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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7880 | POINSETT REHABILITATION AND HEALTHCARE CENTER, LLC | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2013-10-02 | 157 | D | 1 | 0 | 4KB411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .On the days of the complaint inspection, based on record review and interview, the facility failed to notify the physician of an elevated blood sugar for one of one residents with a blood sugar of 500. Resident #1 had a blood sugar over 500 and the physician was not notified. The findings are as follows: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the resident's Physician Cumulative Orders revealed an order for [REDACTED].>(greater than) 500 give 12 units of Insulin SQ (subcutaneous) and call (the doctor). Review of the Diabetes Monitoring Record revealed on 8/7/13 at 7:00 AM, the resident's blood sugar was 529. The resident was given the 12 units of insulin but the doctor was not notified. On 10/2/13 at approximately 1:45 PM the Director of Nursing (DON) was interviewed by the surveyor. The resident's blood sugars were reviewed with the Director of Nursing. After reviewing the medical record, the DON confirmed the physician had not been notified of the 529 blood sugar. | 2016-10-01 |
| 4303 | PRUITTHEALTH-CONWAY AT CONWAY MEDICAL CENTER | 425173 | 2379 CYPRESS CIRCLE | CONWAY | SC | 29526 | 2016-06-23 | 329 | D | 0 | 1 | 55GR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** : Based on record review and interview, the facility failed to implement non-pharmacological interventions prior to administration of an anti-anxiety medication for 1 of 5 residents reviewed for unnecessary medications.(Resident #130) The findings included: The facility admitted Resident #130 with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. Further review of the Medication Administration Records(MAR's) for the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed Resident #130 received [MEDICATION NAME] without documentation of attempting a non-pharmacological intervention as follows: 4/26/16-x 2, 4/27/16 x 2, 4/28/16 x 2 and 4/29/16; 5/2/16, 5/6/16, 5/8/16, 5/12/16, 5/13/16, 5/14/16, 5/15/16, 5/17/16 x 2, 5/20/16 x 2, 5/22/16, 5/23/16, 5/24/16 x 2, 5/25/16, 5/26/16 x 2, 5/27/16, 5/28/16 x 2, 5/29/16 and 5/31/16; 6/2/16 x 2, 6/3/16 x 2, 6/5/16, 6/7/16 x 2, 6/9/16, 6/10/16, 6/11/16 x 2, 6/12/16 x 2, 6/13/16 x 2, 6/14/16 x 2 6/15/16, 6/16/16 x 2, 6/18/16, 6/20/16 x 2, 6/21/16 x2, 6/22/16 x 2. Review of the nurse's notes for the dates listed above for the [MEDICATION NAME] administration revealed no documentation related to implementation of a non-pharmacological intervention prior to the [MEDICATION NAME] administration. During an interview on 6/23/16 at 4:38 PM with the Director of Nursing, after reviewing the resident's nurse's notes, he/she confirmed non-pharmacological interventions were sporadic and he/she would expect nurses to attempt a non-pharmacological intervention prior to the administration of an anti-anxiety medication. He/she stated there was no facility policy related to attempting a non-pharmacological intervention prior to administration of an as needed anti-anxiety medication. | 2020-04-01 |
| 2856 | PATEWOOD REHABILITATION & HEALTHCARE CENTER | 425305 | 2 GRIFFITH ROAD | GREENVILLE | SC | 29607 | 2019-08-09 | 600 | G | 1 | 1 | 0SKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended 01/07/2020 Based on record review and interview, the facility failed to prevent verbal abuse and neglect of Resident #27, 1 of 8 residents reviewed for abuse and/or neglect. Resident #27 made an allegation of verbal abuse and neglect from CNA (Certified Nursing Assistant) #1. Resident #27 waited 4 hours and 15 minutes for care, when the CNA finally responded to the resident a verbal altercation ensued and LPN (Licensed Practical Nurse) #4 asked CNA #1 to leave the room. The facility report indicated the facility substantiated neglect. Review of Resident #27's Social Service Progress Notes revealed the Resident stated that (s/he) is still shook up about it and that (s/he) is fearful that the CNA will try to harm (her/him). (S/he) stated that (s/he) stayed up all night worried that the CNA would come into (her/his) room and harm (her/him) or try to shoot (her/him) through (her/his) window. The findings included: Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #27's medical record revealed the Annual MDS (Minimum Data Set) dated 2/25/19 and the Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact for daily decision-making. On 08/08/19, review of the Initial 2/24-Hour Report dated 5/26/19 revealed Resident #27 made an allegation of verbal abuse and neglect from CNA #1. The facility's report indicated the incident occurred on 5/26/19 at 3:05 PM. Review of the Social Service Progress Notes revealed a note dated and timed 5/31/2019 at 08:50 AM Social Services followed up with resident about the incident on Sunday 5/26 with the CN[NAME] Resident stated that (s/he) is still shook up about it and that (s/he) is fearful that the CNA will try to harm (her/him). (S/he) stated that (s/he) stayed up all night worried that the CNA would come into (her/his) room and harm (her/him) or try to shoot (her/him) through (her/his) window. Review of a facility timeline attached to the Five-Day Follow-Up Report revealed the CNA came into Resident #27's room at 08:00 AM in response to the resident's call light and told the resident the staff was in the middle of passing out breakfast trays and that s/he would return. The aide returned at 10:45 AM and provided pericare and brief change but no AM care. The CNA told Resident #27 s/he would return in 2 hours. The resident called for assistance when the CNA failed to return in 2 hours and finally got a response at 3:00 PM. A verbal altercation ensued and LPN #4 asked CNA #1 to leave the room. The statement indicated the facility substantiated neglect. CNA #1's facility obtained statement dated 05/26/19 indicated at 03:05 s/he saw Resident #27's light on. S/he went in to change her/him and the resident was upset, yelling, cussing, and screaming, saying 4 CNAs walked past her/his room and ignored the call light. The statement indicated the CNA told the resident s/he had no control over the other aides but that s/he would change her/him. The resident was still yelling and s/he asked a second shift CNA to come into the residents room along with LPN #4. The statement indicated the CNA explained that s/he was busy with other residents and did not know the resident waited an hour for help. In a telephone interview on 08/08/19 at 02:14 PM, CNA #1 confirmed her/his statement was accurate. The CNA stated the resident was changed at approximately 08:45 in the morning. S/he further stated the resident was to have vital signs taken every 2 hours because she had been running a fever and that s/he changed Resident #27 every time s/he took her/his vital signs and stated that it was documented on the ADL sheet. Review of Resident #27's Physician order [REDACTED]. Further review of the Follow-Up Report revealed statements from other staff members who witnessed the altercation. LPN #4's statement dated 05/26/19 indicated Resident #27 was upset and crying; stated her/his light had been on a long time and no one answered it. The Resident reported CNA #1 hadn't checked on her/him between 7 AM and 11:00 AM when s/he was finally changed and she smelt (sic) like fish. (CNA #1) said Yeah, I know, because I washed you. The resident started raising her/his voice, and LPN #4 told CNA #1 to leave the room [ROOM NUMBER] times before s/he finally left, slamming the door behind her. CNA #2's statement dated 05/26/19 stated the first shift CNA asked for help to change Resident #27. The resident was complaining to LPN #4 about the first shift CN[NAME] CNA #1 and Resident #27 began yelling at each other. CNA #2's statement indicated Resident #27 said CNA #1 had only changed her/him at 8:00 AM. The statement also stated the CNA (#1) walked up to resident very angry and pointed (her/his) finger at resident. They were arguing back and forth. (LPN #4) asked CNA (#1) to leave the room. The CNA continued to argue on (her/his) way out and slammed the door. CNA #3's statement dated 05/26/19 indicated s/he went into the room and that the LPN and two CNAs were in the room. CNA #3 indicated s/he saw and heard Resident #27 complaining about the morning shift care from her/his CN[NAME] The resident said the call light was taken away from her/him by CNA #1 and s/he was not changed. Resident #27 said s/he saw CNA #1 walk by and not answer her/his call light and CNA #1 said s/he had to do care for another resident and everybody saw that call light and did not answer. The statement indicated CNA #1 and the resident were arguing about the resident's daily care. CNA #3 indicated the LPN asked CNA #1 to leave the room and CNA #1 continued to argue on her/his way out and slammed the resident's door. RN (Registered Nurse) #3's statement dated 05/26/19 indicated Resident #27 asked CNA #1 to change her/him at 8:00 am. The CNA said trays were there and s/he would return after trays were passed out. S/he returned at 10:45 am, changed Resident #27 and provided peri-care. The resident said her/his son stated there was an odor in the room when he and family arrived. The CNA left and said s/he would return in 2 hours. Resident #27 stated s/he turned her/his light on and it was on for 57 minutes before it was answered. When CNA #1 came in s/he told the resident s/he was on break and that s/he was in the room with another resident. CNA #1 and Resident #27 started hollering at each other. The statement further indicated Patient states (s/he) held (her/his) hand back as if (s/he) was going to hit (her/him) and that the CNA threw the diaper and brief on the bed and left the room, slamming the door. The CNA came back with LPN #4, CNA #2, and CNA #3. Another confrontation started between Resident #27 and CNA #1. | 2020-09-01 |
| 2857 | PATEWOOD REHABILITATION & HEALTHCARE CENTER | 425305 | 2 GRIFFITH ROAD | GREENVILLE | SC | 29607 | 2019-08-09 | 607 | G | 1 | 1 | 0SKP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended 01/07/2020 Based on review of facility files, interview and the facility policy tilted Reporting Abuse to State Agencies and Other Entities, the facility failed to implement written policies and procedures related to reporting an allegation of abuse for Resident #346, 1 of 8 residents reviewed for abuse. The findings included: The facility admitted Resident #346 on 05/24/19 with [DIAGNOSES REDACTED]. On 08/06/19 at 03:24 PM, review of the Initial 2/24-Hour Report revealed the facility was notified of Resident #346's spouse's allegation of neglect at 1430 (02:30 PM) on 05/25/19. Further review revealed the facility alleged the report was submitted to the State Agency on 05/25/19 but there was no confirmation that the facsimile was sent to the Agency. Review of the report received by the state agency revealed it was received on 05/25/19 at 05:19 PM and not within the required 2 hour reporting time frame. During an interview on 08/06/19 at 05:15 PM, the Nursing Home Administrator confirmed the report was not submitted timely to the State Agency and that the policy was not followed related to reporting. Review of the facility policy tilted Reporting Abuse to State Agencies and Other Entities revealed under Policy Statement All suspected violation and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Under Policy Interpretation and Implementation Should a suspected violation or substantiated incident of neglect violation or substantiated incident of neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; . Further review revealed Verbal/written notices to agencies will be made no later than two (2) hours if the allegation involves abuse or results in serious bodily injury . | 2020-09-01 |
| 3393 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2019-08-01 | 600 | G | 1 | 1 | V3M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended 2/7/2020 Based on review of facility files and interview, the facility failed to ensure residents were free from abuse. Certified Nursing Assistant (CNA) #1 verbally abused Resident #77 (1 of 1 residents reviewed for abuse). The findings included: The facility admitted resident #77 on 09/05/2018 with [DIAGNOSES REDACTED]. Review of the facility reported incident revealed that on 09/23/2018 at 12:30 PM it was witnessed that CNA #1 pointed his/her finger in Resident #77's face and was yelling. Review of the facility's Abuse/Neglect Prevention Protocol revealed that, Verbal abuse is the use of oral, written, or gestures language that includes disparing and derogatory terms to a resident During an interview with the Administrator on 07/30/2019 at 3:08 PM, s/he stated that the CNA had yelled at the resident but it did not constitute abuse and that is why there was no 2 hour report and they did a 24 hour report when the previous Director of Nursing was here, but they could not find the hard copy. The Administrator further stated the CNA was escorted out of the building and put on administrative leave, but s/he never came back for the meeting after the investigation. S/he agreed that the CNA violated their policy. | 2020-09-01 |
| 3394 | BROAD CREEK CARE CENTER | 425351 | 801 LEMON GRASS COURT | HILTON HEAD ISLAND | SC | 29928 | 2019-08-01 | 607 | G | 1 | 1 | V3M411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended 2/7/2020 Based on review of facility files, interview, and review of the facility's Abuse/Neglect Prevention Protocol, the facility failed to implement policies and procedures that prohibit and prevent abuse. Certified Nursing Assistant (CNA) #1 verbally abused Resident #77 (1 of 1 residents reviewed for abuse). The findings included: The facility admitted resident #77 on 09/05/2018 with [DIAGNOSES REDACTED]. Review of the facility reported incident revealed that on 09/23/2018 at 12:30 PM it was witnessed that CNA #1 pointed his/her finger in Resident #77's face and was yelling. Review of the facility's Abuse/Neglect Prevention Protocol revealed that, Verbal abuse is the use of oral, written, or gestures language that includes disparing and derogatory terms to a resident During an interview with the Administrator on 07/30/2019 at 3:08 PM, s/he stated that the CNA had yelled at the resident but it did not constitute abuse and that is why there was no 2 hour report and they did a 24 hour report when the previous Director of Nursing was here, but they could not find the hard copy. The Administrator further stated the CNA was escorted out of the building and put on administrative leave, but s/he never came back for the meeting after the investigation. S/he agreed that the CNA violated their policy and this was not reported this timely. | 2020-09-01 |
| 954 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 658 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on observations, record reviews and interviews the facility failed to assure that care and services were provided according to accepted standards of clinical practice for 1 of 5 residents reviewed for unnecessary medications. Resident #12 had two different physician orders [REDACTED]. An interview with the Director of Nursing (DON) revealed that the nursing staff providing care to Resident #12 failed to realize there were two different orders in place for finger stick blood sugar testing resulting in additional finger sticks. An interview with Licenses Practical Nurse (LPN) #3 revealed that s/he was aware that the orders were confusing but failed to report this to the DON. The findings included: Resident #12 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/08/20, at approximately 3:47 PM, a random medical record observation revealed that Resident #12 had two different physician orders [REDACTED]. On 1/8/20 at approximately 4:04 PM, LPN #3 stated that the orders were confusing and that he/she had been intending to report this to the DON (Director of Nursing) but had not done so. On 1/8/20 at approximately 4:37 PM, the Surveyor made the DON aware of the finger stick blood sugar testing concerns related to Resident #12. On 1/8/10 at approximately 5:20 PM, a review of physician's orders [REDACTED]. The first was an opened ended physician order [REDACTED]. Blood Sugar is less than [AGE], Call MD. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, Give 6 Units. If Blood Sugar is 301 to 350, Give 8 Units. If blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is greater than 400, call MD. Three times a Day; 07:30 AM, 11:30 PM, 05:30 PM. After reviewing Resident #12's medical record it revealed that Resident #12 was being tested ,[DATE] times daily for blood sugar levels. On 1/8/20 at approximately 5:40 PM, the DON stated that Resident #12 was being tested too frequently, and that the resident had been in and out of the hospital due to [MEDICAL CONDITION] and agreed to generate all physician orders [REDACTED]. On 1/8/20 at approximately 5:55 PM the DON stated that somewhere along the way three different nurses had failed to realize that there were two different orders in place for finger stick blood sugar testing and that the resident was definitely getting stuck to many times per day. On 1/8/20 at approximately 5:45 PM the DON (Director of Nursing) provided a report quantifying the number of unnecessary finger stick per day since October 2019 that had been performed on Resident # 12. There was a total of 121 extras finger sticks performed 10/20/19 through 1/8/20 and they occurred as follows: October 2019 = 11, November 2019 = 28, December 2019 = 61, January 2020 = 21. On 1/9/20 at approximately 10:15 AM, these numbers were confirmed by the DON. | 2020-09-01 |
| 952 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 623 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review and interview, the facility failed to give the resident and the resident representative in writing a notice of transfer in a language understood for 1 of 3 residents reviewed for hospitalization . Resident #78 admitted to hospital with no evidence of notice of transfer given to resident and resident representative. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Record review on 1/8/20 at 5:43 PM revealed the resident was transferred to the hospital on [DATE], 10/14/19, 10/23/19, [DATE], and 1/7/20. Further review of the medical record revealed there was no documentation the resident or the resident representative received a written notice of transfer. During an interview with the Director of Nursing on [DATE] at approximately 11:00 AM, s/he confirmed the transfer forms were not issued to the resident or the resident representative. | 2020-09-01 |
| 953 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 625 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review and interview, the facility failed to issue a bed hold notice to the resident representative upon discharge for 1 of 3 residents reviewed for hospitalization . Resident #78 admitted to hospital with no evidence a bed hold notice was issued. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Record review on 1/8/20 at 5:43 PM revealed the resident was transferred to the hospital on [DATE], 10/14/19, 10/23/19, [DATE], and 1/7/20. Further review of the medical record revealed there was no documentation the resident representative received a bed hold notice. During an interview with the Director of Nursing on [DATE] at approximately 11:00 AM, s/he stated a bed hold notice was not issued due to the resident being private pay. Review of the facility bed detail revealed all [AGE] beds were certified. | 2020-09-01 |
| 958 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 880 | D | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review, observation, interview, and review of facility policies titled Infection Control-Linen and Laundry, Infection Control Prevention and Control Activities, Infection Control-Linen and Laundry and information from ECOLAB, the facility failed to ensure infection control procedures were adhered to for one of one laundry observation and 2 of 2 handwashing observations. During observation of the laundry, staff was observed to carry a soiled gown close to his/her uniform, no separation between clean and soiled items in the personal laundry room. In addition, two observations were made of staff entering a soiled utility room and exiting without washing or sanitizing his/her hands. The findings included: During observation of the laundry on [DATE] at 8:30 AM, Laundry Staff #1 was observed after removing a soiled gown to hold it close to his/her uniform. Observation of the laundry for personal care items revealed one door entering into a small laundry room. To the right of the door soiled items and washers were observed. To the left of the door clean items and dryers were observed. Staff was observed entering the laundry with the soiled bin and clean, uncovered items were stored within 6 inches of the doorway. Measurements from the dirty laundry bin to the clean items was approximately 7 feet 2 inches. Due to the proximity and crowded area in the laundry, Laundry Staff were asked how did s/he manage to get clean items into the dryer. S/he stated the laundry racks were moved back. This placed the clean racks midway and very close to the soiled side of the room. In addition, Laundry Staff was observed to obtain the water temperature of the washer which was 125 degrees. S/he tested the pH of the linen and stated some days it is yellow and some days it is green. When Laundry Staff #1 was asked what the parameters for the water temperature and pH should be, s/he was unable to tell the surveyor. On [DATE] at 11:04 AM, after observing pressure ulcer treatment, Licensed Practical Nurse #1 washed his/her hands, entered the soiled utility room and placed items in receptacles. S/he exited the soiled utility room without evidence of washing or sanitizing his/her hands. During an interview with the Director of Nursing on [DATE] at 4:24 PM, s/he stated staff should wash or sanitize hands after placing items in the soiled utility. Review of the facility policy titled Infection Control-Linen and Laundry revealed the following under Section 2300- Water Supply, Hygiene, and Temperature Control-D. Hot water provided for washing linen and clothing shall not be less than one hundred sixty (1[AGE]) degrees Fahrenheit. Should chlorine additives or other chemicals that contribute to the margin of safety in disinfecting linen and clothing be a part of the washing cycle, the minimum hot water temperature shall not be less than one hundred ten(110) degrees Fahrenheit, provided hot air drying is used. Review of the Fabric pH indicator by ECOLAB revealed instructions for determining the pH from a range of 4-12+ with the number 7 and 8 circled. Written instructions states if color is green or yellow that indicates a good pH. Review of the facility policy titled Infection Control Prevention and Control Activities revealed the following under the Hand Washing section: 2. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Hands will be washed immediately after gloves are removed, between patient contact, equipment handling and when otherwise indicated to wash hands between tasks:. Review of the facility policy titled Infection Control-Linen and Laundry revealed the following: 5. Laundry Process a. Soiled laundry i. The soiled laundry area is to be clearly separate from the clean laundry area. Resident #62 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the pressure ulcer dressing change on 0[DATE]20 at 10:53 AM, Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) # 1 entered the resident's room and both washed hands and donned gloves. The RN #1 removed the soiled dressing, washed her hands with soap/water, and donned new gloves. The RN #1 measured the pressure ulcer 1.13 cm x 0.1 cm x 0.7 cm, then washed hands with soap/water. The LPN #1 washed hands and donned new gloves, cleaned wound with wound cleanser, washed hands with soap/water, and donned new gloves. The LPN #1 applied calcium alginate dressing to sacrum. The RN #1 and LPN # 1 pulled up Resident #62 in the bed, collected the trash and both washed their hands. The LPN #1 then took the trash down the hall to the soiled utility room, entered the soiled utility room and placed the trash in the bin. After leaving the soiled utility room, LPN # 1 did not wash hands with soap or water or appear to sanitize with an alcohol based rub. During an interview with the Director of Nursing on 0[DATE]20 AT 4:16 PM, the concerns about handwashing were mentioned and she confirmed that the LPN should have washed hands after placing trash in the soiled utility. A review of the facility policy titled Infection Control Prevention and Control Activities revealed that 1.) Hands should be washed often. 2.) Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Hands will be washed immediately after gloves are removed, between patient contact, equipment handling and when otherwise indicated to wash hands between tasks. | 2020-09-01 |
| 1775 | PRUITTHEALTH-MONCKS CORNER | 425140 | 505 SOUTH LIVE OAK DRIVE | MONCKS CORNER | SC | 29461 | 2017-10-05 | 282 | D | 1 | 0 | M91211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Base on observations, interviews and record review the facility staff failed to follow the care plan for falls for 1 of 10 residents reviewed for care plans. Resident #9 identified as being at risk for falls was noted with none of the care planned interventions in place. The findings included: The facility admitted Resident #9 with [DIAGNOSES REDACTED]. Review of the medical record revealed a Significant Change Minimum Data Set ((MDS) dated [DATE] that coded the resident as having a BIMS (Brief Interview for Mental Status) of 9. The resident was coded as having clear speech. S/he required extensive assist with one person assist with activities of daily living; s/he needed limited assist of one with walking in the room. A wheelchair was used for ambulation. An Annual MDS dated [DATE] coded the resident as having a BIMS of 8. S/he required limited assist with one person assist with activities of daily living and ambulation; a wheelchair was used by the resident. One to two falls were noted during the assessments, no injuries were described. Review of the resident's care plan reveled a care plan with a problem onset date of 03/25/2014 that identified a risk of falls related to psychoactive medication use, impaired mobility, a history of falls, [MEDICAL CONDITION] and dementia. Interventions included staff to assist with transfers, bed alarm on at HS (hour of sleep) 4/7/2016 chair alarm when out of bed (OOB) . Observation during the initial tour on 10/03/2017 at approximately 5:05 PM revealed Resident #9 was not in his/her bed. The surveyor knocked on the bathroom door and no response was noted, the surveyor asked the 300 Unit Manager to come to the resident's room. The Unit Manager found the resident in the bathroom and assisted him/her back to bed. The bed was noted with an alarm control attached to the bedrail, no alarm was noted in the resident's wheelchair. The Unit Manager was not aware if the resident was at risk for falls; two other licensed staff at the desk confirmed the resident was not a fall risk. After a review of the care plan the staff confirmed Resident #9 was at risk for falls. | 2020-09-01 |
| 728 | RIVERSIDE HEALTH AND REHAB | 425082 | 2375 BAKER HOSP BLVD | CHARLESTON | SC | 29405 | 2017-09-22 | 323 | E | 1 | 0 | MJSH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Observation, record reviews, interviews and review of the facility policy titled, Behavior Management, the facility failed to ensure a wander guard was in place at time of admission for Resident #174 with a history of wandering and exit seeking for 1 of 1 resident reviewed for Behaviors. The facility further failed to ensure safe use of a Hoya lift on the 200 Unit for 1 of 2 residents reviewed for Accidents. The facility additionally failed to ensure a door to electrical equipment was secure on the 200 Unit for 1 of 4 Units observed. The findings included: The facility admitted Resident #174 with [DIAGNOSES REDACTED]. Review on 9/20/2017 at approximately 11:37 AM of the Nurses Notes dated 3/28/2017 through 5/18/2017 states, Roams aimlessly, stands near exit doors and pushes. Goes to unit door and stands in doorway but does not leave. Resident is redirected out of other resident rooms, balls fist up at this nurse . Agitation and constantly trying to get out of the facility. Will wander into resident's rooms and stand by the exit doors. Will resist care at times and is hard to redirect. No interventions during that time were put in place to ensure exit seeking behaviors were reduced, prevented and monitored. Review on 9/20/2017 at approximately 11:45 AM of the physician's phone orders dated 4/9/2017 revealed an order to check wander guard function each shift and to check wander guard placement each shift. Further review on 9/20/2017 at approximately 11:55 AM revealed no other orders for a wander guard to be placed prior to 4/9/2017. During an interview on 9/20/2017 at approximately 1:35 PM with the Consultant MDS (Minimum Data Set) assessment coordinator he/she stated, I came in to help update the care plans on 5/18/2017. Resident #174 was in the hospital due to uncontrollable behaviors, and he/she was on bed hold. The Consultant MDS Coordinator went on to say that the physician had written an order for [REDACTED].#174 was exit seeking. The wander alarm was placed at the time of the order on 4/9/2017. The plan of care did not include the use of a wander guard. Review on 9/20/2017 at approximately 2:40 PM of the facility policy titled, Behavior Management, states, The staff will incorporate Behavior Management techniques to assist patients/residents in reaching and maintaining their highest practical physical and psychosocial well being. Behaviors are a form of communication: behavior management is an attempt to understand that communication and meet the needs of the patients/residents. Resident #217 was admitted on [DATE] with [DIAGNOSES REDACTED]. An observation on 09/19/2017 at 3:19 PM,Resident #217 was sitting in a Geri Chair in hallway directly in front of the Nurses Station on the 300 Unit. CNA #4 began setting up Resident #217 in the Hoyer lift and then began using the Hoyer Lift to lift Resident #217 from the Geri Chair. The Respiratory Therapist #1 was sitting at nurses's desk and got up from the desk and walked over to where Resident #217 was now sitting in the Hoyer Lift and was now hanging from the lift and was being pushed down the hallway. He/She was then transported down the hallway while he was sitting up in the Hoyer lift, his body was swaying back and forth as he was transported down the hallway to his room which was located at the end of the hallway. An interview with Respiratory Therapist #1 On 9/19/2017 at 3:51 PM and he/she said, I thought the CNA was just getting a weight on the resident and then was going to reposition him/her in the chair. As he/she got him out of the chair he had a bowel movement and then I went with her/him and continued down hall. He/She further said: The least little movement startles the resident. The CNA is supposed to have a spotter during transfers using the Hoyer Lift. Not saying this was the best course to take. An interview with the DON on 9/19/2017 at approximately 5:00 PM said she was aware of the incident and both employees had been educated and suspended. The DON said the use of the Hoyer Lift requires 2 people to transfer the resident and that the lift is not to be used to transfer a resident down the hallway. Review of The Resident Profile Orders states: 1) Order Category, A.D. L. (Activities of Daily Living), Start Date, 09/19/2017, Profile Description, Adaptive devices/special needs: low bed, wheel chair, Hoyer lift, 2) Order Category A.D.L. , Start Date, 09/19/2017, Profile Description, Transfer with assist of_2__. Review of the Record of In-service, Date: 9/1717, Time PM, Objectives of the In-Service: Hoyer Lift-2 person process-No using Hoyer lift without assistance. Review of the facility policy and procedure titled, Nursing Policies and Procedures, Subject: Mechanical Lifts General Guidelines, Procedure: .2. Mechanical lifts may be used for enhanced safety of patients, residents, and staff in situations including but not limited to: A. Lifting from floor. B. Bed to Chair transfer. C. Lateral Transfer. D. Toileting and bathing, E. Repositioning .3. Prior to initiating use of mechanical lift for a patient or resident: C. Determine how many caregivers are necessary to safely lift the patient or resident. In most cases and for safety a minimum of 2 caregivers is recommended. During initial tour on 09/18/2017 at 10:17 AM on the 200 unit, the door to the electrical room with a sign on it which states: Warning Electrical Hazards door is unlocked and opens upon pressing the handle down. On 09/18/2017 at 10:19 AM, Maintenance Employee #1 verified that the door opened when the handle was pressed down and was unlocked. He/She verified that the door comes open even after locking the door, the door handle when pressed down opens on multiple repeated attempts. He/She said that the door should be locked he is going to work on it. | 2020-09-01 |
| 2904 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 280 | E | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record Review and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) with responsibility for individual residents participated with the development and/ or revision of the care plan for 7 of 22 residents reviewed. Residents #13, #[AGE], #[AGE], #154, #36, #57. In addition Residents #154 and #57 identified with pressure ulcers failed to have their care plans reviewed and revised with interventions to prevent further skin breakdown and/or falls. Two of two residents reviewed for pressure ulcers. The facility also failed to implement interventions to prevent further skin tears and falls for Resident #158, 1 of 3 residents reviewed for accidents. A therapy evaluation was not done timely after a fall on 01/23/17 and no new interventions were implemented following a fall on 02/08/17. In addition, no interventions were implemented to prevent skin tears. The findings included: During Record Review the care plan meeting attendance form for Residents # 13 and # [AGE], the CNA's did not attend the care plan meeting, 09/19/2017 12:01:40 PM - Interview DON- The CNA's don't attend the care plan meetings, the nurses do. DON unaware that care plan meetings were to be attended by the CNA's, stated ,Our Administrator gets all those memo's and I don't so I don't know to implement them. During review of the medical records on 9/20/17, it was discovered Resident #[AGE] did not have a Certified Nursing Assistant (CNA) in attendance at the Care Plan meetings. An interview conducted on 9/20/17 at approximately 3:56 PM with the Director of Nursing stated that CNAs were not actually attending the care plan meetings. Review of the Care Plan attendance sign in sheets showed there was no place on the form for CNAs to sign. The facility admitted Resident #36 with [DIAGNOSES REDACTED]. Record review revealed the Care Plan Conference attendance form dated 7/13/17 included spaces for attendee signatures. Further review of the form revealed no signature of a Certified Nurse Aide (CNA) to indicated they were part of the Interdisciplinary Team that developed the care plan. On 9/20/17 the Director of Nursing reviewed the form and confirmed the finding. The facility admitted Resident #154 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes on 9/18/17 at 4:55pm revealed a new unstageable pressure area to the left lateral sacrum that measured 2 centimeters (cm) x 2cm x 0cm, and a new unstageable pressure area to the right lateral and lower sacrum that measured 5.5cm x 4cm x 0cm. Record review on 9/19/17 at 8:20am revealed physician's orders [REDACTED]. Review of the Comprehensive Care Plan on 9/20/17 at 10am revealed it had not been updated to address the pressure ulcers. There was an identified Problem/Need for Potential For/Alteration in Skin Integrity but there were no resident specific interventions regarding skin treatments, alternating pressure mattress, or wedge. Further review of the Care Plan revealed a Problem/Need for Alteration in Independent Mobility. Approaches included: Trunk restraint per order and fall mat in place per orders. During resident observations on 9/18/17 at 11:30pm, 1:40pm, and 3:15pm, on 9/19/17 at 12:36pm and 2:45pm, and on 9/20/17 at 8:30am there was no restraint in use and there was only one fall mat on the left side of the bed. Review of the Nursing Assistant Report Sheet on 9/20/17 at 2pm revealed no evidence of instruction for use of a wedge, fall mat, or bed/chair alarm. During an interview on 9/20/17 at 8:40am, Licensed Practical Nurse (LPN) #4 verified that Resident #154 only had one fall mat on the left side of the bed. S/he reviewed the Nursing Assistant Report Sheet used to guide the Certified Nursing Assistant's (CNA's) care and confirmed that it did not have instructions for the fall mat, turning wedge, or bed/chair alarm. S/he stated the information should be on the Nursing Assistant Report Sheet. The nurse was unaware who was responsible for updating the sheets. During an interview on 9/20/17 at 12:44pm, Registered Nurse (RN) #2, who assisted with completion of Minimum Data Set (MDS) Assessments and Care Plans, stated that if a resident had a fall mat at the bedside, then the Care Plan should list either 1 or 2 fall mats and include which side of the bed if only using 1 fall mat. S/he also verified that the Trunk Restraint should not be on the Care Plan. Review of the Care Plan Meeting attendance record on 9/20/17 at 10:15am revealed no evidence of CNA participation. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Review of Wound and Skin Reports on 9/19/17 at 3:13pm revealed an entry dated 8/14/17 for a left medial foot unstageable pressure ulcer that measured 1cm x 0.8cm x 0cm. Further review revealed an entry dated 9/13/17 that measured the pressure ulcer at 1.2cm x 0.8cm x 0cm. Record review on 9/19/17 at 3:45pm revealed physician's orders [REDACTED]. Review of the Comprehensive Care Plan on 9/19/17 at 4pm revealed a problem for Potential for/Alteration in Skin Integrity but the plan had not been updated to include the pressure ulcer identified on 8/14/17. Approaches did not include the resident specific interventions for the blue booties. Further review revealed no evidence of CNA participation in the Care Plan meeting on 7/25/17. During an interview on 9/20/17 at 12:44pm, Registered Nurse (RN) #2, who assisted with completion of Minimum Data Sets (MDS) Assessments and Care Plans, verified that the plan did not include the newly identified pressure ulcer or the blue booties. The facility admitted Resident #158 with [DIAGNOSES REDACTED]. Review of the medical record revealed the Admission Minimum Data Set ((MDS) dated [DATE] coded Resident #158 as having a BI[CONDITION] (Brief Interview for Mental Status) score of 8 indicating the resident had short-term and long-term memory problem with impaired cognitive skills for daily decision-making. On 09/18/17 at 3:59 PM, review of the care plan dated 08/03/16 revealed impaired skin integrity related to [MEDICAL CONDITION] on the right eye brow and forehead was also identified as a problem area. Interventions included skin evaluations per protocol, podiatry, Range of Motion, Turn and reposition, and bowel and bladder management per protocols and/or as needed. There were no interventions for prevention of skin tears. In addition, self-care deficit was identified as a problem area with interventions including, but not limited to, assist with transfers as needed. No other skin tear prevention interventions were in place. Further review of the care plan dated 08/03/16 revealed impaired mobility was identified as a problem area. The goal was listed to have no further falls and/or injury. Interventions and approaches included, but not limited to, PT (physical Therapy) and OT (Occupational Therapy) evaluation and treatment as needed. There were no dates listed when the interventions were added. Bed alarm and fall mat were not listed on the care plan. On 09/19/2017 at 11:17 AM, review of the cumulative orders revealed treatment orders for skin tears 1/11/17 (right shin), 1/23/17 (left forearm), 1/21/17 (right upper arm), 2/4/17 (right lower leg), 2/6/17 (right inner knee), 2/26/17 (right upper arm), 3/1/17 (right elbow), 3/14/17 (left hand), 3/31/17 (left lower leg), 4/5/17 (right great toe). Further review revealed leg protectors were ordered on [DATE] but were not listed on the care plan. Additional review of the orders revealed orders dated 12/22/16 for a span (fall) mat, bed alarm and Tab alarm and to be checked for function and placement every shift. During an interview on 09/20/2017 at 10:56 AM, the Director of Nursing (DON) declined to either confirm or deny that the slip resistant pad had not been added to the care plan. In addition, the DON stated s/he would have to investigate further to determine if the policy had been followed to re-assess the effectiveness of current interventions or adding/ changing interventions to prevent further falls and revise the care plan accordingly. No further information was provided by the facility at the time of exit. On 09/19/17, review of the 01/20/17 incident report indicated the immediate action was to place a slip resident pad to the chair, keep the call light within reach and the bed in the lowest position. On 02/08/17, the immediate action taken was documented as placing the resident in the bed with the bed alarm and fall mat. . | 2020-09-01 |
| 2902 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2017-09-20 | 225 | D | 1 | 1 | WB9011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record Review, Facility Policy and Interview, the facility failed to report an incident timely within the 2 hour time frame to the State Agency. The findings included: The facility admitted resident # [AGE] on November 26, 2010 with diagnoses, including but not limited to, Dementia with behavioral disturbances, history of falls, [MEDICAL CONDITION], Cognitive communication deficit, muscle weakness, oral dysphagia, Major [MEDICAL CONDITION], Anxiety disorder, other secondary [MEDICAL CONDITION], Primary generalized [MEDICAL CONDITION] and [MEDICAL CONDITION] not due to to a substance or known physiological condition. During review of the 24 hour Incident Report dated 05/11/2017, documentation showed that the date and time of the Reportable Incident was 05/03/2017. The 24 hour was dated 05/11/2017 and the 5- day follow up was dated 05/14/2017. The weekend nurse was requested by the resident's son on 05/03/2017 at approximately 5-6 PM to evaluate the resident's ring finger on the right hand. Upon assessment, the nurse discovered dried blood on the residents right hand with a dressing intact and the fourth digit was crooked and swollen. A communication form was placed in the Communication Book for the Physician. The Nurse Practioner ordered an x-ray on 05/06/2017 which was positive for a right hand fourth digit middle phalanx head and neck fracture. | 2020-09-01 |
| 2753 | CAPSTONE REHABILITATION AND HEALTHCARE | 425298 | 1850 CRESTVIEW ROAD | EASLEY | SC | 29642 | 2017-08-28 | 314 | G | 1 | 0 | 29HN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Record review and interview, the facility failed to implement interventions to prevent the development of a pressure ulcer for Resident #4 and inaccurately documented the status of a Stage IV pressure ulcer as a Stage II for Resident #3, 2 of 3 residents reviewed for pressure ulcers. The findings included: Resident #4 was admitted to the facility with [DIAGNOSES REDACTED]. Record review revealed the MDS (Minimal Data Set) coded Resident #4 as requiring extensive assistance to total dependence for all aspects of ADLs (Activities of Daily Living). Review of the Physicians Orders on 08/24/2017 revealed an order dated 06/08/17 for Sureprep to intact blister left outer heel q (every) shift until healed. Additional review revealed an order dated 06/20/17 for a [MEDICATION NAME] dressing to the left heel every Tuesday and Friday for an Unstageable ulcer and on 06/27/17 an order was received to apply [MED] 250 units per gram to eschar, cover with non-adherent pad and wrap with [MEDEQUIP]. On 08/24/17 at 12:17 PM, review of the care plan dated 06/12/17 revealed problem areas included, but were not limited to, Impaired Functional Mobility related to recent [MEDICAL CONDITION] dated 05/31/17. Interventions included assisting with ADLs, assisting with oral care, call light within reach and encourage resident to call for help as needed, PT (Physical Therapy) to evaluate and treat, remove staples in 14 days, and two 1/2 siderails up as needed for increased bed mobility. Further review revealed a care plan dated 06/09/17 for Potential/actual impairment of skin integrity including an intact blister to the left outer heel. Interventions included floating the heels initiated 06/08/17. There were no interventions to prevent pressure ulcers prior to 06/08/17. On 08/24/17 at 12:28 PM, review of the Evaluations revealed a Braden Scale completed 06/01/17 with a score of 14, indicating moderate risk of developing a pressure ulcer. No interventions were implemented to prevent the development of a pressure ulcer until 06/08/17 when the resident was noted to have a blister on her left heel. During an interview on 08/24/17, the Director of Nursing confirmed the care plan indicated that the intervention to float heels was initiated on 06/08/17 and that the resident was identified as being at risk on 06/01/17 per the Braden Scale. S/he also confirmed the onset date of the pressure ulcer was 06/08/17. The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Record review on 0[DATE] revealed Resident #3 had a Stage IV on the coccyx on 11/14/14. Review of the Weekly Pressure Ulcer log dated 08/17/17 indicated the resident had a Stage II on the coccyx with a date of onset 11/14/16. During an interview on 08/24/17, the Director of Nursing stated the documented onset date of 11/14/16 was an error and that it was the same wound that the resident had since 2014. The Director of Nursing and the wound nurse stated that the wound had the appearance of a Stage II wound when the wound nurse started in that role and that the previous documentation stated the wound was Stage II. The wound nurse stated that since the previous documentation indicated the wound was a Stage II, s/he had continued to document the wound as a Stage II. | 2020-09-01 |
| 4041 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 328 | D | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on an observation, interview and review of the facility policy titled, Medication Administration: Enteral Tubes, the facility failed to confirm placement of and flush a [MEDEQUIP] tube for Resident #178 prior to administering a medication via the tube. The facility further failed to ensure the correct tube feeding was infusing as ordered by the physician for Resident #178 for 1 of 1 resident observed with a [MEDEQUIP] tube. The findings included: The facility admitted Resident #178 with [DIAGNOSES REDACTED]. An observation on 9/7/2017 at approximately 11:45 AM, during wound care for Resident #178, Licensed Practical Nurse (LPN) #4 administered a pain medication via a [MEDEQUIP] tube without first checking for placement and flushing the [MEDEQUIP] tube with a physician ordered water flush. During an interview on 9/7/2017 at approximately 11:48 PM with LPN #4 it was verified that placement had not been checked and the water flush was not done for Resident #178 prior to administering a medication via a [MEDEQUIP] tube. Review on 9/7/2017 at approximately 1:48 PM of the facility policy titled, Medication Administration: Enteral Tubes, number 8 states, Enteral tubes will be flushed before administering medications with 15 mls (milliliters) of water, with 5 mls of water after each medication, and 15 mls at completion of the medication administration. Flushes may be changed due to physician's order. Under, Scope: Procedure & Key Points, number 5 states, Verify tube placement using the following procedures: Inject 15 - 20 cc's of air into the tube with the syringe and listen to stomach with stethoscope for distinct whooshing sound. Aspirate stomach contents with syringe. Observations made on all days of the survey revealed Resident #178 with a tube feeding of Glucerna 1.5 at 45 cc's infusing hourly with a water flush of 125 centimeters every 4 hours. Review on 9/8/2017 at approximately 5:28 PM of a physician's order for Resident #178 dated 7/31/2017 states, D/C (discontinue) Juven, Vitamin C, Zinc Sulfate. D/C current tube feeding and flush orders. [ENTITY]t [MEDICATION NAME] 1.5 at 50 cc's per hour x 20 hours and a 100 ml every four hour water flush. The [MEDICATION NAME] was not infusing via the [MEDEQUIP] tube as ordered by the physician. During an interview on 9/8/2017 at approximately 5:47 PM with the DON (Director of Nursing) confirmed that Glucerna was infusing and the physician's order for Resident #178 was changed on 7/31/2017 to [MEDICATION NAME] 1.5 to infuse at 50 cc's per hour. | 2020-09-01 |
| 5158 | MAGNOLIA PLACE - SPARTANBURG | 425175 | 8020 WHITE AVENUE | SPARTANBURG | SC | 29303 | 2016-04-21 | 514 | D | 1 | 0 | 77LK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and interview, the facility failed to maintain clinical records that were readily accessible and systematically organized for 1 of 9 residents reviewed. Resident #19 failed to have readily accessible documentation related to her/his change in condition and admission to the hospital on [DATE]. The findings included: Resident #19 was readmitted to the facility with [DIAGNOSES REDACTED]. A review of the clinical record for Resident #19 revealed a Clinical Progress Note written by Activities dated 4/11/16 at 11:38 AM that stated, Neighbor sent out to hospital on [DATE] . and was not a bed hold. Further review of the clinical record revealed a note by the nursing staff dated 4/4/16 at 3:23 PM that stated, Resident confused and agitated. Trying to get up, talking to people that are not there. Notified Nurse Practitioner . new TO (telephone order) rec'd (received) for ua (urinalysis) with c&s (culture and sensitivity). This review failed to show a rationale for why or when the resident was sent to the hospital on [DATE]. In an interview with the surveyor on 4/18/16 at approximately 3:00 PM the Director of Nursing (DON) was asked to provided additional information about Resident #19's hospital admission on 4/4/16. S/he stated that s/he had assessed the resident and found her/him to be confused, not at her/his baseline. S/he stated that Resident #19's husband was in the facility and agreed the was not her/his usual self. The Director of Nursing stated s/he would need to look for the SBAR and her/his note to the hospital. The information was found after the DON looked through several large stacks of resident information in her/his office. | 2019-04-01 |
| 1027 | MILLENNIUM POST ACUTE REHABILITATION | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2019-11-07 | 656 | D | 1 | 0 | QOW511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident interview, staff interview, and policy review, the facility failed to develop a comprehensive person-centered care plan for 1 of 1 sampled resident reviewed for a toileting program (Resident #8). The resident was assessed as incontinent for bowel and bladder but did not have an assessment completed to determine candidacy for bowel and bladder retraining. There was no care plan developed to address this need. The findings included: Review of the facility's Bowel and Bladder Assessment Policy, revised 5/2007 documented the following: Procedures: 1. Resident's care plan will be updated accordingly 2. Residents will be re-evaluated by the Interdisciplinary Team (IDT) quarterly and when a significant change occurs. Review of Resident #8's record revealed that the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) assessment for determining the resident's attention, orientation and ability to register and recall new information was conducted. The resident scored 15/15, indicating that the resident was cognitively intact. The resident was assessed as requiring extensive assist with bed mobility, transfers, dressing, toileting and personal hygiene with 1-person physical assist. The resident was also assessed as having occasional urinary incontinence and frequent bowel incontinence. Review of the resident's care plan dated, 10/14/19, revealed the resident was care planned for the following: ADL Self Care Performance Deficit related to Limited Mobility; Hypertension; Anticoagulant use related to history of [MEDICAL CONDITION] Embolism; Potential for Constipation and [DIAGNOSES REDACTED]. Further review revealed that there was no care plan for incontinence. Record review revealed that no bowl and bladder assessment was conducted from admission on 10/11/19 to current date. An interview with the resident was conducted on 11/7/19 at approximately 10:45 AM. The resident was pleasant upon approach and greeted this surveyor. The resident stated that she was doing fine and didn't have any concerns or issues. An interview was conducted with the Assistant Director of Nursing (ADON) on 11/7/19 at approximately 11:28 AM, who confirmed that a bowel and bladder assessment should have been completed based on the facility policy. An inquiry was made regarding a care plan for incontinence. The ADON went to get the MDS coordinator. An interview was conducted with the MDS Coordinator on 11/7/2019 at approximately 11:45 AM. The MDS Coordinator presented a care plan addressing a skin condition that included checking for incontinence; however, it did not address Resident #8's bowel or bladder incontinence. The MDS Coordinator explained that the care plan she provided had been deleted by another staff member when a skin issue for the resident had been resolved. | 2020-09-01 |
| 1028 | MILLENNIUM POST ACUTE REHABILITATION | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2019-11-07 | 690 | D | 1 | 0 | QOW511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, resident interview, staff interview, and policy review, the facility failed to ensure that a resident experiencing incontinence received appropriate assessment, treatment and services to prevent decline or to restore as much normal bladder function as possible for 1 of 1 sampled resident (Resident #8). The facility was unable to provide documentation that any type of restorative program was attempted and/or implemented. The findings included: Review of the Incontinence Managing Guidelines, Revised 11/2007 noted: All incontinent residents should be evaluated on admission and on condition change for potential incontinence management program Review of the facility's document titled Bowel and Bladder Assessment Policy, with a revision date of 5/2007 documented: It is the policy of this facility that a Bowel and Bladder assessment will be completed within the first fourteen (14) days of admission. Purpose: The purpose of the bowel and bladder assessment is to offer a structured, goal-oriented approach with the intent that the resident attains the highest level of independence in bowel and/or bladder continence. Procedures: 1. A bowel and bladder assessment will be completed by day fourteen (14). 2. Resident's care plan will be updated accordingly 3. Residents will be re-evaluated by the Interdisciplinary Team (IDT) quarterly and when a significant change occurs. Review of Resident #8's record revealed that the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #8 was assessed to have intact cognition. The resident was assessed to require extensive assistance with bed mobility, transfers, activities of daily living (ADLs), toileting and personal hygiene. The resident was also assessed as being occasional incontinent of urine and frequently incontinent of bowel. Review of the skilled nursing progress notes revealed that the resident utilized a brief for incontinence. Further review of the record revealed that Resident #8 utilized incontinence briefs at times; however, the resident was not care planned for incontinence or use of incontinent products. Progress notes 10/13/2019: Daily Skilled Note: GASTROINTESTINAL: Bowel Sounds are Present Bowel Sounds are Active, No GI changes observed. No GI appliance(s) used No nutritional deficits observed. [MEDICAL CONDITION] and RENAL: Urine is brief in place for incontinence. yellow, no odor. No GU changes observed. No GU appliances used. 10/16/2019: Daily Skilled Note: GASTROINTESTINAL: Bowel Sounds are Present Bowel Sounds are Active, No GI changes observed. No GI appliance(s) used, No nutritional deficits observed Nutritional approaches include Therapeutic diet. Other observations and interventions include not observed brief in place for incontinence. yellow, no odor. [MEDICAL CONDITION] and RENAL: Urine is not observed brief in place for incontinence. yellow, no odor. No GU changes observed. No GU appliances used. Review of the resident's care plan dated, 10/14/19, revealed there was no care plan developed for the resident's incontinence issues. Additional record review revealed the facility failed to complete a bowel and bladder assessment according to facility policy. An interview was conducted with the Assistant Director of Nursing (ADON) on 11/7/19 at approximately 11:28 AM., who confirmed that a bowel and bladder assessment should have been completed based on the facility policy. The ADON stated that the unit nurses are responsible for completing the assessments. An interview was conducted with the Director of Nursing (DON) on 11/7/19 at approximately 12:15 PM. The DON inquired about the issues regarding Resident #8. The DON was informed that since admission on 10/11/19, Resident #8 had not had a bowel and bladder assessment done within the 14 days as outlined on the facility policy; neither had an assessment been completed at all. The DON was informed that the resident had been assessed as incontinent of bowel and bladder on the MDS and had not been care planned. The DON was informed that the lack of an assessment prevented the facility from providing care and determining the resident's potential for bladder retraining. The DON expressed an understanding of the situation. | 2020-09-01 |
| 209 | WHITE OAK MANOR - SPARTANBURG | 425024 | 295 EAST PEARL STREET | SPARTANBURG | SC | 29303 | 2017-06-08 | 314 | D | 1 | 1 | FPCM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review and interview the facility failed to do skin assessment sheets or wound documentation for December 2016 and January 2017 for Resident # 16. ( 1 of 2 residents reviewed for pressure ulcers.) The findings included: The facility admitted Resident # 16 with [DIAGNOSES REDACTED]. In connection with a family concern related to possible skin breakdown, documentation for any previous skin breakdown and skin assessment sheets were looked for in the medical record. No documentation could be found. During an interview with the Nurse Consultant on 6/7/17 at 12 Noon, the consultant stated there were no sheets available for skin audits or wound assessments for December 2016 and January 2017. A Quality Assurance Problem was identified by the facility and corrective action plan put into place on 5/23/17. The family concern was identified in January, 2017. At that time the facility was not doing daily skin sheets or weekly wound documentation. The family member brought to the attention of the nurse on 12/22/16 an area of broken skin on Resident # 16's left heel. The nurse assessed the area, called the physician, and treatment started. The calloused area on the left heel had begun to break down but not completely. There was a circular area of red skin underneath. The physician ordered the skin to be left in tact, skin prep, and a border foam ordered for every other day. The area was documented as healed on 1/20/17. | 2020-09-01 |
| 4987 | BAYVIEW MANOR | 425067 | 11 TODD DRIVE | BEAUFORT | SC | 29901 | 2016-06-16 | 314 | G | 1 | 0 | XYM311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, record review, observation, staff interview, review of facility policy the facility failed to ensure that 2 residents (Residents #1 and #2) of 9 sample residents received the care and services necessary to promote healing and prevent the development of pressure ulcers. Specifically, the facility: -Failed to identify and implement measures to promote healing for existing pressure sores. - The facility failed to timely implement measures for preventing development of new pressure ulcers. -The facility ' s failures contributed to the delay in healing and worsening of the resident ' s pressure ulcers. The findings include: The facility Wound Care Policy (dated 10/2010) documents the purpose of this procedure is to provide information regarding the identification of pressure ulcers risk factors and interventions for specific risk factors. Item #6 documents the facility should have a system/procedure in place to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, ad family and addressed. 1. [AGE] year-old sample Resident #1 was originally admitted to the facility on [DATE]. The facesheet indicated Resident #1 s most recent admission from the hospital to facility was on 11/20/15. The resident was admitted for therapy treatment . A hospital physician discharge summary dated 11/20/15, indicated resident #1's primary [DIAGNOSES REDACTED]. Resident #1 was admitted to the facility for skilled therapy. RECORD REVIEW: MINIMUM DATA SET (MDS) According to the most recent MDS, dated [DATE], Resident #1 was totally dependent on staff for all activities of daily living (ADLs) and was non-ambulatory. The MDS indicated the resident refused care at times and had a catheter in place. Resident #1 had a stage 1 or higher pressure ulcer with three unstageable deep tissue injury pressure sores on admission. The MDS indicated Resident #1 had pressure ulcer on prior assessment and received therapy. CARE PLAN : On 11/20/15, an admission temporary pressure ulcer care plan was initiated. The temporary care plan indicated a problem of an unstageable sacral wound and DTI (deep tissue injury) to bilateral feet. The goals indicated pressure ulcer will decrease in size, monitor for incontinence, provide care if soiled, turn q 2 hrs, administer treatment as ordered, measure ulcer monitor depth, odor and drainage at least weekly. A care plan dated 11/26/15, indicated Resident #1 had a potential for skin breakdown related to (R/T) decreased mobility, although documentation indicated no healed pressure sores. The goals indicated skin would remain intact, although the Resident was admitted with pressure sores which were still present by 11/26/16. Interventions included admistration of medications, diet as ordered, labs were to be monitored. Although the resident was identified with multiple pressure sores, other than the temporary care plan, no care plan was updated for indication of the presence of actual pressure sores. No specific goals or approaches were set in regards to healing/worsening of actual pressure sore or prevention of development of more pressure sore. Instead, the care plan set goals and approaches for potential skin breakdown, for a resident with actual pressure sores. PHYSICIAN ORDERS: Admission Physician (MD) orders dated 11/20/15-11/30/15, indicated clean right (R) lateral calf with wound cleanser apply skin prep daily. Clean sacral wound with wound cleanser, apply Duoderm MWF. Clean the left (L) heel wound with wound cleanser apply skin prep daily. Clean (R) heel and lateral foot with wound cleanser apply skin prep daily. Admission skin assessment dated [DATE], indicated Resident #1 had a scab to the middle of his head, a bruising and an unstagable necrotic area measuring 6.5 cm to 8.5 cm to the sacral area. The assessment indicated multiple bruises to both arms, scabs, bruising were noted to the left foot and toes. The assessment indicated multiple bruises to the right leg, the right heel was red with bruising measuring 3.5cm x 6.0cm and multiple bruised right toes (middle and 3rd toes). A Wound Assessment Report dated 11/20/15, indicated Resident #1 was admitted with the following wounds: a. An unstageable sacral wound with slough/eschar. The wound had scant seranguineous drainage, and in length (L) 6.50 cm X width (W) 8.5 cm X depth (D) 0.0 cm. The wound had no infection. The wound bed had [MEDICATION NAME] tissue, granulation tissue, slough and eschar. The wound edges had well defined and normal healthy tissue. The physician was notified of the wound status. b. The Wound Assessment Report dated 11/20/15, further indicated a wound to the top of lateral (R) right foot , The measurements indicated were : (L) 1.50 cm X (W) 1.50 cm X (D) 0.0 cm. The wound had [MEDICATION NAME] tissue with granulation, and the surrounding skin was normal. The (R) lower extremity had normal color, normal temperature and was warm to touch. The skin had normal elasticity. c. On 11/20/15 the left heel was assessed with [REDACTED]. The measurements indicated were : (L) 14.50 cm X (W) 3.5 cm X (D) 0.0 cm. The wound had [MEDICATION NAME] tissue with granulation, and the surrounding skin was normal. The left lower extremity had normal color, normal temperature and was warm to touch. The skin had normal elasticity. Although, the resident had deep tissue injury to the left foot, the care plan indicated no floating of the injured foot. As indicated above, Resident #1 was admitted with multiple pressure sores and deep tissue injury, no specialized mattress was ordered, no documentation or care plan indicated floating of the left heel was initiated for Resident #1. There were no specific interventions in place for prevention of worsening of existing pressure sores or prevention of facility acquired pressure sores, as indicated by the Director of Nursing on 6/17/16, below. Nurse ' s notes dated 12/1/15, in pertinent parts indicated, Resident #1 had new blisters and bruising to the right lateral calf and low air loss mattress was initiated for the resident, after he acquired more skin breakdown. A Wound Assessment Report dated 12/1/15 revealed a nursing assessment of the resident ' s right shin. The Wound Assessment Report documented a new right lateral shin pressure ulcer identified on 12/1/15. The pressure ulcer was unstagable due to slough/eschar. The right shin wound measured 23.00 (L) x 10.00 (W) x 0.0 cm (D). Nurse ' s assessment furtherdescribed an area with multi color with a small area of eschar to the top of the wound (towards the knee) area with presence of fluid. The Wound Assessment Report indicated, the physician was notified and ordered a low air loss mattress, after the resident acquired the above pressure, 10 days, after he was admitted to the facility. Wound Assessment Report indicated resident refused to get out bed at times and wife was aware. However, a review of nurses documentation revealed the resident had no refusals for getting out of bed or refusals for wound treatment between 11/20/15 and 12/1/15. On12/1/15 Physician (MD) orders indicated, place Resident#1 on a low air loss mattress, after the Resident acquired a pressure sore to shin. Again, there was no indication the care plan was updated for indication Resident #1 had acquired skin breakdown to his shin on 12/1/15 or indication a low air loss mattress was initiated on that date, as ordered by the Physician. STAFF INTERVIEWS: Wound Care Nurse Interview: The Wound Care Registered Nurse (WCRN) was interview on 6/17/16 at 4:00 PM. In the interview with the WCRN, she confirmed the current care plan was inaccurate. The WCRN stated the care plan erroneously indicated care for potential skin breakdown, did not identify actual skin breakdown for a resident with actual skin breakdown. The WCRN stated she initiated the temporary care plan but did not initiate the care plan dated 11/26/15. The WCRN stated the skin issues she identified on the interim care plan should have been carried over onto the final care plan but they were not. The WCRN stated, she would have care planned each one of the wounds, then would have identified Resident #1 ' s risk for further skin breakdown related to his decreased mobility, incontinence and presence of multiple wounds. Director of Nursing (DON) interview: On 6/17/16 at 8:11 PM, the DON was interviewed. In the interview, the DON stated the facility regular mattresses were rated as pressure relief mattresses. The DON stated, in good judgment Resident #1 should have been placed on a low air loss mattress, as the specialized mattress was better for prevention of additional pressure sites and also easier for positioning and turn, created less friction therefore less risk of sheer for resident #1. The DON confirmed Resident #1 ' s assessment indicated Resident # 1 was a high risk for pressure sores as he was admitted with multiple pressure sores and should have been placed on a low air loss mattress on admission. The DON indicated clinical judgment would have been to place Resident #1 on a low air loss mattress on admission to the facility. The DON further confirmed, each one of the pressure wounds should have been identified on the care plan. The DON stated the care plan should have indicated the Resident was at risk for further skin breakdown related to his decreased mobility, incontinence and presence of multiple wounds. The DON confirmed the care plan should have identified the presence of actual pressure sores, goals and interventions for the actual skin breakdown. Within twelve days of admission, nurses notes indicated Resident #1 had acquired another pressure sore to his right shin and no specialized mattress had been initiated by that time, the facility failed to identify and intiate timely measures for prevention of further skin breakdown, for a resident who was admitted with unstageable skin breakdown. The facility failed to update care plan with proper care and prevention of pressure ulcers. 2. Resident #2 was admitted to the facility original admitted [DATE] with readmitted [DATE] with [DIAGNOSES REDACTED]. Annual MDS dated [DATE] Brief Interview Mental Status (BIMS) 11 coded for behaviors towards others; resident coded for total dependence on staff for all levels of care with 2+ person assistance; receives tube feeding, has limited functional range of motion of both upper and lower extremities; incontinent of bowel and bladder; at risk for pressure ulcers and falls. Quarterly MDS 3/9/16 BIMS 5, coded for resisting care 4 to 6 days; resident completely dependent on staff all activities of daily living (ADLs), impairment of both upper and lower extremities; incontinent of bowel and bladder; assessed as frequently having pain; no falls during the assessment period; at risk for pressure ulcers. Care Area Assessment summary dated 12/29/15 triggered for these care areas cognition, mood/depression, nutritional status/dehydration, communication, pain, ADL functions, pressure ulcers, falls, and [MEDICAL CONDITION] drugs. Care plans dated 12/4/15 with latest revision date of 6/15/16 revealed the resident problems included at risk for skin breakdown related to decreased mobility, fragile skin, incontinent B&B, [MEDICAL CONDITION] skin on back observe for skin breakdown, and report findings to MD, assess skin weekly and record findings; notify MD of any abnormal findings; turn and reposition during rounds and PRN; ensure staff places soft or cushioned nasal cannula on resident; treatment as ordered by MD; provide low air mattress and heel protectors to both heels per order. Review of the Unit ' s Weekly Summary Schedule documents the following instructions weekly summaries are to be completed on all Medicare A residents on assigned days. Complete body audits must be done. Weekly summaries will be checked by the unit manager. If weekly summary is not completed you will be called in to complete it. According to the schedule Resident #2 was scheduled for weekly summaries on Saturday 7p-7a shifts. A review of the weekly summaries obtained from the wound care nurse revealed summaries for the following dates 4/9, 4/16, 5/7, and 5/14/16. Each summary identifies Resident #2 had reddened areas on both ears from the nasal oxygen tubing. The facility was unable to provide any documentation related to assessing this resident ' s reddened areas on the ears after 5/14/16 weekly summary. Nurse ' s notes dated 6/9/16 at 7:00am document the CNA providing care noted an open area behind the left ear. Nurse cleaned and prepped area and covered with bandage. Responsible Party notified and obtained a physician order [REDACTED]. However the facility failed to complete a body audit sheet per facility policy when residents receive shower. MD orders 6/9/16 clean area behind ear with wound cleanser and bandage prn. Monitor area for signs and symptoms of infection every sift convert O2 mask until area healed. 6/15/16 9:45am -During initial tour resident was observed in bed positioned on back; HOB elevated 15 degrees with tube feeding infusing. O2 face mask positioned incorrectly on resident ' s face, not completely covering her mouth and nose, straps putting pressure on resident ' s ears; resident has open area on left ear. Bilateral hand contractures, not wearing splints. 6/15/16 4:45pm Remains positioned on back. Wedge cushion on floor behind the bed. HOB elevated 35 degrees; still no splints bilaterally. CNA checked resident for incontinence, adult diaper; wearing bilaterally heel protectors. CNA unaware if resident is supposed to wear hand protectors/splints and cannot explain why resident has floor mat at bedside. Oxygen mask placed improperly, CNA readjusted oxygen mask to completely cover face and adjusted straps to relieve pressure on ear. On 6/16/16 at 5:30pm in an interview RN#2 stated if weekly assessment and body audits were completed according to policy the issue of the resident ' s skin break down behind the ear should have been identified earlier. RN #2 states the weekly assessments and body audits reviewed and signed off by unit manager. At this time B wing does not have a unit manager and the issue of incomplete reports has not been addressed. The assessment and body audit sheets go to the WCN who review the sheets and assessment to determine if any residents identified with new break down areas. The WCN should have identified those areas on the resident ' s ears before it developed into an open area. The WCN is also responsible for maintaining those sheets for QA purposes. Interview with WC #1 on 6/16/16 at 7:00pm revealed the staff will send her note a when a resident develops an open area or requires wound care treatment. WC#1 was unaware that she was responsible for assessing residents with gastrostomy feedings. Asked the WC #1 who was responsible for the assessment and body audit sheets, WC#1 responded it was the responsibility of the unit manager. WC#1 stated she did not always review the body audit sheets and weekly summaries. WC#1 then admitted the sheets were maintained in her office but did not know why. Requested the WC#1 to bring the body audit and summaries for the past 8 weeks for Resident #2. The WC#1 provided body audit sheets for 4/30/16 and 5/3/16 (shows redness on resident ' s back and buttock). And weekly summaries for 4/9/16, 4/16/16, 5/7/17 and 5/14/16 which documents the resident with redness on the ears. The sheets were reviewed with the WC#1 confirmed the resident was identified with redness on the ears which was probably the beginning of skin breakdown. The WC#1 stated she had not seen the resident until this morning when the staff brought it to her attention about the resident ' s hands and the resident ' s ears. The facility failed to properly assess Resident #2 after it was identified starting on 4/9/16 to 5/7/16 the resident had reddened areas on the ears from the oxygen tubing. The facility failed to conduct body audits and weekly summaries to assess the resident ' s skin. It was documented on 6/9/16 that the resident had developed an open area behind the ear from the oxygen tubing. | 2019-06-01 |
| 3960 | THE RETREAT AT BRIGHTWATER | 425395 | 171 BRIGHTWATER DRIVE | MYRTLE BEACH | SC | 29579 | 2019-04-19 | 689 | J | 1 | 1 | LJH411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, staff interviews, and review of the facility's investigation, the facility failed to provide adequate supervision for 1 of 1 resident reviewed for elopement (Resident #45). The facility failed to assess elopement risk and implement interventions in a timely manner resulting in Resident #45 wandering out of the facility on three separate occasions (9/2/2018, 9/7/2018, and 9/17/2018). On 4/18/19 at 2:02 PM, the facility Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified related to Complaint SC 940 and cited at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 9/2/18 and is ongoing. The findings included: Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility assessed the resident on admission with a Brief Interview for Mental Status (BI[CONDITION]) score of 3 indicating severe cognitive impairment. Resident #45's Wandering/Elopement Risk Screening dated 8/21/2018 documented a score of 0 out of 0-9 with 9 being the highest risk. Record review revealed the 08/23/2018 nurses notes for Resident #45 documented that the resident was wandering in room and hallways and calling for his/her son/daughter. Acts of diversion and reorientation were used as requested by the son/daughter. No new wandering/elopement risk screening was performed, and no new interventions were added to the resident's care plan. Review of the 9/2/2018 nurses' notes revealed Resident #45 wandered outside at midnight stating that s/he was unsure of where s/he was. No new wandering/elopement risk screening was performed, and no new interventions were added to the resident's care plan. Review of Resident #45's nurses notes dated 9/7/2018 revealed Resident #45 wandered from the facility down the road and across the street. The facility courtesy officer went on a golf cart and brought the resident back to the facility. On 9/7/2018 after the elopement, Resident #45 was reassessed for wandering/elopement and scored a 4 out of 0-9 with 9 being the highest risk. On 9/7/2018 the facility placed a wanderguard on Resident #45 and updated Resident #45's care plan to reflect the new intervention. During an interview with the facility Administrator and Director of Nursing (DON) on 4/18/2019 at approximately 1:51 PM confirmed that education related to the incident was not performed or completed for all staff who work on the 400 and 500 units in the facility. The DON reviewed Resident #45's care plan intervention for a wanderguard device and confirmed that this intervention was not implemented until after the 9/7/2018 elopement incident. During record review of the incident logs since last Recertification Survey on 3/11/2018 and interview with the DON on 4/18/2019 at approximately 2:00 PM the DON stated that no residents have had any elopements since 9/7/2018; however, further review of the nurse's notes revealed another elopement by Resident #45 was documented on 9/17/2018. Resident #45 was found right outside the gates on the sidewalk. Resident #45 was brought back into the facility. There was no documentation that a new wandering/elopement assessment was performed and there were no new care plan interventions. The facility did not provide any further education to staff regarding elopement and wandering risks after the 9/17/2018 elopement incident. Resident #45 was discharged home with home health services on 9/19/2018 with his/her son/daughter. The facility submitted a Removal Plan dated 4/19/19 and accepted on 4/19/19 at 12:30 PM: - The resident no longer resides in our community. - All current residents will be assessed for elopement risk by RN (Registered Nurse) supervisors by 4/18/19. - All staff that work in the 400-500 halls will be in serviced on Signs of Elopement Risk and Review of Wondering, Unsafe Resident Policy Statement, will be in serviced by RN supervisor/designee. (Any staff not on duty will be in serviced at start of next shift), as well as all employees will receive an email regarding the Policy/Inservice on elopement 04/19/2019. New and readmitted residents will be assessed for elopement within 24 hours of admission/readmission. Residents will also be reassessed quarterly or as needed. If the resident triggers for a risk, the care plan will be updated as needed with new interventions. DON or designee will review chart of new admissions for elopement risk. - Random Audit of elopement risks will occur 3 times per week for 1 month then 1 time per week for 3 months until compliance is achieved. All audits will be reported to QA (Quality Assurance) committee. As part of verifying the facility Removal Plan, Facility staff interviews were conducted with 15 staff members on 4/19/2019 from approximately 2:30 PM through 3:00 PM by three different surveyors. During interview with a Certified Nursing Assistant (CNA) on 4/19/2019 at 2:52 PM, the CNA was asked when s/he was last trained on elopement/wandering. The CNA stated, I don't remember the exact date. It was a couple of weeks ago. The surveyor asked why s/he signed the sign in sheet attached to the training information. The CNA stated, because they told me to. The surveyor asked if s/he received any training before signing the form. The CNA stated, no, (s/he) didn't. (S/he) just signed it. The CNA stated, s/he usually does trainings from home but had not done any in a while. On 4/19/19 at approximately 3:45 PM the Administrator was notified that the facility Removal Plan was verified as not implemented based on staff interview regarding training and that the Immediate Jeopardy is ongoing. | 2020-09-01 |
| 3967 | THE RETREAT AT BRIGHTWATER | 425395 | 171 BRIGHTWATER DRIVE | MYRTLE BEACH | SC | 29579 | 2019-04-19 | 835 | J | 1 | 1 | LJH411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed record review, staff interviews, review of the facility's investigation, and review of the facility's policy titled Wandering, Unsafe Residents, the facility failed to be administered in a manner to prevent elopement for 1 of 1 resident reviewed for elopement (Resident #45). The facility failed to adequately assess wandering/elopement, implement interventions for elopement, and provide education to all staff on the 400 and 500 units to prevent further elopement by Resident #45. On 4/18/19 at 2:02 PM, the facility Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified related to Complaint SC 940 and cited at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on 9/2/18 and is ongoing. The findings included: Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #45 was admitted with a BI[CONDITION] (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment. Review of nurse's notes dated 8/21/2018 through 9/19/2018 revealed Resident #45 wandered out of the facility on 9/2/2018, 9/7/2018, and 9/17/2018. Review of Resident #45's care plan revealed it did not include new interventions after the elopement on 9/2/2018. Review of Resident #45's care plan after the 9/7/2018 elopement revealed a wanderguard device was added as an intervention. Review of the 9/17/2018 nurses' notes revealed Resident #45 was found outside of the facility and a wanderguard was placed. No new interventions were documented. During an interview with the facility Administrator on 04/17/2019 revealed s/he did not recall the incident on 9/7/2018. The Administrator stated s/he had been employed there approximately a week. S/he stated, we try so hard not to restrict residents' movement. During an interview with the Director of Nursing (DON) on 4/17/2019 confirmed documentation in the nurses notes of the elopement on 9/2/2018 with no new interventions. The DON stated they should have put a wanderguard on then. During an interview with Certified Nursing Assistant (CNA) #3 on 4/17/2019 at 6:20 PM regarding the 9/7/2018 elopement, s/he stated, I remember like it was yesterday. I saw someone outside wearing clothing that looked like (him/her). I ran. (S/he) said (his/her) knees were getting weak. The courtesy officer on the golf cart came and took (him/her) to Willows. (S/he) wanted to talk to (his/her) (son/daughter). We called (his/her) (son/daughter), got (his/her) vital signs. (S/he) said (s/he) wanted to go home and then we gave (him/her) some water. They put a wanderguard on (him/her) on the same night and reported to the next shift. We were to keep an eye on (him/her). During an interview with the DON on 4/18/2019 at approximately 2:00 PM, the DON stated that no residents have had any elopements since 9/7/2018; however, further review of the nurse's notes revealed another elopement by Resident #45 was documented on 09/17/2018, which was two days prior to Resident #45's discharge home with his/her son/daughter. Resident #45's care plan did not include any further updates after the 9/17/2018 elopement. Review of the facility policy titled Wandering, Unsafe Residents revealed under Policy Interpretation and Implementation 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. Resident care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. 5. When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall: .e. Complete and file an incident report; and f. Document relevant information in the resident's medical record. An incident report was not provided by the facility for the 9/2/2018 and the 9/17/2018 elopement incidents. Relevant information related to the incidents ( i.e., witness statements, supportive documentation in the medical record) was not provided to the State Agency. Facility Removal Plan dated 4/19/19 and accepted on 4/19/19 at 12:30 PM: - The resident no longer resides in our community. - All current residents will be assessed for elopement risk by RN (Registered Nurse) supervisors by 4/18/19. - All staff that work in the 400-500 halls will be in serviced on Signs of Elopement Risk and Review of Wondering, Unsafe Resident Policy Statement, will be in serviced by RN supervisor/designee. (Any staff not on duty will be in serviced at start of next shift), as well as all employees will receive an email regarding the Policy/Inservice on elopement 04/19/2019. New and readmitted residents will be assessed for elopement within 24 hours of admission/readmission. Residents will also be reassessed quarterly or as needed. If the resident triggers for a risk, the care plan will be updated as needed with new interventions. DON or designee will review chart of new admissions for elopement risk. - Random Audit of elopement risks will occur 3 times per week for 1 month then 1 time per week for 3 months until compliance is achieved. All audits will be reported to QA (Quality Assurance) committee. As part of verifying the facility Removal Plan, Facility staff interviews were conducted with 15 staff members on 4/19/2019 from approximately 2:30 PM through 3:00 PM by three different surveyors. During interview with a Certified Nursing Assistant (CNA) on 4/19/2019 at 2:52 PM, the CNA was asked when s/he was last trained on elopement/wandering. The CNA stated, I don't remember the exact date. It was a couple of weeks ago. The surveyor asked why s/he signed the sign in sheet attached to the training information. The CNA stated, because they told me to. The surveyor asked if s/he received any training before signing the form. The CNA stated, no, (s/he) didn't. (S/he) just signed it. The CNA stated, s/he usually does trainings from home but had not done any in a while. On 4/19/19 at approximately 3:45 PM the Administrator was notified that the facility Removal Plan was verified as not implemented based on staff interview regarding training and that the Immediate Jeopardy is ongoing. | 2020-09-01 |
| 1383 | CONWAY MANOR | 425121 | 3300 4TH AVENUE | CONWAY | SC | 29527 | 2018-06-27 | 609 | D | 1 | 0 | TMQR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility file review and interview, the facility failed to immediately report an incident of alleged abuse for 1 of 4 residents reviewed for abuse/neglect. Resident # 3 was allegedly struck by a staff member. The witness to the incident did not report the incident until the next day. The findings included: The facility admitted resident #3 on 1/29/17 with [DIAGNOSES REDACTED]. Review of the Facility investigation revealed on 5/16/18 at approximately 6:30 PM, resident #3 could not be found for dinner. Resident was found in another resident's room in another resident's bed. The Certified Nursing Assistant (CNA) and Activity Assistant (AA) attempted to get resident out of bed and walk her/him to the dining room. The resident was resistant and began to strike out at the CN[NAME] The Activities Assistant (AA) reported the resident was hitting out. The CNA, allegedly told the resident, if you hit me I'll hit you back. The CNA then reportedly hit the resident with open hand on the resident's arm and caused a small red area. The Activities Assistant left the room, leaving the resident and the CNA alone in the room. The AA did not report the alleged abuse until the next day, 5/17/18. 6/21/18 9:30 AM: Resident observed in the bed lying on right side, with bed covers pulled up to face. Resident dressed in street clothes. Right 1/2 rail elevated. Resident with eyes closed. Did not respond to knocking on door or calling resident's name. Review of the medical record revealed a Quarterly Minimum Data Set (MDS) of 3/23/18. Brief Interview for Mental Status (BIMS) was scored a 6 out of 15. No mood or behavior problems. S/he required supervision with most of her/his Activities of Daily Living, independent with eating, extensive assist with dressing and bathing, and limited assistance with hygiene. S/he was 64 inches tall and weighed 120 pounds. S/he received antipsychotic medications. physician progress notes [REDACTED]. Resident is unable to remember the events that took place due to a history of Dementia. S/he denies pain to the area. There is no visible bruising to resident's body at this time there is currently prescribed. [MEDICATION NAME] 0.5 mg twice a day. Resident can be found wandering the halls and into other resident's rooms at times. Assessment: Accidental hit or strike by another person, initial encounter. Further review of the medical record revealed Nurses Notes: 5/7/18: Up walking around unit until 3:00 AM. 5/17/18: Activity staff member reported that yesterday, 5/16/18 at approximately 6:30 PM, s/he and a cna were looking for resident. They located resident in another room in bed, says tried to encourage her/him out of bed with no success and so staff member stepped back- says CNA did manage to coax the resident out of bed and then tried to encourage her/him out of the room. At that point resident began striking out at CNA and did hit the CN[NAME] CNA told resident that s/he hit her/him so the CNA was going to hit the resident back, and the CNA did hit the resident. The staff member witnessed the CNA strike the resident with open hand on the right arm. Director of Nursing (DON) was notified immediately and Nurse Practitioner made aware. Body audit done on resident and nurse practitioner asked to assess resident. No new findings on body audit done today other than a small reddish area on right top hand approximately 0.5cm by 0.5 cm in size. No complaints or evidence of pain. Responsible Party (RP) made aware. 5/19/18. No bruising seen on right arm-small discoloration to top of right hand. 5/24/18 Resident wandering in and out of other residents rooms taking belongings of other residents, snatching belongings from other residents and staff. Resident took trash barrel and was pushing it. As soon as resident stopped pushing it aide went to move the barrel and resident slapped and pulled aides hair. Resident continued to swing. Nurses Notes through 6/19 continued to address resident's behaviors of going in and out of resident's rooms, taking belongings, digging through trash bins, swinging, aggressive, screaming, wearing other residents clothing, throwing other residents belongings. Resident behaviors continued with refusing to be bathed or changed. Activities Assistant statement dated 5/17/18 stated, Myself and (CNA #2) found resident in another res (residents) bed. We tried talking to her/him and getting her/him out the room. When that didn't work I then step out the way letting CNA handle getting resident out the bed and began try to remove her/him from the room. The resident then began to strike out hitting the CN[NAME] The CNA told the resident 'if you hit me ill hit you back' then hit resident on the right arm. The CNA then called for help from other CNA and nurses. On 6/20/18 at 12:35 PM, a face to face interview was conducted by the surveyor with the activity assistant. S/he stated, we were getting ready for dinner. We were looking for the resident. We found her/him in another resident's room in the bed. We went to get her/him up and the resident started hitting. The CNA told the resident if you hit me, I'll hit you back. The resident hit the CNA and the CNA open handed, hit the resident on the right arm. I removed myself, stepped out of the room- left the resident in the room with the CN[NAME] After I saw that I got scared. I reported it the next day. Policy is if I see it, I remove the resident from situation and report it immediately. I panicked, and I was scared. The facility obtained statement of the LPN #1 (Licensed Practical Nurse) dated 5/20/18, stated, I was on 600 hall, called to hall 500 to assist with resident. Resident noted to be agitated and hitting CNA attempting to redirect resident down call.(sic) Resident to dining room, refused to sit and eat, went to room for rest period. Noted to be lying on bed resting-then proceeded to dining room for meal. I didn't witness CNA strike resident or any indication of being struck. Other CNA employees in presence and did not report anything to me. Did see CNA shielding herself/himself and resident herself/himself from harm. On 6/20/18 at 2:27 PM LPN #1 (Licensed Practical Nurse) Nurse on duty at the time of incident with resident #3. I had no knowledge of anything until the next day. It is a secured unit. I heard the CNA calling me. When I got to him/her the CNA was walking with the resident down the hall. S/he didn't eat. So I took her/him back to the room and waited awhile and took her/him back and s/he ate. The AA never reported anything to me. I didn't know anything had happened. I was very upset that it was not reported immediately when it happened. Everything was normal. The two employees were around each other and acted no differently. They were coming down the hall with the resident. There was no indication that anything had happened. I questioned why the employee who was not a direct care staff in the room with a resident. I never got an answer. Review of the Activities Assistant employee file revealed the CNA received in service on Abuse on 3/28/18. S/he received additional counseling and training on reporting abuse and resident protection. | 2020-09-01 |
| 1233 | EDISTO POST ACUTE | 425116 | 575 STONEWALL JACKSON BOULEVARD | ORANGEBURG | SC | 29115 | 2019-04-18 | 610 | D | 1 | 1 | Y2KT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility files and interview, the facility failed to have evidence that all alleged violations were thoroughly investigated. The facility did not thoroughly investigate an injury of unknown origin for Resident #[AGE]5 and an allegation of mental abuse for Resident #[AGE]7 (2 of 6 residents reviewed for abuse). The findings included: The facility admitted Resident # [AGE]5 on 1[DATE]17 with [DIAGNOSES REDACTED]. Review of the facility files revealed that on 03/15/2019 the facility noted a discolored area on the resident's left upper thigh and facial grimacing when touch. The facility sent the resident to the emergency room for evaluation. In the facility file there was only four statements from staff. During an interview on 04/17/2019 at 4:00 PM, the Director of Nursing (DON) confirmed that only four statements were obtained during the investigation. The facility admitted Resident #[AGE]7 on 10/13/18 with [DIAGNOSES REDACTED]. During the investigation of a Facility-Reported Incident, review of the Five-Day Follow-Up Report revealed the incident occurred on 10/19/18 at 07:20 PM. Further review revealed a statement from the alleged perpetrator. No staff statements, other than the alleged perpetrator, were obtained by the facility. Review of the assignment sheet dated 10/19/18 revealed the alleged perpetrator was listed on the schedule from 3:00 PM until 11:00 PM on that date. The assignment sheet also showed another Certified Nursing Assistant was also listed and assigned to the same group. During an interview on 04/18/19 at 02:15 PM, the DON neither confirmed nor denied that the incident was not reported timely, was not thoroughly investigated, or the that the facility failed to follow their policy related to reporting and investigating. The facility's Abuse policy was reviewed during the recertification and complaint survey. Review of the policy Abuse Investigation and Reporting revealed Role of the Investigator: 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); f. Interview the resident's Attending Physician as needed to determine the resident' s current level of cognitive function and medical condition; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the resident's roommate, family members, and visitors; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident. During an interview on 04/18/19 at 02:15 PM, the DON neither confirmed nor denied that the incident was not reported timely, was not thoroughly investigated, or the that the facility failed to follow their policy related to investigating. During an interview at approximately 03:10 PM, the DON stated that she need to look further for any additional investigation. At approximately 4:00, the DON confirmed there was no additional information related to an investigation. | 2020-09-01 |
| 3435 | MAGNOLIA PLACE - GREENVILLE | 425361 | 35 SOUTHPOINT DRIVE | GREENVILLE | SC | 29607 | 2017-07-12 | 223 | D | 1 | 0 | OJU911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility files and interviews, the facility failed to protect 1 of 1 residents from verbal abuse. Resident #1 was involved in an altercation with a Certified Nursing Assistant (CNA), and was threatened with physical harm. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the facility reported investigation revealed the resident was involved in an altercation with a CN[NAME] The facility investigation revealed on 12/18/2016 at approximately 3:00 PM, the resident was cursed and yelled at by the CN[NAME] The CNA threatened to tie the resident's catheter around the resident's neck. Nurses Notes reviewed from 12/2/16 through 1/28/17: Resident was noted to be alert and oriented, cooperative with care and no behavior issues. There were no nurses' notes regarding the alleged incident of 12/18/16. On 7/10/17 at approximately 5:00 PM Licensed Practical Nurse (LPN) #1 was interviewed by the surveyor. The LPN stated s/he could not give the name of the CN[NAME] I do remember the resident and the CNA were arguing back and forth. The two of them were threatening each other. They were at the nurses' station. I do remember s/he (CNA) said she would wrap the foley around her/his (resident's) neck. I don't know how it started or what led up to that. On 7/10/17 at approximately 5:20 PM, LPN #2 was interviewed by the surveyor. I don't remember the CNA's name. I heard her/him say something about wrapping her/his foley around her/his neck or hurting her/him in some type of way. S/He had said something about not giving her/ him a proper bed bath or proper shower or something like that. Me and the staff went up and separated them 7/11/17 at 8:15 AM, Resident #1 was observed in bed with blanket pulled over her/his head. Resident was alert and oriented. The resident was interviewed by the surveyor. It was my shower day. Someone told her/him s/he didn't have any showers to give. S/he left me in my room in my bed. S/he refused to get me up and refused to give me a shower. The nurse, #3 gave me a shower. When I was going by the nurses' station, s/he was saying my name. I told her/him not to be using my name. S/he started cursing at me. S/he said, you can' t do anything, you can' t move. We exchanged words. Then s/he told me if I said one more word s/he was going to wrap my catheter around my neck There were witnesses. They moved me away from her/him . | 2020-09-01 |
| 1442 | INMAN HEALTHCARE | 425122 | 51 N MAIN ST | INMAN | SC | 29349 | 2018-08-01 | 568 | F | 1 | 0 | QNRI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility files reviewed and interviews, the facility did not provide quarterly statements to residents with facility maintained accounts for multiple residents. The findings included: The facility reported to the state agency an allegation of misappropriation on [DATE]. A visit was made to the facility to investigate the allegations. At the time of the investigation on [DATE] the facility did not have the investigation at the facility. During the Entrance Conference, the Administrator informed the surveyor, s/he had only been at the facility for approximately three (3) weeks and the Corporate Office handled the investigation. The Administrator was aware of the incident but did not know the specifics. The facility District Director of Business Office Services stated that 21 resident accounts were involved. Then stated there were 11 resident accounts affected. Their investigation showed only six residents with accounts affected were reimbursed and 5 residents were reimbursed for cash receipts. (Total of 11). One resident that deceased in 2016 had a cash receipt for $500.00, which was not posted to Accounts Receivable or to Resident Trust. The residents did not receive bank statements, confirmed by the Corporate District Director (one resident said for over a year). Interest was not applied to the residents reimbursed. Only residents that were able to say they had a problem were reimbursed by the facility/corporation. Residents did not receive quarterly Bank statements or statements when requested. At Approximately 12:30 PM on [DATE], the corporate representative, District Director of Business Office Services, was interviewed by the surveyor. We restructured in November of 2016, and I got these buildings. I provide support and training to Business Office Staff and audit annually and as needed per company policy. Every month the Business Office prepares a copy of all patient trust transactions, withdrawals, deposits, checks and it is sent to Houston, [STATE]-Sava Company that does general accounting. One auditor in the sister facility office noticed what appeared to be forged resident signatures with withdrawal slips. This happened in mid to late May. They sent me copies and I felt they were forged and came to facility and started an investigation. After I looked at the couple months of resident trust files, it appeared the same handwriting forged resident slips. We suspended the BOD pending a more thorough investigation. During the call I asked the BOD if s/he knew our policy on obtaining resident signatures. I asked if s/he ever forged resident signatures. S/he said no. S/he was able to walk me through what the process was. The process was- resident comes in, Business Office Director (BOD) would fill out a withdrawal slip for how much they wanted with name and date. The resident would sign withdrawal slip. If resident could not sign then two witnesses were required. The Administrator was the back up if the BOD was not here. There was a different administrator here at that time. 21 resident accounts were affected at this facility. 6 Patient Trust Accounts and 5 cash receipts. We looked at current in-house residents for Resident Trust Accounts. One (1) discharged resident was seen in the cash receipts. We looked at all cash receipts back to January. Reimbursements were made where resident said they never got money and who had excessive transactions. Reimbursed based on interviews and excessive transactions. The sister facility's cash receipts were $13,218 and in Patient Trust was $5,032. This facility had $15,640 in Patient Trust and $1,766.[AGE] in cash receipts were refunded. There was no dollar amounts on forged receipts. No outside agency has audited the accounts. We did an internal audit. The Business Office would key withdrawal slips into the system. It's transferred from Resident Trust account into Resident Trust checking account. The BOD would print the checks. The Administrator, Director of Nursing or Minimum Data Set Nurse would sign the check. The check would be taken to the bank. It should not be the BOD, but it was. It should have been anyone other than the BOD, or whoever signed the check. Some handwriting at the top of the withdrawal slip and the resident's signature were the same. On [DATE] at approximately 11:32 AM The District Director of Business Office Services (DDBOS) was again interviewed for some clarification. No, families have not been notified. Review of her/his investigation. Resident Trust identified with forged signatures was 15, $640.00 and the cash receipts were payments not applied to resident accounts, $1,766.[AGE] for a total of $17,406.[AGE], money unaccounted for. Total of 11 residents involved. One resident said s/he does receive money but had never been asked to sign for it. S/he denied residents were paid interest on their accounts. Residents did not receive quarterly statements. On [DATE] at 4:00 PM, the resident identified by the District Director was interviewed by the surveyor. No problem now. I did when ____ (BOD) was here. S/he was over the money. S/he wouldn't give you any accounting of your money. S/he wouldn't give you any update or how much money you had in your account. No, I did not get any bank statements for a very long time. I don't know exactly how long, I know it's been better than a year since I got a bank statement. Now they give you a receipt to sign when you get money. When you asked her/him for money s/he would say s/he would get it for you, but you never saw what you asked for. S/he was the one who kept track of it. S/he never said anything to me about my account. No, no one has talked to me about my account. Now, when you get money you sign for it. When s/he was here you couldn't get your money. | 2020-09-01 |
| 3547 | JOHNS ISLAND POST ACUTE | 425368 | 3647 MAYBANK HIGHWAY | JOHNS ISLAND | SC | 29455 | 2019-05-20 | 758 | D | 1 | 1 | WQ8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility policy review, observations, record reviews, and interviews the facility failed to ensure that one (Resident (R) 109) of five residents reviewed for unnecessary medications had adequate indications for use of an antipsychotic medication, [MEDICATION NAME]. Resident (R) 109 was receiving [MEDICATION NAME] without an adequate indication for its use. Findings include: Review of the facility's policy titled, Antipsychotic Medication Use, dated (MONTH) (YEAR), revealed Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Review of R109's undated Face Sheet, found in R109's electronic medical record (EMR) under the [DIAGNOSES REDACTED]. Review of a Physicians Order dated 10/10/18, found in the Orders section of the EMR indicated quetiapine [MEDICATION NAME] ([MEDICATION NAME]) give 1 tablet by mouth in the evening for depression, agitation. This was then discontinued on 10/24/18. Review of a Pharmacy Consultation Report dated 10/11/18, found in the closed thinned portion of the medical record indicated (Name of R109) receives an antipsychotic, quetiapine, but does not have a supporting indication for use documented. Physician's response: See Psych notes 10/24 to 11/2 with [DIAGNOSES REDACTED]. Review of a Psychiatric Evaluation dated 10/24/18, found in the closed thinned portion of the medical record indicated [DIAGNOSES REDACTED]. Recommendations: Continue medication(s) as prescribed, the patient is stable at current dose and/or needs more time to see beneficial effects. Dose reduction attempted and/or reduction will cause decompensation of patient. Review of a Physicians Order dated 01/02/19, found in the Orders section of the EMR indicated [MEDICATION NAME] give 100 mg (milligrams) by mouth at bedtime for [MEDICAL CONDITION] and MDD (major [MEDICAL CONDITION]). Review of a Physicians Order dated 01/14/19, found in the Orders section of the EMR indicated quetiapine [MEDICATION NAME] ([MEDICATION NAME]). Give 100 mg by mouth at bedtime related to unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. Review of a Physicians Order dated 02/18/19, found in the Orders section of the EMR indicated [MEDICATION NAME] tablet Give 25 mg by mouth in the morning related to unspecified mood (affective) disorder. Review of the undated Care Plan for [MEDICAL CONDITION] medications found in the Care Plan section of the EMR indicated, [MEDICAL CONDITION] medications. I have the potential for adverse side effects r/t (related to) use of [MEDICAL CONDITION] medications. I require an antipsychotic medication due to my Dx (diagnosis) of [MEDICAL CONDITION]. During an interview on 05/02/19 at 10:00 AM, when Licensed Practical Nurse (LPN) 7 was asked what is the resident receiving [MEDICATION NAME] for, LPN7 stated, S/he (referring to R109) is on [MEDICATION NAME] related to a [DIAGNOSES REDACTED]. During an interview on 05/02/19 at 10:05 AM, when Unit Manager (UM) 2 was asked what is the resident receiving [MEDICATION NAME] for, Unit Manager 2 stated, S/he is on 100 mg at night for [MEDICAL CONDITION] and s/he has severe [MEDICAL CONDITION]. During an interview on 05/02/19 at 11:23 AM, the Nurse Practitioner stated, I recommended the [MEDICATION NAME] because (s/he) (referring to R109) has a significant and long-term psychiatric history that was being treated even prior to when s/he was at another facility. S/he has a mood disorder and psychotic mood disorder and that is what it is used for. When the Nurse Reactionary was asked if this was an appropriate [DIAGNOSES REDACTED]. I usually put the reason for a medication in my psychiatric evaluations. I write the order for the diagnosis. I saw him/her on 10/24/18 and the [DIAGNOSES REDACTED]. The Nurse Reactionary then stated, When I put in a diagnosis, I use a Geri-med computer system and psychotic affective disorder is the same code as psychotic mood disorder. When the Nurse Reactionary was asked if unspecified [MEDICAL CONDITION] was an appropriate [DIAGNOSES REDACTED]. On my orders, I would not put [MEDICAL CONDITION] for an appropriate use. They (staff) may think the [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. That should be the final deciding factor. During an interview on 05/02/19 at 12:05 PM, Unit Manager 2 stated, It was initiated on (MONTH) 14, 2019 for the [MEDICATION NAME] and what I'm seeing is a [DIAGNOSES REDACTED]. That would be the order I go by related to unspecified [MEDICAL CONDITION]. When Unit Manager 2 was asked about the various other [DIAGNOSES REDACTED]. Then on 1/2/19 s/he was getting it for [MEDICAL CONDITION] and mood disorder. Then on 1/14/19 it was for unspecified [MEDICAL CONDITION]. I just think there is a lack of communication between the nurse practitioner. We didn't question it when it said unspecified [MEDICAL CONDITION]. I never thought to. During an interview on 05/02/19 at 12:43 PM, with the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), the DON stated, I'm not sure why you are seeing all the various diagnoses. The DON then stated, The hospital report indicated the [MEDICATION NAME] was given upon admission for agitation. S/he (R109) was getting [MEDICATION NAME] prior to coming here. The ADON then stated, the nurse practitioner would have been consulted and s/he had a psych consult and was seen by the nurse practitioner on 10/24/18. An attempt to contact the consultant pharmacist via phone on 05/02/19 at 1:20 PM was made. No return phone call was ever received. During a phone interview on 05/02/19 at 1:30 PM, the Medical Director was asked if a [DIAGNOSES REDACTED]. The Medical Director stated, No. But psychotic affective disorder that would mean that there is [MEDICAL CONDITION] and depression. Agitation is not really a diagnosis, it is a symptom of the psychotic depression or the unspecified affective disorder. Agitation should not be listed as a diagnosis. It can still be addressing the issue at hand which is a result of the [MEDICAL CONDITION]. It would be great if everyone wrote down that it was for the same thing. | 2020-09-01 |
| 4015 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2018-05-24 | 609 | E | 1 | 0 | V9CL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility records and interviews, the facility failed to report incidents of alleged abused and/or falls with serious injury timely for 2 of 3 reportable incidents reviewed. Resident #1, #2, #3 and #4 with allegations of abuse and fall with major injury were not reported to administration immediately. The findings included: In response to complaints and reportable incidents received by this office an investigation was conducted into the allegations. The facility admitted resident #1 with [DIAGNOSES REDACTED]. On 5/23/18 at 11:15 AM the resident was observed in wheel chair in room watching TV. The resident's call light was observed to be in reach and activated. Resident alert and pleasant, requesting to go to bathroom. Resident of small thin fragile appearance. Review of the medical record revealed a care plan for falls. Potential for fall related injury related to cognitive loss, dementia, medications that can alter alertness, history of falling with right clavicle fracture. Monitor for changes that may warrant increased supervision/assistance. Call bell within reach and answer promptly, alarms in bed and wheelchair, proper fitting shoes, assist with transfers, dycem to wheelchair. Falls care planned from 7/20/17. Updated 11/25/17, fall no injury, 12/17/17 No further falls, 2/12/18 fall with injury. Review of the Nurse's Notes revealed on 2/11/18: Resident reported to son/daughter that he/she fell in the garage and in the hallway. Son/Daughter stated resident had fallen in the garage at home, years ago. Resident complained (c/o) pain to right hip during the assessment. Resident pointed to right shoulder. Right shoulder observed with dark bluish discoloration with fading yellow. Resident reported pain with facial expressions, Pain scored at 2/10. [MED] 325 milligrams (mgs) one tab given. Doctor was notified. Order obtained for x-ray of the right shoulder, clavicle area to be completed on Monday, 2/12/18. 2/12/18: Doctor notified of x-ray results and noted fracture to right clavicle. S/he does not want the resident sent out. Responsible Party notified. Review of the x-ray report of 2/12/18. There is a [MEDICAL CONDITION] right clavicle. There is mild displacement of the distal fragment. Review of the facility's investigation revealed a SBAR (Situation-Background-Appearance- Review and Notify) dated for 2/7/18 for an unwitnessed fall Resident noted to be on floor in bathroom near wheelchair. Resident stated s/he was trying to use the bathroom and fell . No apparent injuries noted at present time. No bruising noted. No abnormalities noted to arm, shoulder, or back. Resident denies tenderness to right arm. Denies pain with ROM (range of motion). A hand-written note initialed by the Director of Health Care Services on the bottom of the page stated *Charting done on 2/12/18 for 2/7/18. The Director of Health Services (DHS) was interviewed by the surveyor on 5/23/18 at 12:21 PM. The DHS stated the nurse did not report to anyone that the resident had a fall on 2/7/18. We didn't know until we were investigating the injured shoulder. All of his/her documentation for 2/7/18 was actually done on 2/12/18. The resident had a fall on 2/7/18 which was not reported to administration, physician or family. On 2/11/18 the resident complained of pain and was found to have a dark blue discoloration of right shoulder. X-rays were ordered and on 2/12/18 the resident was found to have a fractured clavicle. The fall was not reported by the nurse, Licensed Practical Nurse (LPN) #1. During the investigation another reportable was reviewed, On 3/26/18 a Certified Nursing Assistant (#1) reported that on the night shift of 3/24/18 (early AM of 3/25/18) Licensed Practical Nurse (LPN) #2 had abused/neglected resident #2, #3, and #4. The nurse allegedly would not assist resident # 3 with constipation, resident #2 spilled tube feeding on the resident and would not clean the resident up, and resident #4 was left with dressings under the resident. The complaint was unsubstantiated. The allegations of abuse neglect were not reported immediately to administration. During the interview with the DHS, s/he stated s/he was not aware of the allegations until the morning of 3/26/18 when the CNA was called in regarding not wanting to work with a nurse. | 2020-09-01 |
| 4063 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 520 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on full and/or limited record reviews, interviews and review of the facility policies, it was determined on [DATE] at approximately 11:45 AM that Immediate Jeopardy existed at CFR4[AGE].[AGE] F-520 at a scope and severity level of (J) beginning on [DATE]. The facility failed to identify quality deficiencies related to 2 of 3 sampled residents reviewed for death in the facility for whom cardiopulmonary resuscitation (CPR) was not provided as required. The facility failed to implement a plan of action related to Advance Directives for and initiation of CPR. Failure of the Quality Assurance (QA) Committee to identify and implement action plans to ensure residents who exhibited absence of pulse and respirations received CPR when indicated and according to State Law resulted in Immediate Jeopardy for Residents #205 and #210. It was determined that Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). The findings included: Cross Refer to CFR 4[AGE].10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. Cross Refer to CFR 4[AGE].25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). Cross Refer CFR 4[AGE].[AGE] F-490 Administration was identified at a scope and severity level of (J). The facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation. The failure of the facility to ensure policies and procedures were established and implemented according to State law regarding Advanced Directives placed all residents at risk for serious harm/death. Based on observations made throughout the course of the standard and extended survey process and interviews, the facility failed to identify and implement appropriate plans of action to address issues that resulted in failure to comply with multiple regulatory guidelines that resulted in citations in multiple areas with negative impact on the quality of life or quality of care provided to those residents present in the facility for two of two nursing units. When asked on [DATE] at 8:00 PM if there were any current Quality Assurance action plans in place that addressed any of the numerous concerns identified by the survey team and shared during the survey process that the facility would like to have taken into consideration during the decision making meeting, the Administrator reported that there were areas that they had been addressing; however there were no specific Performance Improvement Plans in place and that what information was available was in the form of notes that s/he would endeavor to locate as soon as possible. There was no further information related to any current Performance Improvement Plans provided to the survey team to review and discuss through the end of both the standard and extended survey process which was concluded on [DATE]. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 12:40 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable and noted to be implemented on [DATE]. The Immediate Jeopardy at F-155, F-309, F-490, and F-520 was removed on [DATE] but the citations remained at a lowered scope and severity of D. The AOC included the following: (1) The residents with the alleged deficient practice are no longer residing in the facility. (2) The Director of Health Services will complete a review of all residents in the facility to ensure that do not resuscitate orders have been obtained per policy and state regulations. The Social Worker will also ensure where appropriate two physician signatures have been obtained. (3) All new residents ' code status will be included on the 24 hour chart check daily and then reviewed during the daily morning meeting for compliance. (4) The DNR policy is as follows: Prior to, or upon Admission, the patient/resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directives Checklist, which is in the South Carolina Admission Packet, will be completed. Should the patient/resident indicate on the Advance Directive Checklist that he/she has issued advanced directives about his/her treatment, the healthcare center will require that copies of such advance directives be given to the healthcare center for inclusion in the patient/resident's medical record. A copy of the advance directive shall become a permanent part of the patient/resident medical record. The Director of Health Services will notify the attending physician of advance directives and document such notification in the medical record. Should the patient/resident indicate on the Advance Directive Checklist that he/she does not currently have an advance directive, but would like further information on advance directives; the patient/resident shall be provided with legal forms located on the [STATE]'s Office on Aging website. If upon admission, or any time thereafter a patient/resident or his Representative requests a DNR order, the Social Worker/Case Mix Director or Director of Health Services shall be responsible for completing the process. If an adult patient/resident HAS decision making capacity, he/she may consent to an order not to resuscitate. If an adult patient/resident does not have decision making capacity and is a candidate for non- resuscitation and the attending physician may decide to withhold life-prolonging measures or discontinue life prolonging measures by initiating a without decision making capacity form and having a concurring physician signature along with the authorized person signature. All resident will be a full code until this procedure is complete (5) The facility Admission Director will review advance directive checklist with resident and or responsible party. If there resident is confused and BI[CONDITION] (Brief Interview for Mental Status) score is 9 or below, a decision making capacity form will be completed with two physician signatures. The BI[CONDITION] score will be completed on the day of admission for all new residents. (6) Social service was educated on the process for obtaining Advance Directive upon admission and change of condition per policy and by regulation, by the Regional Nurse Consultant. All future hires for the department will be trained during the orientation and all of the Social Workers in the facility will be reeducated annually with their evaluation. (7) The Regional Nurse Consultant has educated both physicians at the facility on the DNR and requirements for the second signature. (8) The Clinical Competency Coordinator will educate all of the licensed nursing personnel on the DNR orders and requirements for DNR orders to be valid before the start of their next work shift. | 2020-09-01 |
| 4056 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 490 | J | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on full and/or limited record reviews, interviews and review of the facility policies, the facility administration failed to ensure appropriate polices and procedures were developed and implemented to identify if Advanced Directives were formulated and proper care and services were provided related to cardiopulmonary resuscitation for 2 of 3 sampled residents reviewed for death in the facility. The failure of the facility to ensure policies and procedures were established and implemented according to State law regarding Advanced Directives placed all residents at risk for serious harm/death. CFR 4[AGE].[AGE] F-490 Administration was identified at a scope and severity level of (J). It was determined that Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide cardiopulmonary resuscitation (CPR). The facility failed to establish and implement policies and procedures consistent with State law regarding health care decisions/formulation of advance directives. The facility transferred decision-making responsibility to the legal representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. The findings included: Cross Refer to CFR 4[AGE].10(b)(4) F-155 Right to Formulate an Advance Directive was identified at a scope and severity level of (J). The facility transferred decision-making responsibility to the representatives of Residents #205 and #210 without two physicians' determinations of the residents' inability to make health care decisions. This failure resulted in staff not initiating cardiopulmonary resuscitation (CPR) as required. Cross Refer to CFR 4[AGE].25 F-309 Provision of Care and Services was identified at a scope and severity level of (J). The Immediate Jeopardy existed on [DATE] for Resident #205 and on [DATE] for Resident #210 when licensed nursing staff failed to provide the necessary care and services when the residents exhibited absence of vital signs and did not receive cardiopulmonary resuscitation (CPR). Cross Refer CFR 4[AGE].[AGE](o)(1) F-520 Quality Assurance was identified at a scope and severity level of (J). The facility failed to ensure the Quality Assurance process was utilized to identify, and implement a plan of action regarding adherence to legally executed Advanced Directives. The facility Administration failed to ensure appropriate policies and procedures were developed in accordance with State Law and implemented to identify and clarify Advance Directives, to ensure residents were provided appropriate services related to Advance Directives and provision of care consistent with those directives, and to ensure the Quality Assurance process was utilized to identify, clarify, and implement a plan of action related to such. The [STATE] Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act notes persons who may make health care decisions for a patient who is unable to consent in order of priority. SECTION [DATE]. Definitions states: (8) Unable to consent means unable to appreciate the nature and implications of the patient's condition and proposed health care, to make a reasoned decision concerning the proposed health care, or to communicate that decision in an unambiguous manner. A patient's inability to consent must be certified by two licensed physicians, each of whom has examined the patient. Review of the facility policy titled Do Not Resuscitate Policy: [STATE] and the [STATE] Code of Laws, TITLE 44. HEALTH, CHAPTER 66. Adult Health Care Consent Act revealed the policy was not in conformance with State law. The [DATE] policy stated: Definitions: 4. Decision Making Capacity.Every adult is presumed to have decision making capacity unless determined otherwise by a physician in writing.Procedure: I. Receiving a DNR Order from Another Healthcare Provider: A. Any written order issued by any attending physician using the term 'do not resuscitate', 'DNR',.or substantially similar language, and that is contained in the patient's medical record shall constitute a sufficient order.C. If an adult patient/resident does not have decision-making capacity and is a candidate for non-resuscitation a physician may issue a DNR with the consent of the patient/resident's representative. The facility Administrator was informed of the Immediate Jeopardy on [DATE] at 12:40 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable and noted to be implemented on [DATE]. The Immediate Jeopardy at F-155, F-309, F-490, and F-520 was removed on [DATE] but the citations remained at a lowered scope and severity of D. The AOC included the following: (1) The residents with the alleged deficient practice are no longer residing in the facility. (2) The Director of Health Services will complete a review of all residents in the facility to ensure that do not resuscitate orders have been obtained per policy and state regulations. The Social Worker will also ensure where appropriate two physician signatures have been obtained. (3) All new residents ' code status will be included on the 24 hour chart check daily and then reviewed during the daily morning meeting for compliance. (4) The DNR policy is as follows: Prior to, or upon Admission, the patient/resident and/or their responsible party will be asked about the existence of any advance directives. The Advance Directives Checklist, which is in the South Carolina Admission Packet, will be completed. Should the patient/resident indicate on the Advance Directive Checklist that he/she has issued advanced directives about his/her treatment, the healthcare center will require that copies of such advance directives be given to the healthcare center for inclusion in the patient/resident's medical record. A copy of the advance directive shall become a permanent part of the patient/resident medical record. The Director of Health Services will notify the attending physician of advance directives and document such notification in the medical record. Should the patient/resident indicate on the Advance Directive Checklist that he/she does not currently have an advance directive, but would like further information on advance directives; the patient/resident shall be provided with legal forms located on the [STATE]'s Office on Aging website. If upon admission, or any time thereafter a patient/resident or his Representative requests a DNR order, the Social Worker/Case Mix Director or Director of Health Services shall be responsible for completing the process. If an adult patient/resident HAS decision making capacity, he/she may consent to an order not to resuscitate. If an adult patient/resident does not have decision making capacity and is a candidate for non- resuscitation and the attending physician may decide to withhold life-prolonging measures or discontinue life prolonging measures by initiating a without decision making capacity form and having a concurring physician signature along with the authorized person signature. All resident will be a full code until this procedure is complete (5) The facility Admission Director will review advance directive checklist with resident and or responsible party. If there resident is confused and BI[CONDITION] (Brief Interview for Mental Status) score is 9 or below, a decision making capacity form will be completed with two physician signatures. The BI[CONDITION] score will be completed on the day of admission for all new residents. (6) Social service was educated on the process for obtaining Advance Directive upon admission and change of condition per policy and by regulation, by the Regional Nurse Consultant. All future hires for the department will be trained during the orientation and all of the Social Workers in the facility will be reeducated annually with their evaluation. (7) The Regional Nurse Consultant has educated both physicians at the facility on the DNR and requirements for the second signature. (8) The Clinical Competency Coordinator will educate all of the licensed nursing personnel on the DNR orders and requirements for DNR orders to be valid before the start of their next work shift. | 2020-09-01 |
| 2552 | HEARTLAND HEALTH AND REHABILITATION CARE CENTER-HA | 425289 | 1800 EAGLE LANDING BLVD | HANAHAN | SC | 29406 | 2018-04-14 | 584 | D | 1 | 1 | N9KR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on initial tour and subsequent observations, the facility failed to maintain a sanitary homelike environment for 3 of 3 nursing units. Furthermore the facility failed to create a clean and homelike environment for Resident #11 . The findings included: During environmental rounds with the Administrator and the Maintenance Director on 04/14/18 at 2:28 p.m. the following findings were confirmed from the initial tour on 04/09/18 and 04/10/18: 1. room [ROOM NUMBER] -Left panel of the sink's countertop was peeling away - Brown splatter under the light switch in the restroom -Paint peeling away where the railing is affixed to the wall in the restroom 2. room [ROOM NUMBER] - wall above Heating Ventilation and Air Conditioning unit in disrepair 3. room [ROOM NUMBER] B -Dried splatter on the foot board Observations on 4/10/18 at 3:30 PM and throughout 5 days of the survey revealed that Resident #11 had no personal items in his/her room and there were brown spots/fingerprints all over the hall wall next to the bed. During an interview on 4-13-18 at 12:06 PM, Licensed Practical Nurse (LPN) #2 checked the room wall and verified multiple areas of brown substance on the wall. Observation on 04/11/18 at 09:13 AM revealed that Resident #11's wheelchair frame had a heavy dust build up and dried spills on the sides. This was verified by the Activities Assistant who stated s/he would get someone to clean it. During the Resident Council Meeting on 4/11/18 at 2 PM, Resident #9 complained that staff never made his/her bed. When Resident Council members were asked if they got their beds made, 2 of the 7 active participants stated they had to make their own bed if they wanted it done. Three residents stated they never got their beds made. In addition, for 5 days of the survey, Resident #11's bed was only made up with sheets, no blanket or spread. During an interview on 4/13/18 at 5:30 PM, the Administrator verified that Resident #11's room was bare and the bed was not fully made. S/he also verified that Resident #9's bed was unmade. | 2020-09-01 |
| 1456 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 756 | D | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and medical record review, the facility failed to ensure that any irregularities in medication orders were identified by the pharmacist during monthly reviews. This irregularity should then be addressed by the attending physician/nurse practitioner and the Director of Nursing Services (DNS). This failed practice affected one resident (Resident #35) out of five residents reviewed for Unnecessary Medications. The findings include: Resident #35 was admitted to the facility 05/16/17 with [DIAGNOSES REDACTED]. A medical record review was done on Resident #35 for medications ordered and being administered to this resident. One of the physician orders [REDACTED]. Max dose 4 times in 24-hour period - notify provider if not effective. Diagnosis: [REDACTED]. The order was written by the Nurse Practitioner (NP) and verified by a Registered Nurse (RN) #100. The medical record indicated on the Medication Administration Record [REDACTED]. The reason was not charted on the MAR indicated [REDACTED]. An interview with the Director of Nursing Services (DNS) occurred on 01/13/20 at 3:19 PM concerning the way the order had been written. The DNS stated that she was surprised that the pharmacy had even filled it (the order) the way that it was written. The DNS further stated it was supposed to have a time frequency (such as, every 6 hours) and the federal regulation required that a stop date be entered on all psychoactive medication orders unless the physician documented a rationale for why there was no stop date. At 3:50 PM that same day, the DNS showed the surveyor a new order from the Nurse Practitioner discontinuing the order for [MEDICATION NAME]. An interview was conducted with the Consultant Pharmacist, (PharmD #115), on 01/13/20 at 4:28 PM concerning the order for [MEDICATION NAME] written for Resident #35 on 11/13/19. PharmD #115 was asked if the way this order for a psychoactive medication was written was okay. She stated, I must have missed it. She acknowledged that an order for [REDACTED]. | 2020-09-01 |
| 1457 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 758 | D | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and medical record review, the facility failed to ensure that physician's orders for a psychoactive medication ([MEDICATION NAME], an antianxiety medication) was written with a frequency for administration and a stop-date for the prescription, not to exceed 14-days. This affected one resident (Resident #35) out of five residents reviewed for Unnecessary Medications. The findings include: Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medical record review was done on Resident #35 for medications ordered and being administered to this resident. One of the physician orders observed was for [MEDICATION NAME] (an anti-anxiety medication), [MEDICATION NAME] - Schedule IV solution; 2 mg/mL (milligrams/milliliter; amt (amount): 1 mg; injection. Max dose 4 times in 24-hour period - notify provider if not effective. Diagnosis: [REDACTED]. The order was written by the Nurse Practitioner (NP) and verified by a Registered Nurse (RN #100). The medical record indicated on the Medication Administration Record [REDACTED]. The reason was not charted on the MAR indicated [REDACTED]. An interview with the Director of Nursing Services (DNS) occurred on 01/13/20 at 3:19 PM concerning the way the order had been written. The DNS stated that she was surprised that the pharmacy had even filled it (the order) the way that it was written. The DNS further stated it was supposed to have a time frequency (such as, every 6 hours) and the federal regulation required that a stop date be entered on all psychoactive medication orders unless the physician documented a rationale for why there was no stop date. At 3:50 PM that same day, the DNS showed the surveyor a new order from the Nurse Practitioner discontinuing the order for [MEDICATION NAME]. | 2020-09-01 |
| 1483 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2017-10-23 | 499 | D | 1 | 0 | M6T211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to employ qualified staff. Licensed [MEDICATION NAME] Nurse (LPN) #1 was hired before his/her criminal background check had been completed. The findings included: Review LPN #1's employee file on 10/23/17 at approximately 12:20 PM revealed LPN #1 was hired on 12/3/2003. The employee's criminal background check was completed on 12/11/2003 and revealed the following prior charges: assault and battery, possession of marijuana with intent to distribute, and harassment. Interview with Financial Coordinator on 10/23/17 at approximately 12:30 PM confirmed that LPN #1 was hired before completion of the criminal background check but after commencement of the criminal background check (12/1/2003). | 2020-09-01 |
| 2778 | RICHARD M CAMPBELL VETERANS NURSING HOME | 425301 | 4605 BELTON HIGHWAY | ANDERSON | SC | 29621 | 2018-04-19 | 607 | D | 1 | 1 | 2DMF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to ensure staff followed protocol for caring for difficult and combative residents. Certified Nursing Aide (CNA) #1 did not call for assistance or pause care when Resident #19 became combative, resulting in accidental or inadvertent physical contact for 1 of 1 resident reviewed for abuse. The findings included: Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Facility Investigation on 4/17/18 at approximately 10:21 AM revealed the Resident #19 was combative while CNA #1 was obtaining vitals. The CNA inappropriately touched the resident's face. The resident was assessed with [REDACTED]. At the completion of the investigation it was determined that CNA #1 inappropriately touched the resident and was dismissed. Review of Facility Interviews on 4/17/18 at approximately 11:47 AM revealed CNA #2 entered the room of Resident #19 to assist CNA #1. S/he observed the CNA to grab the nose of the resident when s/he became combative and then slap the resident as s/he continued to be obstreperous. Facility Interview of CNA #1 confirmed s/he slapped the resident accidentally. Interview with CNA #2 4/17/18 at approximately 4 PM confirmed that she entered the room of Resident #19 to assist CNA #1. S/he witnessed the CNA grab the resident's nose when s/he became combative. When the resident continued to fight the CNA, s/he slapped the resident. CNA #2 confirmed the resident appeared unharmed. She confirmed she had never had prior care concerns from CNA #1. Abuse prohibition interviews were conducted throughout 4/19/18 with nursing staff. There were no concerns. All CNAs stated that if handling an obstreperous resident they would ensure safety, withdraw, ask for assistance, and reapproach. Interview with Director of Nursing (DON) on 4/19/18 at approximately 4:20 PM revealed CNAs were expected to walk away and/or ask for assistance when providing care to obstreperous residents. Review of policy for Catastrophic Reactions on 4/19/18 at approximately 7 PM revealed staff is to Prevent escalation by backing off. If the resident does not present a danger to themselves or to others, observe them from a distance and allow them to settle down without intrusion before proceeding further. | 2020-09-01 |
| 3430 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2018-10-04 | 684 | D | 1 | 1 | 2F3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to follow physician's orders for 1 of 5 residents reviewed for unnecessary medications. Body mass index (BMI) for Resident # 40 was not taken as ordered by the physician. The findings included: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders for Resident # 40 on 10/2/18 at approximately 12:15 PM revealed the resident was ordered for [MEDICATION NAME] 5 mg twice a day and monitoring of BMI and waist circumference every 6 months if on an atypical antipsychotic. Review of vitals sheet on 10/2/18 at approximately 1:02 PM revealed missing BMIs. Interview with Registered Nurse #1 on 10/3/18 at approximately 10:02 AM confirmed the missing BMIs in the vitals sheet. S/he was unable to find documentation of BMI within the last 6 months. Interview with Registered Dietitian #1 on 10/3/18 at approximately 12:28 PM revealed the RD records the BMI in the body of the note but was unable to find a BMI within the last 6 months for Resident # 40. | 2020-09-01 |
| 2199 | CARLYLE SENIOR CARE OF FLORENCE | 425163 | 133 WEST CLARKE ROAD | FLORENCE | SC | 29501 | 2020-01-20 | 609 | D | 1 | 0 | 54411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to identify an allegation of potential staff to resident abuse for three of 15 sampled residents (Resident #3, Resident #5, and Resident #18) selected for review. The facility failed to ensure the allegation of potential abuse was reported to Administration in a timely manner and failed to notify the ombudsman of allegations of abuse. The failure to recognize abuse and immediately implement the facility's abuse prohibition policy had the potential to adversely affect all 68 residents residing in the facility. The findings included: Review of Resident #5's Electronic Medical Record (EMR) Admission Record, revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's EMR quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/18 specified the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of zero out of 15, which indicated severe cognitive impairment. The resident required extensive assistance for all Activities of Daily Living (ADLs). Review of Resident #5's EMR nursing Progress Notes dated 01/14/19 did not reveal Resident #5 reported an allegation of abuse. During an interview on [DATE] at 12:45 PM Resident #5 stated the staff were mean to him/her. Resident #5 stated he/she had been sodomized on 01/14/19 by two staff members while other staff members watched. He/she stated the incident was reported to the Administrator on 1/31/19. When asked why the incident was not reported immediately on 01/14/19, Resident #5 stated They already knew. It was them that sodomized me. A request was made on [DATE] at 1:30 PM to the Administrator for the staff to resident incident report that occurred on 01/14/19. Review of the facility's investigation record revealed the investigation into Resident #5's allegation of abuse was not initiated until 01/31/19 after the resident reported the allegation directly to the Administrator. Interviews of additional residents related to staff treatment could not be found in the investigation record. Staff interviews were conducted during the facility investigation and revealed Certified Nurse Aides (CNA) #2 CNA #16, Licensed Practical Nurse (LPN) #6, and the Social Services Director (SSD) were aware of Resident #5's allegation of being sodomized on 01/14/19 (16 days prior to the allegation being reported by the resident to the Administrator). No evidence could be found in the facility's investigation file to indicate the allegation had been reported by these staff members to administration. Review of LPN #6's statement, dated 01/31/19, indicated the resident stated, Get your finger out of my ass! The statement indicated Resident accused CNA of sodomizing (him/her). Review of CNA#16's statement, undated, indicated the resident was yelling, Help .I've been raped and sodomized. Review of a Grievance Form, completed by the SSD on 01/14/19, indicated the resident reported s/he was sodomized on 01/14/19. During the course of the investigation, multiple staff members, including CNA #2, CNA #17, CNA #16, LPN #6, the SSD, and the Administrator were accused of sodomizing Resident #5. Review of the facility's investigation revealed staff members identified in the allegation of abuse were not put on administrative leave during the course of the investigation. Further, the investigation did not include documentation that additional residents were interviewed as part of the investigation or the Ombudsman was notified of the allegation of abuse. Review of Resident #3's EMR Admission Record, revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #3's quarterly MDS assessment with an ARD of 09/22/19 revealed the resident had both short and long-term memory problems and required extensive assistance from staff to complete all ADLs. A request was made on 01/16/20 at 1:00 PM to the Administrator for the staff to resident investigation that involved Resident #3 and CNA #10 on [DATE]. Resident #3's family member alleged CNA #10 was rough with the resident during care on [DATE]. The facility's investigation did not include documentation that the Ombudsman was notified of the allegation of abuse. Review of Resident #18's EMR Admission Record, revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #18's (Re) Admission MDS assessment with an ARD of 12/31/19 specified the resident had both short and long-term memory problems and required extensive assistance from staff to complete all of his/her ADLs. A request was made on 01/16/20 at 1:00 PM to the Administrator for the staff to resident investigation that involved Resident #18 and CNA #9 on 12/25/19. Resident #18's family member alleged that on 12/25/19, CNA #9 was mean and aggressive with the resident during care. The facility's investigation did not include documentation that the Ombudsman was notified of the allegation of abuse. During interview on 01/17/20 at 3:30 PM, the Administrator/Facility Abuse Coordinator stated, allegations of abuse are to be reported immediately and all alleged perpetrators should be immediately put on administrative leave during the course of an investigation. All allegations are to be reported to the local ombudsman within the required timeframe. | 2020-09-01 |
| 3660 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2019-09-05 | 607 | D | 1 | 1 | 5P8P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to implement the facility Abuse Policy to protect 1 of 3 residents from physical abuse. Resident #146 was physically struck Companion #1, a contracted sitter by the facility, during routine AM care. The findings included: Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Incident Report dated 4/5/19 on 9/4/19 at approximately 3:06 PM revealed that Certified Nursing Assistant (CNA) #1 and Companion #1 were toileting and dressing Resident #146 at approximately 6:50 AM - 7 AM on 4/5/19. While Companion #1 was putting on the resident's slacks, s/he began to hit the companion. Companion #1 hit Resident #146's thigh with back of open hand. The incident was reported to Director of Nursing (DON), Resident Representative, Executive Director, Police, and Primary Care. Companion #1 was removed from assignment and will no longer be assigned to the facility. Review of CNA #1 statement on 9/4/19 at approximately 3:41 PM confirmed Companion #1, who worked for a contract company, struck Resident #146's thigh with the back of his/her hand. During an interview with CNA #1 on 9/5/19 at approximately 9:25 AM s/he confirmed that Companion #1 struck Resident #146. Resident #146 was unable to be interviewed by the surveyor due to poor cognition and a Brief Interview for Mental Status (BIMS) of 3. Review of Companion #1's facility obtained statement on 9/4/19 at approximately 3:33 PM revealed I (name of companion #1) was assisting (CNA) this morning with (name of resident) in the process of trying to get (him/her) dressed (s/he) was hitting both of us and refusing to let us get (him/her) dressed. While I was at (his/her) feet trying to put (his/her) pants on (s/he) hit me in my face and arm. CNA said (s/he) does that to us all the time. I started putting (his/her) leg in pants again and (s/he) tried to hit me again. And I popped (him/her) with my inside of my hand on (his/her) left thigh like I would my grandbaby to stop that During an interview with the Administered on 9/5/19 at 8:44 AM s/he stated that the contracted companion is to provide 1 on 1 attention, they do not give care to the resident they assist the CN[NAME] Review of the facility Abuse Policy on 9/5/19 at approximately 10:08 AM revealed Administration will protect residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. | 2020-09-01 |
| 403 | BLUE RIDGE IN GEORGETOWN | 425048 | 2715 SOUTH ISLAND ROAD | GEORGETOWN | SC | 29440 | 2018-11-17 | 600 | J | 1 | 0 | H6ZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to keep residents free from abuse and neglect. Two certified nursing assistants (CNAs), CNA #2 and #3, left their assigned residents unsupervised for approximately 30 minutes during an evacuation. 2 of 2 CNA's reviewed for assignments. The facility failed to protect residents from sexual abuse. Staff members observed sexually inappropriate behavior in a common area between residents #8 and #14. The facility failed to protect residents from verbal abuse. Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. 3 of 10 residents sampled for abuse. The findings included: Two certified nursing assistants (CNAs), CNA #2 and #3, left their assigned residents unsupervised for an hour during an evacuation. Review of the facility assignment sheet for 9/11/18 revealed CNA #2 was assigned 12 residents and CNA #3 was assigned 10 residents. Review of the facility investigation on 11/3/18 at approximately 9:50 AM revealed that CNA #2 and #3 left their assigned residents without permission on 9/11/18 at approximately 10 AM. During an interview with the Director of Nursing (DON) and Chief Operations Officer (COO) on 11/3/18 at approximately 11 AM. The DON and COO stated that CNA #2 and #3 left the facility without reporting to supervisors. Review of 9/11/18 time card reports on 11/3/18 at approximately 11:38 AM revealed CNA #2 clocked out at 10:05 AM and CNA #3 clocked out at 9:50 AM. During an interview with the DON on 11/16/18 at approximately 1:20 pm. The DON stated that the resident assignments were redone within 30 minutes of CNA #2 and #3 leaving. During an interview with the Human Resources Director on 11/3/18 at approximately 11:51 AM. The Human Resources Director confirmed interviews with the DON and COO and stated that resident care was affected because the facility was short-staffed during the evacuation. During an interview with CNA #2 on 11/3/18 at approximately 3:15 PM revealed both CNAs left the facility without arranging for care for residents. CNA #2 stated that s/he did not know who would look after the residents after s/he left. On 7/11/18 staff members observed sexually inappropriate behavior in a common area between residents #8 and #14. Resident #8 was observed to be holding resident #14's penis. Resident #14 had a history of [REDACTED]. The facility admitted resident #8 on 7/20/17 with [DIAGNOSES REDACTED]. Review of Resident #8's medical record revealed Nurse's Notes dated 7/11/18. The Nursed Note revealed Resident noted to be standing in front of resident (#14) holding resident's penis in her/his hand. Resident #14 was sitting in rollator walker. Floor nurse separated the two immediately. Resident's family and physician notified. Review of Resident #8's medical record revealed a Significant Change assessment dated [DATE]. The Significant Change Assessment revealed Long and short term memory impairment. Seldom understood or understands. Never rarely makes decisions. Wanders daily throughout facility. No sexual behaviors were listed for the Significant Change. During an interview with the Unit Manager on 11/16/18 at 12:05PM. The Unit Manager stated that Resident #8 initiated the incident on 7/11/18. The Unit Manager stated that Resident #8 likes to touch and rub on people. The facility admitted Resident #14 on 9/11/17 with [DIAGNOSES REDACTED]. Review of the Resident #14's medical record revealed in (MONTH) of (YEAR), the resident displayed inappropriate sexual behavior of touching a resident's breast. Resident #14's medical record revealed that throughout Resident #14's stay the resident demonstrated inappropriate sexual behaviors of exposing him/herself in public areas. Review of Resident #14's Nurses Notes from (MONTH) 1, (YEAR) through 11/16/18 revealed that Resident #14 noted to be alert and able to make needs known with some confusion noted. The Nurses Notes also revealed that Resident #14 continually takes pull ups off and refuses to wear pull ups or any underwear at times. Review of the Resident #14's Plan of Care dated 9/26/17 revealed, Inappropriate sexual behaviors, such as exposing self in common areas of facility, attempting inappropriate behaviors with female residents, inappropriate comments also noted and can be difficult to redirect. Review of Resident #14's medical record revealed a Psychiatric evaluation dated 9/26/17. BIMS (Brief Interview for Mental Status) - 6 (6 of 15). Due to Dementia, s/he is unable to provide reliable review of systems. S/he has behavioral episodes of resistance to care and unwillingness to participate in PT (Physical Therapy) program. Patient also has been observed with sexually inappropriate behaviors and poor boundaries. Has exposed self inappropriately and touched resident's breast. S/He has poor insight and memory regarding behaviors. During an interview with Licensed Practical Nurse (LPN) #2 on 11/16/18 at approximately 11:45 AM. LPN #2 stated that when Resident #14 first came to the facility the resident would make sexual remarks. LPN #2 also stated that Resident #14 liked for the CNAs to wash him/her. During an interview with the Unit Manager on 11/16/18 at 12:05PM. The Unit Manager stated that when Resident #14 first came to the facility s/he did not wear underwear, and his/her penis would fall out of his/her pants. Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. Review of the facility investigation on 11/3/18 at approximately 3:10 PM revealed that on 4/4/18 Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. Resident #1's roommate confirmed the CNA stating this. The facility investigation revealed that the facility substantiated the allegation and CNA #4 was terminated. During an interview with Resident #1's roommate on 11/3/18 at approximately 4:11 PM. Resident #1's roommate confirmed his/her statement that CNA #4 said s/he would put a bag over Resident #1's head who then started cursing him/her out. During an interview with CNA #4 on 11/4/18 at approximately 11:20 AM. CNA #4 stated that after s/he changed Resident #1 the Resident began cursing at him/her so s/he left and had another CNA care for the resident. CNA #4 denied stating s/he would put a bag over the resident's head. | 2020-09-01 |
| 3916 | THE ARBORETUM AT THE WOODLANDS | 425394 | 50 ARBORTEUM WAY | GREENVILLE | SC | 29617 | 2019-01-15 | 600 | G | 1 | 0 | DBL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to keep residents free from abuse for 1 of 3 residents reviewed for abuse. Certified Nursing Assistant (CNA) #1 verbally and physically abused Resident #1. The findings included: The facility reported an allegation of abuse to the State Agency for physical and verbal abuse of Resident #1 by CNA #1. Review of the facility's Five-Day Follow-Up Report dated 9/21/18 revealed the incident occurred on 9/19/18 between 5:31 AM and 6:00 AM. At approximately 6:11 AM Resident #1 reported to Licensed Practical Nurse (LPN) #1 that CNA #1 had slapped him/her and called him/her a name. Resident #1 was able to identify the CNA when given pictures of several staff members. Review of the facility's investigation revealed a statement by Resident #1 that indicated I got slapped. It was a (wo/man) and (s/he) slapped me in the left side of my face. (S/he) called me something it was not nice . Further review of the facility's investigation revealed a statement completed by the Director of Nursing (DON) on 9/20/18 related to witnessing Resident #1 provide a statement to the police related to the allegation of abuse. The statement indicated (Resident #1) was interviewed by two officers with this nurse present. (S/he) was presented with four pictures to which (s/he) stated No when pictures shown. Officers then brought in picture of accused and resident stated yes beyond a doubt. Resident stated that (CNA #1) called (him/her) a [***] and slapped (him/her) on the left side of my face. Review of the Incident/Accident Report dated 9/19/18 at 6:16 AM completed by LPN #1 revealed Resident #1 was at nursing station with this nurse when s/he stated (S/he) slapped me. After questioning s/he said that it was the girl/guy that got him/her dressed this morning. No injury/marks noted to face where resident showed staff where s/he was hit. Review of the Police Department Supplemental Report dated 9/19/18 revealed the officer was able to speak to Resident #1 and had him/her look at pictures of other females that cared for him/her. Resident #1 informed the officer that none of the pictures were of the person that assaulted him/her. The officer then showed Resident #1 a picture of CNA #1 and informed the resident that the person pictured also may not be the person that assaulted him/her. Resident #1 informed the officer that CNA #1 was the person that assaulted him/her. Interview with the DON on 1/15/19 at approximately 11:10 AM revealed Resident #1 still remembers the incident and talks about it. Resident #1 does not remember the CNA's name, but can still give the details of the incident. The DON stated there were no witnesses to the incident. The DON stated there are cameras in the common area but the videos are not maintained. They reviewed the footage at the time of the incident and noted CNA #1 entering and leaving the room within the same timeframe as when the resident stated the incident occurred. Interview with the DON and Unit Manager on 1/15/19 at approximately 11:20 AM revealed Resident #1 is usually alert and oriented with some confusion. Resident #1 will refuse care at times, it depends on his/her mood and is not a daily thing. Resident #1 is not combative, s/he will move a hand away or verbally decline. Resident #1 may use profanity at times. Staff is trained to walk away when the resident refuses care. CNA #1 was a night shift CNA and was normally assigned to Resident #1. Resident #1 reported the incident to the night nurse, LPN #1. LPN #1 reported the allegation to the DON and told CNA#1 to leave immediately. The DON stated s/he documented Resident #1's oral statement of the incident. They interviewed the resident twice and s/he told them the same thing twice as far as being slapped and called a name. Human Resources printed out pictures of staff who were at the facility at the time of the incident. The police got pictures of random different people to see if Resident #1 could identify the staff member who abused him/her. Resident #1 picked the same person both times. Resident #1 described the same events to the DON on initial interview and again with the police. On the video, you can see CNA #1 leave the resident's room and then Resident #1 come out immediately and go to the nurses' station. On 1/15/19 at approximately 12:25 PM the DON provided a written timeline that included what was observed on video footage at the time of the incident. CNA #1 entered Resident #1's room at 5:31 AM and closed the door. The CNA opened the door at 5:39 AM and got the resident up in the wheelchair at 5:55 AM. Brought resident out of room at 6:00 AM and the resident went to the nurses' station at 6:05 AM. Resident #1 spoke to LPN #1 at 6:11 AM. The DON stated CNA #1 left the door open during care and they could see the foot of the bed. That is how they know the time Resident #1 was up to the wheelchair. Resident #1 went to the nurses' station at 6:05 AM. Resident #1 reported the incident to LPN #1 when s/he came to the nurses' station. LPN #1 took CNA #1 to the therapy room to talk with him/her about the incident. | 2020-09-01 |
| 2869 | HERITAGE HEALTHCARE OF PICKENS | 425306 | 163 LOVE & CARE ROAD | SIX MILE | SC | 29682 | 2018-06-13 | 600 | D | 1 | 1 | 577J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to keep residents free from abuse for 1 of 3 residents reviewed for abuse. Resident #23 was abused by Registered Nurse (RN) #2 on at least two separate occasions. The findings included: Resident #23 was admitted to the facility 6/3/16 with [DIAGNOSES REDACTED]. Review of RN #3's statement on 6/12/18 at approximately 9 AM revealed that RN #3 witnessed RN #2 yelling at Resident #23 on 9/10/17. RN #2 was shouting that the resident had to wear incontinence briefs because there was no clean underwear. Resident #23 was yelling back at RN #2 that s/he did not want to wear a diaper. Review of statement of Certified Nursing Aide (CNA) #1 on 6/12/18 at approximately 9 AM revealed that on 9/10/17 between 4 and 5 PM, Resident #23 had wet her/his clothing. RN #2 told Resident #23 that only babies wet their clothes and that s/he needed to wear incontinence briefs. RN #2 was also trying to force Resident #23 to pick up her/his mess. CNA #1 stepped in to help followed by RN #3. Review of statement of CNA #2 on 6/12/18 at approximately 9 AM revealed RN #2 told Resident #23 to pick up his/her clothes and put on incontinence briefs. When CNA #3 entered, RN #2 had already left and Resident #23 was on the bed fussing and crying. CNA #2 immediately contacted the Activities Director, who also had good rapport with the resident. Review of Social Worker (SW) #1's statement on 6/12/18 at approximately 9 AM revealed that it was reported on 9/11/17 that Resident #23 had defecated on the floor and RN #2 had ordered her/him to clean it up. A visitor witnessed this. Review of the Visitor's statement on 6/12/18 at approximately 9 AM revealed that the Visitor heard RN #2 raising her/his voice and ordering Resdient #23 to pick up something. RN #2 told the resident, We're going to stand here 'til you pick it up. This went on a long time. Review of the Facility's investigation file of the abuse on 6/12/18 at approximately 9:16 AM revealed no 2-hour reportable. Review of RN #2's statement on 6/12/18 at approximately 9:20 AM revealed the following: 1. On Saturday (presumeably 9/9/17 but dated [DATE]) a staff member came to RN #2 stating that Resident #23 had defecated on the floor. RN #2 got a bag and said, We are going to clean this up. 2. On Sunday (presumeably 9/10/17 but dated 8/10/17) Resident #23 had peed on her/his clothing and was standing naked. RN #2 brought her/him to the room and retrieved incontinence briefs becaues there was no more clean underwear. The resident became agitated and RN #2 told the resident to pick up her/his dirty clothes to distract her/him. CNA #1 entered the room and RN #2 told her to leave because s/he was not helping and was only agitating the resident. Then RN #3 entered and tried to calm the resident. RN #2 left because the resident was upset with him/her about the incontinence briefs. Interview with SW #1 on 6/12/18 confirmed his/her statement and revealed that Resident #23 does not like to wear incontinence briefs because she/he views them as diapers and thus unsuitable for an adult. SW #1 also stated that RN #2 had not shown this kind of behavior in the past but stated, She's/hes from up north, so her/his tones and things are a lot different. They can appear rougher. Interview with the Visitor on 6/12/18 at approximately 9:53 AM confirmed his/her statement. Review of RN #2's personnel file on 6/12/18 at approximately 10:10 AM revealed there had been two prior disciplinary incidents but neither were related to abuse. Interview with RN #3 on 6/12/18 at approximately 10:42 AM confirmed his/her statement and also confirmed that the resident prefers underwear to incontinence briefs. RN #3 had not seen this type of behavior from RN #2 before the incident. Interview with CNA #2 on 6/12/18 at approximately 10:46 AM confirmed his/her statement and also confirmed that the resident prefers underwear to incontinence briefs. CNA #2 also stated that RN #2's up north tone and demeanor often seemed confrontational. Interview with CNA #1 on 6/12/18 at approximately 10:46 AM confirmed his/her statement. All observations of resident through the days of the survey revealed no concerns. The resident was calm and pleasant during all encounters. There were no signs of anxiety or agitation during any observed interaction. | 2020-09-01 |
| 3659 | ROSECREST REHABILITATION AND HEALTHCARE CENTER | 425376 | 200 FORTRESS DRIVE | INMAN | SC | 29349 | 2019-09-05 | 600 | D | 1 | 1 | 5P8P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to protect 1 of 3 residents from physical abuse. Resident #146 was physically struck by Companion #1, a contracted sitter by the facility, during routine AM care. The findings included: Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility Incident Report dated 4/5/19 on 9/4/19 at approximately 3:06 PM revealed that Certified Nursing Assistant (CNA) #1 and Companion #1 were toileting and dressing Resident #146 at approximately 6:50 AM - 7 AM on 4/5/19. While Companion #1 was putting on the resident's slacks, s/he began to hit the companion. Companion #1 hit Resident #146's thigh with back of open hand. The incident was reported to Director of Nursing (DON), Resident Representative, Executive Director, Police, and Primary Care. Companion #1 was removed from assignment and will no longer be assigned to the facility. Review of CNA #1 statement on 9/4/19 at approximately 3:41 PM confirmed Companion #1, who worked for a contract company, struck Resident #146's thigh with the back of his/her hand. During an interview with CNA #1 on 9/5/19 at approximately 9:25 AM s/he confirmed that Companion #1 struck Resident #146. Resident #146 was unable to be interviewed by the surveyor due to poor cognition and a Brief Interview for Mental Status (BIMS) of 3. Review of Companion #1's facility obtained statement on 9/4/19 at approximately 3:33 PM revealed I (name of companion #1) was assisting (CNA) this morning with (name of resident) in the process of trying to get (him/her) dressed (s/he) was hitting both of us and refusing to let us get (him/her) dressed. While I was at (his/her) feet trying to put (his/her) pants on (s/he) hit me in my face and arm. CNA said (s/he) does that to us all the time. I started putting (his/her) leg in pants again and (s/he) tried to hit me again. And I popped (him/her) with my inside of my hand on (his/her) left thigh like I would my grandbaby to stop that During an interview with the Administered on 9/5/19 at 8:44 AM s/he stated that the contracted companion is to provide 1 on 1 attention, they do not give care to the resident they assist the CN[NAME] | 2020-09-01 |
| 3429 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2018-10-04 | 623 | D | 1 | 1 | 2F3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to provide written notification of transfer/discharge for 1 of 2 residents reviewed for hospitalization . Resident # 39 was discharged to the hospital on [DATE] but the facility did not provide written notification to resident representative or send a copy of notification to the ombudsman. The findings included: Resident # 39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nursing notes on 10/2/18 at approximately 3:24 PM revealed the resident went out to the hospital on [DATE] to rule out aspiration pneumonia. No documentation that written notification was provided to the family was found in the resident's chart. Review of notification to ombudsman on 10/2/18 at approximately 4:10 PM revealed the ombudsman did not receive written notification of Resident # 39 transfer until 9/13/18. Interview with administrator on 10/2/18 at approximately 4:18 PM confirmed the ombudsman did not receive written notification until 9/13/18. Review of policy for notification of transfers to ombudsman and responsible party on 10/3/18 at approximately 9:19 AM revealed the following: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. | 2020-09-01 |
| 2889 | RIVER FALLS REHABILITATION AND HEALTHCARE CENTER | 425307 | 2906 GREER HWY | MARIETTA | SC | 29661 | 2019-07-17 | 608 | D | 1 | 1 | 55SY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to report a reasonable suspicion of a crime for 1 of 12 residents reviewed for abuse. Resident #24 made an allegation of abuse that was not reported to the police or state. The findings included: Resident #24 was admitted to the facility 6/5/19 with [DIAGNOSES REDACTED]. Interview with Resident #24 on 7/15/19 at approximately 10:15 AM revealed an unidentified Certified Nursing Assistant (CNA) was rough with the resident and bruised him/her. This occurred a week ago. S/he informed CNA #1. Interview with CNA #1 on 7/15/19 at approximately 10:27 AM revealed that s/he spoke with Resident #24 and noticed a bruise on his/her arm. The resident said a colored girl had yanked his/her arm around. The CNA was not sure if it had been reported. Interview with Administrator and Director of Nursing on 7/15/19 at approximately 10:33 AM revealed there had been no reports related to Resident #24. Interview with DON on 7/15/19 at approximately 3:43 PM s/he confirmed CNA #1 should have reported suspected abuse to the facility. Review of the facility Abuse Policy on 7/16/19 at approximately 2:05 PM revealed it is the responsibility of employees, facility consults, physicians, family, visitors, vendors or others to report any incident or suspected incident of neglect or resident abuse. | 2020-09-01 |
| 2892 | RIVER FALLS REHABILITATION AND HEALTHCARE CENTER | 425307 | 2906 GREER HWY | MARIETTA | SC | 29661 | 2019-07-17 | 641 | D | 1 | 1 | 55SY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility miscoded a Minimum Data Set (MDS) for 1 of 3 closed charts reviewed. Resident #384 was discharged to community but coded in MDS as acute hospitalization . The findings included: Resident #394 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of progress notes on 7/16/19 at approximately 3:49 PM revealed the resident was discharged home on[DATE] from his court hearing with the Department of Social Services. Interview with MDS Coordinator on 7/16/19 at approximately 4:04 PM revealed the MDS was coded in error and the resident should have been marked as discharge to community. | 2020-09-01 |
| 1373 | CONWAY MANOR | 425121 | 3300 4TH AVENUE | CONWAY | SC | 29527 | 2019-04-12 | 604 | G | 1 | 0 | 0Q9611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, and review of the facility's policy titled, Use of Restraints, the facility failed to safeguard residents from the use of physical restraints for 1 of 1 residents reviewed for physical restraints (Resident #24). The findings included: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's incident report revealed on 3/19/2019 between 6:15 and 7 PM Resident #24 was found in bed with both the blanket and bedsheets wrapped tightly around the side rails of the bed. During an interview with Certified Nursing Assistant #2 on 4/10/19 at 5:54 PM, s/he demonstrated to this surveyor how Resident #24 was found in bed. S/he stated Resident #24 was attempting to get up, which is usually a sign that s/he needed to be toileted; however, when entering the room, s/he noticed both the blanket and sheets were tightly wrapped around the siderails on the bed, which the resident was not physically capable of doing him/herself. During an interview with the Director of Nursing on 4/10/19 at 4:19 PM, s/he indicated s/he had a conversation with the responsible party that the resident reportedly tied themselves in the bed before while at home. During an interview on 4/11/19 at 9:52 AM, Licensed Practical Nurse #2, s/he confirmed the resident was restrained by both the sheets and blanket in the bed. Review of the facility's policy titled, Use of Restraints indicates practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: tucking sheets so tightly that a bed-bound resident cannot move. | 2020-09-01 |
| 3542 | JOHNS ISLAND POST ACUTE | 425368 | 3647 MAYBANK HIGHWAY | JOHNS ISLAND | SC | 29455 | 2019-05-20 | 600 | D | 1 | 1 | WQ8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, it was determined the facility failed to ensure that a resident was free from physical abuse. A resident, who required supervision due to aggression toward staff and other residents, was observed to have escalating behaviors, resulting in an altercation where Resident (R) 93 struck R 43 on 12/12/18. This deficient practice had the potential to affect two of 27 sampled residents reviewed. (Resident (R) 43 and R93). Findings include: Review of R93's Face Sheet in his/her paper chart revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment for R93, dated 10/19/18, documented a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Further review of the MDS did not indicate any behavioral symptoms. Review of R93's Care Plan revealed no behavioral problems had been identified or interventions initiated prior to 05/01/19. Review of R93's Interdisciplinary Team (IDT) Progress Notes in his Electronic Medical Record (EMR) revealed no documentation of altercations with other residents prior to 12/07/18. On 12/07/18 at 8:45 PM, an Incident Note in R93's EMR documented the resident was transferred from the[NAME]unit to the Angel Oak unit and placed on every 15-minute checks for three days. On 12/11/18 a Five Day Follow Up Report, provided by the facility's Administrator, documented R93 was the aggressor in a resident to resident altercation with his roommate on 12/7/18. The report documented R93 was moved to a different room, and his care plan was reviewed and revised. However, no revisions were documented on R93's care plan regarding the altercation, or the level of supervision required when R93 was in the proximity of other residents. On 12/10/18 at 7:40 PM, a Behavior Note in R93's EMR documented he had a verbal outburst with inappropriate language directed at staff, when they attempted to redirect the resident to remain in the[NAME]unit. On 12/12/18 at 7:53 PM, a Behavior Note in R93's EMR documented, Resident was wheeling self in (wheelchair) on unit. Wheeled into common area where other residents were gathered at a table. Resident engaged in a verbal exchange of angry words with two other residents (R60 and R43). Resident shouted at (R43) and told him/her to 'shut the hell up.' (R43) told this resident not to talk to him/her that way. This resident struck (R43) in the face with his/her hand. Staff immediately intervened . The note documented after the incident indicated a one to one attendant was placed with R93. On 04/29/19 at 2:45 PM, CNA9, who provided a written witness statement following the altercation between R43 and R93, stated s/he did not recall the specific event in question, but knew R93 could get agitated and aggressive towards others. CNA9 stated the agitation and aggression were rare, and usually redirectable by providing R93 with reading material, games, or conversation. An interview with R93 on 4/29/19 at 3:54 PM revealed s/he had no recollection of the event. On 4/30/19 at 4:13 PM, R43 stated s/he recalled the event. R43 chuckled and stated, I like (R93). We're still friends. I already told them I'm over it. S/he wasn't feeling good, and I stuck my nose in where it didn't belong. On 5/1/19 at 10:32 AM, the Social Worker (SW) stated s/he was aware of the altercation between R93 and R43, and that it was the second altercation R93 had within a week's time. The SW stated, prior to the 12/7/18 altercation R93 had with his/her roommate, s/he would not have considered R93 to be aggressive towards other residents. The SW stated, that after the 12/12/18 altercation, the facility placed one to one supervision with R93 pending a review of any medical factors which may have contributed to his/her behavior. The SW stated, R93's physician diagnosed and treated R93 with a Urinary Tract Infection [MEDICAL CONDITION], ordered a psychiatric evaluation, and made some medication adjustments. The SW stated, R93 continued with one to one supervision until the completion of his treatment for [REDACTED]. On 5/1/19 at 2:56 PM, the Administrator and Director of Nursing (DON) confirmed what the SW had reported earlier. The DON stated, that since R93's altercation with his/her roommate on 12/7/18 appeared to be related to some chaos that was occurring in the common area of the unit at that time, and R93 did not have a previous history of aggression towards other residents, there was no reason to adjust his care plan for the potential that he may become aggressive with another resident. The DON stated, that after the altercation with R43, it became apparent that the situation needed to be investigated further. The DON stated, the one to one attendant placed with R93 was able to identify that the resident was experiencing pain with urination. The DON stated, R93's physician ordered a urinalysis based on behavioral changes and painful urination, and it was discovered the resident had a UTI. The DON stated, one to one supervision continued until the facility determined the UTI had resolved, and no further aggressive behaviors were noted. This deficiency was cited based on complaint #SC 868. | 2020-09-01 |
| 300 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2017-05-11 | 278 | D | 1 | 1 | X7DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to accurately code the Minimum Data Set for 1 of 1 sampled resident reviewed for hospice. Resident #113 was not coded as having a terminal illness under J1400. The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. On 5-10-17 at 12:36 PM, review of hospice certifications for 10-26-16 and 1-2-17 noted that the resident's life expectancy was less than 6 months. Review of the 11/14/16 Annual and 2/13/17 Quarterly Minimum Data Sets on 5/10/17 at 10:30 AM revealed that item J1400 was coded as 0 indicating that the resident did not have a life expectancy of less than six months. During an interview on 05/11/2017 at 9:27 AM, Licensed Practical Nurse #3 and Registered Nurse #1 verified the life expectancy was not coded correctly. MDS staff were not aware that the information was located in the hospice book. | 2020-09-01 |
| 2897 | THE PLACE AT PEPPER HILL | 425308 | 3525 AUGUSTUS ROAD | AIKEN | SC | 29801 | 2018-04-23 | 604 | G | 1 | 0 | 62CH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure Resident #4 was free from restraints, for 1 of 3 facility reported incidents reviewed. The findings included: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/20/18, an incident occurred with Resident #4 and the Certified Nursing Aide (CNA) assigned to care for him/her that evening. Cross refer to F0[AGE]0. Resident #4 had a routine per CNA #2 and Licensed Practical Nurse (LPN) #1, to propel her/himself up and down the hallway, using the handrails for momentum until the hours of 2:00 a.m., before going to bed. Based on an interview with LPN #1 on 04/20/18, Resident #4 was in the solarium with CNA#1 and her/his wheelchair brakes were noted to be in the locked position. Per LPN #1, Resident #4 was not capable of locking/unlocking the brakes of her/his wheelchair. This information was consistent with the noted Activities of Daily Living (ADL) functionality indicated on the Minimum Data Set assessment dated , 01/23/18, indicated the resident required extensive assistance for most ADLs - bathing, dressing, grooming and total dependence for eating. LPN #1 instructed the aide to unlock the resident's chair and assist her/him to the restroom. During an interview with the Director of Nursing (DON), s/he stated the resident did not have any restraints in place and therefore would have no restraint assessments. | 2020-09-01 |
| 945 | POINSETT REHABILITATION AND HEALTHCARE CENTER | 425102 | 8 NORTH TEXAS AVENUE | GREENVILLE | SC | 29611 | 2017-11-20 | 223 | D | 1 | 0 | ZQI511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure resident freedom from involuntary seclusion for 1 of 3 residents reviewed for seclusion. Resident #2 was involuntarily secluded in his/her room by Certified Nursing Assistant (CNA) #2 on 6/24/17. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:40 PM revealed the Risk Manager messaged the Greenville County Sheriff explaining that Resident #2 was involuntarily secluded by CNA #2 who was suspended. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:50 PM revealed that CNA #4 went to Resident #2's room several times because the call light was on and found each time that CNA #2 had blocked the door with the chair. S/he walked by the door once more and heard the doorknob turning. Believing that Resident #2 was trying to leave his/her room, CNA #4 informed the nurse. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 4:55 PM revealed that CNA #3 did not see anything, but heard knocking on the door of Resident #2's room. S/he believed it sounded like someone trying to leave the room. Review of facility investigation of involuntary seclusion on 11/19/17 at approximately 5 PM revealed that CNA #4 reported to Licensed [MEDICATION NAME] Nurse (LPN) #2 that Resident #2 was being confined to his/her room by CNA #2. LPN #2 forced open the door to find CNA #2 sitting in chair in front of door. LPN #2 explained that the door cannot be blocked. Resident #2 was found to be agitated and immediately left the room. Review of facility investigation of involuntary seclusion on 11/20/17 at approximately 8:40 PM revealed CNA #2 was with Resident #2 in his/her room and was encouraging him/her to finish his/her supper but the resident kept getting up and down. The tray was taken from the resident's room by another CNA. A nurse told CNA #2 that we cannot keep him/her in the room and CNA #2 explained s/he wanted him/her to finish his/her supper. CNA #2 took the resident out and Resident #2 looked tired and confused and almost fell three times. They made it to Station 1 and went in room [ROOM NUMBER] and the nurse from the agency told CNA #2 to walk him/her out. CNA #2 said s/he would let out the resident slowly because s/he is one on one. Soon after a nurse told CNA #2 to leave and stated that CNA #2 was keeping Resident #2 from leaving the room. Interview with CNA #2 on 11/20/17 at approximately 10 AM revealed that CNA #2 left the door cracked. The door, CNA #2 stated, was not closed or blocked. CNA #2 stated s/he was encouraging Resident #2 to finish his/her supper. Interview with CNA #3 on 11/20/17 at approximately 10:10 AM revealed that CNA #3 was passing trays. S/he heard Resident #2 knocking on the door and trying to get out. CNA #3 tried to locate the resident's CNA. CNA #4, the resident's CNA, tried to open the door but found it blocked by the sitter. CNA #3 admitted s/he did not witness CNA #4 trying to force open the blocked door, and only heard about it after. Interview with CNA #4 on 11/20/17 at approximately 11:05 AM revealed that around lunch CNA #4 knocked on the door and tried to open it. S/he found the sitter's chair was in the way but assumed it was an accident at that time. A few hours later CNA #4 heard the doorknob turning and realized Resident #2 was trying to leave. S/he did not hear CNA #2's explanation but went to find the nurse. Interview with the Director of Nursing (DON) on 11/20/17 at approximately 3 PM revealed that LPN #2 called the DON at home to explain that Resident #2's door had been blocked. LPN #2 stated that CNA #4 informed her of this, and when LPN #2 went to open the door, it had to be forced open because the sitter--CNA #2-- had been blocking it with his/her chair. The DON told CNA #2 to leave the building. Interview with the DON on 11/20/17 at approximately 3:35 PM revealed that CNA #2 told the DON that the reason Resident #2's door was blocked was because s/he kept getting up and down and the CNA wanted to keep him/her in his/her bed so the resident would take a nap. | 2020-09-01 |
| 645 | WHITE OAK MANOR - NEWBERRY | 425077 | 2555 KINARD STREET | NEWBERRY | SC | 29108 | 2017-07-19 | 318 | D | 1 | 1 | DYWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure restorative services were provided for 1 of 3 sampled residents reviewed for range of motion. Resident #147 with physician's orders [REDACTED]. The findings included: The facility admitted Resident #147 with [DIAGNOSES REDACTED]. A review of the medical record on 7/18/17 at approximately 10:48 AM revealed a physician's orders [REDACTED]. Further record review revealed a care plan that indicated resident was to receive PROM five (5) days a week to bilateral upper extremities every shift with a problem onset date of 9/2/16 with the next review target date of 10/03/17. The care plan also addressed Resident #147 receiving PROM to lower extremities times 10 reps three (3) days a week every shift. Further review of the medical record revealed PROM documentation for the months of 4/17/17 to 7/18/17 that indicated documented PROM services was provided to Resident #147 on 4/17/17 one shift, 4/18/17 one shift, 4/25/17 one shift and 4/27/17 one shift. The PROM for the month of May 2017 revealed documented services for 5/01/17 one shift, 5/02/17 one shift, and 5/03/17 one shift. The PROM for the month of June 2017 revealed services were provided on 6/15/17 one shift, 6/21/17 and 6/22/17 one shift. The PROM for the month of July 2107 revealed services were provided on 7/04/17 one shift, 7/11/17 and 7/12/17 one shift. An interview on 7/19/17 at approximately 11:40 AM with the Director of Nursing confirmed the restorative documentation as noted and further stated the blanks noted on the PROM documentation indicated the Certified Nursing Aide may not have been able to provide the services due to being called away. | 2020-09-01 |
| 1129 | SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2020-01-15 | 561 | D | 1 | 0 | 62ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that 2 of 19 sampled residents (Resident #5 and Resident #6) were allowed to make personal choices and engage in intimate behavior in the privacy of their room. Resident #5 was discovered engaging in a sexual activity with Resident #6 on 10/14/19. The facility separated the residents, called the police and prohibited the two residents from visiting privately the rest of the evening. Findings include: Review of Resident #5's face sheet in the Electronic Medical Record (EMR) revealed he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/30/19, located under the MDS tab of the EMR, revealed he/she had a Brief Interview of Mental Status (BI[CONDITION]) score of 14, indicating he/she was cognitively intact. Review of Resident #5's care plan, located under the Care Plan tab of the EMR, documented a focus area for an alteration in mood state initiated on 09/07/17. On 10/12/18 the focus area was amended to include, . resident prefers to engage in sexual activity with other residents. A new intervention of, resident will be redirected when inappropriate behavior is noted, was added on 10/12/18. Review of Resident #6's face sheet, located under the Profile tab of the EMR revealed he/she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS assessment with an ARD of 09/23/19, located under the MDS tab of the EHR, revealed a BI[CONDITION] score of 13, indicating he/she was cognitively intact. Further review of the MDS revealed no hallucinations, delusions, or behavioral concerns. Review of Resident #6's care plan, located under the Care Plan tab of his EMR, revealed a focus which read, I have an alteration in mood (as evidenced by) inappropriate sexual behavior, added 10/01/18. The interventions included, Divert my attention when possible and attempt to refocus me on something else. Review of Resident #5's Interdisciplinary Team (IDT) progress notes for, located under the Prog Notes tab of the EMR, revealed: 10/14/19 at 07:41 PM: . was brought to this nurses (sic} attention that this resident was being sexually inappropriate with (Resident #6) who entered (his/her) room . 10/14/19 at 7:53 PM: . (Resident #6) told to leave the room immediately, which (he/she) did . 10/14/19 at 9:08 PM: . (Resident #6) from earlier incident came down hall stating (he/she) was going to (Resident #5's) room to check on (him/her). Told was (sic) not a good idea and to return to (his/her) unit. (he/she) began swearing and yelling, entered room, told resident to leave door open, again swearing. Nurse entered room and asked (Resident #5) if it was ok for (Resident #6) to be there, (he/she) put thumb up. Staff at door for resident safety. (Resident #6) eventually left unit . nurse . in the meantime, had phoned authorities, who came and questioned both residents. (Resident #5) reported to authorities that they were friends who were watching tv (sic) and they did some kissing . During an interview on 01/14/19 at 10:45 AM the Social Services Director (SSD) stated he/she was aware of Resident #5's right to be sexually active, and that it was commonplace for Resident #5 to exercise that right. The SSD stated initially Resident #5 had a visitor from the community with whom he/she was intimate with in the facility, then later another resident (since discharged from the facility), then finally Resident # 6. The SSD stated while some staff had concern regarding Resident #5's relationship with Resident #6, the residents were both able to make their own decisions and could interact with one another as they chose. The SSD stated he/she was not sure why staff intervened the way they did when the event was discovered, based on Resident #5's known history and ability to consent. An interview with Resident #5's psychologist (Phy.D.) on 01/14/20 at 11:00 AM revealed he/she engaged in regular treatments with Resident #5 beginning in either June or July of 2019. Resident #5 had consistently shown the ability to make his/her own decisions and that Resident #5 had made his/her preference to engage in sexual activity at his/her own discretion known to the facility. The psychologist stated he/she was called in to evaluate Resident #5 the day after the event and Resident #5 was adamant that he/she had wanted the interaction to continue but Resident #6 was not allowed back in the room unattended. An interview with the Administrator on 01/14/20 at 11:45 AM revealed he/she became aware of the incident the following day. The Administrator stated that Resident #5's call light had been on, and as such it had been appropriate for the Certified Nurse Aide (CNA) to enter the room. The Administrator stated it was common knowledge amongst the staff that Resident #5 had been sexually active in the past and was uncertain as to why the CNA responded in that manner at the time of the event. During an interview on 01/14/20 at 2:00 PM, the Director of Nursing (DON) stated he/she was not in the facility but was called when the event occurred. The DON stated he/she instructed staff to interview Resident #5 to make sure he/she felt safe but gave no other direction. The DON stated Resident #6 was known to become angry at times so he/she wanted to make sure there was no anger involved. The DON stated if there was no anger involved and both residents consented to the interaction there should not have been a problem with the interaction continuing. An interview with CNA #5 on 01/14/20 at 3:00 PM revealed he/she was the staff person who discovered Resident #5 and Resident # 6's interaction. CNA #5 stated he/she had worked in the facility for [AGE] years and was aware of Resident #5's history of sexual activity. CNA #5 stated s/he did not know that Resident #5 was in an intimate relationship with Resident #6 and as such was not sure how to respond when he/she discovered the interaction. CNA #5 stated that he/she would have followed the care plan had one been in place. An interview with CNA #6 on 01/15/19 at 02:30 PM revealed s/he had been assigned as a one on one attendant for Resident #6 at the time the event was discovered with the assigned duty of keeping Resident #6 and Resident #5 apart. CNA #6 stated Resident #6 was calm that evening until he/she was told he/she could not return to visit Resident #5. CNA #6 stated at one point it was decided that Resident #6 could visit Resident #5 but the CNA was expected to keep the door open and observe the entire interaction. An interview with the Administrator on 01/15/19 at 03:00 PM confirmed the facility did not have a policy on resident visitation, but provided a copy of Resident Rights, which he/she reported each resident received upon admission. Review of the undated Resident Rights document provided by the Administrator revealed, . You have the right to spend private time with visitors at any reasonable hour. | 2020-09-01 |
| 4050 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2017-09-15 | 387 | E | 1 | 1 | 4HVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure the frequency of physician visits as required. Resident #22, Resident #42, Resident #156, Resident #95, Resident #[AGE], and Resident #207 did not have documented physician visits as required for 6 out of a total of 20 sampled residents reviewed. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 3pm revealed that the only Physician's Progress Notes in the medical record were on 12/16/16 and 8/24/17, after readmission from the hospital to the facility on [DATE]. No further evidence of physician visits were produced after requesting physician progress notes [REDACTED]. The facility admitted Resident #156 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 2pm revealed no evidence of physician visits on the chart. A request for medical records did not produce evidence of physician visits. The resident was admitted on [DATE]. During an interview on 9/15/17 at 10am, the Director of Nursing verified there were no physician visits on the chart for the last 6 months. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Record review on 9/7/17 at 9am revealed an unsigned progress note dated 7/22/16, a Physician's Progress Note dated 7/28/16 signed by an Advanced Practice Registered Nurse, and the progress note on the back of that note was dated 8/24/17. No further evidence of physician visits from 7/28/16 through 8/24/17 were produced after requesting physician progress notes [REDACTED]. The resident was admitted on [DATE]. During an interview on 9/15/17 at 10am, the Director of Nursing verified there were no physician visits on the chart for the last 6 months. The facility admitted Resident #[AGE] with [DIAGNOSES REDACTED]. Review on 9/9/2017 at approximately 2:30 PM of a form titled, Physician's Progress Notes, revealed the most recent note dated 11/02/2016. No other Physician's Progress Notes were found in the medical record for Resident #[AGE] to ensure the attending physician had visited Resident #[AGE] at least every [AGE] days since 11/2/2016. Resident # 207 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's medical record on 9/8/17 at 1:00pm, revealed upon admission the resident was assessed by the physician on 5/15/17. The next documented record of a physician visit did not occur until 7/17/17. After July of 2017 there are no recorded visits by the physician. Resident #55 was admitted to the facility [DIAGNOSES REDACTED]. Review of the resident's medical record on 9/9/17 at 2:45pm, revealed the resident was assessed by the physician on 7/1/17. There is no documented record of a physician or a delegate after the initial assessment. A policy related to physician's visits was requested and the administrator provided a policy entitled, Physician Care on 9/9/17 at 3:42pm. During an interview with the administrator on 9/9/17 at 3:50pm, s/he stated that the facility follows the regulations through Centers for Medicare and Medicaid Services outside of what is outlined in the facility's policy. The facility's policy does not address the concern of physician visits, it referenced to selecting a primary physician and emergency physician services. The facility admitted Resident #22 on 07/05/2017 with [DIAGNOSES REDACTED]. Record review for Resident #22 on 09/08/2017 at 4:35 PM revealed no Physician's Progress Notes in the medical record. The only Physician's documentation included the history and physical on admission. | 2020-09-01 |
| 800 | MAGNOLIA MANOR - GREENVILLE | 425090 | 411 ANSEL ST | GREENVILLE | SC | 29601 | 2017-08-23 | 225 | E | 1 | 0 | FYRU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to implement abuse prohibition policy in 2 of 3 abuse investigations reviewed. Suspected abuse of Residents #15 and #53 were not promptly reported by staff, and the direct consequence was delayed investigation. The findings included: An initial 24-Hour Report was sent to the Department of Health and Environmental Control on 8/1/17 regarding an allegation that Resident #15 was inappropriately touching another resident. Interview with Certified Nursing Assistant (CNA) #1 on 8/22/17 at approximately 6:15 AM revealed that s/he had observed Resident #15 touching other residents and staff inappropriately on 7/23/17 and 7/28/17. S/he stated that both times s/he reported the suspected abuse to a nurse but was unable to name which nurse. Review of facility policy regarding Abuse Prohibition on 8/22/17 at approximately 7:40 AM revealed the following: All alleged isolations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator, and to other officials in accordance with state law including the State Certification Agency (nurse aide registry or licensing authorities). The facility policy also clarified that reporting must be within 24 hours. Review of the 8/1/17 with CNA #1 on 8/22/17 at approximately 9:15 AM revealed that CNA #1 stated that s/he called the Director of Nursing (DON) when s/he witnessed Resident #15 inappropriately touching residents but waited until the DON returned to the facility to discuss it. Interview with DON on 8/22/17 at approximately 10:40 AM revealed that CNA #1 called while s/he was out of town but said her concern could wait until the DON returned. The DON also stated that CNA #1 did not discuss the suspected abuse until a week after the DON had returned. The DON clarified that both the administrator and unit manager were available for CNA #1 to report to. An initial 24-Hour Report was sent to DHEC on 4/29/17 regarding an injury of unknown origin noted on Resident #53. Review of 4/29/17 interview of Licensed [MEDICATION NAME] Nurse (LPN) #1 on 8/22/17 at approximately 11 AM revealed that LPN #1 noted the injury of unknown origin on Resident #53 on 4/24/17. LPN #1 continued that she was aware of the requirement to immediately report injuries of unknown origin but failed to do so. Review of 4/24/17 nursing note on 8/22/17 at approximately 11 AM confirms that abnormal bruising on the abdomen of Resident #53 was identified five days before investigation. | 2020-09-01 |
| 1452 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2020-01-14 | 582 | B | 1 | 1 | ZGSA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to issue Advance Beneficiary Notice of Noncoverage (ABN) for two of two residents (Residents #94 and #255) discharged from Medicare Part A with benefit days remaining. The findings include: 1. Resident #94 was originally admitted on [DATE]. A Notice of Medicare Non-coverage (NOMNC) was issued for services ending on 09/27/19. Although the resident was to be discharged from Medicare Part A with benefits days remaining, he would continue to be a resident in the facility. The facility did not issue an ABN. A second NOMNC was issued for services ending on 01/17/20. The resident was to be discharged from Medicare Part A with benefits days remaining, but he would continue to be a resident in the facility. The facility did not issue an ABN. During an interview on 01/11/20 at 5:39 PM, the Senior Vice President of Clinical Services stated the facility had not been issuing ABNs for any resident. She stated the newly hired Finance Counselor, who issues the notices, began working at the facility in September 2019 and since then, no ABNs had been issued. During an interview on 01/13/20 at 2:20 PM, the Finance Counselor stated she had not been issuing any ABNs. She stated she thought those were only issued if a resident didn't agree and wanted to appeal the decision. No ABN notices had been given to the residents who were discharged from Medicare Part A with benefit days left that remained in the facility. 2. Resident #255 was originally admitted on [DATE]. A Notice of Medicare Non-coverage (NOMNC) was issued for services ending on [DATE]. Although the resident was to be discharged from Medicare Part A with benefits days remaining, she would continue to be a resident in the facility. The facility did not issue an ABN. During an interview on 01/11/20 at 5:39 PM, the Senior Vice President of Clinical Services stated the facility had not been issuing ABNs for any resident. She stated the newly hired Finance Counselor, who issues the notices, began working at the facility in September 2019 and since then, no ABNs had been issued. During an interview on 01/13/20 at 2:20 PM, the Finance Counselor stated she had not been issuing any ABNs. She stated she thought those were only issued if a resident didn't agree and wanted to appeal the decision. No ABN notices had been given to the residents who were discharged from Medicare Part A with benefit days left that remained in the facility. | 2020-09-01 |
| 2815 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-04-25 | 600 | G | 1 | 0 | IJ5G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to keep residents free from abuse and neglect for 1 of 5 residents reviewed for abuse. Resident #188, who had a well-documented history of sexually abusive behavior, sexually abused Resident #45. On 1/2/19 Resident #188 had his/her hand on a Residents crotch area, on 1/15/19 Resident #188 was noted with his/her hand in Resident #45's pants, with his/her hand in motion and on 2/3/19 Resident #188 placed his/her hand on a resident's genitals and rubbed. The findings included: Review of Initial report on 4/22/19 at approximately 3:20 PM revealed Resident #188 touched Resident #45 without permission at approximately 11 AM on 1/15/19. Review of the 5-day report on 4/22/19 at approximately 3:25 PM revealed that Resident #45 was uninjured, both Residents #45 and #188 were cognitively impaired. Resident #188 had a prior history of sexually inappropriate behavior. One of the planned interventions was to move the victim to a further room. Review of witness statements on 4/23/19 at approximately 10 AM revealed that Licensed Practical Nurse (LPN) #7 witnessed Resident #188 leaning forward from his/her wheelchair with his/her right hand extended inside the pants/thighs of Resident #45. Resident #188 moved his/her hand back and forth. When LPN #7 called Resident #188's name, the resident withdrew his/her hand and disappeared into his/her room. LPN #6 performed a body audit on Resident #45 and noted no perineal/vaginal trauma. Housekeeper #1 also witnessed Resident #188 with hand on private part of Resident #45. Review of Resident #188's nursing notes on 4/23/19 at approximately 10:05 AM revealed several notes documenting a history of sexually inappropriate behavior from Resident #188. Nursing note from 1/2/19 documenting that Resident #188 had his/her hand on a Residents crotch area, and the resident was immediately removed. Nursing note on 1/15/19 revealed Resident #188 was noted by 3 employees who took immediate action with his/her hand in Resident #45's pant, with his/her hand in motion. Nursing note on 2/3/19 documenting that Resident #188 placed his/her hand on a resident's genitals and rubbed. This was witnessed by several other residents. A witness (Resident) stated, I'm scared, and started to cry. Record review revealed that the only reference to the two incidents dated 1/2/19 and 2/3/19 were located in Resident #188's nurses notes. The notes did not provide the names of the other residents involved. During an interview with Licensed Practical Nurse (LPN) #6 on 4/23/19 at approximately 12:08 PM s/he confirmed that Resident #188 had attempted to sexually assault a resident at least one other time, though s/he was unable to name the specific date.There was no evidence that the facility reported or investigated the incidents dated 1/2/19 and 2/3/19. Review of Resident #188 Care Plan on 4/23/19 at approximately 10:20 AM revealed Resident #188 was care planned to be taken to a private area for self-intimacy. There was no documented interventions to protect other residents from Resident #188's history of publicly masturbating while staring at female residents and groping female residents. During an interview with LPN #6 on 4/23/19 at approximately 12:08 PM revealed that Resident #188 put his/her hand into Resident #45's pants and moved hand up and down. Residents were immediately separated and the Nurse Practitioner assessed Resident #45. The family of both residents and management were immediately notified. LPN #6 stated that Resident #188 had a history of [REDACTED]. During an interview with Housekeeper #1 on 4/23/19 at approximately 12:44 PM s/he confirmed that Resident #188 had his/her hand in the pants of Resident #45. During an interview with LPN #7 on 4/23/19 at approximately 4 PM revealed that Resident #188 had his/her hand reached down the pants of Resident #45. When LPN #7 discovered this was happening, another nurse was already separating the two. LPN #7 knew of no other instances of Resident #188 touching residents. During an interview with the Administrator and review of Resident #188 and Resident #45's charts on 4/24/19 at approximately 8:50 AM revealed neither residents changed rooms after the incident dated 1/15/19. Review of Resident #188's record revealed that the resident was discharged from the facility on 2/7/19. | 2020-09-01 |
| 1023 | MILLENNIUM POST ACUTE REHABILITATION | 425105 | 2416 SUNSET BOULEVARD | WEST COLUMBIA | SC | 29169 | 2017-09-21 | 514 | D | 1 | 1 | QQ9911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to maintain accurate information and have readily accessible documentation in the medical record for one of five residents reviewed for unnecessary medications. The medical record for Resident #5 contained inaccurate /conflicting information regarding admitted to hospice services. Information requested regarding monthly medication regimen review for resident #[AGE] was not provided as requested during survey. The findings included: The facility admitted Resident #5 with [DIAGNOSES REDACTED]. Review of medical record on 9/20/17 at 9:00 AM revealed a telephone order initiated on 3/8/17 to Admit to Agape Hospice Diagnosis: [REDACTED]. Additional review of Order Summary Report Generated 8/30/17 revealed hospice admit order date of 3/8/2017. Further review of resident Census Report for Resident #5 identified a payer change to Medicaid/ Hospice on 2/1/17. During interview on 9/20/17 at approximately 11:45 AM, the Hospice Case Manager reported that Resident #5 was admitted to hospice services on 1/27/17. Additionally, s/he verified the hospice service start of care date was identified as 1/27/17 on the Hospice Certification of Terminal Illness form. When asked how hospice communicates with facility when a resident is admitted or discharged from hospice services, s/he replied, Once we have admitted , I write a telephone order to evaluate and admit to hospice if appropriate with the [DIAGNOSES REDACTED].#5 was admitted to hospice services on 1/27/17. When asked if she could locate the telephone order that was written to initiate hospice services, s/he replied that s/he would look for the telephone order and return. No further information was provided by the Hospice Case Manager related to a telephone order written on 1/27/17 to admit Resident #5 to hospice services. During interview with Business office manager on 9/21/17 at 4:35 PM, s/he verified that information for Resident #5 has an incorrect date of 2/1/17 listed for conversion to Hospice Medicaid-SC on the resident census. Director of Nursing (DON) verified during interview on 9/21/17 at 6:30 PM that the information in the medical record is inconsistent regarding hospice admitted information. S/he verified the telephone order written on 3/8/17 is the current active order regarding hospice admission; however, the Hospice Certification of Terminal Illness for identifies an admitted to hospice as 1/27/17. S/he agreed that the information was inaccurate/ inconsistent. | 2020-09-01 |
| 2184 | ROCK HILL POST ACUTE CARE CENTER | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2019-11-22 | 881 | D | 1 | 1 | 9X3H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to monitor for antibiotic use, antibiotic resistance patterns, and / or antibiotic outcomes per its Antibiotic Stewardship Program (ASP) policy. The findings included: Review of ASP policy on 11/20/19 at approximately 3:25 PM revealed the facility establishes a ASP team that monitors and summarizes antibiotic use from pharmacy data such as the rate of new starts, types of antibiotics used, or days of antibiotic treatment per 1,000 resident days. The ASP team, per policy, should also summarize antibiotic resistance patterns (e.g., antibiogram) as well as track measures of outcome surveillance related to antibiotic use (e.g., Clostridioides Difficile (C. diff), [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) or Carbapenem-resistant [MEDICATION NAME] (CRE)). Further, the ASP team should report on number of antibiotics prescribed and the number of residents treated each month. Interview with Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 11/20/19 at approximately 3:45 PM revealed there was no monitoring of antibiotic use. Both pointed only to infection surveillance, which was primarily used to track transmissible infections both [MEDICAL CONDITION] and bacterial. Further, the DON and ADON were unable to produce documentation of monitoring for resistance patterns based on lab data, per their policy, or monitoring for potential outcome surveillance to antibiotic use. When asked about how the facility monitors / tracks residents who, for example, may contract [DIAGNOSES REDACTED] after a course of antibiotics, the DON and ADON were unable to answer. | 2020-09-01 |
| 207 | FLEETWOOD REHABILITATION AND HEALTHCARE CENTER | 425018 | 200 ANNE DRIVE | EASLEY | SC | 29640 | 2019-11-27 | 641 | D | 1 | 0 | 4NC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to perform accurate fall assessments for 2 of 6 residents reviewed for accidents. Residents #7 and #13 had inaccurate fall assessments. The findings included: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's fall assessments on 11/25/19 at approximately 1:26 PM revealed the following: 1. 8/30/19 assessment scored at 13. 2. 9/4/19 assessment - after his/her first fall in facility - scored at 3. Discrepancies were noted regarding medicines placing the resident at risk, alertness, and predisposing illnesses. Review of Resident #7's (MONTH) 2019 Medication Administration Record [REDACTED]. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's fall risk assessments on 11/25/19 at approximately 3:15 PM revealed the following: 1. 3/13/19 assessment scoring at 5. The resident was marked as alert with no predisposing illnesses or fall risk medications. This was inconsistent with other fall assessments. 2. 2/6/19 assessment scoring at 7. The resident was marked as alert with no predisposing illnesses. It should be noted that [MEDICAL CONDITION] is listed as a predisposing illness with regard to falls. Review of Resident #7's progress notes on 11/25/19 at approximately 3:25 PM revealed a 2/5/19 psychosocial note stating the resident was severely cognitively impaired related to a dementia diagnosis. Review of Resident #7's (MONTH) 2019 MAR indicated [REDACTED]. Interview with the Administrator and Director of Nursing on 11/26/19 at approximately 3 PM confirmed the inaccurate assessments. | 2020-09-01 |
| 1482 | PRUITTHEALTH- ROCK HILL | 425127 | 261 S HERLONG AVE | ROCK HILL | SC | 29732 | 2017-10-23 | 224 | D | 1 | 0 | M6T211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to prohibit misappropriation of medication intended for 1 of 3 reviewed for pain. Licensed [MEDICATION NAME] Nurse (LPN) #1 stole [MEDICATION NAME] 5 mg intended for Resident #3. The findings included: Review of LPN #1's statement on 10/23/17 at approximately 11:30 AM revealed LPN #1 took medication ([MEDICATION NAME] 5 mg) from Resident #3 and began a few months prior to confessing on 9/1/17. Review of the facility investigation summary on 10/23/17 at approximately 11:40 AM revealed that Resident #3's 30 tablets of [MEDICATION NAME] 5 mg appeared on a pharmacy receipt requisition document. Two days later the same resident's medication was written to have zero pills remaining, despite Resident #3 not receiving any as needed [MEDICATION NAME] 5 mg. The facility concluded the allegation of misappropriation of property was substantiated. Review LPN #1's statement on 10/23/17 at approximately 12:15 PM revealed LPN #1 resigned on 9/1/17 for taking medication from Resident #3. Interview with the administrator on 10/23/17 at approximately 2:40 PM revealed LPN #1 would take [MEDICATION NAME] and then zero out the card by forging a second nursing signature. This was only discovered when LPN #2 attempted to remove the [MEDICATION NAME] 5 mg because it had been discontinued. Interview with LPN #2 on 10/23/17 at approximately 3:40 PM revealed Resident #3's [MEDICATION NAME] 5 mg had been discontinued since the resident had not needed it for three months. LPN #2 attempted to remove it from the med cart and realized there was no medication in it. Since Resident #3 had been moved from Unit 1, LPN #2 asked Unit 1 if the medication had been discontinued and removed there. Upon learning that they had not done so, she alerted the administrator and the investigation began. Review of Controlled Drug Inventory Form on 10/23/17 at approximately 4:30 PM revealed that LPN #1 did zero out the medications of Resident #3 on 6/20/17, 6/24/17 and 6/29/17. LPN #1 initialed and forged a second set of initials. | 2020-09-01 |
| 3197 | L.M.C.- EXTENDED CARE | 425321 | 815 OLD CHEROKEE ROAD | LEXINGTON | SC | 29072 | 2019-12-04 | 641 | D | 1 | 1 | GRSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide accurate assessments for 1 of 40 residents on initial pool. Resident #2[AGE]'s Minimum Data Set (MDS) was inaccurate. The resident was marked as having a stage 4 pressure ulcer when s/he had none. The findings included: Resident #2[AGE] was admitted to the facility on [DATE]. Interview with family of Resident #2[AGE] on 12/2/19 at approximately 5:38 PM revealed the resident had a bed sore on arrival, though it had healed completely since then. Review of 11/9/19 quarterly MDS on 12/3/19 at approximately 11:08 AM revealed Resident #2[AGE] had been coded for a stage 4 pressure ulcer. Review of nursing notes on 12/3/19 at approximately 11:10 AM revealed a 9/22/19 note that the sacral wound had closed. Interview with Registered Nurse (RN) #3 on [DATE] at approximately 12:46 PM confirmed the miscoded MDS. RN #1 stated a trainee had filled out the MDS and had made a mistake. | 2020-09-01 |
| 268 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-10-23 | 684 | D | 1 | 0 | M1W411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide adequate quality of care for Resident #6 (1 of 11 residents reviewed for abuse). Resident #6's head was injured during transfer, and neither Certified Nursing Assistant (CNA) reported it to nursing. The Director of Nursing (DON) agreed that they should have reported the incident as even a minor head injury could be serious in an elderly patient. The findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of investigation summary on 10/22/19 at approximately 9:21 AM revealed the following: 1. On (MONTH) 6, 2019 Resident #6 spoke with Registered Nurse (RN) #1 regarding an incident of alleged abuse that occurred on 5/2/10 at approximately 10 PM. 2. Resident #6 had a BIMS of 13. 3. Resident #6 stated on Thursday around 10 PM, two CNAs entered the room to help him/her get into bed. 4. CNAs helped move the resident's legs on the bed so the s/he could lay down, and one CNA threw them on the bed, causing the resident to hit her head on the wall. 5. Resident #6 stated the CNA hurt him/her. S/he said s/he would report him/her. CNA said, I don't give a (expletive). They won't believe you anyway. 6. Resident #6 did not report to the nurse that night -- either that s/he had hit his/her head or that CNA #1 had cursed at him/her. 7. The resident stated, I didn't want to tell anyone because I have to stay here and was afraid they would hurt me worse or lose their job, and I don't want anyone to lose their job. 8. CNA #1 was the suspect and was an agency CN[NAME] 9. Staff interviewed CNAs #1 and #3. 10. Facility concluded that Resident #6 hitting his/her head against the wall was accidental. Abuse unsubstantiated. Review of CNA #3's statement on 10/22/19 at approximately 9:35 AM revealed the following: 1. CNA #3 was with CNA #1 during resident transfer from wheelchair to bed. 2. Resident #6 hit his/her head when staff placed his/her feet in the bed. 3. Resident did not complain, and nothing was reported to nurse. Review of CNA #1's statement via contractor on 10/22/19 at approximately 9:46 AM revealed the following: 1. CNAs #1 and #3 helped Resident #6 into bed. 2. CNA #1 placed the resident's legs on the bed, and the resident's head bumped lightly against the wall located at the head of the bed. 3. CNA #1 asked if the resident was okay, and resident stated yes. 4. Resident #6 stated s/he would report it. 5. CNA #1 asked if resident was hurting and resident said no. 6. CNA #1 assessed resident and did not observe any signs of bruising or breaks in skin. Resident #6 did not complain of pain or injury. Review of 5/6/19 physician progress notes [REDACTED].#6 denied pain and there was no obvious bruising. Review of Resident #6's closed record on 10/22/19 at approximately 10:27 AM revealed there was no documentation of assessment of resident's head injury prior to physician's note on 5/6/19. Interview with CNA #1 on 10/22/19 at approximately 12:39 PM revealed the following: 1. CNA #1 transferred resident but did not recall specifics. 2. Resident #6 mentioned hitting his/her head. The CNA did not say anything back to her. 4. The nurse was informed and assessed resident. 5. The CNA never worked with that resident again. Interview with CNA #3 on 10/22/19 at approximately 3:17 PM revealed the following: 1. During transfer of Resident #6, the resident tapped his/her head on the wall. 2. The resident did not say anything. 3. The incident was not reported to the nurse. Interview with Licensed [MEDICATION NAME] Nurse (LPN) #4, the nurse on duty during the incident, on 10/23/19 at approximately 9:09 AM revealed s/he could not recall the resident and had not worked in the facility in months. Interview with DON on 10/23/19 at 9:26 AM revealed the CNAs should have notified the nurse if a resident's head was accidentally bumped during transfer. The DON stated minor head injuries may be serious in the elderly and merited nursing assessment. | 2020-09-01 |
| 269 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-10-23 | 745 | D | 1 | 0 | M1W411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to provide adequate social services for Resident #6 (1 of 11 residents reviewed for abuse). Resident #6 alleged staff of abuse, and when recounting abuse to the physician was tearful, but there was no follow-up social services or counseling for the resident. The findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of investigation summary on 10/22/19 at approximately 9:21 AM revealed the following: 1. On (MONTH) 6, 2019 Resident #6 spoke with Registered Nurse (RN) #1 regarding an incident of alleged abuse that occurred on 5/2/10 at approximately 10 PM. 2. Resident #6 had a BIMS of 13. 3. Resident #6 stated on Thursday around 10 PM, two Certified Nursing Assistants (CNAs) entered the room to help him/her get into bed. 4. CNAs helped move the resident's legs on the bed so the s/he could lay down, and one CNA threw them on the bed, causing the resident to hit her head on the wall. 5. Resident #6 stated the CNA hurt him/her. S/he said s/he would report him/her. CNA said, I don't give a (expletive). They won't believe you anyway. 6. Resident #6 did not alert report to the nurse that night -- either that s/he had hit his/her head or that the CNA #1 had cursed at her. 7. The resident stated, I didn't want to tell anyone because I have to stay here and was afraid they would hurt me worse or lose their job, and I don't want anyone to lose their job. 8. CNA #1 was the suspect and was an agency CN[NAME] 9. RN #1 contacted agency regarding the incident and agency did not schedule CNA #1 pending completion of investigation. 10. Staff interviewed CNAs #1 and #3. 11. Social Service was to follow up and offer psychosocial support. 12. Resident was under APS custody due to living situation prior to admission to facility. 13. Facility concluded that Resident #6 hitting her head against the wall was accidental. Abuse unsubstantiated. Review of 5/6/19 physician progress notes [REDACTED]. 1. When abuse allegation was brought up, Resident #6 became teary eyed and stated, I really do not want to talk about this again. I'm afraid, and I was told if I said anything no one would believe me and nothing would be done. I'm not trying to cause any trouble because I have to stay here. I didn't even tell my family what happened to me. I did tell the head nurse about what happened to me. I was getting back in bed. My legs were swung over and my head hit the wall. I asked why s/he was doing this, and when I said I would tell someone, s/he said 'Go ahead. No one is going to believe you.' 2. Resident #6 denied pain and there was no obvious bruising. 3. Physician noted in Assessment and Plan that resident appeared fearful and teary when recounting the abuse allegation. Resident kept insisting s/he did not want to cause any trouble during his/her stay. Review of Resident #6's closed record on 10/22/19 at approximately 10:27 AM revealed the following: 1. Review of orders revealed resident was not taking [MEDICAL CONDITION]. 2. Review of physician progress notes [REDACTED]. 3. Review of nursing notes revealed no other concerns related to mood / behaviors. 4. Review of social service notes did not bring up incident. It was not documented that social services met with the resident following the abuse allegation. Social Worker (SW) #1 was working as director at that time, but he/she was no longer with the facility. Interview with SW #1 on 10/22/19 at approximately 11:03 revealed s/he did not recall the incident or resident and was uncertain if Resident #6 received social services support following the allegation. | 2020-09-01 |
| 266 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-10-23 | 609 | E | 1 | 0 | M1W411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to report abuse timely for Residents #1, #4, #5, and #6 (4 of 11 residents reviewed for abuse). Resident #1's misappropriation of property was not reported timely. Resident #5's sexual abuse allegation was not reported timely. Residents #6, #4, and #1 did not have 5-day reports submitted timely. The findings included: Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of 24-hour report and 5-day report on 10/21/19 at approximately 10:30 AM revealed the 5-day was reported 7 days later. Per the investigation summary, Certified Nursing Assistant (CNA) #4 was caring for Resident #4 when s/he passed gas. Per Resident #4, CNA #4 stated s/he better be glad it was just gas. Interview with Director of Nursing (DON) on 10/21/19 at approximately 11:51 AM revealed confirmed the 5-day report was late. The DON said several other 5-days of Facility Reported Incidents being investigated in the survey were late as well. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of investigation summary on 10/22/19 at approximately 9:21 AM revealed the Resident #6 accused CNA#1 of physical and mental abuse. The facility did not substantiated based on lack of evidence and inability to prove willful intent. Review of 5-day report on 10/22/19 at approximately 10:50 AM revealed the 5-day was submitted on 5/13/19, which was 7 days after the facility discovered the incident (5/16/19). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Facility Summary of Investigation on 10/22/19 at approximately 11:44 AM revealed Resident #1 accused Activities Assistant (AA) #1 of taking his/her money to buy him/her cigarettes. AA #1 shouted at resident that this did not occur and swore at the resident. Review of the 2/24 hour and 5-day report on 10/22/19 at approximately 12:21 PM revealed a delay in the 5-day report. The incident occurred on 5/18/19 and the 5-day was submitted 5/24/19. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. The misappropriation of 60 [MEDICATION NAME] tablets was not reported immediately to Certification. The missing medication was reported to the DON on 9/7/19 but not reported to Certification until 9/9/19 at 12:45 PM. As of 10/21/19, the missing medications had not been reported to Board of Pharmacy or the Board of Nursing. The facility admitted Resident #5 with [DIAGNOSES REDACTED]. While in the shower on 9/24/19 the resident told the CNA that he/she had been sexually assaulted in her room the night before. As soon as the CNA could safely get the resident out of the shower, the CNA notified the supervisor of the alleged sexual abuse. The supervisor waited to interview the resident and other staff before notifying Certification of the alleged abuse. The report was a 24 hour report. | 2020-09-01 |
| 2890 | RIVER FALLS REHABILITATION AND HEALTHCARE CENTER | 425307 | 2906 GREER HWY | MARIETTA | SC | 29661 | 2019-07-17 | 609 | D | 1 | 1 | 55SY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to report potential abuse for 2 of 12 residents reviewed for abuse. Resident #17 received an injury of unknown origin that was not reported to the state agency. Resident #24 made an allegation of abuse that was not reported to the state agencey. The findings included: Resident #24 was admitted to the facility 6/5/19 with [DIAGNOSES REDACTED]. Interview with Resident #24 on 7/15/19 at approximately 10:15 AM revealed an unidentified Certified Nursing Assistant (CNA) was rough with the resident and bruised him/her. This occurred a week ago. S/he informed CNA #1. Interview with CNA #1 on 7/15/19 at approximately 10:27 AM revealed that s/he spoke with Resident #24 and noticed a bruise on his/her arm. The resident said a colored girl had yanked his/her arm around. The CNA was not sure if it had been reported. Interview with Administrator and Director of Nursing on 7/15/19 at approximately 10:33 AM revealed there had been no reports related to Resident #24. Interview with DON on 7/15/19 at approximately 3:43 PM s/he confirmed CNA #1 should have reported suspected abuse to the facility. The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review of Resident #17's nurse's notes on 7/16/19 at 2:26 PM, revealed on 2/6/19 the nurse was called to the resident's room where a nurse aide was with the resident in the bathroom. The resident was tearful, complained of left upper arm pain and a purple/blue discoloration was observed on the resident's left, inner, upper arm. The note indicated the findings were reported to the Director of Nursing (DON) and nurse practitioner. Record review of Resident #17's progress notes from 2/6/19, on 7/16/19 at 3:10 PM, revealed the nurse practitioner evaluated the resident after receiving the report of the injury of unknown origin. The progress note also revealed the resident had tenderness, pain and limited ROM of the left arm. In addition the resident had an ecchymotic area to the left upper arm, trauma unknown. Pt (patient) is poor historian. Review of the facility's reportable incidents on 7/16/19 at 2:45 PM, revealed no documentation indicating the facility investigated the cause of the discoloration and pain to Resident #17's arm. In addition, there was no documentation to indicate the injury of unknown origin was reported to the State Agency. During an interview with the Director of Nursing (DON) on 7/16/19 at 8:47 AM, the DON stated s/he did not know about the Resident #17's injury of unknown origin on 2/6/19. The DON confirmed the nurse's notes indicated she/he was made aware of the injury on 2/6/19 but stated the nurse did not report the incident to her/him. The DON stated a nurse who identifies an injury of unknown origin is to complete an Incident Report and SBAR (Situation, Background, Assessment and Recommendation) note per facility protocol. The DON stated this was not done. The DON stated had s/he been aware of the incident it would have been investigated and reported to the State Agency per the facility's Abuse Prevention Program policy. The DON stated s/he had not read the nurse's note from 2/6/19 until now. During an interview with Licensed Practical Nurse (LPN) #2 on 7/17/19 at 10:32 AM, LPN #2 stated s/he was the nurse who identified the injury of unknown origin for Resident #17 and wrote the nurse's note on 2/6. LPN #2 stated the DON was not in the building at the time s/he evaluated the resident but did report the injury of unknown origin to the DON when s/he arrived in the building. LPN #2 stated s/he also notified the nurse practitioner who ordered x-rays of Resident #17's arm. LPN #2 stated s/he did not complete an Incident Report or SBAR note per facility protocol. Review of Resident #17's nurse's notes and the care plan revealed the resident had a history of [REDACTED]. The x-rays completed on 2/6/19 revealed no fracture. The nurse practitioner followed up with Resident #17 on 2/13/19 and the resident was able to move her/his left arm with no tenderness or pain. During an interview with the Resident Representative (RR), the RR stated the resident had a long history of running into or bumping into things causing bruising or other injuries. The RR stated this hasn't been much of an issue over the last few months due to Resident #17 not trying to get up as much as s/he used to. | 2020-09-01 |
| 345 | CONDOR HEALTH ANDERSON | 425047 | 611 EAST HAMPTON STREET | ANDERSON | SC | 29624 | 2019-03-28 | 608 | D | 1 | 1 | HSS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to report reasonable suspicion of a crime. Resident #75 accused Resident #68 of sexual abuse, and the facility failed to report the allegation to the police for investigation. The findings included: Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent score for Brief Interview of Mental Status (BIMS) was 13. Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent BIMS score was 6. Review of the 24 Hour and 5 Day report on 3/27/19 at 1:51 PM revealed Resident #75 alleged Resident #68 had been messing with his/her genitals a few days before 11/1/18. There were no witnesses. Interview with Social Services Director #1 on 3/27/19 at 4:18 PM revealed that the allegation was not reported to the police. Interview with Resident #75 on 3/27/19 at 3:25 PM revealed s/he maintained the allegation that Resident #68 was messing with (him/her) in her room at night and it had been unwitnessed. S/he was unable to offer further details such as what resident #68 had done or when it occurred. Review of abuse policy on 3/28/19 at 11:59 AM revealed that in response to allegations of sexual abuse the facility is to immediately report the allegation to the administrator, the physician, the appropriate state and local authorities. | 2020-09-01 |
| 267 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-10-23 | 610 | D | 1 | 0 | M1W411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to sufficiently investigate abuse for Resident #4 (1 of 11 residents reviewed for abuse). The facility failed to obtain a proper statement from an Certified Nursing Assistant (CNA) #4. Because the statement taken by the Director of Nursing (DON) was neither signed by the CNA nor witnessed by a third party, and because the CNA later denied making that statement, the abuse could not be substantiated. The findings included: Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of DON's recollection of CNA #4's statement on 10/21/19 at approximately 10:45 AM revealed the following: 1. CNA #4 confirmed s/he stated the resident better be glad it was just gas. 2. CNA #4 stated s/he thinks the resident sprays them with poop on purpose. S/he thinks s/he gets off on getting his/her poop on employees. 4. CNA #4 did not sign this statement. It was written and signed by the DON. There were no witness signatures. Interview with CNA #4 on 10/21/19 at approximately 1:55 PM revealed the following: 1. CNA stated s/he only asked the resident to inform him/her if s/he felt the urge to pass gas. 2. Resident #4 passed gas. CNA #4 denied saying anything to making threats. 3. When asked about his/her statement, CNA #4 denied writing a statement. S/he spoke with staff regarding what happened, but s/he did not see what they wrote. S/he was concerned they misunderstood what s/he said, as s/he did express that s/he was glad (Resident #4) only passed gas to other staff members. Interview with DON on 10/21/19 at approximately 2:10 PM revealed there was no signed statement from alleged perpetrator. DON confirmed there was no third-party witness who could corroborate what CNA #4 told him/her following the incident. S/he stated CNA #4 was fuming and upset following the incident and complained about the resident, saying s/he got off on getting feces on staff. The DON immediately escorted CNA #4 out of the building. | 2020-09-01 |
| 337 | GREENVILLE POST ACUTE | 425042 | 661 RUTHERFORD RD | GREENVILLE | SC | 29609 | 2019-10-17 | 689 | D | 1 | 0 | F9YN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to take reasonable steps to prevent accidents for 2 of 10 residents reviewed for abuse. On 12/10/18 Certified Nursing Assistant (CNA) #1 was pushing Resident #1 in a wheelchair. When the resident lowered his/her feet onto the floor, the CNA continued pushing the resident, directly contributing to the resident's fall. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 12/10/18 incident report on 10/16/19 at approximately 9:25 AM revealed the following. 1. Nurse was near nursing station med cart when she witnessed staff member pushing patient in wheelchair. Resident #1 tried to stop the chair with his feet which caused patient to fall out of chair. 2. Resident was transferred off the floor to the wheelchair with help of another staff member. 3. Vitals were obtained and skin assessment performed. There were no visible injuries observed. Review of CNA #1's statement on 10/16/19 at approximately 9:33 AM revealed the following: 1. CNA #1 was pushing Resident #1 in wheelchair. Resident put both his feet on the floor while she was pushing, slowing the wheelchair down. 2. CNA #1 continued to push the wheelchair. 3. The resident thought s/he had stopped and tried to stand while wheelchair was still in motion, falling to the floor. Review of Registered Nurse (RN) #2's statement on 10/16/19 at approximately 9:37 AM revealed the following: 1. RN #2 was near the medcart. S/he observed CNA #1 pushing Resident #1 in the wheelchair. 2. While approaching room [ROOM NUMBER], the resident tried to get out of the chair. CNA #1 told the resident to pick up his/her feet but continued pushing the chair. 3. Resident #1 fell to the floor next to the 100 room. 4. RN #2 reprimanded CNA #1, explaining the fall could have been prevented and would be reported. 5. Vitals were taken and Resident #1 was assessed. S/he was found to be without injury. Interview with RN #1, Regional Director, and Director of Nursing on 10/16/19 at approximately 12:34 PM revealed CNA #1 should have stopped pushing the wheelchair and reminded the resident to pick up his/her feet. All parties agreed CNA #1 should not have continued pushing the wheelchair when s/he discovered Resident #1 was putting his/her feet down on the floor during transport and that this fall could have been prevented. | 2020-09-01 |
| 276 | MAGNOLIA MANOR - INMAN | 425032 | 63 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2018-12-20 | 607 | D | 1 | 0 | 0G2K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and review of facility Leadership Policies and Procedures for Abuse Neglect, Exploitation, or Mistreatment, the facility failed to implement its policy related to investigations for abuse for 2 of 3 reviewed for abuse related to injury. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Review of the facility's investigation of a fall for Resident #7 on 10/14/18 at 11:30 AM revealed an account of the incident written by the Administrator. Only 2 witnesses were listed . During an interview with the Administrator on 12/20/18 at 8:30 AM, he/she confirmed that he/she did not get a written witness statement from either of the two witnesses involved. He/she also confirmed that no statements were obtained from the other staff working on the unit at the time of the incident. There was also no interview statement from the resident who was interviewable. Review of the facility Leadership Policies and Procedures for Abuse, Neglect, Exploitation, or Mistreatment under Component VI: Investigation: #5 Written summaries of individuals having first hand knowledge of the incident. Designated facility staff will interview the staff and the interviewer will record all witness accounts in a document, written, dated, and signed by the interviewer. No document was submitted by the Administrator or facility staff. The Administrator thought he/she had done interviews but could not find the documentation. Resident #102 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/20/2018 at 3:00 PM, Resident #102 was noted during wound care to have bruising to her left foot, 5th toe. On X-ray the resident was noted with an acute [MEDICAL CONDITION] metatarsal neck. The resident was not ambulatory and transferred by Hoyer Lift. Resident #102 was unable to recall any injury to his/her foot. After interviewing the staff and resident, the facility was unable to determine how the fracture occurred. During the re-certification/complaint survey process, five Certified Nursing Assistants (CNAs) were interviewed related to transfer procedures. All five CNAs stated procedures for resident transfer were located in the Kiosk used by them for daily assignments. Interview with Licensed Practical Nurse (LPN) #5 and LPN #6 on 12/19/2018 at approximately 1:00 pm revealed CNAs were interviewed during the investigation and all stated that they did not bump Resident # 105's toe during care/treatment. Further interview revealed this information was not recorded. During an interview with the Abuse Coordinator, Director of Nursing, and the Administrator on 12/19/2018 at approximately 3:30 pm, it was revealed no direct care staff had been interviewed regarding how Resident #102 sustained the injury to his/her left 5th toe. Further interview verified the facility had no evidence to support that the alleged violation had been thoroughly investigated. | 2020-09-01 |
| 4002 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 550 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review and review of facility documents, the facility failed to ensure one (1) of 20 sampled residents was provided dignity in the provision of services. Resident #61 requested not to be provided care by Certified Nursing Aide (CNA) #8. Responsible nursing staff did not provide follow-up to determine the cause of Resident #61's request. CNA #8 continued to enter Resident #61's room against the resident's request. The findings included: Review of the facility's Patient's/Resident's Rights (not dated) policy noted the following: Quality of Life: You have the right to receive care from the center in a manner and in an environment that promotes, maintains or enhances your dignity and respect in full recognition of your individuality .You have the right to reside and receive care in the center with reasonable accommodations of individual needs and preferences except when your health and safety or the health and safety of other patients/residents would be endangered .You have the right to receive care, treatment and services that are adequate and appropriate and provided: d. With respect for your personal dignity and privacy. Resident #61 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #61's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had mild symptoms of depression and had no documented behavioral symptoms. Resident #61 require extensive assistive of one (1) staff person for bed mobility, dressing, toileting and personal hygiene. Resident #61 was always incontinent of bowel and bladder. Review of The Care Area Assessment (CAA) of the MDS revealed behavioral symptoms were not triggered and not moved forward to the comprehensive care plan. Review of Resident #61's Self-Care Deficit/Activities of Daily Living (ADL) care plan dated [DATE] revealed the resident had a self-care deficit due to impaired mobility and functional weakness related to [DIAGNOSES REDACTED]. Resident #61 requires staff assistance for safe completion of ADLs and mobility devices. The facility initiated a Mood State care plan on 1/15/2020 which noted: Resident #61 has signs and symptoms of mood distress as evidence by verbalizing feeling down, depressed, or hopeless. One approach was to report signs and symptoms of isolation (sad, dull affect, withdrawn, inattention to self-care, etc). Review of the facility's Grievance Log from [DATE] through present revealed there were no grievances submitted by (or on behalf of) Resident #61. Interview on 1/13/2020 at 1:52 PM with Resident #61 revealed the resident recently had a conversation with CNA #8 which caused the resident to no longer receive care from the aide. Resident #61 said a couple of weeks prior, the resident told CNA #8 that (the resident) felt as if the aide did not want to provide care to him/her. According to the resident, the aide responded and told Resident #61 You can't tell me how to feel! Resident #61 said to the aide I'm telling you how I feel. The resident then told the aide he/she felt uncomfortable and preferred not to be cared for by CNA #8. After the incident, CNA #8 no longer provided (Resident #61) personal care; however, Resident #61 said the aide continued to come into the room to care for the roommate which made Resident #61 uncomfortable. The resident thought nursing staff was going to address that part as well (regarding the aide coming into the room). Resident #61 said CNA #8 came into the room earlier on 1/13/2020 to care for the roommate and the aide was slamming doors near Resident #61's side of the room. Interview on 1/13/2020 at 2:30 PM with Resident #61's Registered Nurse/House Supervisor (RN/HS) revealed that CNA #8 reported to the RN/HS that Resident #61 did not want to work with staff of a different gender. The RN/HS did not follow up with Resident #61 to find out from the resident why he/she did not want to be cared for by CNA #8. A follow-up interview was conducted on 1/15/2020 at 10:00 AM with Resident #61 revealed the resident reported the incident to nursing staff. The resident did not give a specific name (regarding who the incident was reported to); however, the resident stated, they all knew about it - I was talking about it to all of them (referring to nursing staff). In another interview on 1/15/2020 at 10:12 AM with RN/HS revealed the nurse reported Resident #61's preference of not wanting to be provided care by CNA #8 was reported to the facility's Social Worker (SW) and the facility's Administrator on 1/14/2020. The SW and Administrator were informed that Resident #61 did not want to receive care from an aide of a different gender. The RN/HS said CNA #8 would not be going back into Resident #61's room. The RN/HS did not follow-up with Resident #61 to find out from the resident why he/she did not want to receive services from CNA #8. Interview on 1/15/2020 at 10:47 AM with CNA #8 revealed that about two (2) weeks ago, the aide was assisting Resident #61 with care and because the aide did not hold a conversation with Resident #61, the resident did not want to be provided care by the aide anymore. CNA #8 said he/she wasn't rude with Resident #61, but the resident had aides who the resident preferred to receive care from. CNA #8 said RN/HS was informed of the resident's request and the RN/HS told the aide not to provide care to Resident #61; however, the aide could provide care for Resident #61's roommate. CNA #8 said Resident #61 told other nursing staff about the preference of not wanting to receive care from CNA #8. The aide said Resident #61 did not make a formal complaint about it, and CNA #8 said he/she was able to provide care to Resident #61's roommate; and was also able to deliver meal trays to Resident #61 in the room. CNA #8 said, I just can't provide personal care. Interview with the facility's Administrator on 1/16/2020 at 10:36 AM revealed the Administrator became aware of Resident #61's concern with the aide when the RN/HS informed him/her of it earlier in the week. The Administrator was informed that Resident #61 did not want to receive care from an aide of a different gender. The Administrator said there was an expectation for the RN/HS to follow-up on most resident concerns to find out the reasons for the resident's report feeling uncomfortable. However, the Administrator stated, Resident #61 was very independent and very communicative, and would tell staff when there was a problem; therefore, nursing did not need to follow-up because the resident had no problem with telling people what (his/ her) problem is. The Administrator did not indicate whether the RN/HS should or shouldn't have followed up with Resident #61 to ensure the resident was comfortable in his/her room. | 2020-09-01 |
| 4008 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 692 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review and review of facility policy, the facility failed to initiate approaches to prevent further weight loss for one (1) of 20 sampled residents (Resident #66). Resident #66 had a 4.4% weight loss in 10 days and the Nurse Practitioner and Registered Dietician recommendations to address the weight loss were not initiated. The findings were: Review of the facility's Weight Monitoring Program last revised 6/13/18 noted residents who experience significant weight loss will be weighed weekly and reviewed weekly for a minimum of four (4) weeks until weight is stable or increasing .A significant weight change is identified as: 5% weight loss or gain in one month; 7.5% weight loss or gain in three months; and 10% weight loss or gain in six months .All disciplines should be aware of all patients/residents who are on a weight monitoring program. Resident #66 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #66's Quarterly Minimum Data Set (MDS) assessment dated [DATE] noted the resident was severely cognitively impaired and required total assistance of staff for eating. According to the assessment the resident was 58 inches in height and weighed 112 pounds (lbs), during the assessment period. Review of Resident #66's Nutrition care plan dated [DATE], Resident #66 was at risk for decline in nutritional status related to increased nutrient needs for wound healing, dependent on staff for feeding, has poor appetite and low [MEDICATION NAME] with [DIAGNOSES REDACTED]. Approaches - follow colored napkin protocol; provide supplements as ordered; provide diet as ordered; ST (speech therapy) to evaluate and treat per physician's (MD) order; weigh and observe result, notify MD/IDT (interdisciplinary team) of significant weight changes. Review of Resident #66's History & Physical (H&P) dated 9/18/19 noted that the resident entered the facility with severe protein malnutrition. Review of Resident #66's Nutrition 14-Day assessment dated [DATE] revealed the resident weighed 112 lbs and was ordered a pureed diet, may have mechanical soft items upon request per speech evaluation. Review of Resident #66's weights revealed the following: 1[DATE] - 113 lbs 12/31/19 - 108 lbs 1/12/20 - 108.2 lbs Review of Resident #66's Progress Notes revealed there was no documentation that the resident's physician was notified of the resident's significant weight loss on 12/31/19. Review of Resident #66's Physician's Progress Notes revealed the following: [DATE] (late entry on 12/29/19) - weight loss - increase 2.0 supplement to 120 ml tid (three times a day) & weekly weights Review of the Registered Dietician (RD) Progress Note on [DATE] noted Resident #66's weight down 4.4% in 10 days, significant weight change.Resident admitted with [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. 1/13/20 - Regular, Puree diet 9/24/19 - Standard 2.0 [AGE] milliliters (ml) by mouth (po) three times per day (tid) 9/24/19 - [MED] 30 ml give 30 ml po twice per day (bid) for nutritional supplement Interview on 1/15/20 at 3:35 PM with Registered Nurse/House Supervisor (RN/HS) revealed that the Nurse Practitioner (NP) or MD left information (orders and recommendations) in a book at nurses' station. RN/HS stated it was more likely that the NP verbally communicated to nursing staff the order to increase the resident's supplement & increase obtaining weights. When asked how the RD's recommendations received follow-up action, the nurse said the RD completed a Recommendation Note and left it at the nurse's station for follow-up. RN/HS confirmed that this information was not followed up on and the resident was still receiving Standard 2.0 [AGE] ml tid instead of Standard 2.0 120 ml tid. The nurse also confirmed that according to documentation, Resident #66 was being weighed weekly. Interview on 1/16/2020 at 9:30 AM with the facility's RD confirmed the resident had experienced significant weight loss recently due to having a urinary tract infection. The RD said when a recommendation was made, a Recommendation Note was completed and forwarded to the Unit Manager for follow-up to discuss the recommendation with the doctor and then an order was initiated. The RD was not aware that the recommendation to increase the Standard 2.0 [AGE] ml tid to 120 ml tid had not been initiated. The RD follows up to see if recommendations are implemented when (weekly) weights are checked. The RD was not sure if Resident #66 was being weighed weekly. Interview on 1/16/2020 at 11:08 AM with the Director of Health Services (DHS) stated the NP should have written an order when the progress note was written. The DHS said it was expected for the NP and/or physician to discuss assessments with the nursing staff and to at least give a verbal order. Regarding the RD, the medical director should look at the RD's recommendation and then a written order should be initiated if the doctor agrees with the recommendation. The DHS confirmed that the NP and RD recommendations should have been given follow-up and an order initiated to address Resident #66's significant weight loss. | 2020-09-01 |
| 2631 | THE RIDGE REHABILITATION AND HEALTHCARE CENTER, LL | 425293 | 226 WA REEL DRIVE | EDGEFIELD | SC | 29824 | 2019-12-12 | 600 | D | 1 | 0 | YLVU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review, and facility policy review, the facility failed to ensure four (4) of 34 sampled residents (Residents #7, Resident #8, Resident #9, and Resident #10) were free of sexual abuse. Resident #7 sexually assaulted Resident #8 while she slept in her wheelchair. Resident #10 was found sexually assaulting Resident #9. The facility did not assess the residents' capacity to consent to sexual activity. The findings included: Review of facility Abuse Prevention policy revised August 2019 revealed Verbal, sexual, physical, and mental abuse, corporal punishment, neglect and involuntary seclusion of the resident, resident exploitation, as well as misappropriation of resident property, are prohibited. 1. Review of Resident #7's face sheet dated 12/12/19 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE], prior to the incident, indicated he was understood by others and usually understood others. The assessment indicated he had no impairment to his cognition with a Brief Interview of Mental Status (BI[CONDITION]) score of 14 out of 15. The assessment did not indicate he had any negative behaviors towards others in the past 14 days. Review of Resident #7's comprehensive care plan revised 6/25/18 revealed Resident #7 had a history of [REDACTED]. Interventions included to have the resident on one to one monitoring (tapered off 7/3/18), resident to be placed on Behavior Management Program, for staff to help him understand why the behavior was inappropriate, a psychiatric consult as ordered. Review of Resident #8's face sheet dated 12/12/19 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's MDS dated [DATE], prior to the incident, indicated she was usually understood and sometimes understands others. She was assessed as having impaired cognition (BI[CONDITION] score of 3 out of 15). The assessment did not indicate she had any negative behaviors towards others in the past 14 days. Review of Resident #8's comprehensive care plan revised 3/19/18 revealed Resident #8 had a history of [REDACTED]. Review of facility incident dated 8/23/18 revealed Certified Nursing Assistants (CNA) #4 and #12 witnessed Resident #7 wheel up to Resident #8, who was in her wheelchair in the television area. CNAs #4 and #12 witnessed Resident #7 stroke Resident #8's thigh and groin area. CNA #12 wrote in her statement that Resident #7 was patting between his legs and saying he wanted some (name for female genitalia). In an interview on 12/12/19 at 8:57 a.m. with CNA #12 revealed she saw Resident #7 wheel himself to the television room, where Resident #8 was asleep in her wheelchair. She said she saw Resident #7 put his hand on her thigh and upper leg area near her groin. CNA #12 said she went to Resident #8 and removed her from the television room. CNA said because Resident #8 was asleep she probably didn't realize it happened. In an interview on 12/12/19 at 9:05 a.m., the Administrator said the facility investigation substantiated the incident, that it was witnessed and did happen. 2. Review of Resident #9's face sheet dated 12/12/19 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's MDS dated [DATE], prior to the incident, revealed Resident #9 sometimes understood others and was usually understood by others. She had impaired cognition (BI[CONDITION] score of 1 out of 15 with disorganized thinking). The MDS did not indicate she had any socially inappropriate behaviors directed toward others in the previous 14-day period. Review of Resident #9's comprehensive care plan revised 1/7/19 revealed she had a history of [REDACTED]. Review of Resident #10's face sheet dated 12/12/19 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's MDS dated [DATE], prior to the incident, revealed he understood others and was understood by others. He had impaired cognition (BI[CONDITION] score of 9 out of 15) and had not had any socially inappropriate behaviors in the prior 14-day period. Review of Resident #10's comprehensive care plan did not reveal any behavioral issues prior to the incident. Review of facility incident dated 3/13/19 revealed on 3/8/19, Registered Nurse (RN) #1 heard a chair alarm and call bell going off in Resident #9's room. When RN #1 entered the room, she found Resident #9 and Resident #10 engaged in sexual activity. The facility investigation determined the incident was substantiated and did occur. In an interview on 12/12/19 at 12:28 p.m., RN #1 stated she heard a chair alarm and call bell go off and wanted to make sure Resident #9 hadn't fallen. She stated she opened the door and found Residents #9 and #10 engaging in a sexual activity, with Resident #9 unclothed and Resident #10's head between her legs. RN #1 stated Resident #10 looked surprised and immediately jumped up when she walked in, but Resident #9 did not appear upset. She said Resident #9 and Resident #10 would call each other boyfriend and girlfriend, but she had not seen them engaged in this kind of activity before. In an interview on 12/11/19 at 5:06 p.m., the administrator said the facility had not done interdisciplinary assessments of any of the residents' capacity to consent to sexual activity. He said Resident #8 probably could not consent to sexual activity because her BI[CONDITION] score was so low, but there was no assessment done for any resident. He said there was no formal policy written down to determine the capacity for a resident to consent, whether they had cognitive impairment or not. | 2020-09-01 |
| 2632 | THE RIDGE REHABILITATION AND HEALTHCARE CENTER, LL | 425293 | 226 WA REEL DRIVE | EDGEFIELD | SC | 29824 | 2019-12-12 | 607 | E | 1 | 0 | YLVU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, clinical record review, and review of facility policy, the facility did not ensure the Abuse Prohibition and Abuse Investigation Policy contained required information regarding investigating sexual abuse for 4 of 6 residents (Residents #7, #8, #9, and #10) reviewed for sexual abuse allegations. Resident #7 sexually assaulted Resident #8, and Resident #9 and #10 were engaged in sexual activity. The facility abuse policy did not contain information how to investigate each resident's capacity to consent to sexual activity. The findings included: Review of the facility Abuse Prohibition policy and the facility Abuse Investigations policy, both revised August 2019, revealed there was no information related to investigating a resident's capacity to consent to sexual activity in a resident to resident alleged sexual abuse incident. Review of facility incident dated 8/23/18 revealed CNAs #4 and #12 witnessed Resident #7 wheel up to Resident #8, who was in her wheelchair in the television area. CNAs #4 and #12 witnessed Resident #7 stroke Resident #8's thigh and groin area. CNA #12 wrote in her statement that Resident #7 was patting between his legs and saying he wanted some (name for female genitalia). Review of facility incident dated 3/13/19 revealed on 3/8/19, RN #1 heard a chair alarm and call bell going off in Resident #9's room. When RN #1 entered the room, she found Resident #9 and Resident #10 engaged in sexual activity. The facility investigation determined the incident was substantiated and did occur. In an interview on 12/11/19 at 5:06 p.m., the administrator stated there was no formal written policy to determine the capacity for a resident to consent to sexual activity, whether they had cognitive impairment or not. Review of Centers for Medicare and Medicaid Services State Operations Manual Appendix PP F[AGE]0, revised 11/22/17, revealed When investigating an allegation of sexual abuse, the facility must conduct a thorough investigation to determine the facts specific to the case investigated, including whether the resident had the capacity to consent and whether the resident actually consented to the sexual activity. A resident's voluntary engagement in sexual activity may appear to mean consent to the activity; in these instances, if the facility has reason to suspect that the resident may not have the capacity to consent, the facility must protect the resident from potential sexual abuse while the investigation is in progress. Determinations of capacity to consent depend on the context of the issue and one determination does not necessarily apply to all decisions made by the resident. For example, the resident may not have the capacity to make decisions regarding medical treatment but may have the capacity to make decisions on daily activities (e.g., when to wake up in the morning, what activities to engage in). Determinations of capacity in this context are complex and cannot necessarily be based on a resident's [DIAGNOSES REDACTED]. Decisions of capacity to consent to sexual activity must balance considerations of safety and resident autonomy, and capacity determinations must be consistent with State law, if applicable. The facility's policies, procedures and protocols, should identify when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded. | 2020-09-01 |
| 2593 | WHITE OAK ESTATES | 425290 | 400 WEBBER ROAD | SPARTANBURG | SC | 29302 | 2019-12-15 | 578 | D | 1 | 1 | WN1111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation and record review, the facility failed to ensure information on formulating an Advanced Directive was discussed with a resident. This affected one out of two sampled residents reviewed for Advanced Directives (Resident #49). The findings included: Review of the clinical record revealed an admission history form dated [DATE]. The admission history documented Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly minimum data set ((MDS) dated [DATE] documented that the resident had no memory impairment. On [DATE] at 3:06 PM, Resident #49's medical record was reviewed. An Advanced Directive could not be located within the medical record. Resident #49's code status could not be located within her medical record. On [DATE] at 11:41 AM, the Nursing Home Administrator (NHA) was interviewed. She stated, we have advanced directive information in the admission packet. Staff are available to assist if someone wants advanced directive information. The resident or their responsible party would be referred to Social Services. If we are notified by admissions, we would give the paperwork for the advanced directives. The admission coordinator asks if there was a living will or healthcare power of attorney. If there was one, we would ask for a copy to be brought in and placed in the medical record. If there isn't one, but they would like more information, we refer them over to Social Services. The admission's coordinator doesn't have any document that is filled out to show they asked besides the signed acknowledgement form that the resident received the admission packet. The admission packet explains about living wills and healthcare power of attorney. On [DATE] at 3:05 PM, Resident #49 was interviewed. Resident #49 stated that she's been at the facility for 3 years and the only thing that they had asked her was if she wanted chest compressions/CPR. She was not aware that she could make her own decisions about feeding tubes, antibiotics, ventilator and any other life sustaining choices. She thought that she could only chose between getting CPR and not getting CPR. Resident #49 stated that she'd like to have an Advanced Directive so that when the time came, her daughter (her designated power of attorney) would know exactly what her wishes were. On [DATE] at 3:52 PM, the Admissions Director was interviewed. She stated, I go through the admission handbook at the end of the admission conference. We talk about the power of attorney and the living will. If the resident says they have one, I ask for a copy. If the resident wants information, I refer them to the social worker. Sometimes, in the quarterly care plan , we will ask again if the resident had not provided any of the documents. I don't put that detail in my notes. The Admissions Director stated that neither requests for information about Advanced Directives or declining to create the advanced directive were documented meetings. On [DATE] at 10:38 AM, the Social Services Director (SSD) was interviewed. The SSD stated, we talk about a resident's code status and if they have a healthcare power of attorney. We go over that with every new admission. I have advanced directive and healthcare power of attorney documents we can provide. We just can't witness them. We complete a social history on admission, and they are asked if they have an advanced directive or healthcare power of attorney. If they do, I ask for them to provide a copy. I have a form I complete in the computer. It's a check off if they have one. If they don't have one, I ask if they are interested in getting a living will or healthcare power of attorney. If they ask for information, I document that I gave it to them. If they decline to take information, I don't document the discussion. If they say they have the paperwork, but don't have it with them, we ask them to bring it in. We would ask again for the paperwork at the quarterly care plan meeting. We would discuss advanced directives again in that quarterly care plan meeting. If they decline again, there wouldn't be any documentation. | 2020-09-01 |
| 301 | J F HAWKINS NURSING HOME | 425035 | 1330 KINARD STREET | NEWBERRY | SC | 29108 | 2017-05-11 | 282 | E | 1 | 1 | X7DC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review the facility failed to follow the care plan for 1 of 5 residents reviewed for unnecessary medications, 2 of 4 reviewed for pressure ulcers, and 2 of 6 residents randomly reviewed for transfers. Resident #70's care plan was not followed with regards to blood sugar, blood pressure, and constipation. Resident #70 and Resident #113 were not positioned as care planned. Residents #101 and #118 were not transferred per care plan. The findings included: Review of transfer assessment for Resident #101 on 5/11/17 at approximately 10:10 AM revealed that the resident required a full body lift with a medium-sized sling assisted by 2 caregivers. Review of the transfer assessment for Resident #118 on 5/11/17 at approximately 10:10 AM revealed that the resident required a full body lift with a small-sized sling assisted by 2 caregivers. Interview with Certified Nursing Assistant (CNA) #3 on 5/11/17 at approximately 10:22 AM revealed that s/he used a large-sized sling when transferring resident #101. When asked if s/he needed to consult the CNA Care Sheet, s/he said no because s/he knew. The CNA stated Resident #101 had gained weight, and the CNA had been using a large-sized sling during transfer to compensate. S/he continued that s/he had not alerted a nurse that the resident may require reassessment. The CNA left during the interview, and s/he returned to state that s/he was mistaken and had only used a large-sized sling once. Interview with CNA #3 on 5/11/17 at approximately 10:22 AM revealed that the CNA did not use a sling or lift to transfer Resident #118 because the resident can pivot weight. When asked about the assessment stating the resident required a lift with a small sling and 2 caregivers for transfer, the CNA stated that the resident was incorrectly assessed and that it depended on her days. Review of Care Plan for Resident #118 on 5/11/17 at approximately 10:30 AM revealed that the resident requires a total lift with 2 caregivers assisting as needed. Interview with Registered Nurse (RN) #4 on 5/11/17 at approximately 10:50 AM confirmed that Resident #101 requires a full body lift with a medium-sized sling and Resident #118 requires a full body lift with a small-sized sling. S/he continued that it is expected of CNAs to follow the transfer assessment to keep residents safe, and that CNAs need to alert the nurse if a resident needs to be reassessed for transfers rather than intervening directly. Interview with the Director of Nursing (DON) on 5/11/17 at approximately 11:13 AM revealed that CNAs are required to follow assessments with respect to transfers. S/he continued that if a CNA recognizes changes in a resident transfer ability, they should inform the nurse so the resident can be reassessed. The facility admitted Resident #113 with [DIAGNOSES REDACTED]. Review of the Skin Pressure Ulcer Assessment tool on 5-11-17 revealed the resident was at risk for pressure ulcers. The 2-13-17 Quarterly Minimum Data Set (MDS) assessment noted that the resident required extensive assistance of 2 persons for bed mobility and was at risk for developing pressure ulcers. No behaviors were coded for rejection of care. Record review on 5/10/2017 at 8:48 AM revealed a current physician's orders [REDACTED]. Review of the Care Plan on 5-11-17 at 9:27 AM revealed Focus areas of Pressure ulcer. Alteration in skin integrity R/T (related to) pressure wound to (R)ight heel and Risk for alteration in skin integrity R/T cognition, medication . Interventions included to encourage/assist to offload heels as much as resident will comply and encourage/assist to turn and reposition every 2 hours and PRN (as needed) as much as resident will comply. Multiple observations revealed Resident #113 laying on his/her back (on 05/08/2017 at 11:18 AM, 2:46 PM, 3:25 PM; on 05/09/2017 at 8:34 AM, 9:53 AM, 10:25 AM; on 05/10/2017 at 10:08 AM, 11:37 AM, 12 PM, 1:00 PM, 2:20 PM, and 4:20 PM) without heels floated. Review of Nurses Notes on 5-11-17 at 11:02 AM revealed no evidence of care refusal. During an interview and observation on 05/11/2017 8:36 AM, Certified Nursing Assistant (CNA) #5 confirmed that Resident #113's heels were not floated and there was no pillow in the bed. During an interview on 5-11-17 at 11:14 AM, CNA #5 reviewed and confirmed the computerized Kardex/care plan with instructions to encourage to float heels as much as resident will comply and encourage/assist to turn and reposition every 2 hours and PRN (as needed) as much as resident will comply. When asked about procedure to follow if the resident refused care, the CNA stated s/he would report to the nurse. The facility admitted Resident #70 with the [DIAGNOSES REDACTED]. Review of the 3-13-17 Quarterly Minimum Data Set (MDS) assessment revealed that the resident required extensive assistance of 1 person for bed mobility and was at risk for developing pressure ulcers. No behaviors were coded for rejection of care. Record review on 5-9-17 at 3:04 PM revealed a current physician's orders [REDACTED]. Review of the current Care Plan on 5-11-17 at 10:02 AM revealed a Focus of Risk for alteration in skin integrity R/T (related to) diagnoses, incontinence, mobility status, . skin desensitized to pain /pressure, [MEDICAL CONDITION], hx (history) impaired skin integrity, [MEDICAL CONDITION]. Interventions included to encourage/assist to turn and reposition every 2 hours and PRN as much as resident will comply and encourage to float heels as much as resident will comply. Multiple observations revealed Resident #70 laying on his/her back (on 05/10/2017 at 10:07 AM, 11:33 AM, 11:55 AM, 12:05 PM, 1:00 PM and 2:20 PM) without heels floated. Review of Nurses Notes on 5-11-17 at 11:32 AM revealed no evidence of care refusal. During an interview on 05/11/2017 at 11:32 AM, Registered Nurse #6 stated that turning and positioning is standard every 2 hours and should be documented per the CN[NAME] Continued review of the Care Plan on 5-11-17 at 10:27 AM revealed Focus areas of [MEDICAL CONDITION]-risk for complications R/T HTN, hypomagnesium, [MEDICAL CONDITION] and Risk for constipation R/T immobility, medication . Interventions included to check vital signs as ordered and PRN (as needed), observe for bowel movements, and administer medications as ordered-see MAR (Medication Administration Record) for specific instructions. Record review on 5/11/2017 at 10:36 AM revealed a physician's orders [REDACTED]. Review of the Medication Administration Records and BM (Bowel Movement) Report on 05/11/2017 at 10:50 AM revealed no documented bowel movements between 2/24/2017 and 3/3/2017 with no evidence of intervention. During an interview on 5/11/2017 at 11:32 AM, Registered Nurse (RN) #4 reviewed and confirmed the physician's orders [REDACTED]. RN #4 confirmed that the resident had an order for [REDACTED]. Additional review revealed physician's orders [REDACTED]. physician's orders [REDACTED]. The BP (Blood Pressure) was not monitored at least weekly for long term use of anti-hypertensives. Review of nursing notes and vital signs on 5/11/2017 at 11:05 AM revealed that the BP had not been done as ordered. There were no documented blood pressures for (MONTH) or May, (YEAR). During an interview on 05/11/2017 at 11:32 AM, Registered Nurse (RN) #4 was unable to locate the weekly blood pressure results. | 2020-09-01 |
| 1130 | SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2020-01-15 | 656 | D | 1 | 0 | 62ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, policy review, and medical record review, it was determined the facility failed to ensure that the care plan was followed for 1 of 19 sampled residents (Resident #16). On [DATE] Certified Nurse Aide (CNA) #3 and CNA #4 transported Resident #16 back to his/her room. CNA #3 and CNA #4 stated although Resident #16 was a mechanical lift for transfer, they transferred Resident #16 back to bed without using a mechanical lift by supporting Resident #16's legs and back. Findings include: The Face Sheet, located in the Electronic Medical Record (EMR) stated Resident #16 was admitted to the facility on [DATE] and his/her [DIAGNOSES REDACTED]. An The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], located in the EMR stated Resident #16 had significant cognitive impairment and had not been transferred out of bed. Review of the Nurse Aide's Information Sheet that was undated, located in the EMR stated Resident #16 was confused and required a mechanical lift with two persons for transfer. During an interview with the Assistant Director of Nurses (ADON) on [DATE] at 12:30 PM, he/she stated a mechanical lift was to be used for residents who were not able to weight bear. The ADON stated Resident #16 was not able to weight bear and a mechanical lift and two staff were to be used for any transfers. The ADON stated Resident #16 was rarely out of bed. The Safe Lifting and Handling of Residents policy, dated July 2019, stated that staff lifting of residents shall be eliminated when feasible. A lift assessment should be completed on admission, quarterly, and annually, or with significant change. The Nursing Lift Evaluation Form, dated 11/4/19, located in the EMR stated Resident #16 was non weight bearing and was a full lift transfer. During an interview with CNA #1 on [DATE] at 2:30 PM and with CNA #2 on [DATE] at 9:28 AM, they stated prior to [DATE], Resident #16 had not requested they transfer him/her out of bed. CNA #1 and CNA #2 stated that on [DATE], Resident #16 requested to be transferred out of bed. CNA #1 and CNA #2 stated Resident #16 required a mechanical lift for transfers. CNA #1 and CNA #2 stated that on [DATE], they used the mechanical lift and transferred Resident #16 to a recliner chair. CNA #1 and CNA #2 said they left the lift pad under Resident #16. During an interview with CNA #3 on 01/14/20 at 2:48 PM and with CNA #4 on [DATE] a 12:59 PM, they stated on [DATE], they transported Resident #16 back to his/her room. CNA #3 and CNA #4 said although Resident #16 was a mechanical lift for transfer, there was no lift pad under Resident #16. CNA #3 and CNA #4 said they did not notify the nurse and they both carefully transferred Resident #16 back to bed, supporting Resident #16's legs and back. CNA #3 and CNA #4 said the transfer was smooth, Resident #16 did not bump his/her leg, and had no signs of pain. During an interview with the Director of Nurses (DON) on [DATE] at 1:35 PM, the DON stated Resident #16's Nursing Lift Evaluation Form, dated 11/4/19, stated the staff were to use a mechanical lift when transferring Resident #16. The DON confirmed that on [DATE] during the evening shift, CNA #3 and CNA #4 transferred Resident #16 back to bed with two staff and did not use the mechanical lift. | 2020-09-01 |
| 1131 | SIMPSONVILLE REHABILITATION AND HEALTHCARE CENTER, | 425112 | 807 SOUTH EAST MAIN STREET | SIMPSONVILLE | SC | 29681 | 2020-01-15 | 657 | D | 1 | 0 | 62ZU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and policy review it was determined the facility failed to revise care plan interventions for 1 of 19 sampled residents, (Resident #5). Resident #5 was discovered engaging in a sexual activity with Resident #6 on 10/14/19. The facility separated the residents, called the police and prohibited the two residents from visiting privately the rest of the evening. Findings include: Review of Resident #5's face sheet, located under the Profile tab of his/her Electronic Medical Record (EMR) revealed an admission date of [DATE] and a [DIAGNOSES REDACTED]. Review of Resident #5's Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 08/30/19, located under the MDS tab of the EMR, revealed he/she had a Brief Interview of Mental Status (BI[CONDITION]) score of 14, indicating he/she was cognitively intact. Review of Resident #5's care plan, located in the EMR, documented a focus area for an alteration in mood state initiated on 09/07/17. On 10/12/18 the focus area was amended to include, . resident prefers to engage in sexual activity with other residents. A new intervention of, resident will be redirected when inappropriate behavior is noted, was added on 10/12/18. Review of Resident #5's Interdisciplinary Team (IDT) progress notes, located under the Prog Notes tab of the EMR, revealed Resident #5 was discovered engaging in a sexual activity with another resident on 10/14/19 at 7:41 PM. Further review of the IDT notes revealed the residents were separated, the police were called, and the residents were prohibited from visiting privately the rest of the evening. Review of Resident #5's clinical record revealed a Death in Facility Tracking Record which documented she passed away on [DATE], thus was unavailable for observation or interview during the survey. An interview with the Social Services Director (SSD) on 01/14/19 at 10:45 AM revealed he/she had been informed that it was Resident #5's right to be sexually active and it was commonplace for the resident to exercise that right. The SSD stated Resident #5 initially had a visitor from the community with whom he/she was intimate in the facility, then became active with other residents. The SSD stated he/she was not sure why staff intervened the way they did when the event was discovered, based on Resident #5's known history. The SSD agreed Resident #5's preference to engage in sexual activity should have been included on his/her care plan. An interview with the psychologist (Phy. D.) on 01/14/20 at 11:00 AM revealed he/she engaged in regular treatments with Resident #5 beginning in either June or July of 2019. The psychologist stated Resident #5 had consistently shown the ability to make his/her own decisions and that he/she had made his/her preference to engage in sexual activity known to the facility. The psychologist stated he/she would have expected Resident #5's preference to be documented on his/her care plan. An interview with the Administrator on 01/14/20 at 11:45 AM revealed he/she became aware of the incident the following day. The Administrator stated that Resident #5's call light had been on, and as such it had been appropriate for the Certified Nurse Aide (CNA) to enter the room. The Administrator stated it was common knowledge amongst the staff that Resident #5 had been sexually active in the past so he/she was not sure why the CNA responded the way he/she did at the time of the event. The Administrator stated Resident #5's care plan should have directed staff how to respond. An interview with the Director of Nursing (DON) on 01/14/20 revealed that he/she was not in the facility but was called when the event occurred. The DON stated if the interaction was consensual there should not have been a problem with the interaction continuing. The DON stated a care plan would have given staff direction in this instance. Review of the facility's Care Planning IDT policy, dated November 2019, revealed, . the facility must develop . a comprehensive person-centered care plan . consistent with resident rights . | 2020-09-01 |
| 2816 | LAKE EMORY POST ACUTE CARE | 425303 | 59 BLACKSTOCK ROAD | INMAN | SC | 29349 | 2019-04-25 | 607 | G | 1 | 1 | IJ5G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment the facility failed to implement the facility policy to keep residents free from abuse. Resident #188, who had a well-documented history of sexually abusive behavior, sexually abused Resident #45. On 1/2/19 Resident #188 had his/her hand on a Residents crotch area, on 1/15/19 Resident #188 was noted with his/her hand in Resident #45's pants, with his/her hand in motion and on 2/3/19 Resident #188 placed his/her hand on a resident's genitals and rubbed. Additionally, the facility failed to report abuse to the state agency and investigate incidents dated 1/2/19 and 2/3/19 involving Resident #188. The facility failed to report incidents of sexual abuse dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188 to Law Enforcement. The facility failed to investigate abuse, Resident #187 made an allegation of abuse and the facility failed to interview the staff members involved or who had knowledge of the allegations. 2 of 5 residents reviewed for abuse The findings included: Resident #188 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Initial report on 4/22/19 at approximately 3:20 PM revealed Resident #188 touched Resident #45 without permission at approximately 11 AM on 1/15/19. Review of the 5-day report on 4/22/19 at approximately 3:25 PM revealed that Resident #45 was uninjured, both Residents #45 and #188 were cognitively impaired. Resident #188 had a prior history of sexually inappropriate behavior. One of the planned interventions was to move the victim to a further room. Review of Resident #188's nursing notes on 4/23/19 at approximately 10:05 AM revealed several notes documenting a history of sexually inappropriate behavior from Resident #188. Nursing note from 1/2/19 documenting that Resident #188 had his/her hand on a Residents crotch area, and the resident was immediately removed. Nursing note on 1/15/19 revealed Resident #188 was noted by 3 employees who took immediate action with his/her hand in Resident #45's pants, with his/her hand in motion. Nursing note on 2/3/19 documenting that Resident #188 placed his/her hand on a resident's genitals and rubbed. This was witnessed by several other residents. A witness (Resident) stated, I'm scared, and started to cry. Review of Resident #188 Care Plan on 4/23/19 at approximately 10:20 AM revealed Resident #188 was care planned to be taken to a private area for self-intimacy. There was no documented interventions to protect other residents from Resident #188's history of publicly masturbating while staring at female residents and groping female residents. During an interview with LPN #6 on 4/23/19 at approximately 12:08 PM revealed that Resident #188 put his/her hand into Resident #45's pants and moved hand up and down. Residents were immediately separated and the Nurse Practitioner assessed Resident #45. The family of both residents and management were immediately notified. LPN #6 stated that Resident #188 had a history of [REDACTED]. During an interview with Housekeeper #1 on 4/23/19 at approximately 12:44 PM s/he confirmed that Resident #188 had his/her hand in the pants of Resident #45. During an interview with LPN #7 on 4/23/19 at approximately 4 PM revealed that Resident #188 had his/her hand reached down the pants of Resident #45. When LPN #7 discovered this was happening, another nurse was already separating the two. LPN #7 knew of no other instances of Resident #188 touching residents. During an interview with the Administrator and review of Resident #188 and Resident #45's charts on 4/24/19 at approximately 8:50 AM revealed neither residents changed rooms after the incident. Record review revealed there was no evidence that Law Enforcement was notified of the incidents dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188. During an interview with the Administrator on 4/23/19 at approximately 12:15 PM revealed that incidents dated 1/2/19, 1/15/19 and 2/3/19 involving Resident #188 were not reported to Law Enforcement. It was also revealed that incidents dated 1/2/19 and 2/3/19 involving Resident #188 were not reported to the State Agency. Record review revealed that the only reference to the two incidents dated 1/2/19 and 2/3/19 were located in Resident #188's nurses notes. The notes did not provide the names of the other residents involved. During an interview with Licensed Practical Nurse (LPN) #6 on 4/23/19 at approximately 12:08 PM s/he confirmed that Resident #188 had attempted to sexually assault a resident at least one other time, though s/he was unable to name the specific date. There was no evidence that the facility investigated the incidents dated 1/2/19 and 2/3/19. Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed under Policy 1. The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse . 2. The facility shall report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures .Under section III. Prevention 5. Ongoing assessment, care planning, and monitoring of those patients/residents with special needs that may lead to neglect, for example: [NAME] History of aggressive behavior; B. History of entering other patient/resident rooms; C. History of self-injury; D. Communication disorder; and/or, E. Patients/residents requiring excessive nursing care or staff attention. F. Residents with history of resident to resident altercations. Under Component V. Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator and the other officials in accordance with state law including the State Survey and Certification Agency (nurse aide registry or licensing authorities). Review of Resident #188's record revealed that the resident was discharged from the facility on 2/7/18. The facility admitted Resident #187 on 10/16/18 with [DIAGNOSES REDACTED]. A review of the facility's abuse investigation on 4/24/19 at approximately 2:20 PM revealed that Resident #187 informed the facility on 10/30/18 he/she was neglected and verbally/mentally abused by the assigned physical therapist and a certified nursing aide. Further review of the facility's investigation documentation revealed there was no documentation to indicate the alleged perpetrator was interviewed. There was also written documentation provided by Certified Nursing Aide (CNA) #1 involved in the incident that revealed there was another CNA working with the resident on the unit at the time of the incident that was not interviewed. During an interview on 4/24/19 at approximately 2:35 PM with the facility Administrator revealed during his/her investigation into the allegations of abuse/neglect he/she failed to interview the alleged perpetrator and another CNA that was named in CNA #1 witness statement. Review of the facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed under Component VI: Investigation 1. The facility maintains that all allegations of abuse, neglect, misappropriation of property, etc. are thoroughly investigated and appropriate actions are taken. 5. The investigation may include but is not limited to the following: E. Written summaries of interviews with individuals having first-hand knowledge of the incident . | 2020-09-01 |
| 4005 | PRUITTHEALTH-BLYTHEWOOD | 425400 | 1075 HEATHER GREEN DRIVE | COLUMBIA | SC | 29229 | 2020-01-16 | 677 | D | 1 | 1 | YEP811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility policy, it was determined the facility failed to provide the necessary services to provide and/or maintain activities of daily living (ADLs) related to personal hygiene and/or bathing for three (3) of 20 sampled residents (Residents #26, #34 and #68). Resident #26 requested but did not receive a shower between August 2019 and January 1, 2020. The resident was provided bed baths only. Resident #34 was assessed as extensive assistance with one (1) person for personal hygiene; however, staff failed to provide weekly showers as scheduled on Tuesday, Thursday and Saturdays. Resident #34 had not had a documented shower since 11/12/19 during the day shift. Resident #68 did not receive assistance with nail care when the resident's nails were long and jagged. The findings include: Review of the facility's Patient's/Resident's Rights (not dated) policy noted the following: Quality of Life: You have the right to: c. Make choices about aspects of your life in the nursing center that are significant to you. Review of a policy entitled Documentation: Charting Activities of Daily Living (ADLs) (reviewed 10/24/18) revealed a policy statement that it is required for ADL care given by Certified Nursing Assistants (CNAs) and nurses to be documented using the CNA ADL Flow Sheet Form. For facilities with smart charting, all documentation will be completed using the smart charting system. During interview on 1/16/2020 at 3:47 PM, the Director of Health Services (DHS) stated the facility did not have a policy for bathing a dependent resident. Resident #26 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of Resident #26's annual Minimum Data Set (MDS) Assessment, dated [DATE] revealed a brief interview for mental status score of 13, indicating the resident was independent in cognitive skills for daily decision making. Resident #26 was identified on the assessment to have no symptoms of a mood deficit and to exhibit no behavioral symptoms. When assessing the importance of being able to choose between a tub bath, shower, bed bath, or sponge bath the resident scored a five (5), indicating it was important, but can't do or no choice. The MDS Assessment for activities of daily living (ADL) functional status indicated the resident required the total assistance of two (2) staff persons with transfers, toileting, and bathing. Resident #26 was assessed to have functional limitations in range of motion to one side of upper extremities and impairment to both lower extremities. The resident was always incontinent of bowel and bladder. The resident triggered for further review of ADL functional potential and urinary incontinence, requiring the facility to conduct further assessment using the Care Area Assessment (CAA) summary process to determine risk factors and complications for consideration in the development of a care plan. Review of the CAA summary documentation for ADL functional status revealed when assessing a bathing care deficit, the facility indicated there were no mental errors or issues but has physical limitations to the point that he/she requires total care for bathing. Further review revealed an analysis of findings that specified the resident could voice needs and wishes and was encouraged to participate to best of his/her ability to maintain current ADL ability. A decision was made to proceed to the care plan. Review of the care plan (revised 11/14/19) revealed Resident #26 had a problem deficit of requiring assistance with ADL care due to weakness and impaired mobility, secondary to multiple medical issues. The goal established to address the problem deficit was for the resident to have ADL care needs met through the next review date (2/14/2020). Approaches developed to address the resident's need for total care with bathing included providing showers/bath on scheduled days, specifically, resident was to have showers on the 3:00 PM to 11:00 PM shift on Tuesday, Thursday, and Saturday. The Certified Nurses' Aide (CNA) was to notify nursing if the resident refused. Continued review of the care plan developed for Resident #26 revealed on 12/11/19 a problem deficit of behavioral symptoms was added to the care plan. The problem stated the resident resisted care on occasions, prefers to stay in his/her room, and does not want to be bothered when on the cell phone, even after calling for assistance. The goal established stated the resident would accept assistance for ADLs and not have increase in resistance thru the next review date (3/10/2020). Approaches developed to address the potential problem deficit included: Actively involve the resident in care, activities of choice. Express willingness to adjust regimen. Allow resident to choose options Would you like to bathe in the daytime or evenings?. Allow resident to have control over situations, if possible. Assess possible reasons for resisting care, attempt to resolve as able, re-approach later when resident not on phone. Reiterate the purpose and advantages of care being provided and explain possible risk of resisting care. When resident begins to resist care, STOP and try task later. Do not force the resident to do the task. Review was conducted of the Point of Care ADL Category Report form utilized by CNA staff to document when Resident #26 was provided with assistance with bathing/showering, for the months of July 1, 2019 thru January 16, 2020. The resident was documented as having received assistance with a shower on 7/29/19, 8/8/19, 8/24/19, and 9/14/19 (four showers during the six (6) and one-half month timeframe). The documentation reflected that throughout that timeframe the resident had received assistance from staff with a partial or full bed bath, two (2) to three (3) times each week. Review of physician's orders for Resident #26 revealed no specific order for the provision of ADLs for the resident, however, the orders did note the physician's review and approval of the Interdisciplinary (IDT) plan of care. Review of the Matrix Care/Care Assist form revealed documentation that reflected Resident #26 was to receive assistance with showers on the 3:00 PM to 11:00 PM shift, on Tuesday, Thursday, and Saturday. The form documented staff were to notify the nurse if the resident refused. Nursing staff indicated this was the formal document to direct the staff regarding a resident's shower time and days scheduled. However, review of a Shower List for Unit form that was kept at the nurses' station to direct CNAs for providing shower assistance revealed Resident #26 was documented to receive assistance with showers on the 7:00 AM to 3:00 PM shift. Review of progress notes for Resident #26 revealed documentation by a Registered Nurse (RN) on 8/13/19 at 4:30 PM that stated the patient was offered a shower by the CNA, patient refused due to knee pain. CNA to offer again. Review of documentation for the provision of ADLs revealed no evidence the resident was offered assistance again with showering and the documentation reflected the resident did not receive assistance with a shower on that date. A progress note dated 8/25/19 at 3:22 PM documented by a RN stated the patient was offered a whirlpool bath today. (He/She) refused this, put (his/her) finger up to stop the conversation and continued (his/her) phone call. (He/She) was offered a chance for a bath earlier today and refused around 1445 (2:45 PM). The patient stated from the earlier request No I had one yesterday. Review of the documentation revealed the resident was correct and had received assistance with a shower the previous day, on 8/24/19. Documentation by an RN on a progress note, dated 10/3/19 at 6:27 PM revealed the patient did have a shower today and did get (his/her) hair washed. This documentation did not match the Point of Care ADL Category Report form utilized by CNAs to note when the resident received assistance with a shower. However, this progress note documentation would reflect the resident had received assistance with showering on one (1) occasion during the month of October 2019. Social Services documented a progress note on 12/3/19 at 11:34 am indicating a care plan meeting had been scheduled for 12/12/19, per the resident's responsible party's request. The progress notes contained no further documentation regarding the resident's refusal or receipt of a shower for the months of July 1, 2019 thru January 16, 2020. Review of a Grievance/Complaint Form dated 12/12/19 revealed Resident #26 and his/her responsible party had filed a grievance with the facility that specified the resident and his/her responsible party verbalized during a care plan meeting that the resident had not received any showers. The form indicates the steps taken to investigate included interviewing the resident and staff. The documented summary stated Grievance confirmed. Resident regularly refuses shower. Will continue to monitor resident's shower schedule for follow through. Unit Manager agrees with assessment upon review of grievance. In addition, after speaking with the resident, he/she continues to decline CNA or nurse assistance to accept showers. Resident #26 was observed on 1/16/2020 at 11:17 AM to be lying in bed on his/her back, wearing a hospital gown. The resident was neat in appearance with no hygiene or grooming problems noted. Resident #26 was observed on 1/16/2020 at 3:18 PM and at 4:56 PM to be up in a wheelchair, in her room. The resident was appropriately dressed in street clothing. There were no hygiene or grooming problems noted during the observations. A CNA #16 was observed to be in the room during the 3:18 PM observation and indicated the resident had requested assistance with going outside to sit for a while in the sunshine. Resident #26 was observed to be pushed in the wheelchair by CNA #16 down the hallway and outside to the courtyard. Interview was conducted with Resident #26 on 1/16/2020 at 11:17 AM. Resident #26 stated the facility did not have enough staff to assist him/her (resident) with taking a shower. Resident #26 stated he/she could not remember the last time he/she had taken a shower but that it had been months. Resident #26 expressed being aware he/she was supposed to receive assistance with a shower every Tuesday, Thursday, and Saturday. However, according to Resident #26 the staff always tell him/her that because he/she (resident) requires two (2) staff assistance with a shower there is never a second person available to assist. The staff person assigned to help him/her will tell him/her that he/she will receive a good bed bath instead. Resident #26 stated staff did give a very thorough bed bath most times but he/she (resident) misses being able to get in a shower and have his/her hair and body washed good. Resident #26 stated his/her responsible party had contacted the Social Worker several weeks ago to request a special meeting to discuss the concern of the resident not receiving assistance with a shower as scheduled. Resident #26 stated the meeting did take place with his/her responsible party on a conference call. The facility told the Resident's responsible party the resident had been refusing to take a shower. Resident #26 stated they told his/her responsible party it was documented. Resident #26 stated he/she told them he/she did recall one time when he/she had not felt like taking a shower when offered and the staff person who offered had told him/her he/she (staff person) was going to report him/her for refusing. Resident #26 stated during the meeting it was decided that since there might not be enough staff available on the 3:00 PM to 11:00 PM shift to assist with a shower, the resident's shower time would be changed to the 7:00 AM to 3:00 PM shift. Resident #26 stated he/she had agreed to the change. Resident #26 stated however, since the meeting no one had offered to assist him/her with a shower on either the 7:00 AM to 3:00 PM shift or the 3:00 PM to 11:00 PM shift. According to the resident, during the care plan meeting his/her responsible party had decided to file a grievance regarding Resident #26 not receiving assistance with receipt of a shower. Interview was conducted on 1/16/2020 at 11:20 AM with the CNA #15 assigned to provide care for Resident #26. CNA #15 was starting to enter the resident's room. The CNA stated he/she did not know what the resident's shower schedule was and although the current day was Thursday (a scheduled shower day for Resident #26), the CNA stated he/she was going into the resident's room to provide a bed bath. Interview was conducted on 1/16/2020 at 11:40 AM with the RN House Supervisor. When questioned regarding Resident #26 not receiving assistance with a shower as scheduled and planned on the care plan, the RN House Supervisor stated the resident would refuse to take a shower. A request was made for the RN House Supervisor to provide documentation for the past four (4) months of evidence to show Resident #26 refused assistance with a shower every Tuesday, Thursday, and Saturday as scheduled. The RN House Supervisor stated the documentation should have been in the progress notes. The RN House Supervisor presented a copy of the behavioral symptoms care plan which was developed on 12/11/19, the day before the resident and responsible party had filed a grievance regarding the facility's failure to provide staff assistance with showers. Interview was conducted on 1/16/2020 at 2:43 PM with the MDS Coordinator. The MDS Coordinator stated he/she was not aware of Resident #26 refusing assistance with showers until the last care plan meeting (12/12/19) when the resident and his/her responsible party reported a concern with staff not giving the resident a shower. The MDS Coordinator stated the resident indicated there had been an occasion when he/she (resident) was on the phone and staff came to take him/her to the shower. The resident reported staff did not come back later to offer a shower. According to the MDS Coordinator the Unit Manager was present at the meeting and was supposed to look at changing the shift on which the resident received a shower to help resolve the problem. The MDS Coordinator did not know if the change had occurred. Interview was conducted on 1/16/2020 at 4:30 PM with the Social Worker (SW) assigned to provide services for Resident #26. The SW stated he/she was not aware of the resident refusing or not receiving assistance with showers until the care plan meeting (12/12/19) when the resident and his/her responsible party had reported a concern. According to the SW if there was an on-going problem with the resident refusing showers staff would have reported it to social services as a potential psychosocial well-being need to be addressed. No staff had reported the refusals to social services. The SW stated he/she had documented a grievance/complaint form on behave of the resident and his/her responsible party on the day of the care plan meeting and given it to the Director of Nursing Services (DNS). Review of the clinical record revealed the facility admitted Resident #34 on 11/30/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 8/2/19, revealed the facility assessed Resident #34's cognition as intact with a Brief Interview of Mental Status (BI[CONDITION]) score of fourteen (14) which indicated the resident was interviewable. Further review of the MDS assessment, revealed the resident was assessed as extensive assistance of one (1) person with personal hygiene, limited range of motion (LROM) of bilateral upper and lower extremities and occasional incontinence of bladder and frequently incontinent of bowel. Additionally, review of the Annual MDS dated [DATE] revealed Resident #34 stated it was very important to choose a tub bath, shower, bed bath, or sponge bath while at the facility. Review of the Resident #[AGE]'s Comprehensive Care Plan, dated 11/21/19, revealed an intervention to keep skin clean and dry to prevent skin breakdown and development of pressure ulcers related to decreased mobility, [MEDICAL CONDITION], decreased ROM to bilateral upper and lower extremities, incontinence and need for assistance with bed mobility. Further review of the comprehensive care plan revealed an intervention to assist with Activities of Daily Living (ADLs) as needed. Review of Resident #34's Certified Nursing Aide Care Plan, dated 11/21/19, revealed an intervention to assist with ADL care as needed. Review of the Shower List for the Transitional Care Unit (TCU), not dated, revealed Resident #34 was to receive a shower on Tuesday, Thursday and Saturdays during the 3-11 PM shift. Review of Resident #34's shower documentation on the ADL Report, revealed from [DATE] to 12/31/19, the resident should have received twenty-six (26) showers; however, documentation revealed Resident #34 received one (1) shower, on 11/12/19. The CNAs documented the resident received bed baths on thirty-two (32) days and staff did not document the resident had refused or was ill on any scheduled shower day. Interview with Resident #34 on 1/13/2020 at 3:18 PM, revealed he/she is supposed to get showers three times a week, he/she wants one (1) shower a week but staff gave him/her bed baths instead of showers. Further interview revealed that he/she hasn't had a shower in over a month and when the shower day came, the staff stated that they are short staffed and don't have time to give her/him a shower. Interview with the Certified Nursing Assistant (CNA) #4 on 1/15/2020 at 1:08 PM, revealed that he/she worked the day shift from 7:00 AM to 3:00 PM and wasn't assigned to provide Resident #34 showers for he/she was listed to receive showers on Tuesday, Thursday and Saturday during the 3:00 to 11:00 PM shift according to the Shower List. He/she further stated that he/she documented baths and showers provided to residents in the CNA kiosk under the bathing tab. CNA #4 stated that the day shift is often short staffed and doesn't have enough help to get him/her work done. Interview with Licensed Practical Nurse (LPN) #3, on 1/16/2020 at 2:08 PM, revealed residents are assigned showers from Monday through Saturday during the day and evening shifts. He/she stated that if a resident wants a shower, whether the resident really needs one or not, the CNA should give the resident a shower. LPN #3 further stated that if the CNA can't provide the shower, then it should be reported to the nurse assigned to the hall or unit manager. Interview, on 1/16/2020 at 3:44 PM, with CNA #5, revealed that he/she worked the 3:00 to 11:00 PM shift on the 100 hall, where Resident #34 resides. He/she checked the Shower List for assigned resident showers. When he/she arrived at 3:00 PM he/she made rounds on the residents, took vital signs if needed by the nurse and on new admissions to the hall, then took residents to the dining area for dinner, then would ask the residents if they want showers. If the resident refused a shower, he/she asked two more times, then reported the refusal to the nurse so that the nurse could encourage the resident to take a shower. He/she stated that there is not enough staff scheduled on the evening shift to complete all the showers and he/she passed the shower on to the next shift. Interview, on 1/16/2020 at 3:54 PM, with CNA #6, revealed that he/she worked yesterday during the 3:00 to 11:00 PM shift and didn't give or offer Resident #36 a shower for he/she was already in bed. Further interview revealed that the shower list showed the resident's assigned shower days; however, he/she doesn't follow the schedule instead he/she asked the residents if they want a shower every day. He/she stated that he/she doesn't ask residents if they want a shower last week because the facility didn't have enough staff. He/she stated that there was only one (1) CNA and one (1) nurse scheduled for 3 halls; he/she couldn't turn and reposition the residents and showers were not provided due to the staffing shortage. Interview with the Director of Health Services (DHS), on 1/16/2020 at 2:36 PM, revealed that when residents are admitted to the facility, the admitting nurse asks the resident their shower preference. There is a shower log on every unit with resident shower assignments and he/she expected the CNAs to provide showers as scheduled. The DHS stated that the 3-11 shift is trickier, but he/she doesn't remember receiving any reports from staff or residents that showers weren't provided. Interview with the Administrator on 1/16/2020 at 2:46 PM, revealed all staff are responsible for the care of the residents in the facility and it's important to honor the resident's preferences and choices. He/she expected staff to report if they need anything to her. He/she monitored that nursing staff work is done by interviewing residents to validate that care has been provided. Review of Resident #68's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behavioral symptoms and required extensive assistance of staff for personal hygiene and bathing. Review of Resident #68's Activities of Daily Living (ADL) care plan dated 4/24/19 directed staff to anticipate and meet resident's ADL (personal hygiene, bathing, etc.) and incontinent care needs. Observation on 1/13/2020 at 12:48 PM revealed Resident #68's fingernails on bilateral hands were long and jagged. Interview with the resident at this time revealed the resident preferred to have short cut nails, but staff has not cut them in a while. During a follow-up observation and interview with Resident #68 on 1/15/2020 at 10:40 AM, the resident's fingernails on both hands remained long and jagged. Resident #68 said staff still hadn't cut them yet. Interview on 1/15/2020 at 3:10 with CNA #9 revealed the resident was diabetic and licensed nursing was required to clip the resident's nails. The aide said licensed staff had been informed that the resident's nails needing clipping. Interview with Registered Nurse/House Supervisor (RN/HS) on 1/15/2020 at 3:35 PM confirmed licensed nurse had to clip Resident #68's fingernails. Interview on 1/15/2020 at 4:05 PM with RN #3 revealed there was no formal schedule for clipping Resident #68's fingernails. The nurse said when the resident's nails became long and rough the nails were clipped. RN #3 the resident's fingernails were last cut approximately two (2) weeks prior. RN #3 confirmed Resident #68 asked for his/her nails to be trimmed earlier today (1/15/2020). At the time of this interview, Resident #68's fingernails had not been trimmed. Interview on 1/16/2020 at 10:40 AM with the facility's Director of Health Services (DHS) revealed that licensed nursing staff were to perform nail care for residents with DM. The Administrator confirmed that Resident #68's nail care should have been provided by licensed nursing staff before the resident's nails became long and jagged. | 2020-09-01 |
| 1065 | SUMTER EAST HEALTH & REHABILITATION CENTER | 425107 | 880 CAROLINA AVENUE | SUMTER | SC | 29150 | 2017-05-06 | 247 | D | 1 | 1 | G1PJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of the facility's policy entitled Room and Roommate Assignment, the facility failed to provide prior notice of a change in roommate for 1 of 1 resident reviewed for Admission, Transfer and Discharge. The findings included: The facility admitted Resident #136. During an interview on 04/07/17, Resident #136 stated after returning from [MEDICAL TREATMENT] s/he learned s/he had a new roommate. In a follow up interview, the Admissions Director revealed that Resident #136 had two roommate changes on (MONTH) 10th and 25th of (YEAR). Review of the Social Services Notes on 04/07/17 revealed there was no evidence of notification of Resident #136 or the responsible party In a subsequent interview, the Director of Social Services stated that Resident #136 was not notified because the new roommates were new admissions. Review of the facility's policy entitled Room and Roommate Assignment, revealed that when there is a change all parties involved will be provided with a 48-hour advance notice of the change whenever possible. | 2020-09-01 |
| 2196 | ROLLING GREEN VILLAGE | 425160 | 1 HOKE SMITH BOULEVARD | GREENVILLE | SC | 29615 | 2019-11-14 | 610 | D | 1 | 0 | NVCX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and facility policy review, the facility failed to conduct a thorough investigation for one (1) resident who made an allegation of sexual abuse (Resident #1). The findings included: Review of the facility's undated Abuse Policy: documented the following: Protection Abuse Policy .The progress notes, concerning all residents involved, should include: 6. What was done to prevent further harm to resident or others. Documentation will continue over 72 hours. An acute care plan will be developed that identifies methods for prevention of further occurrence .In House Investigation .Steps taken to protect the alleged victim from further abuse, particularly when an alleged perpetrator has not been identified. Actions taken as a result of the investigation, to include corrective action taken .Abuse Prevention Program, Community Procedures VI. 4. Investigation procedures: The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents .7. Final Abuse Investigation Report .The final investigation report shall contain the following .Facts determined during the process of the investigation, review of medical record and interview of witnesses . Conclusion of the investigation based on known facts .Attach a summary of all interviews conducted .VIII. External Reporting of Potential Abuse. 1 .Steps the community has taken to protect the resident. Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] recorded the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating moderate cognitive impairment. The MDS recorded the resident had minimal hearing difficulty, clear speech, made herself understood, and understood others with clear comprehension. The MDS recorded the resident had no signs or symptoms of [MEDICAL CONDITIONS], hallucinations or delusions, and had rejected care one (1) to three (3) days during the assessment period of seven (7) days. The MDS further recorded the resident required extensive assistance of one (1) staff for toileting and personal hygiene, and the resident had occasional urinary incontinence. The resident was documented as receiving antidepressants seven (7) days during the assessment period. Review of Resident #1's care plan dated 6/26/19 for occasional urinary incontinence directed staff: Check for incontinence; change if wet/soiled. Clean skin with mild soap and water, apply moisture barrier, keep path to bathroom clear and well lit, select clothing that is easily removed for toileting, answer call bed quickly, remind to empty bladder before meals, at bedtime, and before activities. Review of the Clinical Notes from 6/30/19 through 8/1/19 written by Nursing and Social Services (SS) recorded several instances of behaviors by the resident including confusion, disorientation, refusals of care, accusations toward staff, and hallucinations. Dates for the behavior notes in the record were 6/30/19, 7/1/19, 7/6/19, 7/8/19, 7/9/19 (two notes), 7/16/19, and 7/24/19. Staff did not document any additional behaviors in the medical record. On 7/24/19, the Social Worker (SW) documented, SW place (sic) in psychiatrist book to be seen for increase (sic) hallucinations. Review of the Psychiatrist and Psychiatric Nurse Practitioner (NP) notes from 7/10/19 through 8/20/19 recorded the resident was frustrated, irritable, disoriented at times, had cognitive impairment, and expressed having hallucinations. The Psychiatric notes were dated 7/10/19, 7/16/19, 7/23/19, 7/31/19, 8/7/19, and 8/20/19. Review of the initial abuse allegation report dated 8/1/19 revealed the resident's family member reported to the Executive Director that the resident told her on a couple of occasions a staff member came to her room at night and put their finger in her vagina. The facility documented, Investigation initiate (sic). No staff member identified at this time, however the Charge Nurse for 2nd shift and 3rd shift aware and will monitor staff and resident interactions during the investigation and will notify ED/DON (Executive Director/Director of Nursing) of any questionable interactions. Review of the final abuse investigation report dated 8/6/19 recorded, no witnesses, no description of perpetrator, no date given, happened during the night, and list of 3rd shift employees. Interventions by facility to prevent future Injury/Alleged Abuse: Res (resident) to be 'checked' for incont (incontinence) last on 2nd shift, only visual checks when asleep and 1st check on 1st shift. Limit waking up the res (resident) to provide care as long as res (resident) remain (sic) safe and clean. The abuse investigation did not contain any witness statements or written statements by staff, and the facility did not interview any other residents to determine the potential scope of the alleged sexual abuse. The abuse investigation did not consider an increase in the resident's negative behaviors and hallucinations as a potential expression of actual sexual abuse. During interview on 11/14/19 at 10:20 AM, the DON presented a narrative she wrote on 11/14/19 of what transpired on the night shift, the day the allegation was made, 8/1/19. This narrative was not part of the actual sexual abuse investigation. The DON stated Licensed Practical Nurse (LPN) #A was the night time supervisor and the DON asked her to interview the three (3) Certified Nursing Assistants (CNAs) who worked the night shift on 8/1/19. The DON stated that the LPN reported the CNAs were, Turning on the lights, pulling back the covers, doing visual checks of the resident's brief, and it was apparent how the resident could have felt concerned about it; they were waking her up to check her, and she is a very sound sleeper. The DON continued, We did not do any other resident interviews on the unit. We thought it was an isolated event. We did not hear anything from other residents about night time staffing or care concerns, but no we didn't directly ask them (the residents). We did not get individual statements from staff. Statements weren't put on paper, but they occurred on the 3rd shift, with the 3 CNAs, the communication was done, and put in a summary, not individually. The residents on that unit, care issues/concerns are discussed at each care plan meeting. The Social Worker (SW) asks how the care is and how the staff is treating them. We ask the families and the resident. During interview on 11/14/19 at 2:38 PM, LPN #A stated she received an email from the DON who asked LPN #A to do a body audit on the resident and talk to the CNAs on 3rd shift. Then she reported back to the DON. LPN #A stated she asked the CNAs how they toilet and check the resident's brief. LPN #A further stated she did not get any written statements from the three (3) CNAs, she met with them and they talked about care, and she did not interview any other residents. LPN #A determined the resident was a heavy sleeper and misunderstood the staff was providing incontinent care, not sexually abusing her. After discussing it with the DON, they decided to change the way the staff checked and changed the resident, to the last check on the evening shift and the first check on the day shift. LPN #A also stated, The whole investigation process was done in one (1) day. I really did think it was a behavior (the sexual abuse allegation) from transitioning from home to LTC (Long Term Care). The (family member) stopped coming as much so that the resident could adjust and make friends, and I think (the resident) was trying to sort of manipulate her (family member) to go back home. I didn't discount what she was saying about the abuse. The reason I say that's what her problem was (versus potentially acting out with behaviors as a result of abuse) rather than actual abuse; I could tell she missed being at home. During interview on 11/14/19 at 3:24 PM, the MDS nurse stated for an acute problem, such as abuse issues, The SW is the first go-to. They write up the initial report usually. They primarily do the interviews. They would update the care plan. During interview on 11/14/19 at 4:05 PM, SW #1 stated she was informed about Resident #1's sexual abuse allegation, and staff was going in to check if she was incontinent and they put their finger down her brief. SW #1 stated the discussion was about that the resident would be the last check on 2nd shift about 11:00 - 11:30 PM and 3rd shift would not check her, and then she would be the first person on the 1st shift to be checked. SW #1 stated staff did the investigation by interviewing the resident, but did not interview anyone else, I wrote up the initial concern form and gave it to the DON. At 4:45 PM, the SW stated she did not take any actions to protect the resident during the investigation. During interview on 11/14/19 at 4:28 PM, CNA #1 stated she worked both evening and night shifts and provided care for Resident #1 on the night shift and checked the resident every two (2) hours. CNA #1 stated. I pull the covers back to check her brief and look for the line (line on the brief turns blue when wet). I wake her up, she wakes up when you go in unless she's in a deep sleep, she doesn't sleep deeply. Nobody ever interviewed me about (the resident) for anything about sexual abuse. Nobody told me or trained me about any new care interventions or procedures since then. During a follow-up interview on 11/14/19 at 4:47 PM, the DON stated the facility did not protect the resident during the investigation because, It was a quick investigation. We had the family involvement and the staff knew exactly what could have happened. The DON stated they, Should have checked to see if it was unit wide. The DON stated the abuse policy does state the resident should be protected during the investigation, But we didn't feel that there was anyone who was harming her. The DON stated typically they do take into consideration that an increase in behaviors could be a response to sexual abuse, but in this case they didn't because, We felt we knew what happened. During interview on 11/14/19 at 5:17 PM, the Executive Director (ED) stated staff usually looks at the pieces for what is causing behaviors and talk to the physician. I feel that we did a thorough investigation, and We act on the information we think is truthful, and I think we did a thorough investigation .looking back, we should have had other things documented. It may have been a nurse's rush to judgement, but she's a good judge of what has occurred because she knows the resident. | 2020-09-01 |
| 2652 | PRINCE GEORGE HEALTHCARE CENTER | 425295 | 901 MAPLE STREET | GEORGETOWN | SC | 29440 | 2020-01-03 | 550 | D | 1 | 0 | XVX011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of facility policy, the facility failed to ensure dignity was provided to 1 of 1 resident reviewed for quality of care (Resident #340). The findings included: Resident #340 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/13/2019, the facility was notified that Resident #340 had arrived to their [MEDICAL TREATMENT] appointment only wearing a shirt and a brief. Record review on 1/2/2020 at 3:57 PM revealed Resident #340 had a Brief Interview of Mental Status (BI[CONDITION]) score of 4, indicating s/he was cognitively impaired. S/he was extensive assistance to total dependence with activities of daily living (ADLs). Review of the medical record shows a Physician order [REDACTED].>During an interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 1:51 PM, s/he stated The night shift washed the resident off and got them situated. When transport picked them up, s/he was in another room and did not get a chance to double back and finish getting them dressed. Transport sometimes comes early, but will ask if the resident is ready prior to taking them. Since the resident is tube-fed, the nurse has to disconnect it prior to them leaving. Since the nurse had to disconnect it prior to them going, it should have been noted that the resident was not properly dressed. When asked by the surveyor if it would have been realized that the resident was not dressed at any other time prior to leaving the facility, the CNA confirmed that it would have been noticeable, although a sheet was in place. The facility was unable to provide a policy related to dignity, but did provide a list of residents' rights. During an interview with the Director of Nursing on [DATE] at 1:30 PM, s/he stated it is the facility's expectation that when residents leave to go to outside appointments that they are properly dressed. Per the facility's policy titled, Self Determination reviewed on [DATE] at 2:15 PM, it states, Basic Rights - Each resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The facility must provide equal access to quality care regardless of diagnosis, severity of condition or payment source. | 2020-09-01 |
| 143 | CARLYLE SENIOR CARE OF AIKEN | 425014 | 123 DUPONT DR NORTHEAST | AIKEN | SC | 29801 | 2020-01-22 | 758 | D | 1 | 0 | E8OZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, it was determined the facility failed to identify and monitor specific target behaviors for residents taking [MEDICAL CONDITION] medications. This was true for one of seventeen residents (Resident #16) sampled for [MEDICAL CONDITION] medication use. The findings included: Review of Resident #16's Face Sheet, provided by the facility on 01/20/20, revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16 Admission physician's orders [REDACTED]. [MEDICATION NAME] (an antipsychotic medication), 5 milligrams (mg) twice daily for a [DIAGNOSES REDACTED]. [MEDICATION NAME] (a benzodiazepine), 2 mg three times daily beginning 08/05/19; and [MEDICATION NAME] (an antipsychotic), 1 mg twice daily beginning 08/05/19. Physician's telephone orders located in the Orders tab of Resident #16's paper clinical record revealed: 08/06/19, decrease [MEDICATION NAME] to 2.5 mg twice daily and decrease [MEDICATION NAME] to 0.5 mg three times daily; 11/21/19, increase [MEDICATION NAME] to 1 mg three times daily; [DATE], increase [MEDICATION NAME] to 5 mg twice daily; 12/05/19, decrease [MEDICATION NAME] to 0.5 mg three times daily. Review of Resident #16's Quarterly Minimum Data Assessment (MDS) with an Assessment Reference Date of 11/08/19 revealed he/she was unable to complete the Brief Interview of Mental Status (BI[CONDITION]) interview but was assessed by staff to have moderately impaired decision-making abilities; had no behavioral symptoms directed at others; and ambulated independently. On 01/21/20 at 10:15 AM, an interview with the Director of Nursing Services (DNS) revealed the facility monitored behaviors for [MEDICAL CONDITION] medications on the Medication Administration Record [REDACTED]. Review of Resident #16's MAR for November and December 2019 and January 2020 revealed, Monitor Resident every shift for behaviors and side effects related to [MEDICAL CONDITION] medication use. The MAR indicated [REDACTED]. An interview with the DNS on 01/21/20 at 02:30 PM revealed the facility had not identified a specific behavior for Resident #16, but he/she was known to wander, become agitated with staff and others, and resist care. The DNS stated the facility did not review the behavior monitors and did not use them when coordinating with the physician or Nurse Practitioner (NP) when discussing [MEDICAL CONDITION] medication dosages or changes. The DNS stated Resident #16's medication changes had all been because he/she either appeared to be over medicated or had engaged in altercations with other residents. An interview with Resident #16's NP on 01/21/20 at 02:45 PM revealed he/she had decreased Resident #16's [MEDICAL CONDITION] medications when he/she saw him/her the day after he/she was admitted because he/she appeared to be so overly sedated and he/she was drooling. The NP stated he/she had made the remainder of the [MEDICAL CONDITION] medication changes based on what he/she saw of Resident #16 when he/she was in the facility, based on staff report, or based on resident to resident altercations. Review of the facility's policy titled, Behavior Management Plan and Form - Policy, dated 03/18/19, indicated, .4. Behaviors should be documented clearly and concisely by facility staff. Documentation should include specific behaviors, time and frequency of behaviors, observations of what may be triggering behaviors, what interventions were utilized, and the outcomes of the interventions.8. Behavior monitoring will be completed through the electronic medical record process. | 2020-09-01 |
| 2198 | CARLYLE SENIOR CARE OF FLORENCE | 425163 | 133 WEST CLARKE ROAD | FLORENCE | SC | 29501 | 2020-01-20 | 607 | D | 1 | 0 | 54411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility's policy, the facility failed to implement their abuse policy by failing to identify an allegation of potential staff to resident abuse for three of 15 sampled residents (Resident #3, Resident #5, and Resident #18) selected for review. The facility failed to ensure the allegation of potential abuse was reported to Administration in a timely manner, failed to place potential perpetrators on leave during investigations, failed to ensure residents were interviewed during the course of the investigations, and failed to notify the ombudsman of allegations of abuse. The failure to recognize abuse and immediately implement the facility's abuse prohibition policy had the potential to adversely affect all 68 resident's residing in the facility. The findings included: Review of Resident #5's Electronic Medical Record (EMR) Admission Record, revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #5's EMR quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/02/18 specified the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of zero out of 15, which indicated severe cognitive impairment. The resident required extensive assistance for all Activities of Daily Living (ADLs). Review of Resident #5's EMR nursing Progress Notes dated 01/14/19 did not reveal Resident #5 reported an allegation of abuse. During an interview on [DATE] at 12:45 PM Resident #5 stated the staff were mean to him/her. Resident #5 stated he/she had been sodomized on 01/14/19 by two staff members while other staff members watched. He/she stated the incident was reported to the Administrator on 01/31/19. When asked why the incident was not reported immediately on 01/14/19, Resident #5 stated, They already knew. It was them that sodomized me. A request was made on [DATE] at 1:30 PM to the Administrator for the staff to resident incident report that occurred on 01/14/19. Review of the facility's investigation record revealed the investigation into Resident #5's allegation of abuse was not initiated until 01/31/19 after the resident reported the allegation directly to the Administrator. Interviews of additional residents related to staff treatment could not be found in the investigation record. Staff interviews were conducted during the facility investigation, and revealed Certified Nurse Aides (CNA) #2 CNA #16, Licensed Practical Nurse (LPN) #6, and the Social Services Director (SSD) were aware of Resident #5's allegation of being sodomized on 01/14/19 (16 days prior to the allegation being reported by the resident to the Administrator). No evidence could be found in the facility's investigation file to indicate the allegation had been reported, by these staff members, to administration. Review of LPN #6's statement, dated 01/31/19, indicated the resident stated, Get your finger out of my ass! The statement indicated Resident accused CNA of sodomizing (him/her). Review of CNA#16's statement, undated, indicated the resident was yelling, Help .I've been raped and sodomized. Review of a Grievance Form, completed by the SSD on 01/14/19, indicated the resident reported s/he was sodomized on 01/14/19. During the course of the investigation, multiple staff members, including CNA #2, CNA #17, CNA #16, LPN #6, the SSD, and the Administrator were accused of sodomizing Resident #5. Review of the facility's investigation revealed staff members identified in the allegation of abuse were not put on administrative leave during the course of the investigation. Further, the investigation did not include documentation that additional residents were interviewed as part of the investigation or the Ombudsman was notified of the allegation of abuse. Review of Resident #3's EMR Admission Record revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #3's quarterly MDS assessment with an ARD of 09/22/19, revealed the resident had both short and long-term memory problems and required extensive assistance from staff to complete all ADLs. A request was made on 01/16/20 at 1:00 PM to the Administrator for the staff to resident investigation that involved Resident #3 and CNA #10 on [DATE]. Resident #3's family member alleged CNA #10 was rough with the resident during care on [DATE]. The facility's investigation did not include documentation that additional residents were interviewed as part of the investigation or the Ombudsman was notified of the allegation of abuse. Review of Resident #18's EMR Admission Record revealed the resident was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of Resident #18's (Re) Admission MDS assessment with an ARD of 12/31/19, specified the resident had both short and long-term memory problems and required extensive assistance from staff to complete all of his/her ADLs. A request was made on 01/16/20 at 1:00 PM to the Administrator for the staff to resident investigation that involved Resident #18 and CNA #9 on 12/25/19. Resident #18's family member alleged that on 12/25/19, CNA #9 was mean and aggressive with the resident during care. The facility's investigation did not include documentation that additional residents were interviewed as part of the investigation or the Ombudsman was notified of the allegation of abuse. During interview on 01/17/20 at 3:30 PM, the Administrator/Facility Abuse Coordinator stated, allegations of abuse are to be reported immediately and all alleged perpetrators should be immediately put on administrative leave during the course of an investigation. All allegations are to be reported to the local ombudsman within the required timeframe, and all parties who might have knowledge about a reported allegation should be interviewed as part of the investigation. This includes any interviewable residents potentially affected by the allegation. Review of the facility's policy titled, Elder Abuse, revised 09/04/19, indicated, . An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation occur, the facility will,.Provide residents, representatives, and staff information on how and whom they may report concerns, incidents, and grievances without the fear of retribution.Written procedures for investigations include: Identifying and interviewing all persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, .Alleged violations will be reported to the Administrator, state agency, adult protective services, and all other required agencies immediately, but no later than 2 hours after the allegation is made. | 2020-09-01 |
| 2296 | CARLYLE SENIOR CARE OF FOUNTAIN INN | 425168 | 501 GULLIVER ST | FOUNTAIN INN | SC | 29644 | 2019-05-09 | 610 | D | 1 | 1 | LM2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigation, it was determined the facility failed to ensure all allegations of abuse and neglect were thoroughly investigated for three of ten sampled residents reviewed for Facility Reported Incidents (FRIs) (Resident (R) 151, R152, and R25 . Review of the FRI's revealed during the course of the investigations, the facility failed to ensure other residents and staff not involved in the allegations but may have had information related to the allegations were interviewed per the facility's policy. Findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 07/14/17, specifically section 7. Investigation of Alleged Abuse, Neglect, and Exploitation, revealed when reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Continued review of the policy revealed once the resident was cared for and initial reporting has occurred, an investigation should be conducted. Further review of the policy revealed components of an investigation may include: a. Interview the involved resident, if possible, and document all responses and if the resident is cognitively impaired, interview the resident several times to compare responses; b. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident; c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements according to appropriate policies. All statements should be signed and dated by the person making the statement. 1.Review of R151's Face Sheet, located in the front of the resident's clinical record, revealed the facility admitted the resident on 01/28/19 with [DIAGNOSES REDACTED]. Review of R151's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/04/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Continued review of the MDS revealed the resident was assessed to need extensive assistance of two staff persons for transfers to or from the bed. Review of the facility's Initial 24-hour Report, dated 02/17/19, provided by the facility's Administrator, revealed the type of reportable incident was alleged abuse. Continued review of the report revealed R151 alleged Certified Nursing Assistant (CNA) 12 spoke abusively to him/her then left him/her unattended causing her to fall. Review of the facility's Five-Day Follow-Up Report, dated 02/21/19, revealed the summary report of the facility's investigation was attached to the report. Review of the attached summary revealed on 02/17/19 R151 indicated CNA12 talked to him/her abusively and left him/her unattended and s/he fell and suffered discoloration to the elbow. Further review of the summary revealed R151 and CNA12 were both interviewed. The summary indicated there were no other witnesses to this interaction. The summary further revealed the facility's investigation found that there were some discrepancies between the resident's initial and follow up report regarding whether the CNA assisting him/her had assisted him/her to the side of the bed or not and whether the CNA was with him/her the entire times of the incident. The facility conclusion was While the facility cannot substantiate the allegation of abuse/neglect, we do find that this CNA requires counseling and re-education regarding residents' right concerning out policy to provide showers upon request and the need for staff to approach all residents with pleasant and helpful demeanor. Review of the facility's investigation revealed during the course of the investigation the alleged victim (R151), the alleged perpetrator (CNA12), and RN (Registered Nurse) 2 who completed the incident report were interviewed and their statements documented; however, there was no documented evidence the facility interviewed other staff persons who worked with CNA12 and also there was no documented evidence the facility interviewed other residents assigned to CNA12. 2.Review of R152's Face Sheet, located in the front of her clinical record, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R152's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/12/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Continued review of the MDS revealed the resident was assessed to need limited assistance of one staff person for transfers to or from the bed. Review of the facility's Initial 24-hour Report, dated 01/08/19, provided by the facility's Administrator, revealed the type of reportable incident was alleged abuse of rough handling. Continued review of the report revealed R152's son/daughter reported the resident reported to a visitor, who then reported to him that a CNA treated the resident rough and hurt the resident's arm when getting the resident up to go to the bathroom. Further review of the report revealed the resident stated 2 CNA's were watching him/her from the doorway as s/he was trying to get out of bed and when s/he asked them if they were going to help him/her, s/he said they stated no but did help him/her eventually. Review of the facility's Five-Day Follow-Up Report, dated 01/11/19, specifically the Summary Report of Facility Investigation, revealed On 01/09/19 the next day after reporting this, the son/daughter reported to the social worker that s/he was not sure s/he believed the story from yesterday given by his/her parent. S/he stated when s/he came in the following morning, s/he was talking about a pair of socks that someone had given him/her and how s/he loved him/her. The socks were our facility skid socks. His/her son/daughter stated s/he seemed very confused today and that s/he did find out his/her parent has a Urinary Tract Infection [MEDICAL CONDITION]. Our investigation showed that two white CNA's had taken care of him/her on Saturday and Sunday, not two black CNA's as s/he reported. No one knows of any complaints with this resident from the weekend. An x-ray was performed on his/her arm because s/he said it was hurt. The x-ray was negative for any injuries. The resident has had some confusion with the UTI. I cannot substantiate anyone for abuse or neglect. His/her son/daughter is satisfied with this report. Results of UA C&S (cultural and sensitivity) received did not meet the criteria of UTI. Resident was placed on [MEDICATION NAME] for urinary frequency and pain. Review of SSD Statement, undated, revealed I spoke with R152 on 01/08 regarding his/her concern with what happened over the weekend. R152 stated that when someone was helping him/her they grabbed his/her right arm (which is non-weight bearing) and s/he said they were being rough with him/her, so they didn't want to help him/her again. Another time s/he was trying to get her up to BSC (bedside commode) and 2 people were standing at doorway just watching him/her, they did not offer to help. R152 said that the 3 people were A[NAME] The resident said that s/he told a white female staff member what happened. Review of the facility's investigation revealed no other residents of the facility were interviewed and no other staff members were interviewed to question if the resident had reported the alleged incident to them. Continued review of the investigation revealed no further investigation was completed after the interview with the resident's son/daughter related to s/he was not sure if s/he believed the story. Interview, on 05/08/19 at 5:00 PM, with the Administrator and the Former Administrator, revealed when staff are accused of abuse or neglect, they first suspend the accused staff person then report to the state agency within two hours. Continued interview revealed they start the investigation by talking to staff members, starting with the staff who reported the allegation, then they would interview the resident, other staff, other residents, and visitors in the proximity to the event. Further interview revealed witness statements would be obtained in writing. The Former Administrator revealed when determining which other residents to interview for an investigation, they would start with the alleged victim's roommate, then interview other residents who received care from the alleged perpetrator. Continued interview with the Administrator revealed when investigating an allegation from a confused resident and if the resident's family reported to the facility they did not believe the allegation happened, the facility would continue to investigate the allegation The Administrator stated it was important to continue the investigation to protect the resident. The former Administrator stated regarding the investigation regarding R151, at the time of the investigation, s/he felt like s/he had done a thorough job because s/he interviewed the alleged perpetrator (CNA12) and the CNA seemed nice, but in hindsight, s/he should have interviewed other residents. Subsequent interview, on 05/09/19 at 5:10 PM, with the Administrator, revealed it was his/her expectation the abuse policy would have been followed 100% and the facility had zero tolerance for abuse. Continued interview revealed it was his/her expectation other residents would have been interviewed during the investigation. This deficiency was cited based on complaint #'s SC 214 and SC 220. 3. Review of R25's facility investigation file, provided by the Administrator, related to a verbal abuse allegation on 02/6/19 at 3:30 PM, revealed Certified Nurse Aide (CNA) 5 had reported that CNA4 made a reference to resident's (R25's) size and girth in a negative way that could be offensive. The file did not contain a written statement about the alleged incident from the accuser, CNA5 and there was no evidence that R25's spouse had been interviewed concerning the incident. An interview was conducted on 05/08/19 at 5:19 AM with the facility Administrator. During the interview the Administrator was asked to review the verbal abuse investigation file related to the alleged verbal abuse by CNA4 to R25. The Administrator was asked if a written statement had been obtained from the reporter, CNA5, the only witness. When asked if a written statement had been obtained from CNA5, the only witness/accuser, the Administrator stated, Not that I have seen. When asked if the resident's spouse had been interviewed, s/he stated, I think (name withheld, the former Director of Nursing) did, but there is no documentation. When asked if there was documentation which indicated a thorough investigation had been conducted, the Administrator stated, No. The surveyor was unable to interview the two CNAs involved in the event due to their non-availability. Other staff provided written statements but could not confirm the incident since they were not in the resident's room at the time of the event. Based on facility document review, interviews and policy review, the facility failed to conduct a thorough and credible investigation of a facility documented verbal abuse allegation according to regulatory statutes and facility policy. Finding related to complaint SC 217. | 2020-09-01 |
| 3544 | JOHNS ISLAND POST ACUTE | 425368 | 3647 MAYBANK HIGHWAY | JOHNS ISLAND | SC | 29455 | 2019-05-20 | 610 | D | 1 | 1 | WQ8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigation, it was determined the facility failed to ensure all allegations of neglect and resident to resident abuse were thoroughly investigated for two of 11 sampled residents reviewed for Facility Reported Incident's (FRI's) (Resident (R) 99 and R43). On 01/22/19 the facility initiated an investigation for an allegation of neglect related to R99, which concluded on 01/25/19; however, when reviewing the investigation, the facility failed to ensure all components of the complaint were investigated. Additionally, during an investigation related to resident to resident abuse involving R43, the facility failed to interview a cognitively intact resident who witnessed the incident. Findings include: Review of the facility's policy titled, Abuse Investigation and Reporting, revised (MONTH) (YEAR), revealed, all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Continued review of the policy revealed. the individual conducting the investigation will, as a minimum: .d. interview any witnesses to the incident; .g. interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. 1. Review of R99's, Face Sheet, located in the front of the resident's paper chart, revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Initial 24-hour Report, dated 01/22/19, provided by the facility's Administrator, revealed the type of reportable incident was alleged abuse. Continued review of the report revealed the RR (resident representative) made allegation of neglect. Investigation initiated immediately. Full report to follow in 5 days. Policy/Ombudsman/MD/RR notified. Further review revealed the date and time of the reportable incident was 01/22/19 at 3:00 PM. Review of the facility's Five-Day Follow-Up Report, dated 01/25/19, specifically, Details of Reportable Incident: revealed, Resident's son/daughter believes his/her mother was neglected on 01/12/19 because s/he was wearing the same clothing in the morning that s/he was wearing the night before and thought s/he was up in her wheelchair all night. S/he stated s/he did not report it to anyone until 01/22 during a care plan meeting. Continued review of the report revealed multiple facility staff including Certified Nursing Assistant's (CNAs) and Licensed Nurses were interviewed regarding R99 being up in her wheelchair at the nurses station all night on 01/12/19; however, there was no documented evidence the staff members were questioned regarding if R99 had been changed out of his/her clothing or not. Interview on 05/01/19 at 1:04 PM, with R99's son/daughter revealed on 01/15/19 it had been reported to him/her by two different CNAs that on 01/12/19, her father/mother was left in her wheelchair all night long and s/he was not changed out of his/her clothes. Continued interview revealed s/he reported this to the former Unit Manager on 01/16/19 via telephone and again on 01/22/19 during his/her parent's care plan meeting. Interview, on 05/02/19 at 5:47 PM, with the Administrator, revealed s/he initiated and completed the investigation. Continued interview revealed when s/he was looking at the allegation of neglect, s/he was seeing the neglect was that the resident was left in his/her wheelchair and not that s/he was not changed out of his/her clothes. This deficiency was cited based on complaint #SC 295. 2. Review of R93's Face Sheet, located in his/her paper chart, documented s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Five Day Follow-Up Report provided by the facility Administrator, documented that on 12/12/18 at 6:59 PM, while R93 was engaged in a verbal argument with R60 (while resident was sitting at a table), R43 approached and tried to intervene. The report documented R93 then struck R43 in the face. The report, which the Administrator identified as the completed investigation of the event, did not include a witness statement from R60. On 5/2/19 at 2:43 PM, the Administrator stated s/he was responsible for coordinating the investigations into incidents, including resident to resident altercations. The Administrator stated a thorough investigation should include statements from all witnesses, and s/he would usually interview any resident with a BIMS of a 6 or greater. The Administrator stated s/he could not explain why s/he did not interview R60 as part of his/her investigation into the incident. This deficiency was cited based on complaint #SC 886. | 2020-09-01 |
| 3543 | JOHNS ISLAND POST ACUTE | 425368 | 3647 MAYBANK HIGHWAY | JOHNS ISLAND | SC | 29455 | 2019-05-20 | 607 | D | 1 | 1 | WQ8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigation, it was determined the facility failed to implement their Abuse Prevention Program policy and ensured employees identified and reported an allegation of neglect to the facility's administrator immediately for one of 11 sampled residents reviewed for Facility Reported Incident's (FRI's) (Resident (R) 99). On 01/22/19, the facility reported an allegation of neglect to the state agency and initiated an internal investigation. During the review of the facility's investigation and interviews, it was determined R99's son/daughter reported the incident to a facility Registered Nurse (RN); however, the RN failed to identify the reported incident as an allegation of neglect and failed to report the allegation immediately to the facility's Administrator. Findings include: Review of the facility's policy titled, Abuse Prevention Program, revised (MONTH) (YEAR), revealed as part of the resident abuse prevention, the administration would: 3. Develop and implement policies and procedures to aid in the facility preventing abuse, neglect, or mistreatment of [REDACTED]. Require staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior, and .6. Identify and assess all possible incidents of abuse. Review of R99's, Face Sheet, located in the front of the resident's paper chart, revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R99's Annual Minimum Data Set (MDS), located in the Electronic Medical Record (EMR) under the MDS tab, dated 04/10/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident was severely cognitively impaired. Continued review of the MDS revealed the resident displayed no behaviors and required extensive assistance of one staff person for transfers, dressing, and personal hygiene. Review of the facility's Initial 24-hour Report, dated 01/22/19, provided by the facility's Administrator, revealed the type of reportable incident was alleged abuse. Continued review of the report revealed the RR (resident representative) made allegation of neglect. Investigation initiated immediately. Full report to follow in 5 days. Policy/Ombudsman/MD/RR notified. Further review revealed the date and time of the reportable incident was 01/22/19 at 3:00 PM. Review of the facility's Five-Day Follow-Up Report, provided by the facility's Administrator, dated 01/25/19, specifically, Details of Reportable Incident: revealed, Resident's son/daughter believes his/her (parent) was neglected on 01/12/19 because s/he was wearing the same clothing in the morning that s/he was wearing the night before and thought s/he was up in her wheelchair all night. S/he stated s/he did not report it to anyone until 01/22 during a care plan meeting. Interview, on 05/01/19 at 1:04 PM, with family member (F) 1 revealed on 01/15/19 it was reported to him/her by two different CNAs that on 01/12/19, the resident was left in his/her wheelchair all night long and s/he was not even changed out of his/her clothes. Continued interview revealed s/he visited the resident on 01/13/19 and the resident appeared very tired, and eyes swollen from crying. Further interview revealed s/he next visited R99 on the evening of 01/15/19, when s/he was approached by two different CNAs who reported to him/her that R99 was left in his/her wheelchair all night and not even changed out of his/her clothes s/he had on during the day. F1 stated there was no one there that evening to report what s/he had been told by the CNAs, so s/he called the very next day on 01/16/19 and reported exactly what the CNAs told her to RN20, who at that time was the Savannah Unit Manager. F1 further stated s/he did not want to reveal who the CNAs were that reported the incident to him/her. Interview on 05/01/19 at 1:24 PM, with RN20, revealed s/he was the Unit Manager for the Savannah unit during the dates of the allegation. Continued interview revealed s/he did remember F1 calling him/her and telling him/her about the incident, but F1 would not reveal who the staff members were that reported the incident to him/her. Further interview revealed F1 told him/her that two facility staff stated that R99 sat up all night in his/her wheelchair and had the same clothes on as s/he did the day before. RN20 stated F1 was very upset. The RN further stated, the stuff F1 was explaining to him/her was that staff needed to do better. Continued interview with the RN revealed s/he did not remember when F1 had called and all s/he could say is that F1 did call and tell him/her this over the phone. RN20 stated s/he did not document anything regarding the call. Interview on 05/01/19 at 1:43 PM with the Administrator, who indicated, during the care plan meeting on 01/22/19 was the first time the facility became aware of the allegation, and s/he had no knowledge that F1 had spoke with RN20. Continued interview revealed if F1 reported the allegation to RN20 by telephone, it was his/her expectation the RN would have reported the allegation to him/her immediately no matter if it was the day of the care plan meeting or on 01/16/19. Subsequent interview on 05/01/19 at 2:05 PM with RN20, revealed when reviewing his/her written witness statement dated 01/22/19, s/he could not remember if F1 called and told him/her about the incident the day of his/her statement or prior to the day s/he wrote her statement. Interview on 05/02/19 at 5:36 PM with the Director of Nursing (DON), revealed it was his expectation RN20 would have identified the incident as an allegation of neglect and reported it to the Administrator immediately, as soon as s/he hung up the phone. This deficiency was cited based on complaint #SC 295. | 2020-09-01 |
| 2 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 610 | E | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigations, the facility failed to ensure all allegations of abuse and injury of unknown sources were thoroughly investigated for four of 14 sampled residents reviewed for facility reported incidents (FRI's) (Resident (R) 1, R4, R9, and R11). On 10/29/18 an allegation of verbal abuse toward R9 was made; however, the facility failed to interview other residents of the facility. On 12/02/18 a sewing needle was discovered in R4's wound on top of her right foot; however, even though the resident was not cognitively intact, and the event was unwitnessed, the facility failed to identify the occurrence as an injury of unknown source and failed to initiate an investigation. On 01/08/19 R1, who was not cognitively intact, experienced what the facility identified as an injury of unknown source; however, it was not thoroughly investigated. On 09/11/18 the facility became aware that R11's narcotic pain medication was missing; however, the facility failed to conduct a thorough investigation. Findings include: Review of R9's, Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R9's admission Minimum Data Set (MDS) completed on 11/05/18 revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicating the resident was severely cognitively impaired. Review of the facility's Initial 24-Hour Report, dated 11/01/18, revealed the type of reportable incident was alleged abuse. Continued review revealed the date and time of the reportable incident was 10/29/18 at 7:17 PM. Review of the facility's Five-Day Follow-Up Report, dated 11/5/18, revealed Registered Nurse (RN) 2 and Certified Nursing Assistant (CNA) 1 were the only staff interviewed about the incident. Additionally, there was no documented evidence interviewable residents in the facility were interviewed. During an interview on 01/20/19 at 6:10 PM, the facility's Risk Manager (RM) revealed s/he was responsible for reporting all reportable incidents to the state agency and investigating the reportable incidents. Continued interview with the RM revealed s/he did not interview any interviewable residents in the facility that had received services from RN2. During an interview on 01/21/19 at 9:50 AM, the Director of Nursing (DON) revealed s/he assisted the RM in completing the investigation of alleged abuse against R9. The DON revealed that s/he believed, based on RN2's typed witness statement, RN2's verbal explanation, and the two staff members' witness statements, that was all that was needed to unsubstantiated the allegation. Review of R4's, Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R4's quarterly MDS, completed on 10/24/18 revealed the facility assessed the resident to have a BIMS score of four out of 15, indicating the resident was severely cognitively impaired. Review of the facility's reportable incidents revealed no documented evidence the sewing needle being discovered in R4's wounds was identified as an injury of unknown source to be investigated. A subsequent interview on 01/20/19 at 2:35 PM with the facility's Risk Manager (RM), the RM revealed, even though the resident's cognitive status prevented the resident from explaining how the needle got into the wound and it was not witnessed, the facility did not identify the incident as an injury of unknown source. During an interview on 01/21/19 at 8:38 AM, the Administrator revealed s/he did not participate in the investigation related to the allegation of verbal abuse to R9. The Administrator revealed when the survey team showed her/him the witness statements, it was the first-time s/he had seen the statements. The Administrator revealed s/he did not remember the allegation being reported to her/him by the RM and s/he did not have any documented evidence it was reported to her/him. The Administrator stated s/he can see how R4's injury could have been identified and investigated as an injury of unknown source. During an interview on 01/21/19 at 3:10 PM, Licensed Practical Nurse (LPN) 2 revealed s/he was the one who discovered a sewing needle in R4's wound on top of her/his right foot. Continued interview revealed after pulling the sewing needle out, s/he notified her/his supervisor per policy. LPN2 revealed, to her/his knowledge, there was no investigation completed. Review of LPN2's nursing notes, dated 12/02/18, revealed while doing wound care on the top of R4's right foot where the resident had an ulcerated lesion, the gauze got caught on what was thought to be a scab; the gauze got caught on a sewing needle that was sticking out of the wound. The nursing notes revealed the nurse pulled the sewing needled out of the wound and then notified her/his supervisor and the resident's daughter. Review of the undated policy Abuse Investigation and Reporting revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . the role of the investigator at a minimum would interview any witnesses to the incident, interview the resident's roommate, family members and visitors, and consult daily with the administrator. Review of R1's Face Sheet in the clinical record revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R1's quarterly MDS, dated [DATE] indicated that R1 was severely cognitively impaired an unable to answer the questions on the Brief Interview for Memory Status. Review of the Initial 24-hour Report, dated 1/14/19, indicated swelling to R (right) hand with skin tears. The date and time of the reportable incident indicated 1/14/19 at 8:00 PM. Review of the Five-Day Follow-up Report, dated 01/18/19, indicated the same injury as the initial report and the same date and time. The document indicated the category of Details of Reportable Incident the following, Resident noted to have swelling to R hand on 1/14(/19) at approx. 8:00 pm, son notified nursing staff . Staff report resident was restless during the day. Review of the facility's documentation provided by the Administrator indicated that the facility obtained written statements from the nurses and nurse aides on 01/13/19 and 01/14/19. The Assistant Director of Nursing (ADON) confirmed that the night nurse (LPN1) on the night shift, starting at 7 PM on 01/13/19 and ending at 7 AM on 01/14/19, did not write a statement. Review of the statement written by Certified Nurse Aide (CNA) 2 dated 01/18/19 indicated, I worked with (R1) on Monday, (MONTH) 14th in Rose Cottage . I removed her/his hand brace, like usual and gently cleaned just under her/his fingers. S/he had the skin tears and band aids, so I left those on. Review of the statement written by CNA3 dated 01/14/19 indicated, I worked on Sunday evening/night shift . there was no problem with (R1) the night or when I left work on Monday morning at 7 am. When I returned to work on Monday evening around 7:35 pm, her/his son (son's name) was here and asked me if I knew about the scratch and bruise to her/his right hand. Her/his hand was swollen and appeared to be bruised . The CNA did not mention anything about her/him having any problem with her/his hand during the day. Review of R1's Progress Notes, dated 01/10/19 through 01/16/19, revealed that there was no documentation regarding how R1's skin tears occurred or that band aids were placed over the right-hand skin tears. During an interview on 01/21/19 at 1 PM with the Administrator and ADON, the Administrator confirmed that LPN1 did not write a statement and that the facility did not have any further documentation that an investigation had been conducted to determine how the skin tears occurred that were documented in NA2's written statement. The Administrator confirmed that the CNA3 documented on Sunday, 01/13/19, there was no problem with R1's right hand; however, CNA2 documented on the day shift of 01/14/19, R1 had band aids and skin tears to the right hand. Review of R11's medical record revealed Physician Orders, dated 09/10/18, which indicated (narcotic medication) (buprenorphine) Patch Weekly 5 MCG (microgram)/HR apply 5 MCG/hr [MEDICATION NAME] (sic) weekly every Mon (Monday) for pain. Review of an email dated 09/20/18 at 7:18 AM from RN4 indicated, (name of Nurse Practitioner) left a prescription (dated 09/11/18) on the keypad for the (name of brand of narcotic) (buprenorphine) patch. I promptly faxed it and fax confirmation was received. I did not call (Name of Pharmacy) with a follow-up phone call to confirm receipt of the prescription. Review of a hand-written document that was part of the facility's investigation file, dated 09/19/18, indicated on 9/11/17 (sic - the year should have been (YEAR)) I did not receive the (name of brand of narcotic) (buprenorphine) patch for resident (R11) in narcotic bag. The document was signed by RN5. Review of the email from the ADON to the facility's Risk Manager dated Monday, 09/17/18 indicated, I received a call from (LPN 7) . s/he was unable to find the narcotic medication, '(name of brand of narcotic) (buprenorphine) [MEDICATION NAME]es.' The medication was signed as received by RN5 on (MONTH) 11th at 11:07 pm. After searching all subacute cottages for the med (medication) to no avail, I called the pharmacy and asked for a copy of the signature page. The signature page was sent and does appear to have been signed by the said nurse at the said time. I called (RN5) . s/he has no recollection of receiving any narcotic patches. I informed (RN 5) I have a copy of the signature page showing s/he signed for the med (medication). (RN5) again stated, 'If I did sign the paper, I do not remember receiving any narcotic patches.' During an interview on 01/20/18 at 9 AM with the ADON and Administrator, the ADON stated that the pharmacy sent the residents' medication by courier. The courier delivered the medications to each cottage. The narcotics arrived in a pink bag with a pink slip that the nurse had to sign. The ADON stated that the facility did not have the pink slip that someone signed on 09/11/18. The ADON stated that when the nurse received the narcotic there was a narcotic sheet in the bag that the nurse then signed, added the number of pills, and placed the sheet in the cottage's narcotic book. The ADON stated that since the facility did not receive the buprenorphine patches for R11, there would not have been a narcotic sheet in the narcotic book. Therefore, that was why the nurses did not notice after 09/11/18 that the resident did not have the buprenorphine patches in the locked narcotic drawer. During an interview with the RM on 01/20/18 at 2:50 PM, the RM confirmed that s/he was notified by the ADON on 09/17/18 that R11's buprenorphine patches were not available at the facility. The RM stated that there was no documentation in the documents provided by the facility that a search of all 12 cottages' locked narcotic boxes in the medication carts was performed to see if the patches were delivered to another cottage. The RM confirmed that the email from the ADON on 09/17/18 indicated that a search of the subacute cottages was performed, but not of all of the cottages. The RM stated there was no documentation that interviews were conducted with the residents who may have been seated near the medication cart or with the nurse aides who were working during the time on 09/11/18 when the courier brought the medications to the cottage. The RM also confirmed that the facility did not interview the courier. The RM stated that the facility turned the investigation over to the pharmacy and have not heard anything further regarding the missing buprenorphine patches. Review of the undated policy Abuse Investigation and Reporting revealed all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management . the role of the investigator at a minimum would interview any witnesses to the incident, interview the resident's roommate, family members and visitors, and consult daily with the Administrator. | 2020-09-01 |
| 1 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 609 | E | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, review of the facility's policy, and review of the facility's investigations, the facility failed to report an allegation of abuse and injury of unknown source within the required time frame to the appropriate state agency as required for four of 14 sampled residents (Resident (R) 1, R4, R9, and R11). On 10/29/18 an allegation of verbal abuse toward R9 was made; however, the facility failed to report the allegation of verbal abuse to the state agency within the required two-hour time frame. On 12/02/18 a sewing needle was discovered in R4's wound on top of his/her right foot; however, even though the resident was not cognitively intact, and the event was unwitnessed, the facility failed to identify the occurrence as an injury of unknown source and failed to report it to the state agency. On 01/08/19 R1 who was not cognitively intact experienced what the facility identified as an injury of unknown source; however, it was not reported to the state agency until 01/10/19 two days after the fact. On 09/11/18 the facility became aware that R11's narcotic pain medication was missing; however, the facility failed to report the misappropriation of the resident's medication within the required two-hour time frame to the state agency. Findings include: Review of R4's Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R4's quarterly MDS, completed on 10/24/18, revealed the facility assessed the resident to have a BIMS score of four out of fifteen, indicating the resident was severely cognitively impaired. During an interview on 01/20/19 at approximately 2:35 PM, the facility's Risk Manager (RM) revealed the incident of the sewing needle being discovered in R4's wound on her/his foot was not reported to the state agency as an injury of unknown source. The RM stated the resident could not tell how the needle got into the wound and it was not witnessed either. During an interview on 01/21/19 at approximately 8:38 AM, the Administrator revealed s/he was not aware of the requirement that all abuse and injuries of unknown source had to be reported to the state agency no later than two hours. The Administrator stated s/he can see how R4's injury could be an injury of unknown source. During an interview on 01/21/19 at approximately 9:50 AM, the Director of Nursing (DON) revealed s/he was previously the staff training coordinator and that s/he last received abuse training in (MONTH) of (YEAR). The DON revealed s/he was not aware of the requirement to report abuse and injuries of unknown source to the state no later than two hours. Review of R9's Face Sheet revealed s/he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R9's admission Minimum Data Set (MDS), completed on 11/05/18, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three out of fifteen, indicating the resident was severely cognitively impaired. Review of the facility's Initial 24-Hour Report, dated 11/01/18, revealed the type of reportable incident was alleged abuse. Continued review revealed the date and time of the reportable incident was 10/29/18 at 7:17 PM, indicating the incident was not reported to the state agency until three days later. During an interview on 01/20/19 at approximately 6:10 PM with the RM revealed s/he was responsible for reporting all reportable incidents to the state agency. The RM revealed the allegation of verbal abuse that occurred on 10/29/18 was not reported to her/him until 11/01/18. The RM revealed after the incident was reported to her/him late, s/he sent out mass emails to nursing supervisors reeducating them about reporting requirements. Review of R11's Physician order [REDACTED]. Review of a copy of the actually script dated 09/11/18 indicated, [MEDICATION NAME] 5 mcg patch weekly on Tuesday. On the copy of the script was the notation faxes - received. Review of an email dated 09/20/18 at 7:18 AM from Registered Nurse (RN) 4 indicated, (name of Nurse Practitioner) left a prescription (dated 09/11/18) on the keypad for the [MEDICATION NAME]. I promptly faxed it and fax confirmation was received. I did not call (name of contract pharmacy) with a follow-up phone call to confirm receipt of the prescription. Review of a typed document that was part of the facility's investigation file by the facility's Risk Manager indicated 9/10/18 [MEDICATION NAME] not given by (RN4). 9/17/18 [MEDICATION NAME] not given by LPN6. On 9/17/18, LPN7 called (name of contract pharmacy) to request patches. Review of a hand-written document that was part of the facility's investigation file dated 09/19/18 indicated, on 9/11/17 (sic - the year should have been (YEAR)) I did not receive the [MEDICATION NAME] for resident (R11) in narcotic bag. The document was signed by RN5. Review of the email from the Assistant Director of Nursing (ADON) to the RM, dated Monday 09/17/18 indicated, I received a call from (LPN7) . (s/he) was unable to find the narcotic medication, '[MEDICATION NAME]es.' The medication was signed as received by RN5 on (MONTH) 11th at 11:07 pm. After searching all subacute cottages for the med (medication) to no avail, I called the pharmacy and asked for a copy of the signature page. The signature page was sent and does appear to have been signed by the said nurse at the said time. I called (RN5) . (s/he) has no recollection of receiving any narcotic patches. I informed (RN 5) I have a copy of the signature page showing (s/he) signed for the med (medication). (RN5) again stated, 'If I did sign the paper, I do not remember receiving any narcotic patches.' Review of an email from LPN 7, dated Tuesday 09/18/18 which indicated, On (MONTH) 17th, a medication on the EMAR (Electronic Medication Administration Record) was ordered for [MEDICATION NAME] Patch once a week . I was told in report that the medication was not here so I thought pharmacy had not sent it yet . I called (name of contract pharmacy) and was told that the medication was delivered and that a staff member at (name of facility) had signed for it. I believe (s/he) said it was delivered 9/10 or 9/11 . I reported this information to the nurse supervisor and (s/he) came over to look for the medication. I held the dose due to unavailabity. Review of a hand-written note that was part of the facility's investigation file dated 09/18/18 written by LPN6 indicated On 9/17/18 there was an order for [REDACTED]. I reported this to oncoming nurse to call pharmacy. Review of the Initial 24-hour Report dated 09/19/18 indicated the date and time of the incident was 09/18/18 at 2:00 PM. The description of the incident revealed, Missing Medication. Review of the Fax Call Report indicated the Initial 24-hour Report was faxed to the State Agency on 09/19/18 at 12:36 PM. Review of an email from the State Agency dated 09/19/18 at 2:53 PM indicated, It has been received and will be reviewed. During an interview with the RM on 01/20/18 at 2:50 PM, the RM confirmed that s/he was notified by the ADON on 09/17/18; however, the RM confirmed that R11's [MEDICATION NAME]es were not available at the facility on 09/11/18. The RM confirmed the State Agency should have been notified on 09/11/18 when the pharmacy indicated that the patches had been delivered and the patches were not in the facility. Review of the undated policy titled, Narcotics, Controlled Substances, and Preventing Drug Diversion indicated d. any discrepancies are immediately reported to the Administrator. Review of R1's clinical record revealed R1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R11's quarterly MDS dated [DATE] indicated that R1 was severely cognitively impaired an unable to answer the questions on the Brief Interview for Memory Status. Review of the facility's document titled Initial 24-hour Report dated 01/10/19 indicated, the type of injury of unknown source was documented, non-displaced right [MEDICATION NAME] patella fracture. The date and time of the reportable incident indicated 1/10/19 at 9:30 AM. Review of the facility's document titled, Five-Day Follow-up Report, dated 01/11/19, indicated the same injury as the initial report; however, the date and time of the Reportable Incident indicated 1/8/19 at 20:35 (8:35 PM) reported to Risk Manager 1/10/19 at 8:30 AM. The document indicated the category of Details of Reportable Incident the following, 1/8/19 Resident presented with right knee swelling and redness. Review of R1's Physician order [REDACTED]. During an interview with the RM on 01/20/18 at 2:50 PM, the RM confirmed that s/he was notified on 01/10/19 by a supervisor who no longer worked for the facility. The RM confirmed that R1's injury of unknown origin should have been reported to the State Agency on 01/08/19. Review of the facility's undated policy, Abuse Investigation and Reporting revealed all alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two hours to the state licensing/certification agency responsible for surveying/licensing the facility. | 2020-09-01 |
| 3269 | HALLMARK HEALTHCARE CENTER | 425326 | 255 MIDLAND PARKWAY | SUMMERVILLE | SC | 29485 | 2018-08-21 | 839 | D | 1 | 0 | CMHW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and facility files, the facility failed to prevent an unqualified staff member from providing phlebotomy services for 1 of 1 residents reviewed for blood draw. Resident #3 had blood drawn from a Certified Nursing Assistant (CNA). The findings included: In response to an initial reportable incident received in this office an investigation was conducted at the facility. Per the facility report, a Registered Nurse (RN) allowed a Certified Nursing Assistant to draw blood on a resident, resident #3. The facility investigation included statements given by the RN and the CNA. Both the RN and CNA confirmed the CNA had drawn blood on the resident. The CNA said s/he was a phlebotomist at the hospital. The RN stated s/he was not aware the CNA could not draw blood in the long term care setting. The RN and the CNA were placed on suspension pending the investigation. On [DATE] at 1:09 PM, the surveyor interviewed the Director of Nursing (DON). A nurse called me yesterday and asked me to look into it. S/he said s/he was told that a CNA had drawn labs on a resident. The CNA works part time and draws labs at the hospital. The nurse knew s/he was a phlebotomist at the hospital. The nurse was here yesterday that had worked the weekend. I asked her/him about labs being drawn on the weekend. I asked if s/he had drawn labs. The RN stated s/he had drawn the labs but the CNA was right there with her/him. I told the nurse I had already talked to the CNA. S/he then retracted it, and said the CNA drew the labs but the RN was right there. S/he said it was only the one resident. I asked where s/he was at the time and s/he said s/he was at the door within direct sight of the CNA. I told the nurse and the CNA that a CNA could not draw blood here at the facility, it was beyond their scope of practice. The DON had not seen a certification on phlebotomy for the CNA. At 2:40 PM the CNA was interviewed per phone by the surveyor. I am a PCT (Patient Care Technician) as well as a CNA. In [STATE] I can do lab draws. I have a certification as a PCT. I only work part time and come in to give a hand. I went to the unit and asked if they needed any help. The nurse said s/he needed a lab draw done. So I did it. I have advanced skills of phlebotomy and a few other things. After speaking with the DON, I know that my PCT does not cover in a nursing home. On [DATE] the RN was interviewed via phone by the surveyor. The CNA came in and asked me if I had any labs. I had one. I didn't know that it was against regulations. I worked several places that it was alright. S/he told me s/he was certified. We have talked about her/him certification before. I strongly regret it, I didn't know. I do know s/he has drawn blood before. The facility admitted resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed the resident was alert and oriented. S/he had a Brief Interview for Mental Status (BI[CONDITION]) score of 14 out of 15. Review of the medical record revealed a physician's orders [REDACTED]. On [DATE] at 3:20 PM the resident was observed lying in bed with head of bed elevated. Resident clean and well groomed, smiling. Alert, oriented and verbally responsive. Resident interviewed regarding blood draw and care provided. Yes, I had my blood taken this weekend. It came back great, I am happy to say. No there was no problem getting my blood. S/he got it right off, nothing unusual about it. The CNA provided a copy of her certificate from the technical college. The certificate was for the completion of Patient Care Technician, dated February 27, 2014. The certificate also stated, Advanced Skills: Basic EKG, Basic Phlebotomy and CPR-112 hours-11.20 CEUs No harm resulted to the resident. | 2020-09-01 |
| 402 | BLUE RIDGE IN GEORGETOWN | 425048 | 2715 SOUTH ISLAND ROAD | GEORGETOWN | SC | 29440 | 2018-11-17 | 550 | D | 1 | 0 | H6ZB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, the facility failed to ensure Resident #4 was treated with respect and dignity during activities of daily living. 1 of 3 sampled residents for dignity. Resident #4 stated that Certified Nursing Aide (CNA) #1 left her/him uncovered for thirty minutes during incontinent care. The findings included: The facility admitted Resident #4 on 2/17/16 with [DIAGNOSES REDACTED]. Review of Resident #4's electronic medical record on 11/04/18 at approximately 12:44 PM revealed a quarterly Minimum Data Set ((MDS) dated [DATE] that indicated Resident #4 had a Brief Interview of Mental Status (BIMS) score of 14. The resident was listed on the interviewable list provided by the facility during the survey. During an interview with Resident #4 on 10/03/18 at approximately 10:45 AM. Resident #4 stated that when he/she was evacuated to another facility, CNA #1 provided incontinent care and left the bed covers pulled up from his/her feet to his/her waist for about thirty minutes until the CNA returned and provided care. During an interview with CNA #1 on 11/04/18 at approximately 8:45 AM. CNA #1 confirmed he/she did leave Resident #4 uncovered for approximately 15 to 20 minutes. | 2020-09-01 |
| 239 | MOUNTAINVIEW NURSING HOME | 425027 | 340 CEDAR SPRINGS ROAD | SPARTANBURG | SC | 29302 | 2019-10-20 | 609 | D | 1 | 1 | 4IGP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record reviews, the facility failed to report allegations of abuse and bruises of unknown origin to the appropriate agencies within the required time frames for two of five residents reviewed for allegations of abuse (Resident #11 and Resident #94). Findings include: 1. Resident #11 According to the Face Sheet, Resident #11 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment, dated 07/14/19, Resident #11 was moderately cognitively impaired with a Brief Interview of Mental Status (BIMS) score of nine out of 15. She required total assistance with all activities of daily living (ADL). The reportable incident investigation and letter were reviewed. The letter was sent to the state agency on 08/16/19. The letter served as the initial and final notification of the reportable incident. The reportable incident was that a Certified Nurse Aide (CNA) had repeatedly bashed Resident #77's head against the nightstand and twisted her arm on 08/09/19. Through the investigation, it was determined the incident occurred on 08/08/19 and not 08/09/19. Three CNA statements were obtained on 08/15/19. CNA #31 was interviewed on 10/18/19 at 5:39 PM. She was the CNA working with Resident #11 the evening of 08/08/19. She said when dinner trays were being passed, it was announced that bingo was going to be starting. Resident #11 requested to go. CNA #31 told her that she could not get her up right then because she needed to finish passing trays and assist with feeding residents. She said Resident #11 was very upset and took her reacher and hit the end of the bed. The following day, on 08/09/19, Resident #11 had a bruise on her arm, so she was questioned about it. She said charge Nurse #9 and Social Worker #108 completed the investigation. Resident #11 informed them that CNA #31 had banged her head against the bedside table and she grabbed her arm. She said she did neither of those and the resident was just upset about bingo. She thought the bruise was from the reacher, when Resident #11 was hitting it against the bed. The reportable incident investigation was reviewed once more. The skin tear/discoloration investigation form was completed on 08/09/19. There was no report informing the state agency of the bruise of unknown origin and alleged abuse on 08/09/19, when the staff were made aware. Charge Nurse #9 was interviewed on 10/20/19 at 10:45 AM. She recalled the incident. She said Resident #11 told her about the incident during first shift and staff found a bruise on her arm at that time. The incident occurred on the 2nd shift the previous day. Resident #11 told her that a CNA attacked her. She looked at the schedule and figured out which CNA it was and spoke with the CN[NAME] Charge Nurse #9 called Social Worker #108 and that was when the investigation started. The investigation was started because they noticed the bruise and Resident #11 said a CNA attacked her. She thought the bruise was from the wheelchair. She said the social workers complete the investigations and the Director of Nursing (DON) does the paperwork and reporting. Social Worker #108 was interviewed on 10/20/19 at 12:32 PM. She said she helped investigate the incident with Resident #11. She knew allegations of abuse had to be reported to the state agency within two hours of the staff being made aware. She said the DON did all of the reporting. She was informed by Charge Nurse #9 that Resident #11 said a CNA had attacked her. When she spoke with the resident on 08/09/19, Resident #11 told her that the CNA caring for her got mad and banged her head against the bedside table. This would be an allegation of abuse. Once she spoke with Resident #11 and the nursing staff, she reported it to the DON. The DON was interviewed on 10/20/19 at 12:42 PM. She said they were required to report incidents to the state agency within two hours if the resident could be in immediate danger, like abuse. If there was no immediate danger, then they had 24 hours to report it to the state agency and then a five day follow up was required. She said the time frames began from when they were notified of the situation. She said she was not notified of the incident until 08/15/18. Social Worker #108 joined the interview. She said she informed the DON on 08/09/19. She said she would not have kept that information to herself and not reported it. A concern form was completed on 08/09/19 by Social Worker #108. The concern from was regarding Resident #11's bruise. Nursing got statements from the nurse and CNAs providing care and the Social Worker spoke with Resident #11. Resident #11 was banging her reacher against the bed when she was upset and possibly hit her arm to cause the bruise. There was no evidence the bruise was caused by the staff. The Information sent to and date sent section was blank. Based on all of the information gathered, the staff were made aware of the bruise and the abuse allegation on 08/09/19, but the DON did not complete her investigation until 08/15/19. The incident was not reported to the state agency until 08/16/19. 2. Resident #94 Review of the clinical record revealed an admission history form dated 03/06/19. The admission history documented Resident #94 was admitted to the facility on [DATE] with a readmitted d of 04/19/19. The quarterly MDS assessment, dated 09/08/19, documented that Resident #94 had severe memory impairment and needed extensive assistance for all ADLs. Resident #94 had a plan of care (P[NAME]), initially dated 04/19/19, for being a high fall risk. Interventions included constant observation and maintain a safe unit environment by removing excess equipment/supplies/furniture from rooms and hallways. Resident #94's P[NAME], dated 03/19/19 and updated on 10/17/19, documented her need for extensive assistance for bed mobility, assist for transfers, and assist for personal hygiene. P[NAME] also documented that Resident #94 got distracted while feeding herself. On 10/17/19 at 12:16 PM, during the first dining observation, Resident #94 was observed with a large bruise to the left side of her eye, between her eyebrow and the side of her eye. The bruise was purple and pink with a greenish/yellowish discoloration around the edges. Resident #94 appeared to be calm and was focused on eating lunch. Investigation: On 10/20/19 at 8:28 AM, facility's investigation for a 'discoloration' of unknown origin was reviewed. The investigation revealed the following: On 10/13/19 at 7:30 AM, Resident #94 was in the day room, sitting up in her wheelchair when Licensed Practical Nurse (LPN) #56 observed a raised discoloration above the Resident's left eyebrow. The physician's office was not notified until 9:20 AM, the resident's responsible party was not notified until 9:22 AM, and the nurse on call was not notified until 9:25 AM. A statement dated 10/13/19 from LPN #38 documented, I was the med nurse on cart 2 and I was not aware of a raised discoloration area on Resident #94 above left eyebrow. A statement dated 10/13/19 from LPN #56 documented, When this nurse arrived this AM, Resident #94 was up sitting in wheelchair in common area. When this nurse administered morning meds a purple discoloration was noted to left outer eyebrow. A statement dated 10/13/19 from CNA #29 documented, I had the resident last night but did not notice a bruise on her at all. I didn't have her the night before, so I am not sure if it was there or not. A statement dated 10/13/19 from CNA #41 documented, To whom it may concern, I don't know anything about no bruise on Resident #94. A statement dated 10/13/19 from CNA #14 documented, During my 7 PM to 7 AM shift I, CNA #14, did not note any discoloration to Resident #94's left side throughout my shift. While administering meds, I was on her right side of bed. A Restorative Nursing Note from Registered Nurse (RN) #24 dated 10/17/19 at 8:30 AM documented in part, .Resident was unable to tell nurse what happened due to her dementia. There were no indicators of abuse noted. Resident does not exhibit any fear of caregivers nor were there any collateral signs of abuse. Incident not referred to DON due to no indicators of abuse noted. The staff were educated on monitoring more closely while helping Resident #94 dress and when she is eating to make sure resident doesn't hurt herself due to poor safety awareness. On 10/20/19 at 8:43 AM, the DON was interviewed. The DON stated that she had asked RN #24 to investigate the discoloration of unknown origin for Resident #94's left eye and 'try to narrow down what happened.' The process was to talk to staff, look at the actual bruise, find out if there was an altercation with any other resident(s), we get statements from everybody we can, but definitely statements from staff who took care of Resident #94. We look for patterns and/or anything suspicious. DON stated that if it feels suspicious, I report it within 24 hours and conduct a more in-depth investigation for the 5 day report. The DON stated that she followed up with staff after this incident but did not document. The DON stated that based on RN #24's findings, she did not report the bruise of unknown origin. Policy: Mountainview Abuse and Neglect Management Policy Statement, dated (YEAR), documented the following (in part) under the section entitled Reporting: It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect of resident abuse, including of unknown source, and theft or misappropriation of resident property to facility management. #5. When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will immediately (within twenty-four hours of the alleged incident) notify the following persons or agencies of such incident: a. The state licensing/certification agency responsible for survey/licensing the facility. b. The local/state Ombudsman c. The Resident's representative of Record d. Adult Protective Services e. Law enforcement officials f. The Resident's attending physician g. The facility Medical Director | 2020-09-01 |
| 1445 | INMAN HEALTHCARE | 425122 | 51 N MAIN ST | INMAN | SC | 29349 | 2018-08-01 | 602 | F | 1 | 0 | QNRI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of facility files, the facility failed to safeguard resident financial accounts against misappropriation for 11 of 21 resident accounts. The findings included: Cross refer to F567, F568, F569 related to resident funds. Review of the facility investigation of allegations of misappropriation of resident financial accounts revealed the facility stated 21 resident accounts were involved. Then it stated there were 11 resident accounts affected. Their investigation showed six (6) residents with accounts affected were reimbursed and 5 residents were reimbursed for cash receipts. (Total of 11). One resident who deceased in 2016 had a cash receipt for $500.00, which was not posted to Accounts receivable or to Resident Trust. The residents did not receive bank statements, confirmed by the Corporate District Director (one resident said for over a year). Interest was not applied to the residents reimbursed. Only residents that were able to say they had a problem were reimbursed by the facility/corporation. The facility did not provide the total amount of monies involved, only the amount of money reimbursed. The District Director stated that only the residents that could confirm there was a problem with their accounts were reimbursed. On [DATE] at approximately 9:30 AM, the facility's Business Office Manager was interviewed by the surveyor. I was just hired in June. Things didn't look right, so I started doing an audit and things were not right. I sent the information of the audit to my boss at corporate and they took over the investigation. The final audit has not been completed yet, only the in-house residents. discharged resident accounts have not had a completed audit yet. The previous Business Office Director (BOD) was just arrested last night. At this time the amount is over $50,000.00. At Approximately 12:30 PM, the corporate representative, District Director of Business Office Services, was interviewed by the surveyor. We restructured in November of 2016, and I got these buildings. I provide support and training to Business Office Staff and audit annually and as needed per company policy. Every month the Business Office prepares a copy of all patient trust transactions, withdrawals, deposits, checks and it is sent to Houston, [STATE]-Sava Company that does general accounting. One auditor in the sister facility office noticed what appeared to be forged resident signatures with withdrawal slips. This happened in mid to late May. They sent me copies and I felt they were forged and came to facility and started an investigation. After I looked at the couple months of resident trust files, it appeared the same handwriting forged resident slips. We suspended the BOD pending a more thorough investigation. During the call I asked the BOD if s/he knew our policy on obtaining resident signatures. I asked if s/he ever forged resident signatures. S/he said no. S/he was able to walk me through what the process was. The process was- resident comes in, Business Office Director (BOD) would fill out a withdrawal slip for how much they wanted with name and date. The resident would sign withdrawal slip. If resident could not sign then two witnesses were required. The Administrator was the back up if the BOD was not here. There was a different administrator here at that time. The person giving out money would not sign the withdrawal. 2 others would witness the transaction. The BOD was suspended and I continued to look through the resident withdrawals and found more. I worked back from May to January. I worked with the area Human Resource Manager (HR). The BOD called the Administrator of the sister facility and resigned. I then looked at this facility for the same time frame. We found evidence of Barber and Beauty services, Beautician invoice. The BOD's handwriting listed resident names to have hair done. We saw white out had been used on the form and a different resident's name was written over it. The beautician would write what service was done with the cost. What I think was happening was the BOD would debit a resident's account that had money so a resident who didn't have money could have their hair done. Both facilities had forged withdrawal slips. Once the BOD was no longer an employee, we (Vice President of Operations-Finance) continued to take a look. S/he went to sister facility in June and in July s/he was in both buildings. We looked at files. We started to look at older files from December backwards. We looked at the actual Funds Management System. The files were withdrawal slips, deposits and copies of checks. Any checks written to beautician or to replenish petty cash. These files are business/fund files. We looked at actual residents' accounts in June for both facilities. We were looking for excessive transactions or transactions where residents said they never received money. In July we interviewed residents. They said they were never asked to sign for withdrawals. During July, as we continued to investigate, we looked at receipt books. We saw where cash payments were received but never applied to resident accounts or deposited into Resident Trust Accounts. Resident's at both facilities were affected by that. After going through receipt books at both locations, we wrapped up our investigation that is when we reported to the state agencies and to the Police Chief. When we wrapped up our investigation, two residents at the sister facility and a higher volume of residents here, but not more money. We estimated around $36,000.00, between both facilities. The Police Chief wanted to pursue. I was able to take her/him just under $21,000.00 worth of receipts. That was all I could get copied by the time s/he wanted it. I gave her/him the copies. The BOD was arrested sometime yesterday. The charge was Breach of Trust. 21 resident accounts were affected at this facility. 6 Patient Trust Accounts and 5 cash receipts. We looked at current in-house residents for Resident Trust Accounts. One (1) discharged resident was seen in the cash receipts. We looked at all cash receipts back to January. Reimbursements were made where resident said they never got money and who had excessive transactions. Reimbursed based on interviews and excessive transactions. The sister facility's cash receipts was $13,218 and in Patient Trust was $5,032. This facility had $15,640 in Patient Trust and $1,766.[AGE] in cash receipts were refunded. There was no dollar amounts on forged receipts. No outside agency has audited the accounts. We did an internal audit. The Business Office would key withdrawal slips into the system. It's transferred from Resident Trust account into Resident Trust checking account. The BOD would print the checks. The Administrator, Director of Nursing or Minimum Data Set Nurse would sign the check. The check would be taken to the bank. It should not be the BOD, but it was. It should have been anyone other than the BOD, or whoever signed the check. Some handwriting at the top of the withdrawal slip and the resident's signature were the same. On [DATE] at approximately 11:32 AM The District Director of Business Office Services (DDBOS) was again interviewed for some clarification. No, families have not been notified. Review of her/his investigation. Resident Trust identified with forged signatures was 15, $640.00 and the cash receipts were payments not applied to resident accounts, $1,766.[AGE] for a total of $17,406.[AGE], money unaccounted for. Total of 11 residents involved. One resident said s/he does receive money but had never been asked to sign for it. S/he denied residents were paid interest on their accounts. On [DATE] at 4:00 PM, the resident identified by the District Director was interviewed by the surveyor. No problem now. I did when ____ (BOD) was here. S/he was over the money. S/he wouldn't give you any accounting of your money. S/he wouldn't give you any update or how much money you had in your account. No, I did not get any bank statements for a very long time. I don't know exactly how long, I know it's been better than a year since I got a bank statement. Now they give you a receipt to sign when you get money. When you asked her/him for money s/he would say s/he would get it for you, but you never saw what you asked for. S/he was the one who kept track of it. S/he never said anything to me about my account. No, no one has talked to me about my account. Now, when you get money you sign for it. When s/he was here you couldn't get your money. Review of the Corporate Investigation completed [DATE] revealed: General Accounting Staff in Houston questioned signatures. DDBOS completed initial review in [DATE]. Full review in process as of [DATE]. Current Summary of Findings: Resident Trust Withdrawals $15,640.00. Cash Receipts $1,766.[AGE], for a total of $17,406.[AGE]. Actions completed: BOD was suspended during investigation and then resigned. Reported to State. Refunds completed for residents whose funds were missing. Six (6) residents were listed to have discrepancies. Of the six, four (4) residents were listed to have received refunds for a total of $15,640.00. Cash Receipt Review revealed five residents listed with a total refund of $1,766.[AGE]. Resident previously identified by the DDBOS was interviewed. S/he has an account and gets money all the time when s/he needs it. | 2020-09-01 |
| 1441 | INMAN HEALTHCARE | 425122 | 51 N MAIN ST | INMAN | SC | 29349 | 2018-08-01 | 567 | F | 1 | 0 | QNRI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of facility files, the facility failed to safeguard resident financial accounts for 11 of 21 resident accounts. The findings included: The facility reported to the state agency an allegation of misappropriation on [DATE]. A visit was made to the facility to investigate the allegations. At the time of the investigation on [DATE] the facility did not have the documentation of the investigation at the facility. During the Entrance Conference, the Administrator informed the surveyor, s/he had only been at the facility for approximately three (3) weeks and the Corporate Office handled the investigation. The Administrator was aware of the incident but did not know the specifics. The facility at one point stated that 21 resident accounts were involved. Then it stated there were 11 resident accounts affected. Their investigation showed only six residents with accounts affected were reimbursed and 5 residents were reimbursed for cash receipts. (Total of 11). One resident who deceased in 2016 had a cash receipt for $500.00, which was not posted to Accounts receivable or to Resident Trust. The residents did not receive bank statements, confirmed by the Corporate District Director (one resident said for over a year). Interest was not applied to the residents reimbursed. Only residents that were able to say they had a problem were reimbursed by the facility/corporation. On [DATE] at approximately 9:30 AM, the facility's Business Office Manager was interviewed by the surveyor. I was just hired in June. Things didn't look right, so I started doing an audit and things were not right. I sent the information of the audit to my boss at corporate and they took over the investigation. The final audit has not been completed yet, only the in-house residents. discharged resident accounts have not had a completed audit yet. The previous Business Office Director (BOD) was just arrested last night. At this time the amount is over $50,000.00. At Approximately 12:30 PM, the corporate representative, District Director of Business Office Services, was interviewed by the surveyor. We restructured in November of 2016, and I got these buildings. I provide support and training to Business Office Staff and audit annually and as needed per company policy. Every month the Business Office prepares a copy of all patient trust transactions, withdrawals, deposits, checks and it is sent to Houston, [STATE]-Sava Company that does general accounting. One auditor in the sister facility office noticed what appeared to be forged resident signatures with withdrawal slips. This happened in mid to late May. They sent me copies and I felt they were forged and came to facility and started an investigation. After I looked at the couple months of resident trust files, it appeared the same handwriting forged resident slips. We suspended the BOD pending a more thorough investigation. During the call I asked the BOD if s/he knew our policy on obtaining resident signatures. I asked if s/he ever forged resident signatures. S/he said no. S/he was able to walk me through what the process was. The process was- resident comes in, Business Office Director (BOD) would fill out a withdrawal slip for how much they wanted with name and date. The resident would sign withdrawal slip. If resident could not sign then two witnesses were required. The Administrator was the back up if the BOD was not here. There was a different administrator here at that time. The person giving out money would not sign the withdrawal. 2 others would witness the transaction. The BOD was suspended and I continued to look through the resident withdrawals and found more. I worked back from May to January. I worked with the area Human Resource Manager (HR). The BOD called the Administrator of the sister facility and resigned. I then looked at this facility for the same time frame. We found evidence of Barber and Beauty services, Beautician invoice. The BOD's handwriting listed resident names to have hair done. We saw white out had been used on the form and a different resident's name was written over it. The beautician would write what service was done with the cost. What I think was happening was the BOD would debit a resident's account that had money so a resident who didn't have money could have their hair done. Both facilities had forged withdrawal slips. Once the BOD was no longer an employee, we (Vice President of Operations-Finance) continued to take a look. S/he went to sister facility in June and in July s/he was in both buildings. We looked at files. We started to look at older files from December backwards. We looked at the actual Funds Management System. The files were withdrawal slips, deposits and copies of checks. Any checks written to beautician or to replenish petty cash. These files are business/fund files. We looked at actual residents' accounts in June for both facilities. We were looking for excessive transactions or transactions where residents said they never received money. In July we interviewed residents. They said they were never asked to sign for withdrawals. During July, as we continued to investigate, we looked at receipt books. We saw where cash payments were received but never applied to resident accounts or deposited into Resident Trust Accounts. Resident's at both facilities were affected by that. After going through receipt books at both locations, we wrapped up our investigation that is when we reported to the state agencies and to the Police Chief. When we wrapped up our investigation, two residents at the sister facility and a higher volume of residents here, but not more money. We estimated around $36,000.00, between both facilities. The Police Chief wanted to pursue. I was able to take her/him just under $21,000.00 worth of receipts. That was all I could get copied by the time s/he wanted it. I gave her/him the copies. The BOD was arrested sometime yesterday. The charge was Breach of Trust. 21 resident accounts were affected at this facility. 6 Patient Trust Accounts and 5 cash receipts. We looked at current in-house residents for Resident Trust Accounts. One (1) discharged resident was seen in the cash receipts. We looked at all cash receipts back to January. Reimbursements were made where resident said they never got money and who had excessive transactions. Reimbursed based on interviews and excessive transactions. The sister facility's cash receipts was $13,218 and in Patient Trust was $5,032. This facility had $15,640 in Patient Trust and $1,766.[AGE] in cash receipts were refunded. There was no dollar amounts on forged receipts. No outside agency has audited the accounts. We did an internal audit. The Business Office would key withdrawal slips into the system. It's transferred from Resident Trust account into Resident Trust checking account. The BOD would print the checks. The Administrator, Director of Nursing or Minimum Data Set Nurse would sign the check. The check would be taken to the bank. It should not be the BOD, but it was. It should have been anyone other than the BOD, or whoever signed the check. Some handwriting at the top of the withdrawal slip and the resident's signature were the same. On [DATE] at approximately 11:32 AM The District Director of Business Office Services (DDBOS) was again interviewed for some clarification. No, families have not been notified. Review of her/his investigation. Resident Trust identified with forged signatures was 15, $640.00 and the cash receipts were payments not applied to resident accounts, $1,766.[AGE] for a total of $17,406.[AGE], money unaccounted for. Total of 11 residents involved. One resident said s/he does receive money but had never been asked to sign for it. S/he denied residents were paid interest on their accounts. On [DATE] at 4:00 PM, the resident identified by the District Director was interviewed by the surveyor. No problem now. I did when ____ (BOD) was here. S/he was over the money. S/he wouldn't give you any accounting of your money. S/he wouldn't give you any update or how much money you had in your account. No, I did not get any bank statements for a very long time. I don't know exactly how long, I know it's been better than a year since I got a bank statement. Now they give you a receipt to sign when you get money. When you asked her/him for money s/he would say s/he would get it for you, but you never saw what you asked for. S/he was the one who kept track of it. S/he never said anything to me about my account. No, no one has talked to me about my account. Now, when you get money you sign for it. When s/he was here you couldn't get your money. Review of the Corporate Investigation completed [DATE] revealed: General Accounting Staff in Houston questioned signatures. DDBOS completed initial review in [DATE]. Full review in process as of [DATE]. Current Summary of Findings: Resident Trust Withdrawals $15,640.00. Cash Receipts $1,766.[AGE], for a total of $17,406.[AGE]. Actions completed: BOD was suspended during investigation and then resigned. Reported to State. Refunds completed for residents whose funds were missing. Six (6) residents were listed to have discrepancies. Of the six, four (4) residents were listed to have received refunds for a total of $15,640.00. Cash Receipt Review revealed five residents listed with a total refund of $1,766.[AGE]. Resident previously identified by the DDBOS was interviewed. S/he has an account and gets money all the time when s/he needs it. | 2020-09-01 |
| 651 | WHITE OAK MANOR - NEWBERRY | 425077 | 2555 KINARD STREET | NEWBERRY | SC | 29108 | 2019-12-12 | 842 | D | 1 | 1 | 5CPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, observation, and record review, the facility failed to ensure that clinical paper and electronic records were complete and accurate for 1 of 25 sampled resident reviewed. Resident #87 had no dietary/nutritional notes in his/her medical record. The findings included: The facility admitted Resident #87 on 7/30/19 with [DIAGNOSES REDACTED]. During individual interview on 12/10/19 at approximately 9:55 AM Resident #87 stated he/she would like a variety of foods in his/her diet. When asked if anyone has specifically addressed his/her diet the resident stated he/she would like to talk to someone about his/her diet. A review of the electronic medical record on 12/11/19 at approximately 1:07 PM revealed the resident was on a regular renal diet with no fluid restrictions noted. A meal delivery observation on 12/11/19 at 1:18 PM revealed Resident #87 received diet as ordered. Staff had to encourage the resident to wake up to eat. Staff placed the food tray on the bedside table and raised the resident's bed. A review of the medical record on 12/11/19 at 2:40 PM revealed no dietary/nutritional notes in paper or electronic medical records. The paper chart had multiple yellow sheets indicating diet changes with no accompanying notes or dietary consults/assessments. The facility staff could not locate any dietary/nutritional notes in the paper chart or electronic records and referred the surveyor to the registered dietitian. An interview on 12/11/19 at 8:25 AM with the Registered Dietitian (RD) revealed he/she had a system in place to ensure documentation was completed and stated he/she had meet with Resident #87 on 10/30/19 to address his likes and dislikes but could not find the documentation. The RD further stated he/she looked through the electronic medical records under multiple tabs and could not find any dietary/nutritional notes to indicate a dietary consult/assessment had been done for Resident #87. | 2020-09-01 |
| 3432 | C M TUCKER NURSING CARE CENTER / RODDEY | 425360 | 2200 HARDEN STREET | COLUMBIA | SC | 29203 | 2018-10-04 | 840 | D | 1 | 1 | 2F3711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, observations and record reviews, the facility failed to ensure that a written contract/agreement was accessible for residents receiving [MEDICAL TREATMENT] services from outside resources. Resident #20 and #65 received outside facility [MEDICAL TREATMENT] services with no written agreement in place. Two of 2 [MEDICAL TREATMENT] residents reviewed. The findings included: An interview on 10/01/18 at approximately 11:30 AM facility administrator revealed the facility had residents that required [MEDICAL TREATMENT] services but the facility had no agreement/contract with an outside source for [MEDICAL TREATMENT] services. The facility admitted Resident #65 on 9/26/08 with [DIAGNOSES REDACTED]. An individual resident interview on 10/02/18 at approximately 8:35 AM revealed that Resident #65 [MEDICAL TREATMENT] lunch was not packed in an insulated container with ice packs. The resident stated he/she received items like macaroni salad, turkey sandwich, apple juice and fruit cup. The resident further stated that his/her meals were hot when he/she gets to eat and he/she does not like hot macaroni salad. A review of the medical record revealed a physician's orders [REDACTED]. The physician's orders [REDACTED]. The facility admitted Resident #20 on 5/11/16 with [DIAGNOSES REDACTED]. A review of the medical record on 10/01/18 revealed a physician's orders [REDACTED]. The cumulative physician's orders [REDACTED]. An interview and observation on 10/02/18 at approximately 11:58 AM with Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #1 confirmed the observation. CNA #1 stated the resident meals are transported to [MEDICAL TREATMENT] in the white paper bags inside the clear paper bags. CNA #1 further stated there were no insulated containers to transport resident's food. An observation of the unit refrigerator ([NAME] 132) revealed there were no ice packs to use if insulated containers were available. An interview with the facility administrator on 10/02/18 at approximately 2:35 PM regarding a [MEDICAL TREATMENT] contract. The facility administrator stated the [MEDICAL TREATMENT] agreement/contract had not been addressed because he/she was informed by someone within his/her agency that they did not need an agreement to accept [MEDICAL TREATMENT] residents at the facility. | 2020-09-01 |
| 2526 | PRUITTHEALTH- RIDGEWAY | 425288 | 213 TANGLEWOOD COURT | RIDGEWAY | SC | 29130 | 2018-06-15 | 692 | D | 1 | 1 | RRBC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on limited record review and interview, the facility failed to appropriately monitor the resident's weights to maintain appropriate nutrition parameters, resulting in significant weight loss, for 1 of 7 residents reviewed for nutrition. The findings included: Resident #76 was admitted to the facility, with diagnoses, including but not limited to, Gastro-[MEDICAL CONDITION] Reflux Disease, Hypertension, [MEDICAL CONDITIONS] Fibrillation, and Depression. To maintain appropriate and adequate nutritional status and values, the resident receives nutrition via tube feeding, as outlined in the physician's orders [REDACTED]. Review of the resident's recorded weights indicated the resident weighed approximately 177.4 pounds on 02/09/18. The resident was again weighed in March, on the 8th and weighed 160 pounds. The next weight was not captured until the next month in which the resident weighed 165 pounds. Review of the 'Weight Progress Notes Form' indicate a progress note written on 04/13/18, stating Current weight stable with increase to rate of nutrition and toleration. Increased ideal body weight. Weights monitored weekly x 3 , signed by the Dietary manager. The previous note was written on 05/30/17. Review of 'Enteral Feeding Progress Notes Form' indicated a progress note dated 02/06/18, signed by the dietician, in which the resident's nutritional needs were being met. The next note, dated 04/02/18, revealed significant weight decrease x past month, weight variability noted month to month A recommendation was made to increase the rate of the tube feedings. Review of nurse's notes and physician progress notes [REDACTED]. Review of the physician's orders [REDACTED]. Since this change the resident's weights have trended upward. During an interview with the Director of Nursing and the Administrator on 06/15/18, at approximately 10:12 a.m. it was discussed that residents are weighed monthly, unless orders dictate otherwise. Further interview with the Administrator revealed the weight loss experienced by Resident #76, was significant, without appropriate intervention. | 2020-09-01 |
| 2170 | ROCK HILL POST ACUTE CARE CENTER | 425159 | 159 SEDGEWOOD DR | ROCK HILL | SC | 29732 | 2018-08-24 | 641 | D | 1 | 1 | C4HW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on limited record review and interview, the facility failed to ensure MDS assessment was coded accurately related to falls, for 1 of 4 reviewed for accidents. The findings included: Resident #14 was admitted to the facility with [DIAGNOSES REDACTED]. The Director of Nursing provided a list of falls the resident sustained [REDACTED]. Review of the resident's care plan reflected the resident's risk for falls, poor balance and safety awareness. Furthermore the care plan detailed the dates of the falls that occurred. Review of the Minimum Data Set quarterly assessment dated [DATE], indicated no falls since the admission or reentry. On 08/24/18 at 1:08pm the DON reviewed and confirmed the assessments to be inaccurately coded related to the number of falls sustained. | 2020-09-01 |
| 2524 | PRUITTHEALTH- RIDGEWAY | 425288 | 213 TANGLEWOOD COURT | RIDGEWAY | SC | 29130 | 2018-06-15 | 679 | D | 1 | 1 | RRBC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on limited record review and interview, the facility failed to ensure to provide quality of care for 1 of 1 resident reviewed for activities. No activities were provided for Resident #105 during the week of the survey. The findings included: Resident#105 was admitted on [DATE] with [DIAGNOSES REDACTED]. During observation on 6/11/18 at 04:10 PM Resident was in her room while activities were occurring. Observation on 06/13/18 at 10:30 AM Resident was in her/his room TV was not on and no music. Observation on 06/14/18 at 3:30 PM Aromatherapy and Music activity was occurring but Resident #105 was not present. During record review on 6/15/18 at 9:10 AM revealed Care Plan Resident #105 unable to express her/his customary routine and or past leisure interest? Resident's siblings stated loved listening to gospel music. Approaches listed will accept small group programing and or individual programming visits from staff. During record review on 6/15/18 at 9:30 AM revealed Resident#105 Group Attendance Record Form have Actively Participated under other, but no documentation on the back of the form of what type of activities is listed for others. During interview with Activities Director on 6/15/18 at 9:50 AM, surveyor asked what type of activities are done with residents that are not alert and oriented. S/he stated will go by the family preference. Activities Director reviewed Resident# 105 activity forms and stated the Administrator just made me aware the other activities need to be listed on the form. | 2020-09-01 |
| 440 | PRUITTHEALTH-WALTERBORO | 425053 | 401 WITSELL STREET | WALTERBORO | SC | 29488 | 2019-10-25 | 600 | D | 1 | 0 | TFZI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on limited record review and interview, the facility failed to protect Resident #3 from physical abuse by 1 of 4 residents reviewed for physical abuse (Resident #4). The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/24/19 at 02:06, review of the facility's Initial 2/24-Hour Report revealed an incident occurred on 07/26/19 at 07:30 PM. At 02:11 PM, review of the facility's Five-Day Follow-Up Report revealed Resident #4 entered Resident #3's room. Resident #3 reported Resident #4 had a fork raised and was going to stab her/him and that s/he knocked the fork out of (his/her) hand, and yelled for help. Upon entering the room, staff observed Resident #4 with his/her hands around Resident #3's wrists. Review of the Nursing Progress Notes revealed on 07/14/19 Resident #4 attempted to go outside stating s/he saw his/her mother's car. Resident #4 became angry with staff attempts at re-direction, jumped out of (his/her) wheelchair and walked quickly to the front doors and walked out the building. When s/he realized it was not his/her mother's car, the staff were able to bring Resident #4 back in the building. On 07/16, Resident #4 went into a resident's room on another unit. When the resident told Resident #4 to get out of her/his room, Resident #4 kept moving towards (her/him) with his/her w/c (wheelchair) and the other resident swung at Resident #4 to leave and he rammed into (her/him) with his w/c. On 07/17, the nurse observed Resident #4 grab the tire on (a) hall 3 resident's w/c and would not let her/him move. The note indicated Resident #4 was easily directed to release the resident's wheelchair. At 07:10 PM on 07/18, Resident #4 entered room [ROOM NUMBER]B and the resident started waving (her/his) arms and yelling at resident to get out and (Resident #4) hit the other resident's wheelchair when he/she turned to leave. On 07/21/19, Resident #4 tried multiple times to get outside this evening and documented that attempts to re-direct were not successful. A Wanderguard was placed on the resident's right arm by the nurse. At 03:31 PM, Social Services documented it has been noted that resident is wandering, getting out of his wheelchair and at times hard to be redirected back to chair. Review of Licensed Practical Nurse (LPN) #1's facility-obtained statement indicated s/he heard Resident #3 screaming, saying stop it, get off of me. Upon entering the room, the LPN found Resident #3 sitting in the wheelchair with Resident #4 holding her/his wrists tightly in his/her hands and Resident #3 still yelling. The LPN told Resident #4 to stop and yelled for help. Other staff arrived and removed Resident #4 from the room. When the LPN asked Resident 3 what happened, s/he reported that s/he was watching television when Resident #4 came in the room holding the fork up like (he/she) was going to stab me. I knocked the fork out (the resident's) hand and (he/she) grabbed both my wrist (sic) and held them tight, so I started screaming to get some help. Review of Registered Nurse (RN) #1's facility-obtained statement dated 07/26/19 indicated that at 07:20 PM, s/he was receiving report when s/he heard screams. The RN ran down the hall with LPN #1 to Resident #3's room and observed Resident #4 with a tight grip on Resident #3's right wrist. During an interview on 10/25/19 at approximately 11:30 AM, the Nursing Home Administrator (NHA) confirmed the documentation of Resident #4 exhibiting aggressive behaviors towards other residents prior to the incident with Resident #3. The NHA further confirmed Resident #4 abused Resident #3 and that person-centered interventions were not provided when Resident #4 was wandering and that the facility failed to provide adequate supervision to prevent wandering and prevent abuse of other residents. | 2020-09-01 |