not reported timely to the physician. The findings included: The facility admitted Resident #2 on 08/21/2009 with [DIAGNOSES REDACTED]. Resident #2 was sampled as a result of a complaint related to foot care. A review of the nurse's notes revealed documentation that the podiatrist on 01/10/2010 for routine care saw Resident #2. On 03/10/2010 the physician saw Resident #2 due to pain in the left great toe and ordered triple antibiotic ointment for 7 days and Keflex 250 milligrams for 10 days. Nurse's notes from 03/11, 03/12, and 03/13/2010 documented a purulent yellow discharge from the left great toe. The Nurse's notes on 03/14/2010 at 3:45 PM stated, "CNA (certified nurse aide) reported to me Res (resident) in need of toenail trim. Removed bil (bilateral) bunny boots and both feet extremely dry and cracked no open areas noted. Velcro closure of top of (L) foot has rubbed reddened area to skin but intact. Attempted to trim toenail of (L) great ft (foot) and pus actively comin (sic) out. Toenail fell off. Trimmed all toenails and all came off either whole or crumbled. Skin underneath old nail pink and very healthy in appearance. Cleansed feet multiple times with warm water at bedside... Has had trx (treatment) ongoing to (L) great toes for inf (infection) with TAO. Had foul odor and purulent pus before cleaning. At present no active bleeding. Continued review of the nurse's notes revealed the physician was not notified about the drainage on 03/11, 03/12 and 03/13/2010 or that during foot care the toenails came off on 03/14/2010. The physician examined Resident #2's toes on 03/16/2010. | 2014-01-01 | ||
| 10297 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 272 | D | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents were comprehensively assessed related to a history of falls for 2 of 2 residents reviewed who had repeated falls (#1 and #3). Both residents had a history of [REDACTED]. The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation. She was discharged home on[DATE]. The admission nursing fall assessment showed a score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) notes revealed the resident was at risk for falls. "She is at risk for falls related to Hx (history of) falls and Dx ([DIAGNOSES REDACTED]. The note failed to provide any history of the resident's falls, and therefore there was no evaluation of any pattern or possible triggers for the falls. The RAP note did not evaluate the resident's internal or external risk factors. The resident fell three times while at the facility, 7/27/10, 7/28/10, and 8/22/10. One fall, the one on 7/28/10, resulted in a fractured distal right clavicle. Review of the medical record revealed the resident was independent and wanted to do for herself. She also participated in therapy with improving functional status. However, the facility failed to use this information to adapt to the resident's changing status in an effort to prevent accidents. There was no evidence of a comprehensive assessment of the resident's falls either on admission or throughout the resident's stay. Resident #3 with [DIAGNOSES REDACTED]. The resident was hospitalized from 7/14 to 7/21/10 for Asthmatic [MEDICAL CONDITION] and Decompensated [MEDICAL CONDITION]. The resident received therapy and was discharged on [DATE]. An admission nursing assessment for falls revealed a score of 22. Scores above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10 stated the resident had had multiple falls. Review of the RAI of 7/25/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person with bed mobility, transfer, dressing, hygiene, and bathing. He was incontinent of bowel and bladder. The RAI showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. The RAP notes showed no further information or assessment of the resident's fall history or risks. Review of the Nurse's Notes showed the resident had 11 falls while at the facility: Review of the medical record showed no evidence that the facility assessed the resident's falls in any attempt to find a pattern and possible triggers for the falls. | 2014-01-01 | ||
| 10298 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 280 | G | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents' care plans were periodically reviewed an updated to reflect changing status for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. The resident was hospitalized after a fall for evaluation of hip pain. No fractures were diagnosed at the hospital. The resident went to the facility for short term rehabilitation after hospitalization . She was discharged home on[DATE]. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed a fall in the last 30 days. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility. One of the falls resulted in a fractured distal right clavicle. Review of the care plan showed it was not updated to show the falls and no new interventions were planned to assist the resident in fall prevention. Resident #3 with [DIAGNOSES REDACTED]. An admission nursing assessment for falls revealed a score of 22, any score above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10, the resident had had multiple falls. Review of the RAI of 7/25/10 showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. Review of the care plan dated 8/3/10 revealed a problem of "high risk for falls related to Hx (history of) falls, decreased mobility." Interventions included: gather information on past falls; be sure call light is in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; activities for diversion and strengthening; and appropriate footwear. Review of the medical record showed the resident had 11 falls while at the facility. The care plan showed no changes throughout the resident's stay. | 2014-01-01 | ||
| 10299 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 323 | G | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on record reviews, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 2 of 2 residents reviewed who had repeated falls (#1 and #3). The findings included: Resident #1 with [DIAGNOSES REDACTED]. No fractures were diagnosed at the hospital. Resident #1 went to the facility for short term rehabilitation. Review of the admission nursing assessment showed a fall risk score of 20. A score above 10 indicated risk for falls. Review of the Resident Assessment Instrument (RAI) for 7/12/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person for bed mobility, transfer, dressing, and bathing. She required total assistance for toilet use and hygiene. The resident was incontinent of bowel and bladder. A fall in the last 30 days was noted. Review of the Resident Assessment Protocol (RAP) noted revealed the resident was at risk for falls related to her history of falls. The note did not provide any history of the past falls. There was no evaluation of any pattern or triggers for the falls. Review of the plan of care dated 7/15/10 showed a problem of risk for falls with interventions of: gather information about past falls; keep call light in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; and proper footwear. The resident fell three times while at the facility: 1. A Nurse's Note on 7/27/10 at 7 AM stated the resident was found lying on the floor in her bathroom. The resident could not explain how she got on the floor. A small skin tear on the left elbow resulted from the fall. There was no evidence the facility changed or added interventions to the resident's care plan after this fall. 2. On 7/28/10, at 7 PM, the Nurse ' s Note said her Certified Nursing Assistant (CNA) put the resident on the toilet. The CNA went to get a brief out of the closet. Resident #1 tried to get up alone and fell , hitting her right shoulder. The nurse's assessment showed a red area to the shoulder, and skin tears to the right wrist and left forearm. An orthopedic assessment and x-ray done on 8/6/10 showed a fractured distal right clavicle. There was no evidence the facility changed or added interventions to the resident's care plan after this fall. An interview with the CNA providing care to the resident on 7/28/10 revealed the resident had never tried to get up by herself before when in the CNA's care. The CNA said she found out from the nurse after the fall that the resident had fallen the day before while getting up unassisted. On 8/21/10, a Nurse's Note stated the resident was alert and oriented to herself. She was up at the bedside eating breakfast and took her morning medications. "... Informed pt to call for assistance daughter found up in BR (bathroom) had concerns of safety. ..." A personal safety alarm for the wheelchair was ordered that day. 3. The Nurse's Note on 8/22/10 at 12 PM stated a nursing assistant found the resident on the floor, lying by the bed. Skin tears to the left forearm and elbow were noted. The documentation in the Nurse's Notes, and the incident report, failed to say if the safety alarm was in use at the time of the fall. Review of the medical record revealed the resident was independent and wanted to do for herself. She also participated in therapy with improving functional status. The facility failed to use this information to adapt to the resident's changing status in an effort to prevent accidents. The resident was discharged home on[DATE]. Resident #3 with [DIAGNOSES REDACTED]. An admission nursing assessment for falls revealed a score of 22. Scores above 10 indicated a risk for falls. The facility physician's history and physical dated 7/22/10, the resident had had multiple falls. Review of the RAI of 7/25/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. The resident needed extensive assistance of one person with bed mobility, transfer, dressing, hygiene, and bathing. He was incontinent of bowel and bladder. The RAI showed no falls. Review of the RAP notes of 7/28/10 showed the resident triggered for falls related to daily use of an antidepressant. Review of the care plan dated 8/3/10 revealed a problem of "high risk for falls related to Hx (history of) falls, decreased mobility." Interventions included: gather information on past falls; be sure call light is in reach; anticipate and meet needs; provide safe environment; physical therapy evaluation and treatment; adaptive equipment as needed; activities for diversion and strengthening; and appropriate footwear. The care plan showed no changes throughout the resident's stay. Review of the Nurse's Notes showed the resident had 11 falls without injury while at the facility: On 8/1/10, at 2 AM, the resident tried to get up and slid off the low bed. On 8/3/10, at 7:35 AM, the resident was found on the floor by his low bed. He was yelling for help and told the staff he was "trying to get up to go to therapy." On 8/9/10, at 5:20 AM, the resident was found lying on the floor with his head under the bed and his legs partially extended out on the right side. On 8/10/10 at 11:15 PM, the resident was found lying on the floor beside the bed with his head resting on the bed. On 8/14/10, at 4 AM, the resident was found lying on the floor beside his low bed with a pillow still under his head. On 8/15/10, at 10:45 PM, the resident rolled out of bed. On 8/18/10, at 4:30 AM, the resident was found on scooting on his stomach on the floor by his bed. He told the nurse "he crawled out of bed and couldn't bet back in." On 8/30/10, at 11:45 PM, the resident was found sitting on his buttocks with his back against the low bed. On 9/1/10, the resident was found on the floor in front of his wheelchair. He reported that he was trying to get something off his bedside table, leaned forward and fell . On 9/5/10, at 1:50 PM, the resident was found on the floor by his bed. "I was going to a meeting." On 9/6/10, at 3:40 AM, the resident was found on the floor by the bed. "I have to go to work." He also complained that the "bed is curved in the middle and it messed me up." The resident was discharged on [DATE]. Review of the medical record showed no evidence that the facility assessed the resident's falls in an attempt to find a pattern and possible triggers for the falls. The resident did have a bed in the low position but no other interventions were noted. | 2014-01-01 | ||
| 10300 | WILDEWOOD DOWNS NURSING AND REHABILITATION CENTER | 425385 | 1215 WILDEWOOD DOWNS CIRCLE | COLUMBIA | SC | 29223 | 2010-09-20 | 496 | D | 9EZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on review of a Certified Nursing Assistant's employee file and interview, the facility failed to ensure that information was sought from every State registry before allowing an individual to serve as a nurse aide for 1 of 1 employee file reviewed. The findings included: The employee file of a Certified Nursing Assistant (CNA) who was assigned to a resident who fell and was later diagnosed with [REDACTED]. The facility checked the South Carolina CNA Registry for information prior to hire, but failed to check with the Massachusetts CNA Registry. The Assistant Director of Nurses confirmed this after she spoke with Human Resources personnel. | 2014-01-01 | ||
| 10283 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 281 | D | OR4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to clarify and follow a Physicians order related to discontinuing [MEDICATION NAME] for Resident # 12, 1 of 1 resident reviewed on anticoagulant therapy. The findings included: Resident # 12 was admitted by the facility on 3/16/10 with [DIAGNOSES REDACTED]. The record review on 9/21/10 revealed a physician's orders [REDACTED].= 2.0". Further record review revealed an INR drawn on 9/13/10 was 4.05 and on 9/14/10 the INR was 3.03. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The INR results dated 9/9/10 had an order written [REDACTED].> 2). On 9/21/10 at 1:00 PM Licensed Practical Nurse (LPN) # 2 stated during an interview that "the order should have been clarified, because the orders are not the same. Someone should have called the doctor and asked about it, I think it should be stopped after it is greater than 2.0." The Unit Manager for the 100 hall stated during an interview on 9/21/10 at 2:00 PM " It (the [MEDICATION NAME]) should have been stopped when they got a INR of 2.0 or greater." During a telephone interview with LPN # 3 on 9/22/10 at 10:40 AM she confirmed that she took the order and stated " they were to stop the [MEDICATION NAME] when the INR is 2.0 or greater, I don't know why I would have written equal, that is just a slip of the pen or something, but it should be stopped when the INR is 2.0 or greater.". LPN # 2 called the Physician and received a clear order on 9/21/10 at 1:00 PM which reads "D/C [MEDICATION NAME] when INR greater than or equal to 2.0". | 2014-01-01 | ||
| 10284 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 329 | E | OR4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey based on record review and interview the facility failed to decrease [MEDICATION NAME] as ordered for Resident # 12. The resident received 30 mg (milligrams) of [MEDICATION NAME] instead of 15 mg as ordered. The findings included: Resident # 12 was admitted by the facility on 3/16/10 with [DIAGNOSES REDACTED]. The record review on 9/21/10 revealed an order written [REDACTED]. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Licensed Practical Nurse (LPN) # 2 stated during a interview on 9/21/10 that "the nurse who checked the MAR indicated [REDACTED]." The Unit Manager for Hall 100 stated during an interview on 9/21/10 " I checked those MAR's and I missed that, it is a problem." Both nurses stated " we will need to do a medication error report on this." | 2014-01-01 | ||
| 10285 | HEARTLAND OF LEXINGTON REHAB AND NURSING CENTER | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2010-09-22 | 502 | D | OR4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview the facility failed to ensure that laboratory services were provided in a timely manner for 1 of 13 residents (Resident #4) reviewed for laboratory services. The findings included: The facility admitted Resident # 4 on 6/18/10 with the following Diagnoses: [REDACTED]. The record review on 9/20/10 revealed an order for [REDACTED]. On the bottom of this report a note/recommendation was made that stated " Mixed culture: 3 or more organisms isolated suggest repeat culture to rule out contamination." No other reports were found on the medical record. During an interview with Licensed Practical Nurse # 2 she stated " we should get another urine sample". This resident does have a Foley catheter and a history of Urinary Tract Infections with the last one documented and treated in July 2010. | 2014-01-01 | ||
| 10274 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 225 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and review of facility documents, the facility failed to report an injury of unknown origin within the allowed time frame, failed to promptly begin an investigation into the injury, and failed to thoroughly investigate the resident's injury for a possible explanation of how it occurred for 1 of 1 resident reviewed who had an injury of unknown origin (#3). The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instruments of 5/14/09 and 4/23/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. Communication was sometimes understood. The resident required total care from the staff for all activities of daily living. Staff transferred the resident by mechanical lift. The resident received nutrition and hydration via feeding tube and maintained a steady weight (206 pounds recorded on the 5/14/09 assessment and 204 pounds on the later assessment.) Resident Assessment Protocol (RAP) notes revealed the resident had left side weakness from the stroke. She could mumble some words and was able to relay simple messages at times. The resident understood simple communication and followed simple commands. Two staff members assisted with bed mobility and transfers with the mechanical lift. Review of the medical record and facility documents showed the resident first showed signs of injury on 7/13/10 when a bruise was discovered after the resident's shower. Review of the Change Of Condition Nurses Notes and Resident Incident Report showed the discoloration was to the left back. There was no inflammation or [MEDICAL CONDITION] noted to the area. The facility did not report this injury of unknown origin or begin any investigation into the injury's possible origin. The facility did report to the State survey and certification agency on 7/15/10 that the resident's weekly skin audit done on 7/15/10 showed purple discoloration on the upper anterior left arm and chest. The resident grimaced when the left arm was manipulated. X-ray and assessment at the hospital showed a fractured left humeral head. The facility began an investigation into the resident's injury at that time. The Five-Day Follow-Up Report dated 7/20/10 stated the area found on 7/13/10 was a discoloration to the left flank. Review of the facility's investigative materials showed on their final report: "Res. was noted to have bruising on back on 7/13/10 which was noted on 7/15/10 to also have new area on arm. No pain noted w/verbalization or movement until 7/15/10. Res. had sling too small for her size on 7/13/10 (sic), which is the date the initial bruising was noted. ..." The facility's investigation revealed interviews were done with direct caregivers and a determination was made that the resident's injury was due to staff using the wrong size mechanical lift sling during transfer. Written statements were taken from the LPN who assessed the bruises, and from Certified Nursing Assistants (CNAs) who provided care to the resident. CNA #1 worked the 3-11 shift on 7/12/10, CNA #2 worked the 7-3 shift on 7/12, 13, 14, and 15/10, and CNA #3 worked the 3-11 shift on 7/13/10. CNA #4 provided a written statement but was not listed on the daily schedule as being assigned to the resident during the same time period. The investigative materials did not show evidence of interviews or written statements from the 11-7 staff, the 7/14/10 3-11 CNA, or any of the staff that assisted the assigned caregivers during transfer of the resident from bed to chair on the days of 7/12-14/10. The investigation did not show what size sling was used for the resident on 7/13/10, which allegedly caused the injury. (The CNA statement alleging the wrong sling size was used was for 7/12/10, not 7/13/10.) Nor did the investigation show any information about which sling size was used for the resident on 7/14/10. The delay in beginning the investigation allowed for the possibility of further injury to the resident. During the survey, discrepancies were noted in the facility's investigative report, statements obtained, and information revealed in staff interviews concerning the sling used, and the location and characteristics of the bruises: CNA #1 stated on 9/28/10 at 12:25 PM that he found the resident on 7/12/10 up in the recliner chair with the wrong type of sling underneath her. He stated the resident needed a full body sling, not the divided leg sling. CNA #1 stated he and another CNA, who he could not recall, removed the sling from under the resident and then applied a full body sling under her before assisting the resident to bed. When asked how the slings were changed, the CNA stated they did it while the resident was still in the recliner by turning her from side to side. CNA #1's written statement said: "... Resident up on (with) sling under her in Geri chair. He states he was nervous to move her (with) smaller sling so he went to get another CNA to help him. The two CNA removed the small sling & replaced (with) a larger sling and she was then transferred to the bed (without) incident." Review of the manufacturer information on mechanical lift slings revealed divided leg slings were designed to allow for application while a resident was seated, full body slings were not. CNA #3 stated in an interview on 9/28/10 at 4:20 PM that the resident was in the recliner chair on 7/13/10 when he started his 3-11 shift. The CNA gave the resident her shower while she remained in the recliner chair, then got assistance from another staff member to transfer the resident to bed. CNA #3 could not recall what type of sling was used for the transfer. While getting the resident ready for bed, CNA #2 noticed a blackish blue area under the resident's left axilla extending under the left breast. The CNA gave an approximate size of 4 centimeters. The resident showed no signs of distress from the area. CNA #3 reported his finding to the nurse. CNA #3's statement for the facility's investigation stated the area was black in color or very dark and it was under her axilla. The information from CNA#3 did not indicate injury to the left flank or left back. LPN #1 was interviewed on 9/29/10 at 10:35 AM. She stated that on 7/13/10, she observed an elongated, approximately 3 inches by 1 inch reddish purple area on the resident's upper back at the axilla level. LPN #1 denied seeing a blackish bruise under the resident's arm, extending under the left breast. On 7/15/10, the LPN witnessed a deep purple bruise on the left breast/chest area. It was approximately 4 inches in size. The back of the resident's upper left arm was also purple in color, about "3 fingers" large. The previously noted area on the resident's upper back was lighter in color and smaller in size. Resident #3's left clavicle appeared different and the physician was notified. LPN #1's written statement said discoloration was noted on the left back on 7/13/10 with improvement noted on 7/14/10. On 7/15/10 "body audit noted discoloration anterior Lt. arm, Lt back same area, same discoloration Lt rib area to under Lt breast. Grimacing when Lt arm moved. Appearance of Lt clavicle area different than Rt. ..." LPN #1 did not reference the resident's left flank in either her interview or in her statement. CNA #2's statement for the facility's investigation revealed she saw on Wednesday (7/14/10) or Thursday (7/15/10) a bruise at the resident's left breast under and toward "(R) back" in axilla line. She also noticed discoloration to the left arm that was a yellow-greenish color from elbow to shoulder. The resident moaned when moved, as if in pain. CNA #2 reported her findings to LPN #1 on 7/15/10. During an interview with the Administrator and DON on 9/29/10 at 12:30 PM, they stated their conclusion that the wrong size sling caused the resident's injury was based on the CNA admitting that the wrong size sling was used. However, the DON continued to say that CNA #2 reported that a too small sling was used on 7/12/10 but CNA #2 reported an appropriate sling size was used with the resident on 7/12/10. When asked why the facility failed to report and begin an investigation on 7/13/10, with the first signs of injury to the resident, the Administrator and DON stated it was because the bruising noted on 7/13/10 was not reported to them until the injuries on 7//15/10 were reported. The Administrator and DON said that prior to the resident's incident, no direction was provided to the CNA staff about which type of lift sling or what size of lift sling was to be used with each resident. | 2014-01-01 | ||
| 10275 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 496 | D | LLC411 | On the days of the survey, based on review of employee information provided, the facility failed to ensure that registry verification was completed before allowing an individual to serve as a Certified Nursing Assistant (CNA) for 2 of 3 employees reviewed who were hired in 2010 as CNAs. The findings included: During the complaint investigation, information concerning the staff on duty around the time of an injury of unknown origin was requested from the facility. The information provided failed to show that two of the CNAs had registry verification checks done prior to hire. The Director of Nurses (DON) was asked for this information on 9/28/10. On 9/29/10, the DON stated she knew the registry verification checks were done before hire, but Human Resources could not produce evidence of this. | 2014-01-01 | ||
| 10276 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 514 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews, the facility failed to ensure that resident records were complete and accurately documented for 1 of 3 resident records reviewed (#3). Documentation in the medical record concerning Resident #3's injury of unknown origin was incomplete and inaccurate. The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the Change Of Condition Nurses Notes showed staff found a discoloration on the resident's left back. The area was without inflammation or [MEDICAL CONDITION]. The nurse's note by LPN #1 did not describe the discoloration's size, shape, color, or specific location on the resident's left back. Certified Nursing Assistant (CNA) #3 found the area on 7/13/10 after the resident's shower and reported it to the nurse for assessment. This CNA was interviewed on 9/28/10 at 4:20 PM and stated what he saw was an area under the resident's left axilla extending to the left breast, it was blackish blue in color, and was approximately 4 by 4 centimeters big. LPN #1 was interviewed on 9/29/10 at 10:35 AM. She stated that on 7/13/10, she observed an elongated; approximately 3 inches by 1 inch, reddish purple area on the resident's upper back at the axilla level. LPN #1 denied seeing a blackish bruise under the resident's arm, extending under the left breast. Documentation in the Change of Condition Nurses Notes on 7/14/10 by LPN #1 described the "left flank discoloration" as not as large as yesterday. The medical record showed no information of any discolored area on the resident's flank. LPN #1 did not reference the resident's left flank in either her interview or in her statement. The information at the top of the page on the 7/15/10 Change of Condition Nurses Notes showed the resident's bruise on the left back was not as large. Purple discoloration was noted on the upper anterior left arm and left chest. Farther down the page, under the Current Care Plan Interventions and physician's orders [REDACTED]." LPN #1 did both entries. The documentation did not show measurements or any other defining characteristics of the new bruising. Review of the skin assessment dated [DATE] showed that an area described as deep purple was outlined on the body form that included the posterior elbow to shoulder and corresponding area on the upper back on the resident's left side. A deep purple area was outlined on the body depiction at the right breast/chest area. LPN #1's statement for the facility's investigation stated that on 7/15/10 "... body audit noted discoloration anterior Lt. arm, Lt back same area, same discoloration Lt rib area to under Lt breast. ..." Documentation in the medical record showed no mention of the rib area or left breast involvement. During the interview with LPN #1, she said that on 7/15/10, she witnessed a deep purple bruise on the resident's left breast/chest area. It was approximately 4 inches in size. The back of the resident's upper left arm was also purple in color, about "3 fingers" large. The previously noted area on the upper back was lighter in color and smaller in size. CNA #2 provided care to the resident on the 7-3 shift on 7/13, 14, and 15/10. Her statement for the facility's investigation revealed she saw on Wednesday (7/14/10) or Thursday (7/15/10) a bruise at the resident's left breast under and toward "(R) back in axilla line." She also noticed discoloration to the left arm that was a yellow-greenish color from elbow to shoulder. | 2014-01-01 | ||
| 10277 | UNIHEALTH POST ACUTE CARE ORANGEBURG, LLC | 425085 | 755 WHITMAN STREET SE | ORANGEBURG | SC | 29115 | 2010-09-29 | 323 | D | LLC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observations, interviews, and review of facility documents, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed who had an injury of unknown origin (#3). The findings included: Resident #3 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instruments of 5/14/09 and 4/23/10 showed the resident had short and long term memory problems with moderately impaired decision making ability. Communication was sometimes understood. The resident required total care from the staff for all activities of daily living. Staff transferred the resident by mechanical lift. The resident received nutrition and hydration via feeding tube and maintained a steady weight (206 pounds recorded on the 5/14/09 assessment and 204 pounds on the later assessment.) Resident Assessment Protocol (RAP) notes revealed the resident had left side weakness from the stroke. She could mumble some words and was able to relay simple messages at times. The resident understood simple communication and followed simple commands. Two staff members assisted with bed mobility and transfers with the mechanical lift. Review of the medical record and facility documents showed the resident first showed signs of injury on 7/13/10 when a bruise was discovered after the resident's shower in the left axilla area. On 7/15/10, the resident's weekly skin audit on 7/15/10 showed purple discoloration on the upper anterior left arm and chest. The resident grimaced when the left arm was manipulated. X-ray and assessment at the hospital showed a fractured left humeral head. The facility began an investigation into the resident's injury at that time. The Five-Day Follow-Up Report dated 7/20/10 stated the area found on 7/13/10 was a discoloration to the left flank. Review of the facility's investigative materials showed on their final report: "Res. was noted to have bruising on back on 7/13/10 which was noted on 7/15/10 to also have new area on arm. No pain noted w/verbalization or movement until 7/15/10. Res. had sling too small for her size on 7/13/10 (sic) which is the date the initial bruising was noted. ..." The investigation did not show what size sling was used for the resident on 7/13/10, which allegedly caused the injury. (The CNA statement alleging the wrong sling size was used was for 7/12/10, not 7/13/10.) Nor did the investigation show any information about which sling size was used for the resident on 7/14/10. CNA #1 stated on 9/28/10 at 12:25 PM that he found the resident on 7/12/10 up in the recliner chair with the wrong type of sling underneath her. He stated the resident needed a full body sling, not the divided leg sling. CNA #1 stated he and another CNA, who he could not recall, removed the sling from under the resident and then applied a full body sling under her before assisting the resident to bed. When asked how the slings were changed, the CNA stated they did it while the resident was still in the recliner by turning her from side to side. CNA #1's written statement said: "... Resident up on (with) sling under her in Geri chair. He states he was nervous to move her (with) smaller sling so he went to get another CNA to help him. The two CNA removed the small sling & replaced (with) a larger sling and she was then transferred to the bed (without) incident." Review of the manufacturer information on mechanical lift slings revealed divided leg slings were designed to allow for application while a resident was seated, full body slings were not. During an interview with the Administrator and DON on 9/29/10 at 12:30 PM, they stated their conclusion that the wrong size sling caused the resident's injury was based on the CNA admitting that the wrong size sling was used. However, the DON continued to say that CNA #2 reported that a too small sling was used on 7/12/10 but CNA #2 reported an appropriate sling size was used with the resident on 7/12/10. The Administrator and DON said that prior to the resident's incident, no direction was provided to the CNA staff about which type of lift sling or what size of lift sling was to be used with each resident. | 2014-01-01 | ||
| 10292 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 441 | F | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record reviews and interviews, the facility failed to provide Tracheostomy care for one of one resident reviewed for tracheostomy care in a manner that would prevent possible infection on Resident #11. In addition the facility failed to track/trend infectious organisms and failed to adequately notify visitors of contact precautions. The findings included: The facility admitted Resident #11 on 5/12/10 with [DIAGNOSES REDACTED]. Review of the September 2010 cumulative physician's orders [REDACTED]. Observation on 9/28/10 at approximately 4:50 PM revealed Licensed Practical Nurse (LPN) #5 entered the resident's room. After assessing the resident, he put on a pair of clean gloves and suctioned inside and around the tip of the tracheostomy opening with a [MEDICATION NAME] suction catheter. He did not wash his hands prior to putting on the gloves. With the same gloved hands that he had used to suction with the [MEDICATION NAME] catheter, he opened a new inner cannula from a box container, removed the inner cannula from the resident's tracheostomy, and inserted the new inner cannula into the tracheostomy. With the same gloved hands, he then opened the drawer to the bedside table and removed a sterile suction kit. He put one sterile glove on his left hand without removing the other gloves and proceeded to perform endotracheal suctioning to the resident. During an interview on 9/29/10 at 5:13 PM, LPN #5 verified he put on gloves without washing his hands first, put on a sterile glove over a dirty one, and touched the drawer handle and supplies with the same gloved hands used for suctioning. He stated that the reason he put the sterile glove over the dirty one was that the sterile gloves were too small and ripped causing mucus to get on his hands. Review of the policy provided by the facility entitled "Suctioning of Tracheostomy" (dated 11/25/97) on 9/29/10 at 12:58 revealed under Procedure..."3. Assemble equipment at bedside...4. Wash hands...7. Don sterile gloves 8. Open catheter package". Resident #7, admitted [DATE], with [DIAGNOSES REDACTED]. Diff), Stage III Decubitus, Diabetes Mellitus. Record review on 9/28/10 at approximately 10:45am revealed a physician's orders [REDACTED]. Diff. Result of the culture on 9/16/10 reported positive for [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Interview with Certified Nursing Assistant #2 on 9/28/10 at approximately 1:35pm indicated that nursing notifies staff of when a resident has an infectious disease and when there was a need to glove and/or gown before entering room. Interview with Registered Nurse #5 on 9/29/10 at approximately 9:55am indicated that when determined resident had [DIAGNOSES REDACTED] the facility notified physician, informed Responsible Party, put resident on contact isolation, placed a yellow cart outside door of resident's room, and informed staff. Asked if the facility posted signage asking visitors to see nursing before entering room. She stated that the facility does not post signage. Asked how visitors would know about need for contact precautions. Stated when visitors saw cart they were to come and speak with nursing. On 9/28/10 at approximately 1:30 PM, interview with the infection control nurse and review of the monthly infection control logs revealed that the facility failed to track/trend organisms. Further review of the infection control logs revealed that the facility tracked the number of infections and type of infection by each unit, however did not track/trend infections by room location on the units. When questioned if she had made formal infection control rounds to observe treatments and insure that staff were following infection control practices, she stated no. | 2014-01-01 | ||
| 10293 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 225 | D | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview and review of the policy provided by the facility entitled "Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint, Complaint Responsibilities" dated 8/7/09, the facility failed to report to the state agency and investigate the alleged verbal abuse of Resident #13, one of 18 residents reviewed for abuse and neglect; the facility failed to complete an incident report related to a skin tear on Resident #30. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an individual interview on 9/29/10 at 11:05 AM, Resident #13 stated that she was lying on her side when a Certified Nursing Assistant (CNA) laughed and made an unprofessional/inappropriate remark related to the resident's size.. Resident #13 stated the CNA pushed her so hard she almost pushed her out of the bed. The resident stated that it had not been long since the incident occurred. She stated she had asked that the CNA not be allowed to take care of her and stated that the CNA had been taken off the floor. During an interview on 9/29/10, the Assistant Director of Nursing (ADON) stated she was unaware of the incident and it had not been reported to her. During an interview on 9/30/10 at approximately 11:00 AM, Nurse A stated she was aware of the incident, but hadn't been on duty at the time the incident occurred. Nurse A stated she had reported the incident to her supervisor, RN #2. Nurse A stated the CNA involved in the incident had requested to be moved off the floor, and had not been moved as a result of any disciplinary action. During an interview on 9/30/10 at approximately 11:30 AM, RN #2 denied any knowledge of the incident and stated that the nurse must have reported the incident to another nursing supervisor. During an interview on 9/30/10 at 12:00 Noon, the Director of Nursing (DON) stated she was unaware of the incident. After reviewing the CNA's personnel record, the DON verified the CNA had been transferred to another unit at the CNA's request. The DON agreed that the incident would need to be investigated had it been reported. Review of the policy provided by the facility entitled "Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint, Complaint Responsibilities" dated 8/7/09 revealed under "5. Investigation, A. All suspicious incidents will be thoroughly investigated in a timely fashion, documented via an Alleged Abuse/Incident of Unknown Origin packet, and forwarded to the required state agencies as outlined in policy 02-22, Alleged Abuse/Incident of Unknown Origin/Accident-Injury Complaint Responsibilities". The Policy/Procedure section stated that "DHEC Certification and the facility administrator shall be notified immediately but not to exceed 24 hours after discovery of all alleged violations involving abuse (physical, verbal, sexual, or mental)...". Under Abuse Reporting Procedure the "1. Nurse or Shift Supervisor: a) Receives the complaint from a resident..., b) Assesses the complaint and interviews the complainant, c) Obtains a written statement form included in packet, d) Obtains written statement notarized or signed by two witnesses, e) Contacts shift supervisor, f) Completes incident report." From there, the packet goes to the "2. Shift Supervisor...3. Assistant Director of Nursing or Nurse Supervisor...," and then to "4. Administration". Interview on 9/29/10 with the Assistant Director of Nursing, who performs investigations of abuse, indicated that s/he was not aware of the alleged verbal abuse. The facility admitted Resident #30 on 05/28/2010 with [DIAGNOSES REDACTED]. Resident #30 sampled as a result of a complaint concerning skin tears. Review of Resident #30's closed medical record on 09/27/2010 revealed nursing documentation on 06/07/2010 and 07/21/2010 regarding skin tears. On 06/07/2010 a nurse's note stated, "...F/U (follow-up) to skintear..." Review of the Occurrence Reported dated 06/07/2010 indicated that the resident received the skin tear while participating in physical therapy. Continued review of the nurse's notes revealed a 07/21/2010 note at 2000 that stated, "...Res (resident) has ST (skin tear) on (R) (right) elbow..." The facility was unable to provide an Occurrence Report for the 07/21/2010 skin tear. Review of the skin integrity care plan dated 06/16/2010 did not address the skin tears. | 2014-01-01 | ||
| 10294 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2010-09-30 | 280 | D | IK8X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to review and update the Care Plans for 2 of 18 sampled residents reviewed for comprehensive Care Plans. Resident #13's Care Plan was not updated related to [MEDICAL CONDITION] and drug seeking behaviors; Resident #30's Care plan was not updated related to skin tears. The findings included: The facility admitted Resident #13 on 6/27/07 with [DIAGNOSES REDACTED]. During an interview on 9/30/10 at approximately 12:15 PM, Registered Nurse (RN) #2 stated Resident #13 had been exhibiting drug seeking behavior. According to the nurse, the resident told the physician on 9/20/10 that the [MEDICATION NAME] wasn't working any more and he subsequently discontinued it. Review of the physician's orders [REDACTED]. The nurse stated that the resident kept asking for the [MEDICATION NAME] again, so the nursing staff had to call the on-call physician that same night who gave an order for [REDACTED]. MD (physician) will evaluate in AM". When asked what was being done to address this issue, the nurse stated the resident had been seen by Psychiatry and had a trial of [MEDICATION NAME]. Review of the "Psych Consult and Progress Notes" dated 3/10/10 revealed that Resident #13 had been diagnosed with [REDACTED]. According to the note "Case discussed with staff. Pt. (Patient) had been refusing q (every) hs (Bedtime) [MEDICATION NAME] (Secondary) to "SE" (Side Effects) Upset stomach, [MEDICAL CONDITION] of feet which attributed to (increased) dose. Pt. would like to try another medicine & asks for [MEDICATION NAME]. I explain(ed) to her that this will not help (with) depression & Pt. is already taking [MEDICATION NAME] which is similar. Pt denies SI (Suicidal ideation). She has been cooperating with care. (No) voiced [MEDICAL CONDITION]. Pt is oriented x3. Meds (Medications) [MEDICATION NAME] 1 mg (milligram) PO (By Mouth) Q (every) AM. [MEDICATION NAME] 60 mg PO Q AM, [MEDICATION NAME] 20 mg PO BID (Twice Daily)". The plan was to taper and discontinue the [MEDICATION NAME] and start the resident on [MEDICATION NAME] 20 mg PO Q AM, "Refer pain meds to PCP (Primary Care Physician", and follow up in 3 months. Review of the 6/16/10 Progress Notes revealed resident was seen and "having fewer SE (with) the [MEDICATION NAME] No voiced [MEDICAL CONDITION]/U (follow up) in 6 mos. (months)". When asked if the resident had been care planned for her drug seeking behavior or her delusional disorder, RN #2 said "No". Review of the comprehensive Care Plan on 9/30/10 revealed no mention of drug seeking behavior or delusional disorder. The facility admitted Resident #30 on 05/28/2010 with [DIAGNOSES REDACTED]. Resident #30 was sampled as a result of a complaint regarding skin tears. Review of Resident #30's closed medical record revealed nursing documentation on 06/07/2010 and 07/21/2010 regarding skin tears. Review of the skin integrity care plan dated 06/16/2010 did not address the skin tears. | 2014-01-01 | ||
| 10243 | RIVERSIDE HEALTH AND REHAB | 425082 | 2375 BAKER HOSP BLVD | CHARLESTON | SC | 29405 | 2010-10-12 | 225 | E | 8JQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the survey, based on limited record review, interview, and review of the facility's reportable file since 4/9/10, the facility failed to report to the State survey and certification agency 4 of 8 allegations of misappropriation of resident property (Residents A, B, C, D), failed to report timely 3 of 4 allegations of misappropriation (Residents #1, E, F), and failed to thoroughly investigate 4 of 8 allegations of misappropriation (Residents A, B, C, and D). The findings included: Resident #1 reported to the facility on [DATE] that her wallet was missing. The Complaint/Grievance Report stated the resident reported that approximately $30.00 was in the wallet. The facility's initial 24 hour report also noted the resident's debit card was taken and that there had been some activity on the resident's debit card account. The initial report to the State survey and certification agency was dated 9/28/10, which exceeded the 24 hour deadline for reporting allegations of misappropriation. Review of the facility's grievance files revealed three addition allegations of misappropriation around the same time Resident #1 made her complaint. Resident A reported $4.00 missing on 9/24/10. Resident B reported $14.00 missing on 9/27/10. Resident C reported $9.00 missing on 9/28/10. Residents B and C had notations on their grievance stating "resolved by personnel action (secondary to) cluster of similar events on Unit 200." None of these allegations was reported to the State survey and certification agency or thoroughly investigated. Continued review of the facility reportable incidents revealed another cluster of allegations concerning misappropriation of resident property in April 2010. Resident E reported on 4/10/10 that $63.00 was missing. The resident's allegation was not reported until 4/12/10. Resident F reported on 4/16/10 that $20.00 was missing. The allegation was reported to State agency on 4/20/10. Resident D reported "missing $" on 4/16/10. The facility was not able to show evident that this allegation was reported or investigated by the facility. | 2014-02-01 | ||
| 10254 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 157 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to consult with the resident's physician when there was a significant change in the resident's condition. Resident #6 had clinical record documentation on 07/24/2010 at 0615 as sweaty, which required a linen and clothing change, later in the day he was described as lethargic. The next day (07/25/2010) at 2:00 AM it was documented that he had a temperature of 100 degrees and twitching of his extremities when touched; at 4:00 AM the twitching continued; at 6:00 AM he pulled away when care was provided and would not take fluids. The documentation indicated that the resident was lethargic at 10:50 AM and was sent to the emergency room at his daughter's request. There was no evidence the resident's physician was notified of the change in condition. (One of six sampled residents reviewed for notification) The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to (sic) cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Will pass to next shift to monitor. 1:35 PM Resident was lethargic at breakfast could not wake up enough to eat. Ate 100 % of lunch. Has been holding head down and drooling excessively all day. Afebrile with VS WNL (within normal limits). Will cont. (continue) to monitor. 2300 Remains in bed. Skin cool to touch and dry at this time. No twitching of extremities. No cough or resp distress. 07/25/2010 0100 No change in condition. Opens eyes when spoken to. 0200 Temp. 100 BP (?) P 100, R 18 BS 166. O2 sat 93% on rm (room) air. Twitching extremities when touched. Oral care. Open eyes when spoken to with no awareness of staff. 0400 Eyes closed, resting quietly. Continues to have twitching episodes when touched or spoken to. 0600 Responds to tactile stimuli. T 99.9 BP 110/50 P 180 R 20 O2 93% rm air. Skin moist warm. Pulls away when care given. Unable to get resident to take fluids. 10:50 AM Resident is lethargic and unresponsive. T 97.5, BP 110/80, P 115, R 20. Sent to ... ER (emergency room ) via EMS (emergency medical service) at dgt's (daughters) request..." On 10/12/2010 at approximately 2:15PM, during an interview with the Family Nurse Practitioner she stated that the drooling was usual for the resident but that she would have expected the staff to call the physician when the resident was noted to be sweating and for sure when he first became lethargic. The Family Nurse Practitioner added that the staff was aware that he had just finished treatment for [REDACTED]. In a face-to-face interview on 10/12/2010 at approximately 12:10 PM the Unit 3 Manager stated that she was not sure why the staff failed to call the physician. | 2014-02-01 | ||
| 10255 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 281 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record reviews and interviews, the facility staff failed to meet professional standards of quality for 1 of 6 residents reviewed for an acute change in condition. The physician was not consulted when Resident #6, treated [MEDICATION NAME] for recurrent urinary tract infections and recently treated with a course of antibiotics for a urinary tract infection, showed evidence of a change in condition. On 07/24/2010 at 6:15 AM he was noted with sweating; blood pressure 141/72, temperature 97.5, pulse 85 and respirations 22, he was described as lethargic at breakfast there was no other documentation until 11:00 PM when it was stated that no twitching of extremities was noted. On 07/25/2010 at 2:00 AM his blood pressure was not noted, temperature 100, pulse 100, respirations 18 and twitching of extremities when touched was noted; "opens eyes when spoken to with no awareness of staff. At 4:00 AM twitching when touched was again documented; at 6:00 AM his blood pressure was 110/50, temperature 99.9, pulse 180, fluids not accepted; at 10:50 AM he was lethargic, unresponsive; his BP was 110/80, temperature 97.5, pulse 115, respirations 20. Resident #6 was transferred to the emergency room . The findings included: The facility admitted Resident #6 with [DIAGNOSES REDACTED]. On 10/12/2010 a review of the resident's closed medical record revealed the following Nurse's Notes from 07/24/2010 thru 07/25/2010: "07/24/2010 0615 Res (resident) has been sweaty this shift requiring linen and night clothing change. Hair damp skin cool and pale, clammy to touch. VS (vital signs) @ present BP (blood pressure) 141/72 p (pulse) 85, resp (respirations) 22 temp (temperature) 97.5 (A) (axillary), BS (blood sugar) 182. Hands to cool for O2 (oxygen) sat (saturation) to register. No s/s (signs/symptoms) of pain/discomfort. No acute apparent distress. Orderly up and showered. On top of bed resting now. Alert with eyes open. Will pass to next shift to monitor. 1:35 PM Resident was lethargic at breakfast could not wake up enough to eat. Ate 100 % of lunch. Has been holding head down and drooling excessively all day. Afebrile with VS WNL (within normal limits). Will cont. (continue) to monitor. 2300 Remains in bed. Skin cool to touch and dry at this time. No twitching of extremities. No cough or resp distress. 07/25/2010 0100 No change in condition. Opens eyes when spoken to. 0200 Temp. 100 BP--, P 100, R 18 BS 166. O2 sat 93% on rm (room) air. Twitching extremities when touched. Oral care. Open eyes when spoken to with no awareness of staff. 0400 Eyes closed, resting quietly. Continues to have twitching episodes when touched or spoken to. 0600 Responds to tactile stimuli. T 99.9 BP 110/50 P 180 R 20 O2 93% rm air. Skin moist warm. Pulls away when care given. Unable to get resident to take fluids. 10:50 AM Resident is lethargic and unresponsive. T 97.5, BP 110/80, P 115, R 20. Sent to ...ER (emergency room ) via EMS (emergency medical service) at dgt's (daughters) request..." Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 10/12/2010 at approximately 2:15 PM, during a telephone interview with the surveyor the Family Nurse Practitioner stated that the drooling was usual for the resident but that she would have expected the staff to call the physician when the resident was noted to be sweating and for sure when he first became lethargic. The Family Nurse Practitioner added that the staff was aware that he had just finished treatment for [REDACTED]. In a face-to-face interview on 10/12/2010 at approximately 12:10 PM the Unit 3 Manager stated that she was not sure why the staff failed to call the physician. | 2014-02-01 | ||
| 10256 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 312 | D | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint survey based on observations, record review and interviews, the facility failed to ensure that care and services necessary to maintain or attain the highest practical physical well being related to grooming and personal hygiene was provided for Resident #3 observed on 10/12/2010 with blood on the left side of the nose; with long fingernails on both hands and what appeared to be blood under her fingernails. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Resident #3 observed at 11:00 AM seated in the day room on Unit 3 with dried blood on the left side of her nose; her fingernails on both hands, were noted to be long, with what appeared to be blood under the index finger and on the thumb of the right hand. At 11:10 AM Resident #3 was rolled in her Geri-chair to her room and transferred to her bed for incontinent care. CNA #2 stated that the resident preferred her nails long and that nails were done on Tuesday. Review of the Weekly Nursing Assessment from 06/19/2010, 09/11/2010,09/25/2010, and 10/09/2010 documented a scab in the crease of the resident's nose on the left side and stated, "scratches won't leave band aid on." On 10/12/2010 at 11:30 AM Resident #3's fingernails were observed with the Director of Nurses, at that time the nails had been cut and cleaned, but were still uneven and rough. The Director of Nurses confirmed that Resident #3 still needed nail care, which should include filing. | 2014-02-01 | ||
| 10257 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 280 | D | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on record review and interview, the facility failed to revise and update the Care Plan for 1 of 6 sampled residents reviewed for Comprehensive Care Plans. Resident #1 had 4 reported incidents where she "slid" out of chairs to the floor without changes to the approaches used to address her falls. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated "8-22-10 at 7:45 AM". Under "Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage." was a handwritten note. "Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor...". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale". Review of a 2nd Incident/Accident Report dated 09/1/2010 revealed that Resident #1 had been "..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she "slid out". She was out of site for app(roximately) 2 minutes". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ...". Review of a 3rd Incident/Accident Report dated 09/13/2010 revealed "Resident found sitting on floor in front of chair". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall". Review of a 4th Incident/Accident Report dated 09/14/2010 revealed "Sitting in w/c trying to push nurse away, slipped to floor from w/c. Also hitting at nurse". There were no additional comments listed. Review of the Care Plan dated 08/30/2010 revealed that Resident #1 had been identified as being "At risk for falls r/t (related to) a hx (history) of falls, "Morse falls score 75". Under "Last fall date" was handwritten in "9/1/10- slid out of w/c, 9/13/10-slid out of chair, 9/14/10-slid out of w/c". The Approaches used were typed and included "1) Encourage resident to use call light, 2) Encourage resident to ask for assistance with transfers as needed, 3) Observe frequently when up and OOB (Out of bed), 4) 1/2 Siderails up X 2 to assist with mobility, and to define the parameters of the bed, 5) Orient to surroundings as appropriate, 6) Review medications for the continued need, appropriateness dosage, continued effectiveness, 7) Perform ongoing assessment of any physical or mental health status changes, 8) Uses low bed to reduce the risk for falls, 9) Use Morse Falls scale to determine risk for falls, 10) Call light in reach". During an interview on 10/12/2010 at 4:05 PM, the Minimum Data Set (MDS) Coordinator stated that she had handwritten the updates regarding the resident sliding out of the chair onto the Care Plan. She stated she had updated this information for the Director of Nursing (DON) since the Nurse Manager had been out on leave. She stated the Nurse Manager was responsible for updating the approaches used and that the DON had taken over this duty since the Nurse Manager had been out. The MDS Coordinator stated she only updated the Care Plan once a year r/t changes the Nurse Manager had already made. During an interview on 10/12/2010 at 4:15 PM, the DON verified the approaches had not been changed related to Resident #1's repeated "sliding" out of chairs and stated it was probably because there had been nothing to change. | 2014-02-01 | ||
| 10258 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 272 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure two of four sampled residents were assessed for transfers. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device for each resident. Resident #3's CNA Care Plan Guide revealed no mention of the level of assistance required for transfers or the mode of transfer. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a [MEDICAL CONDITIONS] and tib-fib (tibia-fibula) [MEDICAL CONDITION] leg. In a letter dated 10/1/2010 from the facility's Director of Nursing (DON), the facility reported that "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aide caring for (Resident #1). Her left foot was moved approx.(approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record conducted on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the physician deferred the issue of transfers or the use of lifts to nursing. Review of the Admission assessment dated [DATE] revealed no mention of the amount of assistance needed for transfers or any lift devices used. Under "Assistive Aides:" wheelchair alarm and bed alarm had been checked. Review of "Weekly Nursing Assessment(s)" dated 8/22/2010 through 9/19/2010 revealed under "ADL's (Activities of Daily Living), that the resident transfers with extensive assistance with 2 person physical help". There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Patient Care Record (PCR) for Resident #1 dated September 2010 revealed no mention of the level of assistance required for transfers or the use of any transfer devices. Review of Nurse's Notes dated 8/16/2010 through 9/26/2010 revealed several entries that stated 2 staff assisted with transfers, but no mention of the use of a mechanical lift. Interviews with nursing staff, however, indicated that the lift had been used many times throughout the resident's stay at the discretion of the nursing staff. The following entries were noted: "8-19-10...Staff x 2 put resident to bed", "8-20-10...Staff x 2 assisted res(ident) to bed", "8-23-10...Staff x 2 assisted to bed...", "8-26-10...Staff x 2 assisted (with) hs (bedtime) care + to bed", "9-26-10...-up to w/c (wheelchair) per 2 CNAs to have haircut". During a phone interview with the surveyor on 10/12/2010 at 11:45 AM, CNA #1 stated that the lift was used for Resident #1 to get her out of bed to the wheelchair. She verified she had used the lift without other staff assistance on several occasions on 9/25/2010 because she didn't have any help. She stated she did get assistance from CNA #2 when she encountered difficulty with Resident #1's foot placement on the lift. During an interview with the surveyor on 10/12/2010 at approximately 12:15 PM, Licensed Practical Nurse #1 stated that she "knew" CNAs had used the lift on Resident #1, but that she had not actually witnessed staff using the lift until 09/25/2010 when CNA #1 had to call CNA #2 for assistance with Resident #1's foot placement. She said that normally 2 CNAs would assist with transfers for Resident #1. LPN #1 verified that the lift had been used to get the resident out of bed on 09/26/2010 and that the resident was placed back into bed with the assistance of 2 CNAs lifting the resident. LPN #1 was asked what she would tell a CNA about the type of assistance Resident #1 required to transfer from the wheelchair to the bed or wheelchair to the toilet. LPN #1 stated that when transferring from the bed to the wheelchair, she would tell them to use the lift and make sure they had someone to help. If they were taking Resident #1 to the toilet, she would tell them to "see if the resident could bear weight with 2 CNAs to assist, and if not, I don't know if they would get the lift into the toilet". During an interview with the surveyor on 10/12/2010 at 1:15 PM, CNA #2 verified she had used the lift on 09/25/10 with CNA #1 and also on 09/26/2010, when she and CNA #3 transferred Resident #1 out of the bed and into the wheelchair. She stated that they had decided to use the lift on 09/26/2010 because the resident had not been able to walk for about a week. She stated that she had used the lift before on Resident #1, due to the residents decline in ability to transfer. During an interview at 1:52 PM, CNA #3 stated that on 09/26/2010, she and CNA #2 were getting Resident #1 up out of bed. When the resident wouldn't help with the transfer, the lift was used to transfer the resident to the wheelchair. A little later when the nurse came to assess Resident #1's leg, the two CNAs transferred the resident back to bed manually using a gait belt. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had been coded under "Transfer" as a "3" requiring extensive assistance with "3" two + persons physical assist. Under "Modes of transfer" she had been coded as "Lifted mechanically". During an interview at 1:48 PM, the MDS Coordinator verified the above MDS coding information. When asked where she had gotten the information for the resident's transfer abilities, she stated she had read the Weekly Nursing Assessment and Nurse's Notes. When asked where she had gotten the information related to the use of a mechanical lift for Resident #1, she looked through the chart and then stated she had spoken with the CNAs about how they transferred the resident. When asked if it was appropriate to obtain this information from a CNA, the MDS Coordinator stated that she thought the CNAs were the best ones to assess whether a lift is needed. When asked what skills CNAs possess in order to determine that a lift is needed, she stated she didn't know- but that "they were certified". Review of the interdisciplinary Care Plan revealed that Resident #1 had the problem of "ADL Deficit, alteration in mobility r/t (related to) recent hospitalization .... transfers-extensive" indicating the amount of assistance needed for transfers. There was no mention of the use of a mechanical lift. During an interview earlier on 10/12/2010 at 9:48 AM, the DON, MDS Coordinator, and ADON were present. When asked about the Care Plan and documentation of the use of a mechanical lift, the MDS Coordinator stated that she did not Care Plan for the use of lifts. She also stated she had never seen staff chart the use of a lift. During a review of Physical Therapy Daily/Weekly Progress Notes for Resident #1 dated 08/16/2010 through 09/24/2010 with the surveyor on 10/12/2010, the Physical Therapist stated that Resident #1's transferring ability varied from day to day and ranged from Total/Maximum assistance of 2-3 staff to minimum/moderate assistance of 1 staff. She verified the following entries related to Resident #1's functional abilities dated 09/21/10 "SPT" (Stand pivot) w/c (wheelchair) toilet max(imum) (assist) x 2" and for 09/22/10 "Bed Chair Max(imum)/Mod(erate) x 2". After reviewing the PT progress notes, she verified there was no mention of a lift and stated she didn't recall that the resident used a mechanical lift device. When asked who determined which residents used a lift device, the Physical Therapist stated that PT and Nursing Staff discuss whether a lift is needed when a resident is admitted , but after that nursing would call PT if they had a concern. When asked if this discussion would be documented somewhere, she stated it would be documented in the PT progress notes. She stated she didn't know who made the decision to use the lift device, but that PT would suggest the lift device if a person was a good candidate. When asked if she thought that a CNA had the knowledge base to determine which resident used a lift, she stated that the CNA knew more about the resident and any changes than PT did. She stated she didn't know about CNA's making the determination. During an interview with the surveyor on 10/12/10 at 4:25 PM, the DON stated that on admission, all residents get a bed alarm and receive 2 person assistance for lifts. Therapy then comes in quickly to give their recommendations on what they think. The nurse and CNAs for that unit then come together and discuss an immediate Care Plan, which the CNA fills out. She was unable to provide a copy of the CNA Care Plan for Resident #1. The DON stated that if there are any changes in the level of assistance needed for transfers, PT is contacted and the CNAs and nurses report to each other. The DON stated Resident #1 responded well to the lift, and that she allowed the CNAs some discretion in the use of the mechanical lift. The facility admitted Resident #2 on 01/14/2009 with [DIAGNOSES REDACTED]. Record review conducted on 10/12/2010 indicated the cumulative physician's orders [REDACTED]. Review of the Weekly Nursing assessment dated [DATE] showed, under ADL's (Activities of Daily Living), the resident's transfer performance as total dependence with 2 person physical support. There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Care Plan Guide for Resident #2 revealed that she was a sit/stand lift with no mention of the level of assistance required for transfers. Review of Nurse's Notes dated 07/26/2010 through 10/12/2010 revealed no mention of the use of a mechanical lift. Observation on 10/12/2010 at 10:40 AM revealed CNA #2 and CNA #4 manually transferred Resident #2 from a high-backed chair to a wheelchair and wheeled her to her room for toileting. CNA #3 brought the Sara Lift into Resident #2's room and CNA #2 and CNA #3 transferred her from the wheelchair to the toilet using the lift. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had been coded under Transfer as a (3) requiring assistance with (2) one persons physical assist. Under Modes of transfer she had been coded as a manual lift. Review of the interdisciplinary Care Plan dated 07/22/2010 and updated 10/12/2010 revealed that Resident #2 had falls identified as a problem. Interventions included lowest bed position, bed alarm to bed and provide a safe environment; there was no mention of transfer needs. The facility admitted Resident #3 on 04/14/2006 with [DIAGNOSES REDACTED]. Record review conducted on 10/12/2010 indicated the cumulative physician's orders [REDACTED]. Review of the Weekly Nursing assessment dated [DATE] thru 10/09/2010 showed under ADL's (Activities of Daily Living), the resident's transfer performance as total dependence with 2 person physical support. Review of the CNA Care Plan Guide for Resident #3 revealed no mention of the level of assistance required for transfers or a mode of transfer. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS assessment dated [DATE] revealed Resident #3 coded under Transfer as a (4) total assistance with (3) two persons physical assist. Under Modes of transfer she had been coded as a manual lift. Review of the interdisciplinary Care Plan dated 06/21/2010 and updated 09/14/2010 revealed that Resident #3 required assistance with Activities of Daily Living. Interventions included sits and transports in a Geri-chair daily; there was no mention of transfer needs. | 2014-02-01 | ||
| 10259 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 225 | E | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on interviews, observation and record review, the facility failed to thoroughly investigate and/or report two incidents involving Resident #1, two incidents involving Resident #2, one incident involving Resident #3 and one incident involving Resident #5. These residents were 4 of 6 sampled residents reviewed for reportable incidents. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility which prompted the complaint investigation. Review of the closed medical record on 10/12/2010 revealed an Incident/Accident Report for Resident #1 dated "8-22-2010 at 7:45 AM". Under "Describe exactly what happened; why it happened; what the causes were. If an injury, state part of body injured. If property or equipment damaged, describe damage." was a handwritten note. "Resident was in shower chair-it tilted forward + she slid out on the BR (Bathroom) floor...". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the Director of Nursing (DON) stated there had been no investigation conducted since the incident had been witnessed. When asked if she knew what had happened to cause the shower chair to tilt forward she did not know. Review of a 2nd Incident/Accident Report for Resident #1 dated 09/1/2010 revealed that she had been "..sitting in w/c (wheelchair)- nurse went to ck (check) on another res(ident)-this res(ident) sitting on carpet in front of upright w/c. States she "slid out". She was out of site for app(roximately) 2 minutes". The "Additional comments and/or steps taken to prevent recurrence:" revealed "Morse Fall Scale completed, w/c alarm in place but didn't sound-magnet was still in place. Alarm ...". During an interview with the surveyor on 10/12/2010 at 4:15 PM, the DON verified an investigation had not taken place. She stated the resident had been in the Day Room and staff pretty much knew what had happened. The "Additional comments.." section was brought to her attention which indicated that the alarm was in place but didn't sound. The facility admitted Resident #2 on 01/14/2009 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/12/2010 revealed a Nurse's Note dated 09/01/2010 at 0800 which stated, "Approx (approximately) 5 cm (centimeter) reddish, brown discoloration noted inner side on lt (left) knee. Denies discomfort at site. Noted to cross and uncross legs freq (frequently) when up in chair." On 09/22/2010 at 2100 a Nurse's Note stated, "Staff called to room to observe a purple bruise to (L) (left) upper arm above elbow. Intact with no c/o (complaint) pain or discomfort." There were no incident reports related to the two incidents and they were not investigated and/or reported to the state survey agency. The facility admitted Resident #3 on 04/14/2006 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/12/2010 revealed a Nurse's Note dated 07/11/2010 at 8 AM which stated, "CNA (certified nurse aide) reported large purple bruise on upper outer (R) (right) arm. No s/s (signs/symptoms) of pain noted. Called nephew..." The facility admitted Resident #5 on 07/21/2010 with [DIAGNOSES REDACTED]. Review of the current medical record on 10/12/2010 revealed a Nurse's Note dated 10/05/2010 at 11:30 that stated, "Res. (resident) up in halls with walker without prob (problem) - no limping, denies discom (discomfort) site of bruising top of lt (left) foot." On 10/06/2010 at 0630 a Nurse's Note stated, "...Resident picked up walker and one leg of walker was placed on top of foot (L) (left) foot and was ready to place her weight down on it. May have been cause of bruising and swelling on top of foot seen yesterday..." The incident was not investigated and/or reported to the state survey agency. During an interview with the surveyor on 10/12/2010 at approximately 11:45 AM, the Assistant Director of Nursing (ADON) stated she was not aware of the incidents related to resident #2 on 09/01 and 09/22/2010, no incident reports were made. When asked about Resident #3 she provided an investigation. The incident was not reported to the state survey agency. During an interview with the surveyor on 10/12/2010 at approximately 12:15 PM the Unit 3 Unit Manager confirmed the only observation documented concerning Resident #5 placing her walker on top of her left foot occurred on 10/06/2010 after the initial injury. The Unit Manager confirmed the incident had not been investigated and/or reported to the state survey agency. | 2014-02-01 | ||
| 10260 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 253 | D | GYKK11 | On the day of the complaint inspection, based on observations and interviews the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 1 Unit reviewed. There were 2 blue wheelchair with cracked, rough and peeling arm supports; 2 black wheelchairs with soiled seats and frames with food particles; 1 Geri-chair with a cracked arm support frame and torn upholstery on the back of the back support at the top. The findings included: Observations on 10/12/2010 at approximately 10:40 AM revealed maintenance issues on Unit 3. The Director of Nurses confirmed the following at 11:30 AM: One Geri-chair with a crack approximately 10 inches long on Resident #3's Geri-chair, right arm support frame; back support, top right back with exposed foam. Resident #2 seated in a blue wheelchair with both armrests torn and cracked. A blue wheelchair with both arm rests torn and cracked; 2 black wheelchairs with soiled seats and frames with food particles. Review of Schedule of Events/Activities revealed that Gerri Chairs and Wheelchairs were to be cleaned once a week and as needed; there was no cleaning log maintained. | 2014-02-01 | ||
| 10261 | MARTHA FRANKS BAPTIST RETIREMENT CENTER | 425334 | ONE MARTHA FRANKS DRIVE | LAURENS | SC | 29360 | 2010-10-12 | 323 | G | GYKK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the complaint inspection, based on observations, record review, and interviews, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Certified Nursing Assistants used a mechanical lift on Residents #1 and #2 without documented assessments as to the appropriateness of the lift device. The findings included: The facility admitted Resident #1 on 08/16/2010 with [DIAGNOSES REDACTED]. Resident #1 was included in the sample due to an incident reported by the facility, which prompted the complaint investigation. Review of the facility investigation revealed that Resident #1 had been sent to the emergency roiagnom on [DATE] for pain, swelling, warmth, decreased range of motion, and a "fading discoloration" around and below the left knee. According to the physician's statement included in those records, the resident had been admitted to the hospital on [DATE] with a Deep Vein Thromboses (DVT) and tib-fib (tibia-fibula) fracture of the left leg. In a letter dated 10/1/10 from the facility's Director of Nursing (DON), the facility reported, "During the investigation it was noted that on September 25, 2010 (Resident #1's) left foot had slipped forward while being lifted with the "stand-up" lift. The lift procedure was stopped, another Certified Nursing Assistant (CNA) joined the aid caring for (Resident #1). Her left foot was moved approx. (approximately) three inches back into the proper position, and the lift and care proceeded. I had the CNAs demonstrate the procedure for me. I did not observe anything that would cause injury". Review of the closed medical record on 10/12/2010 revealed the following: Review of the cumulative physician's orders [REDACTED]. During an interview at 12:15 PM, Licensed Practical Nurse #1 verified this and stated that the physician deferred the issue of transfers or the use of lifts to nursing. Review of the Admission assessment dated [DATE] revealed no mention of the amount of assistance needed for transfers or any lift devices used. Under "Assistive Aides:" wheelchair alarm and bed alarm had been checked. Review of "Weekly Nursing Assessment(s)" dated 08/22/2010 through 09/19/2010 revealed under "ADL's (Activities of Daily Living), that the resident transfers with extensive assistance with 2 person physical help. There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Patient Care Record (PCR) for Resident #1 dated September 2010 revealed no mention of the level of assistance required for transfers or the use of any transfer devices. Review of Nurse's Notes dated 08/16/2010 through 09/26/2010 revealed several entries that stated 2 staff assisted with transfers, but no mention of the use of a mechanical lift. Interviews with nursing staff, however, indicated that the lift had been used many times throughout the resident's stay at the discretion of the nursing staff. The following entries were noted: "8-19-10...Staff x 2 put resident to bed", "8-20-10...Staff x 2 assisted res(ident) to bed", "8-23-10...Staff x 2 assisted to bed...", "8-26-10...Staff x 2 assisted (with) hs (bedtime) care + to bed", "9-26-10...-up to w/c (wheelchair) per 2 CNAs to have haircut". During a phone interview on 10/21/2010 at 11:45 AM, CNA #1 stated that the lift was used for Resident #1 to get her out of bed to the wheelchair. She verified she had used the lift without other staff assistance on several occasions on 09/25/2010 because she didn't have any help. She stated she did get assistance from CNA #2 when she encountered difficulty with Resident #1's foot placement on the lift. During an interview on 10/12/2010 at approximately 12:15 PM, Licensed Practical Nurse #1 stated that she "knew" CNAs had used the lift on Resident #1, but that she had not actually witnessed staff using the lift until 09/25/2010 when CNA #1 had to call CNA #2 for assistance with Resident #1's foot placement. She said that normally 2 CNAs would assist with transfers for Resident #1. LPN #1 verified that the lift had been used to get the resident out of bed on 09/26/2010 and that the resident was placed back into bed with the assistance of 2 CNAs lifting the resident. LPN #1 was asked what she would tell a CNA about the type of assistance Resident #1 required to transfer from the wheelchair to the bed or wheelchair to the toilet. LPN #1 stated that when transferring from the bed to the wheelchair, she would tell them to use the lift and make sure they had someone to help. If they were taking Resident #1 to the toilet, she would tell them to "see if the resident could bear weight with 2 CNAs to assist, and if not, I don't know if they would get the lift into the toilet". During an interview on 10/12/2010 at 1:15 PM, CNA #2 verified she had used the lift on 09/25/2010 with CNA #1 and also on 09/26/2010, when she and CNA #3 transferred Resident #1 out of the bed and into the wheelchair. She stated that they had decided to use the lift on 09/26/2010 because the resident had not been able to walk for about a week. She stated that she had used the lift before on Resident #1, due to the residents decline in ability to transfer. During an interview at 1:52 PM, CNA #3 stated that on 09/26/2010, she and CNA #2 were getting Resident #1 up out of bed. When the resident wouldn't help with the transfer, the lift was used to transfer the resident to the wheelchair. A little later when the nurse came to assess Resident #1's leg, the two CNAs transferred the resident back to bed manually using a gait belt. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had been coded under "Transfer" as a "3" requiring extensive assistance with "3" two + persons physical assist. Under "Modes of transfer" she had been coded as "Lifted mechanically". During an interview at 1:48 PM, the MDS Coordinator verified the above MDS coding information. When asked where she had gotten the information for the resident's transfer abilities, she stated she had read the Weekly Nursing Assessment and Nurse's Notes. When asked where she had gotten the information related to the use of a mechanical lift for Resident #1, she looked through the chart and then stated she had spoken with the CNAs about how they transferred the resident. When asked if it was appropriate to obtain this information from a CNA, the MDS Coordinator stated that she thought the CNAs were the best ones to assess whether a lift is needed. When asked what skills CNAs possess in order to determine that a lift is needed, she stated she didn't know- but that "they were certified". Review of the interdisciplinary Care Plan dated 08/30/2010 revealed that Resident #1 had the problem of "ADL Deficit, alteration in mobility r/t (related to) recent hospitalization .... transfers-extensive" indicating the amount of assistance needed for transfers. There was no mention of the use of a mechanical lift. During an interview earlier on 10/12/2010 at 9:48 AM, the DON, MDS Coordinator, and ADON were present. When asked about the Care Plan and documentation of the use of a mechanical lift, the MDS Coordinator stated that she did not Care Plan for the use of lifts. She also stated she had never seen staff chart the use of a lift. During a review of Physical Therapy Daily/Weekly Progress Notes for Resident #1 dated 08/16/2010 through 09/24/2010, the Physical Therapist #1 stated that Resident #1's transferring ability varied from day to day and ranged from Total/Maximum assistance of 2-3 staff to minimum/moderate assistance of 1 staff. She verified the following entries related to Resident #1's functional abilities dated 09/21/2010 "SPT" (Stand pivot) w/c (wheelchair) toilet max(imum) (assist) x 2" and for 09/22/2010 "Bed Chair Max(imum)/Mod(erate) x 2". After reviewing the PT progress notes, she verified there was no mention of a lift and stated she didn't recall that the resident used a mechanical lift device. When asked who determined which residents used a lift device, the Physical Therapist stated that PT and Nursing Staff discuss whether a lift is needed when a resident is admitted , but after that nursing would call PT if they had a concern. When asked if this discussion would be documented somewhere, she stated it would be documented in the PT progress notes. She stated she didn't know who made the decision to use the lift device, but that PT would suggest the lift device if a person was a good candidate. When asked if she thought that a CNA had the knowledge base to determine which resident used a lift, she stated that the CNA knew more about the resident and any changes than PT did. She stated she didn't know about CNA's making the determination. During the interview, the Physical Therapist was asked if PT provided any training on the use of the lifts. She stated that there had been an inservice done on 09/2/2010 by PT. She stated the training was in response to a resident that was supposed to be non-weight bearing. She stated PT spoke mostly about how to transfer residents with different weight bearing statuses, body mechanics, and hip precautions (what type of care a person with a total hip replacement requires). She stated there were no demonstrations on the use of the lift, but that it was mentioned -"If they needed to use the lift, go ahead". When asked if she had received any training on the use of the lift, she stated she had not received training in this facility, but that she had in other facilities she's worked in. She stated she had not trained any staff in the use of the lift. During interviews with the nursing staff, CNAs were asked about training received on the use of the mechanical lift and how they determined the amount of transfer assistance needed for a resident. Two CNAs indicated that they had not been provided with written instructions on how to use a mechanical lift and that CNAs that trained newly orienting CNAs did not use any set check list to instruct them on lift procedures. During a phone interview on 10/12/2010 at 11:45 AM, CNA #1 was asked if she had received any training on how to use a mechanical lift. She replied that when she did clinicals at the facility, she was taught how to use them. She stated once employed by the facility, she received training in orientation where she was shown how to use the lift by another CNA. When asked how she determined which residents needed to use the lift, she replied that you could tell the ones with more weight than the others. She stated that there was no paper documentation to tell her which residents needed to use a lift, that this was common sense. During an interview on 10/12/2010 at 1:15 PM, CNA #2 stated that she had been working at the facility for [AGE] years. She stated that staff receives inservices on the use of the mechanical lift whenever they get a new one. She stated that CNAs train other CNAs in the use of the lift but that no check off sheets or written instructions are used. When asked what she would do if she didn't know how to transfer a resident, she stated she would first ask the nurse, then ask PT. When asked if she would refer to the CNA Care Plan she said she would. During an interview on 10/12/2010 at 1:52 PM, CNA #3 stated that she had been employed at the facility for approximately 2 years. She stated she had been trained on the use of mechanical lifts during orientation. She stated she did not remember the CNA who trained her, but that she had been told how to use the lift, showed how to use the lift, and had to demonstrate the lift procedure back to her trainer. She was not aware of any check off sheet related to the lift procedure that had been used or turned in. When asked how she determined what type of assistance is required with resident transfers and if a lift is used, CNA #3 stated that she would first ask the nurse or other staff. Then she would look at the CNA Care Plan, which is located in the PCR book at the nursing station. During an interview on 10/12/2010 at 4:25 PM, the DON stated that on admission, all residents get a bed alarm and receive 2 person assistance for lift. Therapy then comes in quickly to give their recommendations on what they think. The nurse and CNAs for that unit then come together and discuss an immediate Care Plan, which the CNA fills out. She was unable to provide a copy of the CNA Care Plan for Resident #1. The DON stated that if there are any changes in the level of assistance needed for transfers, PT is contacted and the CNAs and nurses report to each other. The DON stated Resident #1 responded well to the lift, and that she allowed the CNAs some discretion in the use of the mechanical lift. She verified there were no formal assessments in place for the use of mechanical lifts. When asked how CNAs were trained in the use of the mechanical lift, she stated mentor CNAs checked them off during orientation. She was unable to provide any check off sheets or policies/procedures related to the use of the mechanical lift. She was asked to provide documentation of training for the mentor CNAs but did not provide any. When asked if there was a facility designated inservice trainer, she stated that there was not one, but that the Secretary and ADON kept up with staff training. When asked if any inservices or training had been provided related to using mechanical lifts since the incident with Resident #1's broken leg, she stated that there was an inservice scheduled for October 21st. She stated the inservice was being done in response to the incident with Resident #1 and was going to address the use of lifts and fire safety. Prior to the exit conference, the DON stated she had forgotten about an inservice regarding the proper use and function of the Sara Lift and the Marissa Lift that had been done in July 2010 and provided a copy. The inservice report stated that a demonstration had been done by therapy in which "The actual lifts were brought into the room and several employees acted as residents to properly demonstrate the use and function of these lifts". The inservice sheet did not contain any checklist or written procedures that had been communicated to the staff during the inservice. The signature sheet included CNAs #1, #2, and #3. During an interview on 10/12/2010 at approximately 5:00 PM, the Assistant Director of Nurse's (ADON) stated that inservices related to the mechanical lift devices were done periodically by therapy. She stated that CNAs who have been here a long time and who were very knowledgeable about lifts train new CNAs during orientation. She stated that the licensed nursing staff does not train the CNAs on the use of the mechanical lifts. The ADON stated that "mentor" CNAs use a "Nurse's Aide Checklist For Orientation" and provided a copy for review. She stated that CNAs get checked off on the use of mechanical lifts under the heading "Safety devices" and "Comfort of patients". Review of the checklist under those headings revealed no mention of the use of a lift. When asked how the CNAs were supposed to know this information pertained to the use of a mechanical lift (since there was no mention of a mechanical lift), the ADON stated she guessed they wouldn't. She was unable to provide a check off sheet or any other documentation to show what information the mentor CNAs were using to train new CNAs regarding how the mechanical lift should be operated. Review of the PCR book, which included all the PCR's for Unit 3 revealed a communication in the front of the book dated 3/28/2006 that stated "Residents are to be lifted using one of the lifts or a gait belt. No exceptions. This is to protect the staff as well as the residents. Corrective action will be taken if this is not followed. Thank you for your cooperation!" During an interview at 5:35 PM, the DON, when asked relative to the above communication if the philosophy of the facility had been and now was to use the lift as much as possible to prevent injury, answered "yes". The facility admitted Resident #2 on 01/14/2009 with [DIAGNOSES REDACTED]. Record review conducted on 10/12/2010 indicated the cumulative physician's orders [REDACTED]. Review of the Weekly Nursing assessment dated [DATE] showed under ADL's (Activities of Daily Living), that the resident transfer performance as total dependence with 2 person physical support. There was no documentation that the resident had been assessed for the use of a mechanical lift or that one was being used. Review of the CNA Care Plan Guide for Resident #2 dated September 2010 revealed that she was a sit/stand lift with no mention of the level of assistance required for transfers. Review of Nurse's Notes dated 07/26/2010 through 10/12/2010 revealed no mention of the use of a mechanical lift. Observation on 10/12/2010 at 10:40 AM revealed CNA #2 and CNA #4 manually transferred Resident #2 from a high-backed chair to a wheelchair and wheeled her to her room for toileting. CNA #3 brought the Sara Lift into Resident #2's room and CNA #2 and CNA #3 transferred her from the wheelchair to the toilet using the lift. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had been coded under Transfer as a (3) requiring assistance with (2) one persons physical assist. Under Modes of transfer she had been coded as a manual lift. Review of the interdisciplinary Care Plan dated 07/22/2010 and updated 10/12/2010 revealed that Resident #2 had falls identified as a problem. Interventions included lowest bed position, bed alarm to bed and provide a safe environment; there was no mention of transfer needs. | 2014-02-01 | ||
| 9584 | KINGSTREE NURSING FACILITY | 425117 | 401 NELSON BOULEVARD | KINGSTREE | SC | 29556 | 2010-10-13 | 156 | B | 0 | 1 | M1ZN11 | On the days of the survey, based on record review and interview, the facility failed to provide documentation of the timely notification of Medicare Provider Non-Coverage (CMS Form ) for 1 of 3 residents reviewed (Resident A). In addition, the facility failed to provide the required Liability Notice to 2 of 3 residents reviewed (Resident A and Resident #4). The findings included: Review of Notices of Medicare Non-Coverage for Resident A on 10/12/10 revealed the Centers for Medicare and Medicaid Services (CMS) Form indicated that current Skilled Services would end on 8/26/10. Review of the form revealed no resident or representative (RP) signature and no documentation to indicate when/how the resident or RP was notified of this change. In addition, CMS dated 8/16/10 was issued instead of a Liability Notice (SNFABN-CMS or 1 of 5 CMS approved denial letters) prior to being discharged from Medicare. Review of Resident #4's Notice of Medicare Non-Coverage revealed CMS was issued instead of a Liability Notice (SNFABN-CMS or 1 of 5 CMS approved denial letters) prior to being discharged from Medicare. During an interview on 10/13/10 at approximately 10:30 AM, a member of the facility's business staff reviewed the forms for Resident A and Resident #4 and confirmed the above findings. | 2015-03-01 |
| 9585 | KINGSTREE NURSING FACILITY | 425117 | 401 NELSON BOULEVARD | KINGSTREE | SC | 29556 | 2010-10-13 | 502 | D | 0 | 1 | M1ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to ensure that laboratory test results were available for clinical management in a timely manner for 1 of 2 residents receiving [MEDICATION NAME] (Resident #2). The findings included: The facility admitted Resident #2 on 7/11/07 with [DIAGNOSES REDACTED]. Review of the medical record on 10/11/10 revealed Resident #2 received [MEDICATION NAME] 125 mg/5cc (miligrams/cubic centimeters) every 8 hours. Further record review indicated the current cumulative physician's orders [REDACTED]. LPN #1 was asked to review the laboratory results section of the medical record and confirmed that the May 2010 [MEDICATION NAME] Level was not on the record. When asked about the procedure for tracking when labs are due, LPN #1 stated that the Unit Manager posts a list of due/draw dates at each unit. During an interview on 10/13/10 at approximately 11:00 AM, RN #1 stated that the Unit Manager maintains a log for each resident that indicates when labs are due. RN #1 stated that lab results are faxed to the facility, sorted by the Unit Managers, and filed in the medical records after the physician signs the test results. RN #1 stated that when lab results are received, he/she documents the log with the date the lab was drawn. Review of the laboratory log for Resident #1 revealed the space to document the May 2010 [MEDICATION NAME] Level was blank. | 2015-03-01 |
| 9764 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 323 | E | 0 | 1 | G9M911 | On the days of the survey, based on observations and interviews, the facility failed to ensure that the resident environment was free of accident hazards. The findings included: On 10/13/10 at 11:35 AM, tour of the facility's resident rooms with the Maintenance Director revealed the following resident rooms with linoleum that was in disrepair: Room 13 - Linoleum was observed with adhesive not holding along the seam. The seam was uneven with elevated areas noted on both sides of the seam. Room 14 - Linoleum seam buckled in the middle with elevated areas on both sides of the seam Room 17 - Linoleum seam uneven and elevated in 2 areas (about 8 inches each in length) Room 22,- Linoleum seam on the right side of the room near Bed B was observed with adhesive not holding, resulting in elevated areas. Room 5 - Linoleum seam by bed C was observed with the adhesive not holding resulting in elevated areas along the seam. When a chair was slid across the seam of the linoleum, the leg of the chair caught on the seam. During an interview on 10/14/10 at 8:54 AM, the Maintenance Director stated that he would re-glue the elevated areas of the linoleum and fill in any gaps along the seams with putty or other filler material, allow that to dry and then buff or sand down any uneven areas. | 2014-12-01 |
| 9765 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 332 | E | 0 | 1 | G9M911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record reviews, interview and the Drug Facts and Comparisons book (updated monthly), the facility failed to ensure that it was free of medication errors rates of 5% or greater. The medication error rate was 8.7%. There were 4 errors out of 46 opportunities for error. The findings included: Error #1: On 10/11/10 at 4:25 PM, during observation of medication pass. Licensed Practical Nurse (LPN) #1 was observed to administer one [MEDICATION NAME] 500 milligram (mg) tablet and 4 other medications to Resident A, followed with water. Review of the current physician's orders [REDACTED]. Resident A's meal tray arrived at 5:54 PM. Error #2: On 10/12/10 at 8:10 AM, during observation of medication pass, LPN #2 was observed to administer two puffs of [MEDICATION NAME] Aerosol Inhalation to Resident B. LPN #2 handed the [MEDICATION NAME] Inhaler to the resident without instructing the resident to wait one minute between inhalations. Resident B self administered 2 inhalations with no wait between puffs. The Drug Facts and Comparisons book (updated monthly), page 669b, states (in reference to administration technique for aerosol inhalers): "Allow greater than or equal to 1 minute between inhalations (puffs).". Error #3: On 10/12/10 at 8:40 AM, during observation of medication pass, LPN #3 was observed to administer 1 puff of [MEDICATION NAME] HFA 110 to Resident C without shaking the canister before administration. The Drug Facts and Comparisons book (updated monthly), page 672a, states (in reference to preparation for administration of [MEDICATION NAME] HFA): "Shake well before using.". Error #4: On 10/12/10 at 8:42 AM, during observation of medication pass, LPN #3 was observed to administer one drop of Omnipred Ophthalmic Suspension to the right eye of Resident C without shaking the bottle before administration. The Drug Facts and Comparisons book (updated monthly), page 1725 states (under General Considerations in Topical Ophthalmic Drug Therapy, in reference to suspensions): "Resuspend suspensions (notably many ocular steroids) by shaking to provide an accurate dose of the drug.". During an interview on 10/12/10 at 8:48 AM, LPN #3 stated that she was aware that both medications ([MEDICATION NAME] HFA 110 and Omnipred Ophthalmic Suspension) needed to be shaken. LPN #3 stated that she was so used to giving these two medications that she thought that she had shaken then. | 2014-12-01 |
| 9766 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 460 | E | 0 | 1 | G9M911 | On the days of the survey, based on observations and interview, the facility failed to provide ceiling suspended curtains, which extended around the bed to provide total visual privacy for each resident. The findings included: On 10/13/10 at 11:35 AM, tour of the facility's resident rooms with the Maintenance Director revealed the following resident rooms with curtains that did not extend around the bed to provide total visual privacy. -Room 23, curtain at foot of the bed was too short leaving an open gap -Room 9, bed D with front curtain about one foot too short -Room 12, bed A with front curtain about 8 to 10 inches too short -Room 13, bed C with side curtain too short -Room 19, bed B with curtain at foot of the bed which was hindered from covering the foot of the bed by the sprinkler pipe which was also suspended from the ceiling and touching the metal pipe holding the suspended curtain. The clips holding the curtain could not pass between the 2 pipes. -Room 22 bed A with front curtain which was about 2 feet short -Room 23 bed C with curtain at the foot of the bed too short. During an interview on 10/14/10 at 8:54 AM, the Maintenance Director revealed that the short curtains had been replaced with longer curtains or additional curtains had been added in the affected rooms and that the sprinkler pipe in room 19 at the foot of bed B had been raised enough to allow the curtain to move along the pipe without being hindered. | 2014-12-01 |
| 9767 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 425 | D | 0 | 1 | G9M911 | On the days of the survey, based on observations and interview, the facility failed to follow a procedure to ensure that expired medications and expired resident care products were removed from storage with other medications and resident care products, available for resident use, in 1 of 2 medication rooms. The findings included: On 10/12/10 at 2:53 PM, observation of the Back Hall Medication Room revealed the following: -two 5 Gram packets of Fougera Vitamin A + Vitamin D Ointment, expired 8/10 -three packs PDI Antiseptic/Germicide Swabsticks (3's), expired 3/10 -one Kendall Kangaroo All Silicone Gastrostomy Tube with Y-Port, expired 9/10 During an interview on 10/12/10 at 3:38 PM, Licensed Practical Nurse (LPN) #4 revealed that the Medication Nurses check the medication room for expired insulin and check the emergency drug kits. Pharmacy comes once a month to check medications. LPN #4 did not know who was responsible for checking supplies and stated that she did not know why Vitamin A and D Ointment and Antiseptic Germicide Swabsticks were in the medication room. | 2014-12-01 |
| 9768 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 159 | F | 0 | 1 | G9M911 | On the days of the survey based on record reviews and interviews, the facility failed to hold, safeguard, manage, and account for the personal funds of the residents deposited with the facility. Two (2) of 5 resident trust accounts did not have proper authorization to manage the resident funds, 5 of 5 resident trust accounts were not managed according to accepted accounting principles and the facility failed to provide accurate accounting practices with the petty cash fund. The findings included: On 10/13/10 at 10:15 AM a review of 5 random Resident Trust Fund accounts and an interview with the Business Office Manager was conducted. The sample consisted of Residents # 3, #11, #14, and Resident D and E. Residents #3 and Resident D did not have an authorization in the records to allow the facility to manage their funds. The only authorization found in Resident #3 and Resident D's records related to The Resident Fund Management Service direct depositing the residents' Social Security check and the forms were signed by the Business Office Manager. There was no resident or Responsible Party signature on the form which did not constitute authorization to manage the residents' funds. During an interview with the current Business Office Manager on 10/13/10 at 10:15 AM, she informed the surveyor that they had changed their accounting system last Spring and now had a contract with Resident Fund Management Service in Virginia. It was her understanding that she or the previous Business Office Manager could sign the Resident Fund Management Service Authorization and Agreement to handle Resident Funds and that the resident or responsible party did not need to sign the form. Upon further review of the selected Resident Trust Fund sample on 10/13/10 at 2:30 PM it was revealed that Resident D had disbursements from his account for multiple Beauty/Barber services: 5/25/10-$13.00, 6/17/10-$10.00, 7/13/10-$10.00, 8/12/10-$10.00, and 9/28/10-$10.00. There were no resident signatures or witness signatures found in the file for the services. The only documentation provided was a list of residents for the dates of the service with no authorizing signatures on the list and no verification that the service was provided. Resident D also had disbursements for room and board : 7/2/10-$1047.00, 8/03/10-$1047.00, 8/1/10-$1583.69, 09/03/10-$1047.00, and 10/01/10-$1047.00. There was no authorization on record for the disbursements for room and board for this resident. Resident E's account revealed disbursements from her account for multiple Beauty/Barber services: 7/19/10-$25.00, 08/06/10-$13.00, 08/27/10-$25.00, and 9/30/10-$13.00. There were no resident signatures or witness signatures found in the file for the services. The documentation provided was a list of residents for the dates of the service with no authorizing signatures on the list and no verification that the service was provided. Resident #3's account revealed a Beauty/Barber disbursement on 7/14/10 for $13.00 and there was no resident signature or witness signatures found in the file for the service. The documentation provided was a list of residents for the date of service with no authorizing signature on the list and no verification that the service was provided. Resident #11's account revealed that on 5/7/10 a disbursement of $18.26 for Personal Needs Item was made and there was no resident signature, no witness signatures, or a receipt for the item or identification of the item. On 5/21/10 a disbursement of $5.00 for Personal Needs Item was made with a $5.00 standard receipt with white and pink copy attached available in the record. The receipt was signed with an X with no witness signatures, identification of item purchased, and the Business Office Manager confirmed in an interview on 10/13/10 at 1:30 PM that she had not provided the resident with a copy of the receipt. On 6/4/10 a disbursement of $50.00 for Personal Needs Item was made and a receipt from the Dollar General on 6/3/10 was provided for $18.26. A note on the receipt stated "difference of $31.54 given to resident 6/4/10": the note was not signed. There was no resident signature and no witness signatures for the withdrawal of the $50.00. On 6/25/10 a disbursement of $60.00 for Personal Needs Items was made and a receipt from Lady Foot Locker dated 7/17/10 was provided for $53.49(shoes) and showed tendered change as $6.51. There was no documentation that the change was returned to the resident account or given to the resident. On 7/28/10 a disbursement of $50.00 for Personal Needs Item was made and a receipt from Walmart dated 7/27/10 for $36.38 and a receipt from Dollar Tree dated 7/27/10 for $5.35 were provided. The total for the receipts was $42.73 and there was no record of the remaining $7.27 being returned to the resident account or given to the resident. There was no resident signature and no witness signatures to authorize the withdrawal. On 10/12/10 a disbursement was made for Clothing in the amount of $6.82 and there was a Walmart receipt provided which included purchases for 3 other residents and there was no documentation that the total, including taxes, was equally divided between the 4 residents. There was no signature/signatures to authorize the withdrawal. Review of Resident #14's account revealed a disbursement on 4/6/10 for Clothing in the amount of $25.57 and a receipt from Southern Comfort for $25.57 with no date provided. There was no authorizing signature/signatures for the disbursement. Multiple disbursements for Beauty/Barber Services were made to the resident account: 5/25/10-$13.00, 6/17/10-$10.00, 7/13/10-$10.00, and 8/12/10-$10.00. There was no authorizing signature or signatures for the withdrawals and the only documentation provided was a list of residents for the dates of service with no authorizing signature. During an interview with the Business Office Manager on 10/13/10 at 1:30 PM, she stated that she did not provide receipts to the residents when disbursing money because they usually just dropped them on the floor. She was unaware that the resident must sign for the the withdrawals and if not able to sign there needed to be 2 witness signatures, which could not include her signature. She was unaware that the individual taking the money for resident purchases must be authorized to do so. During the interview, the Business Office Manager was asked about the Petty Cash Fund. She stated that the Human Resources Manager put $50.00 from the facility's monies each Friday on the nurses' cart for the resident's use. She stated that the nurses are supposed to have residents sign for the amount they withdraw, but this usually doesn't happen. According to the Business Office Manager, she tallied up what was spent and reimbursed the facility for that amount on Monday. She did not have a ledger or accounting system for the Petty Cash withdrawals. | 2014-12-01 |
| 9769 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 318 | E | 0 | 1 | G9M911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review and interviews, the facility failed to provide appropriate intervention for identified contractures for one of three sampled residents reviewed with contractures. The facility failed to provide intervention to improve or maintain Resident # 6's range of motion in his upper extremities and failed to adequately assess if the resident had a decline in range of motion. The findings included: The facility admitted Resident # 6 on 4/8/04 with a [DIAGNOSES REDACTED]. On 10/10/10 at approximately 11:00 AM, during initial tour of the facility, Resident # 6 was observed with contractures of the right arm and hand and bilateral contractures of legs and feet. On 10/10/10 review of the resident's clinical record revealed on the MDSs (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening dated 7/8/10, 9/22/10 and 10/5/10, that the facility had coded the resident as having the following limits related to range of motion: arm: one sided limitation with full loss of voluntary movement hand: one sided limitation with full loss of voluntary movement leg: limitation of both sides with full loss of voluntary movement foot: limitation of both sides with full loss of voluntary movement Review of the RAPS (Resident Assessment Protocol) dated 10/5/10 revealed that the resident had right sided [MEDICAL CONDITION] which was the resident's dominate side. Further review of the document on the ADL (Activities of Daily Living) Supplement, revealed that the facility stated that the resident was dependent except for feeding. Review of the Physician's cumulative orders dated 10/1/10 revealed a physician's orders [REDACTED]. Interview with the facility Rehabilitation Manager on 10/13/10 at 10:16 AM, revealed that the facility practice was to inform the nurses on the unit what services should be provided and that the Restorative CNAs are shown what should be done prior to beginning Restorative services. When questioned what had been the recommended plan for Resident # 6, she stated that she did not know and both she and Restorative CNA # 1 were unable to find the Restorative Plan of Care" form for the resident. Reviewed with the Rehabilitation Manager the rehabilitation screen dated 6/30/10 post fall which stated that the resident was receiving restorative services to both the upper and lower extremities. Review of the Restorative Care Flow Records for June, July, August and September. Restorative CNA # 1 stated that she stretches the resident's leg with the contracture when questioned what care she provides to the resident. The Rehabilitation Manager stated that the nurse of the unit supervises the Restorative CNAs. When questioned who evaluates the effectiveness of services, the Rehabilitation Manager stated that Restorative CNAs should report if they notice any decrease in the range of motion. A discussion followed related to Resident # 6's documented contractures of the right hand/fingers and decreased range of motion. When asked why services were not being provided to the resident to maintain or prevent further decline to the upper extremities, the Rehabilitation Manager stated she did not know. When questioned if anyone assessed the degree of contracture or the degree of range of motion, the Rehabilitation Manager stated that this was not done. When questioned how would you be able to evaluate the effectiveness of the services or if the resident had a decline if the facility was not assessing for the degree of contracture/limited range of motion of his lower extremities and no answer was given. When questioned how the Restorative CNAs would be able to assess the resident's upper extremities if no services were being provided and no answer was given. When asked if the resident had been evaluated for any splints or hand rolls, the Rehabilitation Manager stated that she did not know and was unable to provide any documentation that the resident had been assessed for this type of intervention. The above findings were shared with the DON (Director of Nurses) and the facility Nurse Consultant on 10/13/10 at approximately 3:00 PM. | 2014-12-01 |
| 9770 | LAUREL BAYE HEALTHCARE BLACKVILLE | 425319 | 1612 JONES BRIDGE ROAD | BLACKVILLE | SC | 29817 | 2010-10-13 | 278 | D | 0 | 1 | G9M911 | **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 ensure the accuracy of assessments on two of ten sampled residents reviewed for accuracy of assessment. The facility failed to accurately assess Resident # 7 related to wandering behaviors. In addition, the facility failed to accurately reflect Resident # 6's combativeness during care on the MDS ( (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening. The findings included: The facility admitted Resident # 7 on 8/18/10 with diagnoses of [MEDICAL CONDITION]. On 10/10/10 review of the resident's clinical record revealed documentation on the MDS ( (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening dated 8/27/10 that the resident was coded as alert and oriented. In addition, the facility coded that the resident had not displayed any wandering behaviors. Review of the admission resident profile dated 8/18/10 revealed that the nurse had documented under the section for elopement risk, that the resident was not ambulatory, not resistant to being placed in a long-term care facility and had no history of elopement. The nurse documented that the resident displayed no indications or [DIAGNOSES REDACTED]. Review of the "Elopement Assessment Risk Tool" revealed that the resident had been assessed as a "5". Per the form, a score of 0-6 indicated being at low risk for elopement, 7-13 was considered moderate risk and 14 and above was considered a high risk for potential elopement and would warrant the need for extra supervision. No interventions were documented as needed to decrease the risk. Further review of the clinical record revealed a physician's orders [REDACTED]. Review of the admission assessment completed by the Nurse Practitioner dated 8/18/10 revealed that she had documented that the resident was alert and oriented. Further review of the physician progress notes [REDACTED]. Review of the Nurses' notes dated 8/18/10 to current date revealed no documentation of behaviors or wandering behavior. Review of the resident's care plan revealed no care plan related to wandering or behaviors. On 10/12/10 at approximately 10:00 AM, LPN (Licensed Practical Nurse) # 3, was asked why the resident had a wanderguard. She stated that she was not sure but thought he had been seen "Checking the doors". LPN # 3 stated that she did not know who made the decision for wanderguard placement. The Administrator was asked what was the facility's policy related to wanderguards, he stated that wanderguards were placed on all residents on admission, and if after seven days, the resident did not need one, it would be removed. When questioned if this was done for residents who were alert and oriented and he stated yes. The Administrator was asked if a resident was alert and oriented, would he be allowed to leave the facility if he wanted to? He stated no, the resident might wander into the road. There was no determination noted that the resident was not competent. Interview with LPN # 4 at approximately 3:00 PM, revealed that the facility practice was to place wanderguard on all new admissions for the first seven days. Questioned why Resident # 7 had a wanderguard and she stated that he had been "checking the doors." In reviewing the resident's chart with LPN # 4, she confirmed that the resident had not been assessed as being a moderate or high risk for elopement and that there was no documentation of wandering behaviors. When questioned if a resident was alert and oriented - would he/she be free to leave the facility if he wanted to, she stated no. In addition, she stated that the RP (Responsible Party) would have to agree. On 10/13/10 during an interview with the facility Nurse Consultant, she confirmed that the resident's assessments did not reflect the need for a wanderguard. She confirmed that there was documentation in the chart related to wandering or behaviors. On 10/13/10 interview with the MDS Coordinator revealed that she was unaware of the resident having a wanderguard or the resident displaying wandering behavior. She stated that she obtains her information from the chart and the facility staff. The facility admitted Resident # 6 on 4/8/04 with a diagnoses of Late Effect [MEDICAL CONDITION] of the right side and Muscle Disuse Atrophy. On 10/10/10 review of the resident's clinical record revealed that the resident had displayed combative behavior while receiving restorative services during the months of June, July, August and September. Further review of the resident's chart revealed on the MDSs (Minimum Data Set) for Nursing Home Resident Assessment And Care Screening dated 7/8/10, 9/22/10 and 10/5/10, that the facility had coded the resident as having no behaviors. Further review of the resident's clinical revealed that the facility had not care planned the combative behaviors. On 10/13/10 interview with Restorative CNA (Certified Nursing Assistant) # 1 revealed that she provided restorative services to the resident. She stated that the resident frequently tries to kick and hit the restorative CNAs during the provision of restorative services. On 10/13/10 interview with the MDS Coordinator revealed that she was unaware of the resident being combative during care. She stated that she obtains her information from the chart and the facility staff. | 2014-12-01 |
| 10262 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 280 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint survey, based on record review and interview, the facility failed to revise and update the Care Plan for 1 of 4 sampled residents reviewed for Comprehensive Care Plans. Resident #1's Care Plan had not been updated regarding approaches used for proper positioning and to prevent and/or care for Pressure Ulcers. The findings included: The facility admitted Resident #1 on 09/06/2002 and readmitted her on 12/10/2004 with [DIAGNOSES REDACTED]. Observation on 10/18/2010 at 12:35 PM revealed the resident lying on a specialty mattress with the head of bed elevated. Review of the cumulative Physician order [REDACTED]. Review of the Physician/Nurse Practitioner Progress Notes on 10/18/2010 at 1:15 PM revealed the following: 06/16/2010- "S(ubjective): Resident had an area of skin compromise noted to her sacrum. Initial treatment was the use of [MEDICATION NAME] although wound treatment nurse reports the skin was intact at that time. However, we were called to see the resident today due to changes in the sacral wound...P(lan): ...Also, initiate a specialty mattress surface for the resident to minimize skin breakdown and to offload this area". 07/12/2010- "Patient is an elderly white female with a known history of advanced dementia, ... and essentially total care for activities of daily living (ADLs) and instrumental activities of daily living (IADLs)...". 07/14/2010- "Chief Complaint: Pressure Area. S(ubjective): Resident is frail and debilitated, cachectic, with wound on her sacrum...O(bjective): The wound is open...Heels are intact... P(lan): ...Keep resident turned and positioned...". 07/28/2010- "P(lan): She is on double shot protein q.i.d. (4 Times daily)...Heels are intact...Encourage turning and repositioning". 08/09/2010- "P(lan): ...Keep resident turned and repositioned". 08/30/2010- "P(lan):...Encourage turning and repositioning, although due to her frailty and debility would contribute greatly to poor wound healing. She is also very thin...". 09/29/2010- "Chief complaint: Pressure areas. S(ubjective): Resident was seen by this provider for follow up of a pressure area on her sacrum. She has developed other areas of skin compromise. O(bjective): ... On the left outer heel is a smaller wound that measures approximately .1 cm (centimeters) The wound is dark brown, purple coloration, with peeling edges. No open areas at this time...P(lan): Encourage turning and repositioning....She is already on double shot protein...". Review of the Care Plan for Resident #1 on 10/18/2010 at approximately 1:40 PM revealed page 13 of the Care Plan folded over. Written on the fold was "7/7/10 New Skin Integrity Care Plan Printed". On the folded page were approaches listed for the problem of being at risk for impaired skin integrity with the "Date(s)" listed as 10/13/2009, 01/04/2010, and 04/06/2010. The "Goal" was that "Resident's skin will be free from irritation and breakdown" with an evaluation date of 07/06/2010. The approaches listed included "Turn and reposition every 2 HRS (hours), Assess nutritional status, Keep skin dry and clean, Assess skin condition PER POLICY, float heels as ordered, ...". Further review of the Care Plan for Resident #1 revealed there was an entry dated 07/14/2010 that addressed the problem of being at risk for impaired skin integrity related to skin tears, but it did not include approaches to prevent or care for pressure ulcers. Continued review revealed "Problem Start Date: 07/07/10, Resident has a pressure ulcer Stage III to sacrum". The goal was listed as "Resident's ulcer will decrease in size and ulcer will not exhibit signs of infection...". The approaches listed included the following: "Use pads or briefs to maintain personal hygiene and dignity, Keep clean and dry as possible. Minimize skin exposure to moisture, Keep linens clean, dry, and wrinkle free. Conduct a skin inspection weekly, and daily per policy. Report any signs of any further skin breakdown. Assess pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin. Follow wound care nurse and provider's recommendations and orders related to dressing changes. Provide incontinence care after each incontinent episode." There was no mention of the Nurse Practitioner's recommendation to keep the resident turned and repositioned, that the resident used a specialty mattress, that Resident #1's heels were to be floated, or that the resident should be in her geri-chair with foam cushion for proper positioning while out of bed. During an interview on 10/18/2010 at 1:48 PM, one of the Minimum Data Set (MDS) Coordinators (Registered Nurse #1) reviewed the Care Plan and verified that the folded page was not included in the current Care Plan. She verified that there was not a "7/7/10 New Skin Integrity Care Plan" and that the current Care Plan did not address turning and repositioning the resident or floating the resident's heels. She stated that another MDS Coordinator had been responsible for updating Resident #1's Care Plan and that this nurse had just started in July. She stated she would look to see if there were any more pages that should have been included in Resident #1's Care Plan. Upon return, she did have some pages to add, but none related to skin breakdown or pressure ulcer care. | 2014-02-01 | ||
| 10263 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 157 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review, interview, and review of the policy provided by the facility entitled "Physician Communication Grid", the facility failed to notify the physician with changes related to pressure ulcers for 2 of 4 sampled residents reviewed with pressure ulcers. Residents #3 and #4 had pressure ulcers worsen without physician notification. The findings included: The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Record Review on 10/18/2010 revealed a Wound Treatment & Progress Record dated for September 2010. On the front was an order dated "9-15-10" that stated "Cleanse sacral area (with) wound cleanser, pack (with) calcium alginate & cover (with) adhesive foam dsg.(dressing), (Change) qd (daily) & PRN (When needed)". Under this was written "crush [MEDICATION NAME] 500 mg (milligrams) (1) tab(let) into wound on coccyx qd". On the back of the sheet were 3 entries. One of the entries, dated 09/22/2010 revealed that the wound had measured "Length 5.0, Width 8.0, depth 1.0, Undermining 3.9". On 9/29/10 the wound had increased in size to "Length 5.9, Width 8.0, Depth 1.6, and Undermining 4.1". Another Wound Treatment and Progress Record dated October 2010 revealed two entries, one dated for 10/07/2010 that stated the wound measured "Length 6.1, Width 8.0, Depth 1.5, Undermining 3.8"; and one dated 10/14/2010 that stated "Length 6.5, Width 8.0, Depth 1.5, Undermining 4.1". Review of the Physician/Nurse Practitioner Progress Notes revealed the last note in the chart was dated 09/06/2010 and did not mention the sacral wound. Review of Physician order [REDACTED]. Review of the Nurse's Notes for September and October 2010 revealed no mention that the Physician or Nurse Practitioner had been notified that the Pressure Ulcer had gotten bigger. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (NP) as their wound consultant and that she looked at the wounds and changed the dressing orders. When asked how often the NP looked at the wounds, she stated that it depended on how long the resident had the wound, and it was usually once a month. She stated that if the wound had been acquired here at the facility, the NP looked at those more frequently and it was usually every other week. When asked where to find documentation of pressure ulcers, LPN #1 stated that the NP dictated a progress note and that she (the Wound Care Nurse) would document measurements on the treatment sheet. She stated she would also document anything going on or any changes in the Nurse's Notes. She stated that if she were off, the floor nurses document on the wounds. During an interview on 10/18/2010 at approximately 12:00 Noon, the Director of Nursing (DON) reviewed the wound measurements for September and October 2010 and verified the wound had increased in size from 09/22 to 09/29/2010. After reviewing the chart, she verified there were not any Physician/Nurse Practitioner Progress Notes that addressed the wound for the above referenced time periods. When asked about any other progress notes that may not have been in the chart, the DON asked another staff member to check, but was unable to provide any additional progress notes that indicated the Physician/Nurse Practitioner was aware of the worsening pressure ulcer. She stated that the nursing staff talks with the Nurse Practitioner/Physician when they come in twice a week, but they weren't aggressively treating the resident because she was on hospice. During an interview on 10/18/2010 at 4:15 PM, the Nurse Practitioner was asked about the resident's worsening pressure ulcer. She was given the measurements for the following dates and was told that the pressure ulcer had increased in size on 09/29/2010 and had continued to increase in size according to the documentation for 10/07/2010 and 10/14/2010. She was told that there had been no documentation of physician notification and when asked if she would have expected the nursing staff to call and notify her or the physician, she stated "yes". Review of the policy provided by the facility on 10/22/2010 entitled "Physician Communication Grid" revealed an entry for "Pressure Ulcers". Under the heading "Treatment Required within 4 Hours (If no response within 4 hours call medical director)" was listed "New Stage III or higher, any break in skin associated with fever or signs of infection". Under the heading "Routine Physician Notification" was "New Stage II or less". There was no mention of notification for enlargement of existing Pressure Ulcers. The facility initially admitted Resident #4 on 08/11/09 and readmitted him on 03/07/2010 with [DIAGNOSES REDACTED]. Record review on 10/18/2010 at 9:23 AM revealed a Nurse's Note dated 09/19/2010 that stated "Aide doing AM (Morning) care noticed open area to L(eft) heel. Came + got me. Open area bleeding slightly. No drainage noted. Cleansed (with) NS (Normal Saline) + dressed (with) safe gel foam pad + Kerlix. No C/O (complaints) of pain/discomfort voiced". Review of the Wound Treatment and Progress Record dated October 2010 revealed an order dated 09/19/2010. Under "Treatment" was written "Cleanse L(eft) heel (with) NS (Normal Saline) or wound cleanser, apply sm (all) amt (amount) wound gel (with) dry dsg (dressing). Secure (with) tape. May cover loosely (with) gauze, (Change) qd (daily) & PRN (When needed). On the back of the Wound Treatment and Progress Record were two entries. One entry dated 10/07/2010 documented the wound as being "Length 1.8, Width 2.4". The other entry was dated 10/14/2010 and documented "Length 4.6, Width 7.0". There were no other entries on the sheet. Observation of the dressing change to the left heel on 10/18/2010 revealed that the ulcer was located on the left lateral side of the left foot and went up the backside of the heel. The ulcer had some depth in the center of the wound along with a black discoloration along the top edge of the wound. According to the Treatment Nurse (LPN #1), she usually measured wounds once a week. When asked, she stated that she would normally measure any new areas of depth, but verified that she had not done so for the area on the resident's left heel. According to LPN #1, the Nurse Practitioner (NP) had not been informed about the new area of depth on the left heel. She stated that the NP would be there today and she would have the NP look at the wound. Review of the Physician/Prescriber Telephone Orders for October 2010 at approximately 9:00 AM revealed no orders related to the left heel ulcer. Further review of October's Nurse's Notes revealed no mention that the physician or Nurse Practitioner (NP) had been notified that the left heel ulcer had gotten worse. Review of the Physician/Nurse Practitioner Progress notes revealed a note dated 10/05/2010 that stated "...His areas have opened back up on both heels" and "Both heels have darkened skin with blisters and drainage, serous. Right seems larger than the left". There were no other Physician/Nurse Practitioner progress notes for October 2010 provided by the facility. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (NP) as their wound consultant and that she looked at the wounds and changed the dressing orders. When asked how often the NP looked at the wounds, she stated that it depended on how long the resident had the wound, and it was usually once a month. She stated that if the wound had been acquired here at the facility, the NP looked at those more frequently and it was usually every other week. When asked where to find documentation of pressure ulcers, LPN #1 stated that the NP dictated a progress note and that she (the Wound Care Nurse) would document measurements on the treatment sheet. She stated she would also document anything going on or any changes in the Nurse's Notes. She stated that if she were off, the floor nurses document on the wounds. Review of the policy provided by the facility on 10/22/2010 entitled "Physician Communication Grid" revealed an entry for "Pressure Ulcers". Under the heading "Treatment Required within 4 Hours (If no response within 4 hours call medical director)" was listed "New Stage III or higher, any break in skin associated with fever or signs of infection". Under the heading "Routine Physician Notification" was "New Stage II or less". There was no mention of notification for enlargement of existing Pressure Ulcers. | 2014-02-01 | ||
| 10264 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 514 | E | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, the facility failed to ensure that nursing staff initialed treatments when completed for 2 of 4 sampled residents reviewed for completeness and accuracy of clinical records. Residents #3 and #4 had blanks on their treatment record where the nurse failed to initial the treatment as having been completed. Review of the Narcotics Log and Medication Administration Records for the Blue Wing revealed inaccuracies in documentation of narcotic/hypnotic medication administration for Residents A, B, C, D, E, and F. The findings included: The facility initially admitted Resident #4 on 08/11/2009 and readmitted him on 03/07/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for July, August, September, and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd (daily) & PRN (As needed)". Blank spaces were noted for 10/2, 10/3, 10/6, 10/8, 9/4, 9/6, 9/12, 9/13, 9/21, 8/1, 8/24, 8/25, 8/30, 8/31, 7/9, and 7/11/2010. -physician's orders [REDACTED]. Secure (with) tape. May cover loosely (with) gauze. (Change) qd and PRN". Blank spaces were noted for 10/6 and 9/21/2010. -physician's orders [REDACTED]. Wrap (with) Kerlix. (Change) qd & PRN". A blank space was noted for 10/01/2010. The Treatment Nurse on 10/18/2010 verified the blanks for September and October 2010. The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Review of Wound Treatment and Progress Records for August and October 2010 revealed the following blanks indicating that the nurse had not initialed the treatment as having been completed: -physician's orders [REDACTED]. (Change) qd & PRN". A blank space was noted for 10/06/2010. -physician's orders [REDACTED]. (Change) qd & PRN". Blank spaces were noted for 8/24 and 8/29/2010. The Director of Nursing on 10/18/2010 verified these blanks. Review of multiple Medication Flowsheets revealed that narcotic medications had been initialed as having been given when there was no documentation to corroborate this in the Narcotic and Hypnotic Record. There were also instances of medications being signed out on the Narcotic and Hypnotic Record, which were not documented on the Medication Flowsheet as having been given to the resident. The following documentation was reviewed and verified by Registered Nurse (RN) #2 on 10/17/2010. Review of Resident A's October 2010 Medication Flowsheet revealed an order dated 09/11/2010 that stated "[MEDICATION NAME] ([MEDICATION NAME])- Schedule IV Tablet; 0.5 mg; Amount to Administer: 1 tab; Oral PRN-As Needed (Q 4hrs PRN)". This was initialed on the front of the Medication Flowsheet as having been given on 10/10/2010 at 6:30 PM. On the back of the flowsheet, was an entry dated 10/10/10 that stated that [MEDICATION NAME] 0.5 mg had been given at 6:30 PM for agitation. However, the narcotic log documented that [MEDICATION NAME] 0.5 mg had only been signed out at 2 PM on 10/10/2010. There was nothing on the Medication Flowsheet to indicate the resident received any [MEDICATION NAME] at 2 PM. There was another separate entry that revealed that [MEDICATION NAME] 0.5 mg had been initialed as having been given on the Medication Flowsheet for 10/03/2010 at 9 PM, however, the Narcotic and Hypnotic Record did not have an entry for that date and time. Review of the Narcotic and Hypnotic Log for Resident A revealed "[MEDICATION NAME] 0.5 mg, Take 1 Tab by mouth every 4 hours as needed". Further review revealed that [MEDICATION NAME] 0.5 mg had been signed out on the log on 10/07/2010 at 9 AM and 10/15/2010 at 4:45 PM, however, there was no documentation on the Medication Flowsheet to show that the medication had been given at these times. Another order for Resident A, dated 09/21/2010, was listed on the Medication Flowsheet as "[MEDICATION NAME]-[MEDICATION NAME]- Schedule III, Tablet; 2.5-500 mg (milligrams) Amount to Administer: 1 tab (tablet); Oral TID- Three Times A Day". The scheduled times were listed as 9 AM, 1 PM, and 9 PM. Review of the Medication Flowsheet revealed initials in the 10/06/2010, 9 PM square. However, review of the Narcotic and Hypnotic Record revealed that the medication had not been signed out for that date and time. There was another order dated 9/13/10 that stated "[MEDICATION NAME]-[MEDICATION NAME]- Schedule III, Tablet; 2.5-500 mg (milligrams) Amount to Administer: 1 tab; Oral PRN-As Needed". Review of the Narcotic and Hypnotic Record revealed that the medication had been signed out on 10/03/2010 at 1700 but this had not been documented as having been given on the Medication Flowsheet. Review of Resident B's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the Narcotic and Hypnotic Record revealed that [MEDICATION NAME] 1 mg had been signed out on 10/11/2010 at 10 AM, 10/13/2010 at 9:30 AM, and on 10/16/2010 at 9 PM. However, there was no documentation on the Medication Flowsheet to show that the medication had been given at these times. Review of Resident C's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the Narcotic and Hypnotic Record for "[MEDICATION NAME] 10 mg Tablet SUB (Substitute) FOR: AMBIEN" revealed that the medication had been signed out on 10/16/2010 at 9 PM, however, the Medication Flowsheet was blank for that date and time. Review of Resident D's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the Narcotic and Hypnotic Record for the medication revealed [MEDICATION NAME] 0.5 mg had been signed out on 10/3/2010 at 9 PM, however, there was no documentation on the Medication Flowsheet to show that the medication had been given at this time. Review of Resident E's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Review of the resident's Narcotic and Hypnotic Record for "[MEDICATION NAME](one) W(ith) APAP 7.5-500 mg Tablet, Take 1 Tab by mouth every 4-6 hours as needed" revealed that the medication had been signed out on 10/9/2010 at 9 PM and on 10/11/2010 at 9 PM. The Medication Flowsheet, however, was blank and did not document any [MEDICATION NAME] as having been given for these dates. Review of Resident F's October 2010 Medication Flowsheet revealed an order for [REDACTED]. Further review revealed another entry for "[MEDICATION NAME]-[MEDICATION NAME]- Schedule III Tablet; 10-500 mg; Amount to Administer: 1 tab; Oral PRN-As Needed (Q 6hrs PRN)". Review of the Narcotic and Hypnotic Record for the medication revealed that the medication had been signed out on 10/09/2010 at 8 AM, 1:30 PM, and 5 PM only. The Medication Flowsheet for the PRN Hydocodone-[MEDICATION NAME] was blank and did not indicate a 5 PM dose had been given on this date. The nurse had initialed the medication as having been given on the routine (Three Times Daily) entry for 10/09/2010 at 9 AM, 1 PM, and 9 PM; however, there was no 9 PM entry on the narcotic log. Further review revealed this same medication had been signed out on the narcotic log on 10/11/2010 at 9AM, 1 PM, 5 PM, and 9 PM; however, there was no documentation on the Medication Flowsheet that a PRN dose had been given at 5 PM. | 2014-02-01 | ||
| 10265 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2010-10-18 | 314 | D | DFY111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on observation, record review, interview, and review of the policy provided by the facility entitled "Physician Communication Grid", the facility failed to assess and address with the physician changes related to pressure ulcers for 2 of 4 sampled residents reviewed with pressure ulcers. Residents #3 and #4 had pressure ulcers worsen without physician notification. The findings included: The facility admitted Resident #3 on 07/06/2010 with [DIAGNOSES REDACTED]. Record Review on 10/18/2010 revealed a Wound Treatment & Progress Record dated for September 2010. On the front was an order dated "9-15-10" that stated "Cleanse sacral area (with) wound cleanser, pack (with) calcium alginate & cover (with) adhesive foam dsg.(dressing), (Change) qd (daily) & PRN (When needed)". Under this was written "crush [MEDICATION NAME] 500 mg (milligrams) (1) tab(let) into wound on coccyx qd". On the back of the sheet were 3 entries. One of the entries, dated 09/22/2010 revealed that the wound had measured "Length 5.0, Width 8.0, depth 1.0, Undermining 3.9". On 9/29/10 the wound had increased in size to "Length 5.9, Width 8.0, Depth 1.6, and Undermining 4.1". Another Wound Treatment and Progress Record dated October 2010 revealed two entries, one dated for 10/07/2010 that stated the wound measured "Length 6.1, Width 8.0, Depth 1.5, Undermining 3.8"; and one dated 10/14/2010 that stated "Length 6.5, Width 8.0, Depth 1.5, Undermining 4.1". Review of the Physician/Nurse Practitioner Progress Notes revealed the last note in the chart was dated 09/06/2010 and did not mention the sacral wound. Review of Physician order [REDACTED]. Review of the Nurse's Notes for September and October 2010 revealed no mention that the Physician or Nurse Practitioner had been notified that the Pressure Ulcer had gotten bigger. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (NP) as their wound consultant and that she looked at the wounds and changed the dressing orders. When asked how often the NP looked at the wounds, she stated that it depended on how long the resident had the wound, and it was usually once a month. She stated that if the wound had been acquired here at the facility, the NP looked at those more frequently and it was usually every other week. When asked where to find documentation of pressure ulcers, LPN #1 stated that the NP dictated a progress note and that she (the Wound Care Nurse) would document measurements on the treatment sheet. She stated she would also document anything going on or any changes in the Nurse's Notes. She stated that if she were off, the floor nurses document on the wounds. During an interview on 10/18/2010 at approximately 12:00 Noon, the Director of Nursing (DON) reviewed the wound measurements for September and October 2010 and verified the wound had increased in size from 09/22 to 09/29/2010. After reviewing the chart, she verified there were not any Physician/Nurse Practitioner Progress Notes that addressed the wound for the above referenced time periods. When asked about any other progress notes that may not have been in the chart, the DON asked another staff member to check, but was unable to provide any additional progress notes that indicated the Physician/Nurse Practitioner was aware of the worsening pressure ulcer. She stated that the nursing staff talks with the Nurse Practitioner/Physician when they come in twice a week, but they weren't aggressively treating the resident because she was on hospice. During an interview on 10/18/2010 at 4:15 PM, the Nurse Practitioner was asked about the resident's worsening pressure ulcer. She was given the measurements for the following dates and was told that the pressure ulcer had increased in size on 09/29/2010 and had continued to increase in size according to the documentation for 10/07/2010 and 10/14/2010. She was told that there had been no documentation of physician notification and when asked if she would have expected the nursing staff to call and notify her or the physician, she stated "yes". Review of the policy provided by the facility on 10/22/2010 entitled "Physician Communication Grid" revealed an entry for "Pressure Ulcers". Under the heading "Treatment Required within 4 Hours (If no response within 4 hours call medical director)" was listed "New Stage III or higher, any break in skin associated with fever or signs of infection". Under the heading "Routine Physician Notification" was "New Stage II or less". There was no mention of notification for enlargement of existing Pressure Ulcers. The facility initially admitted Resident #4 on 08/11/09 and readmitted him on 03/07/2010 with [DIAGNOSES REDACTED]. Record review on 10/18/2010 at 9:23 AM revealed a Nurse's Note dated 09/19/2010 that stated "Aide doing AM (Morning) care noticed open area to L(eft) heel. Came + got me. Open area bleeding slightly. No drainage noted. Cleansed (with) NS (Normal Saline) + dressed (with) safe gel foam pad + Kerlix. No C/O (complaints) of pain/discomfort voiced". Review of the Wound Treatment and Progress Record dated October 2010 revealed an order dated 09/19/2010. Under "Treatment" was written "Cleanse L(eft) heel (with) NS (Normal Saline) or wound cleanser, apply sm (all) amt (amount) wound gel (with) dry dsg (dressing). Secure (with) tape. May cover loosely (with) gauze, (Change) qd (daily) & PRN (When needed). On the back of the Wound Treatment and Progress Record were two entries. One entry dated 10/07/2010 documented the wound as being "Length 1.8, Width 2.4". The other entry was dated 10/14/2010 and documented "Length 4.6, Width 7.0". There were no other entries on the sheet. Observation of the dressing change to the left heel on 10/18/2010 revealed that the ulcer was located on the left lateral side of the left foot and went up the backside of the heel. The ulcer had some depth in the center of the wound along with a black discoloration along the top edge of the wound. According to the Treatment Nurse (LPN #1), she usually measured wounds once a week. When asked, she stated that she would normally measure any new areas of depth, but verified that she had not done so for the area on the resident's left heel. According to LPN #1, the Nurse Practitioner (NP) had not been informed about the new area of depth on the left heel. She stated that the NP would be there today and she would have the NP look at the wound. Review of the Physician/Prescriber Telephone Orders for October 2010 at approximately 9:00 AM revealed no orders related to the left heel ulcer. Further review of October's Nurse's Notes revealed no mention that the physician or Nurse Practitioner (NP) had been notified that the left heel ulcer had gotten worse. Review of the Physician/Nurse Practitioner Progress notes revealed a note dated 10/05/2010 that stated "...His areas have opened back up on both heels" and "Both heels have darkened skin with blisters and drainage, serous. Right seems larger than the left". There were no other Physician/Nurse Practitioner progress notes for October 2010 provided by the facility. During an interview on 10/18/2010 at 8:42 AM, the Wound Care Nurse (LPN #1) stated that the facility used a Nurse Practitioner (NP) as their wound consultant and that she looked at the wounds and changed the dressing orders. When asked how often the NP looked at the wounds, she stated that it depended on how long the resident had the wound, and it was usually once a month. She stated that if the wound had been acquired here at the facility, the NP looked at those more frequently and it was usually every other week. When asked where to find documentation of pressure ulcers, LPN #1 stated that the NP dictated a progress note and that she (the Wound Care Nurse) would document measurements on the treatment sheet. She stated she would also document anything going on or any changes in the Nurse's Notes. She stated that if she were off, the floor nurses document on the wounds. Review of the policy provided by the facility on 10/22/2010 entitled "Physician Communication Grid" revealed an entry for "Pressure Ulcers". Under the heading "Treatment Required within 4 Hours (If no response within 4 hours call medical director)" was listed "New Stage III or higher, any break in skin associated with fever or signs of infection". Under the heading "Routine Physician Notification" was "New Stage II or less". There was no mention of notification for enlargement of existing Pressure Ulcers. | 2014-02-01 | ||
| 10244 | WHITE OAK MANOR - ROCK HILL | 425088 | 1915 EBENEZER RD | ROCK HILL | SC | 29732 | 2010-10-19 | 225 | D | YPDS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the day of the inspection based on record reviews and interviews the facility failed to ensure that all allegations of abuse/neglect were thoroughly investigate to prevent further abuse to residents #1 and #5. There was no documentation that the facility interviewed all staff on duty at the time of the incident (2 of 5 sample residents reviewed) The findings included: The facility admitted Resident #1 on 06/25/2010 and readmitted the resident on 07/30/2010 with [DIAGNOSES REDACTED]. Review of the facility investigation regarding a facility reported incident involving Resident #1 on 07/23/2010 revealed a statement written by Licensed Practical Nurse #1 that stated, "...I asked her when it started hurting she said yesterday at white guy help me from my bed to my chair he was in white uniform - he was with other workers. He picked me up under my arms and lifted me to the w/c (wheelchair) - felt a little pain not much..." The witness statement indicated the resident informed the facility staff that "he was with other workers". A review of the facility investigation revealed no interviews were done with the staff working at the time of the incident. The Social Services Director (SSD) stated that the facility did not have statements from staff on the unit at the time of the incident with Resident #1. The facility admitted Resident #5 on 12/20/2005 with [DIAGNOSES REDACTED]. Record review revealed a Quarterly MDS (Minimum Data Set) dated 06/17/2010 that indicated the resident had memory problems but had no cognitive problems with daily decision making. Review of the facility grievance log revealed Resident #5 informed the facility on 08/05/2010 that a nurse, in the presence of three CNAs (certified nurse aides), grabbed her wrist and told her to move. There was no documentation the facility investigated the allegation and reported to the State Survey Agency. In an interview on 10/19/2010 at approximately 11:30 PM the DON (Director of Nursing) and the SSD (Social Services Director) confirmed the findings related to Resident #1 and #5. | 2014-02-01 | ||
| 9874 | HERITAGE HEALTHCARE CENTER AT THE PINES | 425113 | 413 LAKESIDE COURT | DILLON | SC | 29536 | 2010-10-20 | 315 | D | 0 | 1 | TQ5V11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview, record review and review of the facility's policy for Catheter Care, one of two resident's observed for catheter care received inappropriate care during the treatment. The Certified Nurses' Assistant CNA anchored the catheter tubing distally and cleansed the tubing moving from the distal portion back to the proximal end of the tubing. The findings included: The facility admitted Resident # 19 on 06/17/2008 with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident received [MEDICATION NAME] 50 milligrams at bedtime as a maintenance dose of antibiotic for urinary tract infections. During the catheter care treatment on 10/20/2010 at 9:45 AM, CNA #1 held the catheter tubing distally from the urinary meatus and with a disposable wipe cleansed the tubing as she moved the wipe up the tubing to the proximal end of the tubing at the opening of the meatus. In an interview with CNA #1, she confirmed that she did hold the tubing distally and that she did move the wipe towards the meatus instead of away from the meatus opening. Review of the facility's Catheters: Care and Anchoring, Changing of policy revealed in item 11.) ....cleanse catheter from insertion site to four (4) inches; outward. | 2014-10-01 |
| 9875 | HERITAGE HEALTHCARE CENTER AT THE PINES | 425113 | 413 LAKESIDE COURT | DILLON | SC | 29536 | 2010-10-20 | 456 | E | 0 | 1 | TQ5V11 | On the days of the survey, based on observation, record review, policy review, and interview, the facility failed to maintain 1 of 2 unit refrigerators in safe operating condition. The North nutrition refrigerator maintained an inside temperature higher than the recommended acceptable parameters. The findings included: Observation of the North Unit nutrition refrigerator on 10/20/10 at 2:15 PM, revealed contents of Med Pass, soft drinks, and applesauce. The inside refrigerator temperature was 56 degrees. The Dietary Manager and Maintenance Director confirmed that the temperature was above the recommended parameters. Review of the refrigerator log for October 2010 revealed temperatures ranging from 42 - 62 degrees. Review of the facility policy titled "Refrigerator Temperatures" revealed that temperatures should be maintained at or below 40 degrees. During an interview with the Director of Nursing on 10/20/10, she stated that the night nurse was responsible for checking and documenting the temperature and should have reported that the temperatures were out of the acceptable range. | 2014-10-01 |
| 10250 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2010-10-26 | 157 | D | M5SK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interview, closed record review, and review of facility policy titled Condition Change (9/03) and Documentation (4/06) the facility failed to provide evidence that the resident's physician and legal representative were notified when Resident # 11 experienced a significant change in his condition. The resident's temperature was significantly elevated to 103.9 and the resident was vomiting brown emesis with a foul odor. The findings included: The facility admitted Resident # 11 on 12/1/08. The resident's [DIAGNOSES REDACTED]. On 10/24/10, a review of the closed medical record revealed the resident was documented as having an elevated temperature of 103.9 on 10/1/10 at 2:30PM. The resident vomited twice. The emesis was noted to be brown, watery with a foul odor. There was no documentation that the attending physician was notified but rather standing orders were initiated which included [MEDICATION NAME] and Tylenol. There was no documentation that the responsible party was notified. During an interview with the facility Director of Nursing on 10/24/10 at 8:30PM, she indicated she felt the nurse had initiated the standing orders appropriately. When questioned about the brown emesis with a foul odor, she stated the resident constantly chewed tobacco and felt that was the cause of the foul odor and brown color. The Director of Nurses did not dispute there was no evidence that the family had been notified. On 10/25/10, at 5PM, during an interview with the attending physician, he stated he did not recall being aware of the resident's illness while in the building. He further stated that if he did see him that day it would have been because the resident was seated in the hallway per his usual custom. On 10/25/10 at approximately 5:45PM, during an interview with Licensed Practical Nurse # 1, she stated that the physician was in the building and was informed of the resident's condition and saw the resident. She stated she did not accompany the physician nor visually see the physician examine the resident. LPN # 1 also stated she called the resident's family and left a message. However, there was no documentation either by the nurse or the physician that had occurred. Review of the facility provided policy for condition change stated: "Any staff member who notices a resident/patient status change shall immediately notify the appropriate licensed personnel. After assessing the resident/patient, the licensed personnel shall contact the physician immediately regarding status change. Family members and or guardians...will be notified, except when the change in status regards such routine lab work, diet changes. and/or minor medication changes. ....Notification of the appropriate individuals is to be documented in the medical record. Documentation on the 24 hour report does not replace documentation in the medical record. Facility policy titled Documentation: Charting stated ...all pertinent information will be charted on each individual/patient/resident in accordance with accepted professional standards and practices. The records will be a complete, accurate and functional representation of the actual experience of the patient/resident. ...The chart is a legal document and must be kept up-to-date at all times. ...Pertinent information requiring documentation will include, but not be limited to the following:....A significant change in physical, mental or psychosocial status...clinical complications related to disease status...new behaviors." | 2014-02-01 |