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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 |
| 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 |
| 3 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 755 | D | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy, the facility failed to assure that each cottages' narcotic medications that were locked in the cottages' medication cart corresponded with the cottages' narcotic count recorded in the narcotic book for two of 12 cottages. Findings include: On 01/18/19 at 4:30 PM, review of the narcotic medications that were locked in the locked compartment of the medication cart and in the presence of the Assistance Director of Nursing (ADON), Licensed Practical Nurse (LPN) 4 stated that Resident (R) 1 had nine tablets of [MEDICATION NAME]-ACET 5 mg (milligrams)-325 mg. However, R1's narcotic sheet for [MEDICATION NAME]-ACET 5 mg-325 mg tablet indicated 10 tablets. LPN4 stated that R1 had two tablets of [MEDICATION NAME] HCL 50 mg; however, review of R1's narcotic sheet for [MEDICATION NAME] HCL 50 mg tablet indicated three tablets. During an interview on 01/18/19 at 4:30 PM, LPN 4 stated that s/he gave R1 one [MEDICATION NAME] tablet when s/he returned from her/his doctor's appointment around 2 PM. LPN4 stated that s/he administered the [MEDICATION NAME] at 12 PM at the scheduled time. LPN4 stated that s/he forgot to document on each of the narcotic sheets that s/he had administered the medications. LPN 4 stated it was the facility's policy to document the administration of the medication after the medication was administered. Review of the Electronic Medication Administration Record (EMAR) with LPN4 and the ADON, revealed that there was no documentation that R1 had received one tablet of [MEDICATION NAME] at 2 PM; however, the [MEDICATION NAME] was documented as administered during the scheduled time at 12 PM. During an interview on 01/19/19 at 8:50 AM with the Administrator, ADON, and Unit Manger, the Unit Manager stated that s/he expected the nurses to document on the EMAR and, if applicable, the narcotic sheet immediately after administering any medication. Review of R15's Face Sheet revealed the facility readmitted the resident on 01/10/19, with [DIAGNOSES REDACTED]. Review of the (MONTH) 2019 Physician order [REDACTED]. Review of the Controlled Medication Utilization Record and the count of R15's [MEDICATION NAME] tablets on 01/18/19 at 4:44 PM revealed, the Utilization Record indicated the resident should have six [MEDICATION NAME] tablets remaining of his/her narcotic pain medication with the last dose being signed out on 01/17/19 at 9:00 PM; however, count of the residents [MEDICATION NAME] tablets revealed only five [MEDICATION NAME] tablets remaining, indicating inaccurate reconciliation. Review of R17's Face Sheet revealed the facility admitted the resident on 12/27/18, with [DIAGNOSES REDACTED]. Review of R17's (MONTH) 2019 Physician order [REDACTED]. Review of the Controlled Medication Utilization Record and observation of R17's [MEDICATION NAME] tablets on 01/18/19 at 4:44 PM revealed the Utilization Record indicated the resident should have had 20 [MEDICATION NAME] tablets remaining of her/his narcotic pain medication with the last dose being signed out on 01/18/19 at 5:20 AM; however, count of the residents [MEDICATION NAME] tablets revealed only 19 tablets remaining, indicating inaccurate reconciliation. During an interview, on 01/18/19 at 4:44 PM with Register Nurse (RN) 3 revealed both R15's and R17's medication cards showed one less narcotic medication than indicated on the narcotic count sheets because s/he got caught up with everything else going on around her/him and forgot to sign it out on the narcotic count sheet. The RN revealed s/he would have seen the discrepancy at the end of her/his shift and would have fixed it then. RN3 revealed s/he should have signed the narcotic medication on the narcotic count sheet before s/he pulled the medication. The RN stated it was important to record the narcotic medication on the narcotic count sheet to keep an accurate record. Review of the undated policy, Narcotics, Controlled Substances and Preventing Drug Diversion indicated Policy interpretation and Implementation . 2. Administration of medication must be documented immediately after (never before) it is given. | 2020-09-01 |
| 4 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-01-21 | 842 | D | 1 | 0 | ZBYG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and review of the facility's policy, the facility failed to document in the resident's clinical record the nursing assessment of the physical condition for one of five residents reviewed for falls. (Resident (R) 2) after R2 fell from the mechanical lift to the floor. In addition, the facility failed to document the reason R2's physician was not notified for approximately one and one-half hours after the fall. Findings include: R2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the 24-hour Report dated 12/28/18 indicated the details of the incident that occurred on 12/27/18 at 7 PM, Resident was in Hoyer lift being placed back to bed. Hoyer lift clip cracked, and resident fell to the floor from an up position to her/his left side . Resident was sent to the ER. Review of R2's Progress Notes dated 12/27/18 at 2240 (11:40 PM) indicated, While CNA (certified nurse aide) was transferring resident to bed via hoyer lift, upon placing the hoyer lift in the upright position, the left side of the sling (black plastic piece) popped. Patient fell on the floor out of the lift. Fall was noted at 1900 (7 PM). Resident was assessed . Resident requested to be sent to ER( emergency room ) . PCP (primary care physician) notified at 2034 (8:34 PM) and informed of incident and request to send to ER. EMS (Emergency Medical Services) arrived at 1906 (7:06 PM). Substitute POA (Power of Attorney) notified at 2234 (10:34 PM). Review of the document titled PACS Nursing - Post Fall Review, dated 12/27/18 at 6:50 PM, addressed that there was no history of falls; the medication the resident received were narcotics, diuretics, and laxatives; memory cognitively intact; adequate vision; total incontinence of urine and bowel movement; no behaviors in last seven days; confined to chair; no problems with blood pressure; and gait indicated unable to independently come to a standing position. The document did not document the physical assessment of R2 when s/he was observed on the floor after the fall from the mechanical lift. The document did not identify who was the writer of the document. Review of the document titled PACS: Nursing-Body assessment, dated 12/27/18 at 7 PM, indicated Body assessment - Skin condition hematoma back of head and complaint of pain to L (left) leg. There was no further documentation on this document nor whom was the writer of the document. Review of a document titled Witnessed Fall, completed by Licensed Practical Nurse (LPN) 5 dated 12/27/18 at 6:50 PM indicated Incident Description - While CNA was transferring the resident to bed via hoyer lift, upon placing the hoyer lift in the upright positions, the left side of the sling (black plastic piece) popped. Patient fell on the floor out of the lift. The Patient stated the sling broke and I fell out onto the floor. Immediate Action Taken - Resident was assessed . Injury type - Hematoma/Bruise back of head, alert, oriented to place time, person and situation. Review of a document titled Health Status Note, dated 12/27/18 at 10:49 PM. indicated While CNA was transferring resident to bed via hoyer lift, upon placing the hoyer lift in the upright position, the left side of the sling (black plastic piece) popped. Patient fell on the floor out of the lift. Fall was noted at 1900 (7 PM). Resident was assessed . sent to ER . PCP notified at 2034 (8:34 PM) . EMS arrived and transported resident at 1906 (7:06 PM). Review of the undated facility's policy titled, Falls-Clinical Protocol indicated, 5. The staff will evaluate, and document falls that occur while the individual is in the facility, for example, when and where they happen, any observation of the events, etc. During an interview on 01/21/18 at 1 PM with the Administrator and Assistant Director of Nursing (ADON), the Administrator stated that s/he was unable to locate any further documentation regarding the physical assessment of R2 after s/he fell to the floor from the mechanical lift on 12/27/18 at 7 PM. The Administrator and ADON stated that it was their expectation that nurses document their assessment of the resident after a fall. The Administrator confirmed that s/he had no explanation, nor could s/he find any documentation why the PCP was not notified until 8:34 PM (almost one and one-half hours after R2 was transported to the ER). | 2020-09-01 |
| 5 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 550 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide dignity and privacy for Resident # 41 by not covering the resident's catheter bag when it was in sight of other people. ( 1 of 2 residents observed with catheters) The findings included: The facility admitted Resident # 41 with [DIAGNOSES REDACTED]. On three days of the survey the resident was observed in bed in his/her room with the catheter tubing hanging uncovered on the side of the bed facing the door. The bag could be seen by anyone walking by the door or out in the dining area. Interview with the resident's spouse revealed the staff usually covered the bag but he/she had not seen the bag covered at all this week. Interview with Certified Nursing Assistant # 1 ( CNA) on 2/28/18 @ 10:15 AM revealed that the catheter bags were covered any time a resident was up or catheter bag was in view of other people to protect the privacy and dignity of the resident. When asked what he/she saw when he/she looked into this resident's room. He/she stated the catheter bag uncovered. The CNA confirmed the resident's privacy and dignity was not being protected. The CNA further stated, The cover was removed the other day and not replaced. There have not been any covers in the closet or in the cottage at all this week. The Licensed Practical Nurse #1 also responded that there were no covers in the cottage and that he/she would order some. | 2020-09-01 |
| 6 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 659 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide care per the Care Plan for Resident #18, 1 of 7 sampled residents reviewed for Falls. Resident #18 was care planned for the bed to be in low position and to remove bed controls due to the resident being a high fall risk. Cross refer to F689 The findings included: The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Resident #21 was observed in bed with the bed in normal position (not low) on 2/26/2018 at 10:59 AM, 2/27/2018 at 3:56 PM and 2/28/2018 at 3:06 PM. Record review of the Care Plan on 2/28/2018 at 3:23 PM, revealed a focus area indicating Resident #21 was at risk for fall related injuries. Interventions listed for the focus area were to keep the bed in lowest position and to remove the bed controls when the bed is in lowest position so the resident can't raise bed to a high position. In addition, the Care Plan indicated the resident was a high fall risk. During an observation and interview with Certified Nursing Assistant (CNA) #2 on 2/27/2018 at 3:58 PM, Resident #18 was observed in bed with the bed in normal position. In addition, the bed controls were observed on the bed, within reach of the resident. CNA #2 stated that the resident was care planned to have the bed low, but she/he did not like the bed in low position. CNA #2 stated that the resident can become very agitated when the bed is in low position and will crawl out of the bed and then be found on the floor in the room. CNA #2 stated that when the bed is in normal position the resident is calm and content. Upon leaving the room, CNA #2 left the bed in normal position with the bed controls within reach of the resident. During an interview with Licensed Practical Nurse (LPN) #5 on 2/28/2017 at 3:06 PM, LPN #5 verbalized fall prevention interventions for Resident #18, including keeping the bed in lowest position. In addition, LPN #5 stated the resident is cognitively intact enough to operate the bed controls and will raise the bed up when it is in low position. LPN #5 stated sometimes we turn the bed controls over so the resident can't raise the bed, but the resident had since figured out how to turn the controls back over and raise the bed. At 3:10 PM on 2/28/2018, Resident #18 was observed in bed with the bed in normal position with the bed controls within the resident's reach. LPN #5 lowered the bed and left the bed controls within reach of the resident upon leaving the room. At 3:16, Resident #18 was observed with the bed back in normal position (with LPN #5 present). Resident #18 had used the bed controls to raise the bed back to normal position. During an interview with Registered Nurse (RN) #1 on 2/28/2018 at 3:55 PM, RN #1 confirmed the Resident was care planned to have the bed in lowest position and to remove the bed controls when in lowest position. RN #1 stated the resident's bed had been lowered and the bed controls were unplugged. Review of Nurse's Notes, Incident Reports, and the Care Plan revealed that the Interdisciplinary Team had reviewed each fall and reviewed and/or revised the Care Plan. | 2020-09-01 |
| 7 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 679 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide a structured program of activities for 1 of 1 sampled resident reviewed/triggered for activities. Resident #82 was observed in bed in his/her room with no structured activities in progress. The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. Observations on 2/26/18 from 10 AM to 1 PM revealed Resident in room in bed with no structured program of activities provided. A record review on 2/26/18 at approximately 11:28 PM revealed documentation on a physician's capacity statement that Resident #82 was admitted on [DATE] and physician's cumulative orders that the resident was admitted on [DATE]. A social note dated 2/06/18 indicated the resident scored 15 cognition indicating cognition was intact and resident able to voice needs. Further record review revealed no activity evaluation was completed and there was no documentation on the paper charting or electronic record to indicate a structured program of activities were provided. An observation on 2/27/18 at approximately 11:33 PM to 1 PM revealed the resident in his/her room with no structured program of activities in place. A nurse's noted dated 2/06/18 indicated Resident #82 refused medication and verbally expressed he/she wanted to die. An interview on 2/28/18 at approximately 8:30 AM with Social Services Assistant #1 revealed the resident received psych services on 2/13/18. A review of the psych results revealed the resident depressed with a recommendation for staff to encourage residents to participate in activities. An interview on 2/28/18 at approximately 10:15 AM with the Activity Director (AD) confirmed the activity assessment/evaluation was not complete and there was no documentation in the medical record (paper/electronic) of activities being provided. | 2020-09-01 |
| 8 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 684 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the necessary care and services for 1 of 6 residents reviewed for unnecessary medications. Resident #115's elevated blood sugars were not reported to the physician as ordered. The findings included: Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of Medication Administration Records for Resident #115 on 2/28/18 at approximately 11:12 AM revealed the resident had an elevated blood sugar of 410 on 2/23/18. Review of Resident #115's Progress Notes on 2/28/18 at approximately 11:50 AM revealed no documentation that the physician was notified of elevated blood sugar on 2/23/18. Interview with Director of Nursing (DON) on 2/28/18 at approximately 1:26 PM confirmed that there was no documentation that the elevated blood sugar on 2/23/18 was relayed to the physician. | 2020-09-01 |
| 9 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 689 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement fall prevention interventions for Resident #18, 1 of 7 sampled residents reviewed for falls. The facility failed to maintain the resident's bed in the lowest position and remove the bed controls per the Care Plan. Resident #18 has a history of multiple falls. Cross refer to F659 The findings included: The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Resident #21 was observed in bed with the bed in normal position (not low) on 2/26/2018 at 10:59 AM, 2/27/2018 at 3:56 PM and 2/28/2018 at 3:06 PM. Record review of the Nurse's Notes on 2/28/2018 at 2:23 PM revealed that the resident had unwitnessed falls in her/his room on 10/30/2017, 11/25/2017, 12/27/2017 and 2/9/2018. In each case the resident was found on the floor near her/his bed. Record review of the Care Plan on 2/28/2018 at 3:23 PM, revealed a focus area indicating Resident #21 was at risk for fall related injuries. Interventions listed for the focus area were to keep the bed in lowest position and to remove the bed controls when the bed is in lowest position so the resident can't raise bed to a high position. In addition, the Care Plan indicated the resident was a high fall risk. Review of the Certified Nursing Assistant task sheet for Resident #18 on 3/1/2018 at 10:25 AM, revealed a task to keep the resident's bed in low position. Removing the resident's bed controls was not listed on the task sheet. During an observation and interview with Certified Nursing Assistant (CNA) #2 on 2/27/2018 at 3:58 PM, Resident #18 was observed in bed with the bed in normal position. In addition, the bed controls were observed on the bed, within reach of the resident. CNA #2 stated that the resident was care planned to have the bed low, but she/he did not like the bed in low position. CNA #2 stated that the resident can become very agitated when the bed is in low position and will crawl out of the bed and then be found on the floor in the room. CNA #2 stated that when the bed is in normal position the resident is calm and content. Upon leaving the room, CNA #2 left the bed in normal position with the bed controls within reach of the resident. During an interview with Licensed Practical Nurse (LPN) #5 on 2/28/2017 at 3:06 PM, LPN #5 verbalized fall prevention interventions for Resident #18, including keeping the bed in lowest position. In addition, LPN #5 stated the resident is cognitively intact enough to operate the bed controls and will raise the bed up when it is in low position. LPN #5 stated sometimes we turn the bed controls over so the resident can't raise the bed, but the resident had since figured out how to turn the controls back over and raise the bed. At 3:10 PM on 2/28/2018, Resident #18 was observed in bed with the bed in normal position with the bed controls within the resident's reach. LPN #5 lowered the bed and left the bed controls within reach of the resident upon leaving the room. At 3:16, Resident #18 was observed with the bed back in normal position (with LPN #5 present). Resident #18 had used the bed controls to raise the bed back to normal position. During an interview with Registered Nurse (RN) #1 on 2/28/2018 at 3:55 PM, RN #1 confirmed the Resident was care planned to have the bed in lowest position and to remove the bed controls when in lowest position. RN #1 stated the resident's bed had been lowered and the bed controls were unplugged. In addition, RN #1 stated the resident's bed would be switched out for a crank bed (a bed without automatic controls). | 2020-09-01 |
| 10 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 732 | C | 0 | 1 | JK8711 | Based on observations, interviews and review of the facility's posting information, the facility failed to complete daily posting information that addressed nursing staff per shift. The posting did not identify whether nurse was registered or licensed and certified nursing to resident coverage was not included. 12 of 12 cottages. The findings included: During initial tour on 2/26/18 of the Forsythia Cottage at approximately 9:30 AM and the Rose Cottage at approximately 9:38 AM review of the hand written staff posting had no documentation of staff coverage related to the second shift (7 PM - 7:30 AM). Random observation on 2/27/18 at approximately 9 AM of the Rose Cottage and 9:30 AM of the Forsythia Cottage revealed the hand written staff posting noted on the wall with no second shift (7 PM - 7:30 AM) staff posted. An interview on 2/27/18 at approximately 12:15 PM with the Director of Nursing (DON) and Facility Administrator confirmed the second shift staff documentation was not posted for any of the cottages until the second shift staff arrived to the facility. Further review of hand written staff postings on the cottage revealed staff posting for 2/24/18 (Saturday) Rose Cottage first shift (7 AM - 7:30 PM) had no documentation of nursing staff coverage and the hand written on 2/25/18 (Sunday) Rose Cottage had no first shift staff coverage. The hand written staff posting for 2/25/18 (Sunday) Forsythia Cottage had no documentation of staff coverage. Review of the hand written posting indicated staff worked 12 and half hours shifts. During the survey, two family members expressed concerns about lack of evening and weekend staff coverage. During group interview on 2/27/18 at approximately 11 AM three of 5 residents who attend resident council regularly expressed concerns about staff coverage at nights and on weekends. A review of a computerized accounting of staff coverage for the past three months on 3/01/18 at 8:40 AM revealed a listing of staff coverage that was not accessible to residents/visitors/families. The computerized staff coverage did not identify whether the nursing staff was a registered or licensed nurse. The computerized documentation was inconsistent as to staff coverage. The handwritten staffing for 2/26/18 indicated a census of 10 residents in the Forsythia Cottage on first and second shift and the computerized copy indicated a census of 12 residents in the Forsythia Cottage. The Administrator confirmed the computerized staffing information was on the unit and not accessible to residents/visitors/families. | 2020-09-01 |
| 11 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 745 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the communication sheet and interview, the facility failed to arrange and provide transportation to a medical appointment for Resident #121, 1 of 1 sampled resident reviewed for medically-related social services. Resident #121 missed a doctor's appointment due to the facility not arranging transportation. The findings included: The facility admitted Resident #121 with [DIAGNOSES REDACTED]. During an interview with Resident #121 and family member on 2/26/2018 at 10:00 AM, Resident #121 stated she/he had an upcoming appointment with his/her Oncologist on 2/28/2018. The family member stated she/he was concerned because the facility had provided no confirmation of transportation to the appointment. Resident #121 produced a form from his doctor with a list of upcoming appointments, including appointments on 2/28/2018 and 3/7/2018. During an interview with Licensed Practical Nurse (LPN) #3 on 2/26/2018 at 10:13 AM, LPN #3 was made aware of Resident #121 's and the family member's concerns related to the upcoming appointment on 2/28/2018. LPN #3 stated she/he would take care of the arrangements. On 2/28/2018 at 12:12 PM, LPN #4 was observed talking to another staff member about Resident #121's Oncology appointment. The staff member told LPN #4 that the Oncologist's office was calling asking why Resident #121 had not shown up for his/her appointment. LPN #4 then called the transporter (person in charge of setting up transportation). After the call, LPN #4 was interviewed and stated that transportation had not been arranged for the resident's appointment. LPN #4 stated transportation had been set up for an appointment on 3/7/2018, but not for today. During an interview with the Director of Nursing on 2/28/2018 at 2:00 PM, the DON confirmed that transportation had not been set up for the resident's appointment today. The DON stated LPN #3 reported to her/him that she/he called the transporter on 2/26 to see if transportation had been set up for the resident's appointment. LPN #3 was told transportation was set up for an appointment on 3/7/2018. The DON confirmed that the facility did not follow up with the resident regarding the appointment scheduled for 2/28/2018. During an interview with Resident #121 and family member on 2/28/2018 at 2:33 PM, the family member stated she/he had informed multiple staff members over the past week regarding the resident's appointment on 2/28/2018. Resident #121 stated he/she had also told staff about the upcoming appointment. The family member stated she/he asked staff if transportation was set up for the appointment or if she/he needed to arrange transportation. Neither the resident or family member could remember names of who they asked about the appointment, but did remember being told the facility would arrange transportation. Review of the transportation schedule on 3/1/2018 at 10:51 AM revealed transportation was not set up for the 2/28/2018 appointment. | 2020-09-01 |
| 12 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 758 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor antipsychotic usage for 1 of 6 residents reviewed for unnecessary medications. Resident #115 was on antipsychotics and the facility failed to monitor him/her for side effects, behaviors, and nonpharmaceutical interventions. The findings included: Resident #115 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #115's Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 2/28/18 at approximately 12:54 PM revealed the order for antipsychotic monitoring was discontinued by the physician. The DON was unable to clarify why the order had been discontinued. Interview with the DON on 2/28/18 at approximately 1:26 PM revealed the facility had resumed monitoring for antipsychotic medications. | 2020-09-01 |
| 13 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-03-01 | 842 | D | 0 | 1 | JK8711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately document a medical record (paper/electronic) for 1 of 42 sampled residents reviewed for advanced directives and clinical accuracy. Resident #82 paper charting was noted with full size red sheet of paper that indicated Do Not Resuscitate (DNR) and the electronic documentation indicated Cardiopulmonary Resuscitation (CPR). There was an inconsistency in the resident's admitted . The findings included: The facility admitted Resident #82 with [DIAGNOSES REDACTED]. A review of the paper charting and electronic charting on [DATE] at approximately 11:28 AM revealed the resident's chart for advanced directive was coded as DNR and CPR. The paper charting was noted with a red sheet of paper that indicated DNR. The electronic record indicated the resident's advance directive was CPR (full code). Further review of the medical record review that one physician's signed resident's inability to consent on [DATE] and the second physician signed the inability to consent on [DATE]. The decisional capacity forms indicated Resident #82 was admitted on [DATE] and the Cumulative physician's orders [REDACTED]. An interview on [DATE] at approximately 12:09 PM with Licensed Practical Nurse (LPN) #2 confirmed the findings that the paper chart indicated DNR and the computer documentation was CPR. | 2020-09-01 |
| 14 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 550 | D | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that residents were treated with respect and dignity in three of 12 Cottages observed. Staff and/or contractor were observed entering residents' rooms without knocking. (Forsythia, Dogwood and Azalea) The findings included: An observation in the Forsythia Cottage on 5/13/19 at approximately 11:30 AM revealed Licensed Practical Nurse (LPN) #1 entering Resident #367 room without knocking. The resident was observed sitting in a wheelchair in his/her room. During an interview on 5/13/19 at approximately 11:33 AM with LPN #1 confirmed the observation. LPN #1 then smiled and knocked on the resident bedside table and playfully stated I have knocked now. A random observation in the Dogwood Cottage on 5/13/19 at approximately 3:13 PM revealed Activity staff entering room [ROOM NUMBER] without knocking. The resident was in the room in bed when the staff member entered the room. During an interview on 5/13/19 at approximately 3:18 PM with the Activity staff confirmed the observation. The Activity staff stated he/she does not generally knock on the resident's door if the door is opened and the resident is looking out toward the door. A random observation in the Azalea Cottage on 5/14/19 at approximately 12:05 PM revealed a nurse entering room [ROOM NUMBER] without knocking. The resident was in the room in bed. A random observation in the Azalea Cottage on 5/14/19 at approximately 12:21 PM revealed someone testing the alarms entering multiple residents' rooms without knocking. During an interview on 5/14/19 at approximately 12:25 PM revealed the alarm tester to be an Outside Fire Contractor who was entering the resident's rooms without knocking. | 2020-09-01 |
| 15 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 565 | E | 0 | 1 | Y5WG11 | Based on interviews and review of the Resident Council Minutes, the facility failed to ensure residents grievance were addressed related to staff being accessible in the cottages. Eight of eight group members and four months of resident council minutes. The findings included: During the agency group interview on 5/14/19 at approximately 10:32 AM eight of eight residents deemed alert, oriented and interview-able by the facility expressed concerns about staff being accessible in the cottages when needed. One resident stated that it takes several hours to see a nurse when needed because there may be one nurse at times who was responsible for rotating between three cottages. Another resident agreed that it takes staff a long time to address needs because staff rotate to other cottages. The resident who expressed concerns about one nurse covering three cottages stated he/she was not sure if one certified nursing aide had to cover three cottages as well. The residents stated they have addressed their concerns in resident council meetings. A review of the resident council minutes on 5/14/19 revealed at the 4/25/19 meeting there were concerns of getting medicine late due to nurse being in another cottage, certified nursing aides (CNA) on cells phone and certified nursing aides cutting off call lights saying they will return, and they do not return. The 3/27/19 resident meetings indicated medication was still being provided late, there are still issues with the certified nursing aides and staff not available to answer phones at night when family members are trying to contact the resident. The 2/28/19 resident meeting indicated concerns with late medications, CNA on cell phones. The (MONTH) 2019 minutes indicated concerns with late medications, cottages being un-staffed at night and CNAs telling residents they are alone in the cottages and unable to answer call lights. During an interview on 5/16/19 at approximately 8:16 AM with the Administrator revealed he/she was aware of the residents' concerns regarding staffing and that it had been an ongoing issue due to how the facility was set up. The Administrator further stated he/she does try to address each identified residents' concerns. | 2020-09-01 |
| 16 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 607 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility's abuse policy, the facility failed to ensure that allegations of abuse were reported to the state agency within 2 hrs per policy for 1 of 6 abuse reports reviewed. Resident #365 allegation of abuse known by the facility to have occurred on 3/24/19 was not reported timely per the facility's abuse policy. The findings included: The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement allegedly written by the CNA/alleged perpetrator was unsigned and further identified another CNA was present during the time of the alleged incident. The other CNA named in the statement did not provide a written statement. The statement written by the CNA indicated he/she provided care to the resident on 3/23/19 which was earlier than the date provided on the facility's investigation reports. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. A review of the facility's abuse policy under Reporting Timeframe, Abuse of any kind is to be reported within 2 hours by the facility as well as serious injury (which could fall under neglect or injury of unknown origin). Further review of the facility's policy under Role of the Investigator under 1(d) Interview any witnesses to the incident, 1(e) Interview the resident if medically possible and 1 (h) Interview family members. During an interview on 5/15/19 at approximately 10:36 AM with Registered Nurse (RN) #2 revealed the incident reportedly occurred on 3/24/19 but he/she does not know what time the incident occurred. RN #2 further stated the nurse who had been informed of the allegation of abuse did not include a date in his/her statement and that there was no statements provided from resident/family member or witness named in the perpetrator's statement. During an interview on 5/15/19 at approximately 12:05 PM with RN #2 he/she confirmed the allegation of abuse was not reported to the state agency within the 2 hours requirement per facility policy. | 2020-09-01 |
| 17 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 609 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that allegations of abuse were reported to the state agency within 2 hours for 1 of 6 abuse reports reviewed. Resident #365 allegation of abuse known by the facility to have occurred on 3/24/19 was not reported until 3/25/19. The findings included: The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement allegedly written by the CNA/alleged perpetrator was unsigned and further identified another CNA was present during the time of the alleged incident. The other CNA named in the statement did not provide a written statement. The statement written by the CNA indicated he/she provided care to the resident on 3/23/19 which was earlier than the date provided on the facility's investigation reports. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. During an interview on 5/15/19 at approximately 10:36 AM with Registered Nurse (RN) #2 revealed the incident reportedly occurred on 3/24/19 but he/she does not know what time the incident occurred. RN #2 further stated the nurse who had been informed of the allegation of abuse did not include a date in his/her statement. During an interview on 5/15/19 at approximately 12:05 PM with RN #2 confirmed the allegation of abuse was not reported to the state agency within the 2 hours requirement per facility policy. | 2020-09-01 |
| 18 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 610 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure that allegations of abuse were thoroughly investigation for 1 of 6 abuse reports reviewed. Resident #365 allegation of abuse had unsigned and undated witness statement and other staff members identified as being present at the time of the incident were not interviewed. The findings included: The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement allegedly written by the CNA/alleged perpetrator was unsigned and further identified another CNA was present during the time of the alleged incident. The other CNA named in the statement did not provide a written statement. The statement written by the CNA indicated he/she provided care to the resident on 3/23/19 which was earlier than the date provided on the facility's investigation reports. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. During an interview on 5/15/19 at approximately 10:35 AM with Registered Nurse (RN) #2 revealed the incident/allegation of abuse occurred on 3/24/19 but he/she does not know the time. RN#2 further confirmed the CNA/alleged perpetrator statement was unsigned and the nurse's statement was not dated. RN #2 confirmed there were no nurses notes to indicate when the resident/family reported the allegations of abuse. RN#2 further stated the new corporation had expressed that more accurate information was needed regarding allegations of abuse. | 2020-09-01 |
| 19 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 725 | D | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide sufficient staffing for 2 of 12 cottages. Staff and residents expressed that the structure and layout of the cottages along with the insufficient staffing led to long wait times and inadequate care of residents. The findings included: Brushy Creek Rehabilitation and Healthcare Center consists of 12 cottages each with 12 beds. The only way to move between cottages is to traverse outside. Review of Grievance Log for Resident #67 on 5/15/19 at approximately 12 PM revealed that on 4/4/19 at approximately 2 PM the resident had rung his/her call light for assistance and walked away. The resident changed his/her own brief and filed a grievance. Review of Resident Council Minutes on 5/15/19 at approximately 12 PM revealed the following: 1. (MONTH) concerns expressed regarding CNA staffing 2. (MONTH) concerns regarding lack of CNAs in nurses and cottages; CNAs continue to tell the residents they are alone in the cottage and thus unable to answer the call button 3. (MONTH) concerns regarding nurses doing a good job but needed more help; CNAs are being split between cottages and care is limited at times and not enough CNAs for residents During an interview with Certified Nursing Aide (CNA) #1 on 5/15/19 at approximately 3 PM revealed during night shifts there often may be just one staff member (CNA) in a building because the nurse is attending to another cottage. During an interview with Licensed [MEDICATION NAME] Nurse (LPN) #2 on 5/16/19 at approximately 9 AM revealed the following: 1. Sometimes during the night shift residents may fall because the CNA is busy with another resident in the cottage while the nurse is in another cottage and unable to assist. 2. During night shift, when two staff members are required for care s/he stated, If the nurse has two cottages they're called over. If they have three cottages they're called over, but it may take longer. 3. LPN #2 stated she has expressed these concerns to administration. Review of schedules for the previous month on 5/16/19 at approximately 9:40 AM confirmed that during night shifts one nurse may have two cottages. | 2020-09-01 |
| 20 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 812 | E | 0 | 1 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to ensure that food was stored, prepared and distributed in an appropriate manner for 5 of 12 Cottages observed for kitchen services. Holly, Magnolia, and Rose Cottages had expired food and foods that were opened with no open date. Magnolia and Rose Cottages were observed with resident's personal food in the refrigerator used by the cook which was against facility policy. The Dogwood Cottage Kitchen had staff preparing meals with facial hair uncovered (thick mustache). The Azalea Cottage Kitchen had staff preparing meals with large trash can with no lid available. The findings included: During the initial tour of Holly Cottage with the Registered Dietitian (RD) on [DATE] at approximately 10:10 AM, butter was observed in the freezer with an expiration date of [DATE]. The expiration date was verified by the RD at the time of the observation. During the initial tour of Magnolia Cottage with the RD on [DATE] at approximately 10:40 AM, Lemon juice was observed in the kitchen area with an expiration date of [DATE]. Also, during the tour, cooking spray, granulated garlic, and ground cinnamon were observed in the kitchen area without dates opened for use. As the tour continued, Paprika had an opened-on date of [DATE], steak seasoning had an opened-on date of [DATE], basil had an opened-on date of [DATE] and vanilla extract had an opened-on date of [DATE]. The expiration date of the lemon juice was verified by the RD at the time of observation. The lack of opened-on dates for the cooking spray, granulated garlic, and ground cinnamon was verified by the RD at the time of observation. When asked about the older opened-on dates, the RD stated that the items should have been thrown out after a year or at expiration. A resident's personal food was observed in the kitchen refrigerator of Magnolia Cottage. This was verified by the RD at the time of observation. During the initial tour of Rose cottage with the RD on [DATE] at approximately 11:00 AM, Jelly was observed with an expiration date of [DATE]. During the observation of the refrigerator, 2 mustards bottles, 3 ketchup bottles, and 1 mayonnaise bottle did not have dates opened for use. Resident's personal food was also observed in the facility kitchen refrigerator. During observation of the counter area near the toaster, bread observed did not have the date opened. The expiration date of the jelly was verified by the RD at the time of observation. The lack of opened-on dates for the mustard, ketchup, mayonnaise and bread was verified by the RD at the time of observation. Resident's food in the facility kitchen refrigerator was verified by the RD at the time of observation. Review of facility policy Refrigerators and Freezers under Policy Interpretation and Implementation on [DATE]. Number 7 stated, All food shall be appropriately dated to ensure proper rotation by expiration dates. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. Review of facility policy Food receiving and Storage under Policy Interpretation and Implementation on [DATE] Number 14e stated, Other opened containers must be dated and sealed or covered during storage. Review of the facility policy Resident Refrigerators on [DATE] states, No Elder/Guest food to be stored in Cook's fridge. A random observation of the Dogwood Cottage on [DATE] at approximately 11:10 AM revealed a staff member preparing meals with a thick mustache uncovered. An interview with Cook #1 confirmed the observation and further stated he/she was not aware the mustache had to be covered. He/She further stated he/she was aware the beard had to be covered. A random observation of the Azalea Cottage on [DATE] at approximately 8:51 AM revealed a large trash can in the kitchen area without a lid. The trash can was positioned between the hand washing sink and dishwasher. A random observation of the Azalea Cottage on [DATE] at approximately 12:26 PM revealed Cook #2 preparing residents meals with the large trash can located between the hand washing sink and dishwasher without a lid. During an interview on [DATE] at approximately 1 PM with Cook #2 confirmed the large trash can in the kitchen during meal preparation did not have a lid. Cook #2 stated he/she was new at the facility and did not recall the trash can ever having a lid. On [DATE] at approximately 2:48 PM the facility's Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy was provided. The policy indicated under #12 Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. | 2020-09-01 |
| 21 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2019-05-16 | 842 | D | 1 | 0 | Y5WG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of facility policy the facility failed to maintain a complete and accurate medical record for Residents #366 and 365, 2 of 27 sampled residents reviewed for complete and accurate records. Resident #365's record did not have complete and accurate documentation related to an incident of alleged abuse. Resident #366's record lacked documentation related to controlled substance medication administration. The findings included: The facility admitted Resident #366 with [DIAGNOSES REDACTED]. Review of a Facility Reported Incident on 5/15/19 at 1:49 PM revealed Resident #366's pain medication [MEDICATION NAME] 50 milligrams (mg) was accidentally placed in a bin for discontinued medications on 4/21/19. After a complete investigation by the facility, the medication was found on 4/23/19. Record review of Medication Administration Records (MAR) and narcotic count sheets on 5/15/19 at 1:51 PM revealed an order for [REDACTED]. The narcotic count sheets revealed the resident's 4/21/19 morning dose of [MEDICATION NAME] was signed out at 8:50 AM and administered to the resident per the MAR. The narcotic count sheets revealed the 2 tablets of [MEDICATION NAME] 50mg were signed out on 2 separate occasions on 4/23/19. The time the [MEDICATION NAME] was signed out was not documented by either nurse signing out the [MEDICATION NAME] on 4/23/19. Record review of notes from the MAR on 5/16/19 at 9:12 AM revealed 2 tablets of [MEDICATION NAME] were administered to Resident #366 on 4/23/19 at 5:06 PM and 10:13 PM, about 5 hours apart. The orders were to receive the [MEDICATION NAME] every 12 hours. During an interview with the Assistant Director of Nursing (ADON) on 5/15/19 at 2:26 PM, the ADON confirmed the narcotic count sheets did not indicate what time Resident #366 [MEDICATION NAME] was signed out on 4/23/19. The ADON stated the resident's [MEDICATION NAME] was found around 4:00 PM on 4/23/19 and the resident requested to receive both the morning and evening doses of [MEDICATION NAME] on 4/23/19. The ADON stated s/he told the resident that would be ok, but the 2 doses would have to be spaced apart due to the every 12 hour order. The ADON stated s/he should have documented this conversation with the resident in the nurse's notes but did not. During an interview with the ADON on 5/16/19 at 9:12 AM, the ADON confirmed Resident #366 received 2 tablets of [MEDICATION NAME] 50mg on 4/23/19 at 5:06 PM and 10:13 PM. The ADON confirmed the orders were to give the [MEDICATION NAME] every 12 hours. The ADON stated the Nurse Practitioner (NP) was called on 4/23/19 and a onetime verbal order was received to allow the resident to have the 2 doses of [MEDICATION NAME] at the times they were administered on 4/23/19. The ADON stated a note and order should have been entered reflecting the NP's orders, but this was not done. During an interview with the NP on 5/16/19 at 9:38 AM the NP stated s/he was on call on 4/23/19 and remembered the nurse calling around 4:50 PM for a verbal order. The NP gave an order for [REDACTED]. Review of the facility's Controlled Substances policy revealed the controlled substance record must contain the time of administration. Additional record review of Resident #366 nurse's notes, the MAR and pain assessments revealed the resident did not experience a decline in functioning or uncontrolled pain as a result of the missing [MEDICATION NAME]. The resident had [MEDICATION NAME] ordered as needed for pain and received 1 dose of this while the [MEDICATION NAME] was missing. The facility admitted Resident #365 on 3/23/19 with [DIAGNOSES REDACTED]. A review of the facility's complaint investigation on 5/15/19 at approximately 8:35 AM revealed a nurse's statement with no date that indicated Resident #365 and his/her family member reported to the nurse that a Certified Nursing Aide (CNA) that night shift told the resident to hold onto the side rail to be changed because the CNA did not want to hurt his/her back trying to change the resident. The statement further indicated the family member demanded that the resident see a physician and the nurse notified the resident. The nurse practitioner was notified, and pain medication was ordered. Further review of the facility's complaint investigation revealed the facility reported the incident of alleged abuse on 3/25/19. A review of the electronic medical record on 5/15/19 at approximately 9:34 AM revealed no documentation to indicate the resident and/or family member expressed concerns about a Certified Nursing Aide's alleged mistreatment/verbal abuse of a resident. Nurses notes dated 3/23/19 (admission) to 4/01/19 (discharge) did not indicate any allegations of abuse. During an interview on 5/15/19 at 10:27 AM with Registered Nurse (RN) #1 revealed he/she did not document anything in the electronic medical record about the allegation of abuse related to Resident #365. RN#1 further stated he/she could not recall when the incident occurred after reading his/her undated written statement. RN #1 stated the incident could have occurred on 3/28/19 then stated it happened when the CNA was fired. RN #1 further stated that it had been a long time ago and honestly, he/she does not remember. | 2020-09-01 |
| 22 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2018-06-26 | 609 | E | 1 | 0 | Y9Q111 | > Based on record review, interview, and review of the facility policy titled Reporting of Alleged Abuse to Facility Management, the facility failed to report injuries of unknown source to the State Agency for 2 of 3 sampled residents reviewed for abuse. The facility failed to report injuries of unknown source for Resident #2 and Resident #3 to the state agency. The findings included: Review of Resident #2's health status note dated 5/30/18 revealed a note from the Risk Manager which stated Resident has a 1.5mm purple discoloration to his/her right bottom inner eye. Residents reports s/he is not really sure how it could have happened nor did s/he know it was there but s/he stated 'Oh it could have happened by rubbing my eye, it doesn't hurt, so don't worry about it' Will continue to monitor. Review of the facility incident report for resident #2 dated 6/19/18 reveled the incident description section which stated I was called to Resident room today regarding bruising to bilateral hands with bruising extending from left hand to left forearm. Resident is alert and orientated and stated I don't know how it happened but I pull my table over, eat all my meals in my bed with the tray on my lap, I have arthritis but no, my hands don't hurt. Review of Resident #2's progress notes dated 6/19/18 revealed a note from a Licensed Practical Nurse (LPN) which stated Unidentified bruising on patients top right and left hand. The CNA (Certified Nursing Assistant) noticed as s/he came on for the 7a-7p shift today and brought it to my attention. Patient appears to be in no pain at this time. __ __ in risk management was notified, visited the patient and said s/he would document on the incident. Will continue to monitor. Review of the facility incident report for Resident #3 dated 4/28/2018 revealed the incident description section which stated Yellow/brownish bruise to Left FA new AC Reddish 7cm bruise to med, right back Resident stated s/he thought is may have occurred when s/he wrapped arm around bed rail to assist with turning/repositioning. Mid, right back possible a sheet or sling shear. Denies anyone harmed (him/her). In an interview with the Risk manager on 6//26/18 at 9:36 AM s/he stated that she did not report both incidents for Resident #2 to the State Agency because the resident had a high BI[CONDITION] (Brief Interview for Mental Status) and the resident did not report bruises to her/him the resident did not know they (the bruises) were there and it did not hurt. S/he stated that s/he did not report the incident for Resident #3 to the State Agency because the resident had a high BI[CONDITION] and can tell you what happened. The Risk Manager confirmed that Resident #3 did not know how s/he received the bruises but thought it may have happened during repositioning/transfer. Review of the facility's policy titled Reporting of Alleged Abuse to Facility Management revealed definitions of abuse to include Injury of unknown source is defined as an injury that meets both of the following conditions: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) The injury is suspicious because of: (a) the extent of the injury; or (b) the location of the injury (e.g. the injury is located in an area not generally vulnerable to trauma); or (c) the number of injuries observed at one particular point in time; or (d) the incidence of injuries over time. Pursuant to the Elder Justice Act, any employee that suspects a crime has occurred against a resident of the facility must report the incident to the State Survey Agency and local law enforcement agency. | 2020-09-01 |
| 23 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2017-08-23 | 224 | D | 1 | 0 | O8U111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Abuse policy and interview, the facility failed to conduct a thorough investigation for Resident #1, 1 of 3 sampled residents reviewed for Injury of Unknown Source. Resident #1 suffered a fracture of unknown origin. The facility failed to interview and obtain statements from direct care staff who provided care for Resident #1, on or around the time the resident suffered the fracture. The cause or exact date of the fracture could not be determined. Cross refer to F225 The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the Initial 24-Hour Report, dated 3/30/2017, on 8/23/2017 at 9:40 AM revealed Resident #1 suffered an injury of unknown source on 3/30/2017 at 12:00 AM. Record review of the Five-Day Follow-Up Report, dated 4/4/ on 8/23/2017 at 9:40 AM revealed the resident suffered an acute non-displaced left fibula and tibial shaft fracture. The injury was discovered on 3/30/2017 at 12:00 AM. Per the Five-Day Follow-Up Report, Resident #1 complained of pain to the left leg with repositioning on 3/29/2017. The resident was able to move her/his left leg. The resident also had a witnessed [MEDICAL CONDITION] on 3/27/2017. In addition, staff attempted to obtain a urine sample on 3/27/2017 via a in and out catheter. Per the report, the resident became very combative with thrashing around in bed while his/her legs were trying to be abducted. The resident spent all day in bed with intermittent diarrhea 3/28/2017. The facility's investigation concluded that the fracture appeared to be the result of the combative behavior during the in and out catheter procedure. Record review of the Telephone Orders on 8/23/2017 at 10:08 AM revealed an order, dated 3/27/2017 at 4:00 PM, for a in and out catheter to obtain a urine sample for urinalysis. A Telephone Order dated 3/28/2017 discontinued the in and out catheter order. Record review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The resident had no pain on 3/27 and 3/28. The resident had mild pain (2/10) on the day shift on 3/29 and 3/30. Record review of the Nurses Notes on 8/23/2017 at 10:16 AM revealed a note, dated 3/27/2017 at 3:45 PM, that indicated at 3:30 PM the resident was in her/his wheelchair pale, limp, drooling and lethargic. At 3:40 PM, the resident was combative, alert and talking. The Nurse Practitioner (NP) was notified and gave new orders, including the in and out catheter. There were no further Nurse's Notes on 3/27/2017 indicating the resident had any additional behaviors. There were no Nurse's Notes indicating the resident became combative during the in and out catheter attempt. A Nurse's Note, dated 3/28/2017, indicated the resident spent the day in bed due to loose stools. The note did not indicate the resident was having pain. A Nurse's Note, dated 3/29/2017, indicated the resident was screaming when staff touched or moved her/his left leg and left foot. There were no open areas, redness, swelling or bruising to the left leg/foot. The NP was notified and an X-ray was obtained at 6:30 PM. A Nurse's Note, dated 3/30/2017 at 12:01 AM, indicated the facility had received the X-ray results and the on call physician was notified. Record review of the practitioner Progress Notes on 8/23/2017 at 10:59 AM revealed a note, dated 3/27/2017. The note indicated the NP was seeing the resident due to a witnessed [MEDICAL CONDITION] a minute that occurred at 3:00 PM. At the time of the NPs exam the resident was alert and combative. The NP ordered a urinalysis and labwork (re 3/27/2017 Telephone Order at 4:00 PM). A 3/29/2017 Progress note indicated that the NP was seeing the resident for pain in the left leg. The note indicated the resident had a [MEDICAL CONDITION] 3/27, was in bed on 3/28 and today (3/29) yells/screams whenever you attempt to raise her/his leg, touch her/his feet. The NPs exam indicated the resident had no obvious fracture and no bruising. In addition, the note indicated the resident's legs were contracted at the knees and the pain could be muscle spasms. The NP ordered scheduled Tylenol and X-rays. A Progress Note from 3/30/2017 indicated the resident was seen for follow up of the acute non-displaced left fibula and tibial shaft fracture. New orders were written, interventions were implemented and the care plan and family were updated on treatment/comfort options. Staff statements related to the incident were reviewed on 8/23/2017 at 11:02 AM. A statement by LPN (Licensed practical Nurse) #1, dated 3/31/2017, indicated that on the night shift on 3/28/2017 nothing abnormal was reported or observed. On 3/29/2017 it was reported to LPN #1 that the resident was having left leg pain during the day shift. LPN #1 Received the X-ray results on her/his shift and called those results to the provider. LPN #1 indicated that the resident was not observed to be in pain and was sleeping during observations that night. A Statement by CNA (Certified Nursing Assistant) #1 indicated that CNA #1 provided care during and after the resident's [MEDICAL CONDITION] on 3/27/2017. The statement did not indicate the resident was having any pain or behaviors. A statement by CNA #2 indicated he/she worked the night shift on 3/27, 3/28, 3/29 and 3/30/2017. CNA #2's statement indicated the resident rested throughout the night each night he/she worked. A statement by LPN #2, dated 4/3/2017, indicated LPN #2 was on duty when the resident had the [MEDICAL CONDITION] on 3/27. LPN #2 notified the NP and the NP saw the resident about 30 minutes later. The resident was agitated during the NP's exam. The NP ordered a in and out catheter, but LPN #2 did not attempt the in and out catheter. A statement by CNA #3 indicated that she/he cared for the resident on 3/27 and 3/28/2017 on the day shift. CNA #3 assisted during the [MEDICAL CONDITION]. On 3/28/2017 the resident was weak, sleepy and having loose stools. CNA #3 provided personal care and dressed the resident. The resident remained in bed for the day per the daughter's request. After supper, CNA #3 required assistance providing evening personal care because the resident was screaming and resisting care. There was no statement from LPN #3, the nurse who performed the in and out catheter procedure on 3/27/2017. There was no documentation in the record of any combative behaviors the resident may have had during the in and out catheter procedure. Review of the Care Plan on 8/23/2017 at 1:17 PM revealed the resident had a problem area for Dementia and Sometimes I resist care and refuse to take my medications. An intervention listed for this problem was to Gently redirect me when I become angry or combative. If I don't respond to redirection, leave me alone for a little while. The problem onset date was 12/9/2016. The care plan was reviewed and revised each quarter and as needed. Record review of the daily Behavior and Mood monitoring flowsheets on 8/23/2017 at 12:22 PM revealed that no problem behavior was noted on 3/27, 3/28, 3/29 and 3/30/2017. During an interview with the NHA (Nursing Home Administrator) on 8/23/2017 at 10:06 AM, the NHA stated that only one staff person attempted the in and out catheter procedure for resident #1 on 3/27/2017. The NHA stated that LPN #3, attempted the procedure and was not assisted by any staff. The NHA stated that LPN #3 was an agency nurse (contracted nurse). During an interview with LPN #3 on 8/23/2017 at 11:42 AM, LPN #3 stated she remembered very little about Resident #1. LPN #3 stated she/he vaguely remembered doing the in and out catheter, but did not remember if it was successful or not. In addition, LPN #3 stated she/he did not recall if Resident #1 was combative or not during the procedure. During an interview with LPN #1 on 8/23/2017 at 12:33 PM, LPN #1 confirmed her/his written statement. LPN #1 stated she/he cared for Resident #1 on the 7:00 PM-7:00 AM shift (night shift). LPN #1 stated she/he did not recall the resident being combative or having any behaviors on 3/28/2017 or 3/29/2017. In addition, LPN #1 stated, she/he did not recall the resident having any behaviors during her/his shifts. During an interview with LPN #4 on 8/23/2017 at 12:55 PM, LPN #4 stated she/he worked with the resident on the 7:00 AM-7:00 PM (day shift). LPN #4 did not recall any specific details about the resident from 3/27-3/30/2017. LPN #4 stated the resident could be a little belligerent at times, but found if you left her/him alone for a bit, she/ he would calm down. LPN #4 stated the resident usually didn't display any behaviors when she/he worked with her/him. In addition, LPN #4 stated that the resident was much more cooperative with staff that she/he recognized and had worked with before. LPN #4 stated that if the resident refused any care, medicine or treatments, she/he would usually cooperate once you left her/him alone and went back to her/him. During an interview with CNA #3 on 8/23/2017 at 1:00 PM, CNA #3 confirmed her/his written statement. CNA #3 stated she/he cared for the resident on the day shift. CNA #3 stated the resident went limp during the [MEDICAL CONDITION] on 3/27 and did not fall from her/his chair or appear to suffer any injury as a result of the [MEDICAL CONDITION]. CNA #3 stated that it was normal for the resident to resist care, become agitated and scream during care. CNA #3 did not think the resident was in any pain during dressing or personal care during her/his shift on 3/28/2017. During an interview with the NP on 8/23/2017 at 1:10 PM, the NP stated she/he ordered the in and out catheter on 3/27/2017 after examining the resident. The NP recalled that the staff were unable to get a urine sample with the in and out catheter and that is why an order to discontinue the in and out catheter was given on 3/28/2017. In addition, the NP recalled she/he looked at the documentation to find out why the in and out catheter was not successful, but found that there was no documentation related to the procedure. During an interview with the Risk Manager with, the DON (Director of Nursing) present, on 8/23/2017 at 10:44 AM, the Risk Manager stated that no statement or interview was obtained from LPN #3 related to the in and out catheter procedure on 3/27/2017. The Risk Manager stated she/he was unable to reach LPN #3 by phone. The Risk Manager confirmed that the facility's investigation concluded that the resident's fracture appeared to be a result of combative behavior during the in and out catheter procedure. During an interview with the Risk Manager on 8/23/2017 at 11:32 AM, the Risk Manager confirmed there was no documentation or staff statements to indicate that Resident #1 was combative during the in and out catheter procedure on 3/27/2017. The Risk Manager also stated that she/he had just spoken to LPN #3 and LPN #3 did not remember anything related to the in and out catheter procedure, including whether the resident had combative behaviors or not. The Risk Manager also stated that CNA #4 may have been present in the room for the in and out catheter procedure. The Risk Manager stated she/he did not have a statement from CNA #4. In addition, the Risk Manager stated CNA #4 did not recall if she/he was in the room or not on 3/27/2017. The Risk Manager stated it was concluded the resident was combative during the procedure based on statements from day shift staff who reported that the resident had been frequently combative or resistant to care on the day shift. During an interview with the DON on 8/23/2017 at 12:22 PM, the DON confirmed there was no documentation or Nurse's Notes to indicate that the resident was combative during the in and out catheter procedure. The DON also confirmed that the daily Behavior and Mood monitoring flowsheets indicated the resident was not having any behaviors on 3/27/2017. During an interview with CNA #4 on 8/23/2017 at 1:27 PM, CNA #4 stated she/he did not recall who Resident #1 was or any details related to the resident's care. Review of the facility's Abuse Prevention Program policy revealed: [NAME] The Administrator/designee will make all reasonable efforts to investigate and address alleged reports, concerns and grievances. B. The person (s) observing the incident will immediately report and provide a written statement that includes the name of the resident, date and time incident occurred, where it occurred, staff involved and a description of what occurred. | 2020-09-01 |
| 24 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2017-08-23 | 225 | D | 1 | 0 | O8U111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of the facility's Abuse policy, the facility failed to report an Injury of Unknown Source that resulted in serious bodily injury for 2 of 3 sampled residents reviewed for Injury of Unknown Source. Resident's #1 and #2 suffered fractures and the injuries were reported later than 2 hours. Cross refer to F 224 The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Record review of the Initial 24-Hour Report, dated 3/30/2017, on 8/23/2017 at 9:40 AM revealed Resident #1 suffered an injury of unknown source on 3/30/2017 at 12:00 AM. The resident suffered a fracture. A time stamp on the faxed report indicated it had been sent to the State Agency on 3/30/2017 at 11:45 AM. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review of the Initial 24-Hour Report, dated 4/28//2017, on 8/23/2017 at 9:40 AM revealed Resident #2 suffered an injury of unknown source on 4/28/2017 at 9:00 AM. Resident #2 suffered a left arm fracture. A time stamp on the faxed report indicated it had been sent to the State Agency on 4/28/2017 at 1:59 PM. During an interview with the risk manager on 8/23/2017 at 12:31 PM, the risk manager confirmed that the injuries of unknown origin were reported later than 2 hours. The Risk Manager stated she/he is aware of the 2-hour reporting requirement. Review of the facility's Reporting Abuse to State Agencies and Other Entities policy revealed Should a suspected crime resulting in serious bodily injury, the employee shall report the suspicion immediately, but no later than 2 hours after forming the suspicion. | 2020-09-01 |
| 25 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 282 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to follow the nutrition care plan for 1 of 1 sampled resident for hospice. Dietary approaches for a low fiber diet with ground meat and nectar-thickened liquids was not followed for Resident #265. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review of nutrition care plan on 11/29/2016 revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Record review on 11/29/2016 revealed Physicians Orders for low fiber diet with ground meat and nectar liquids with no straws. Review on 11/29/2016 of nutrition care plan revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Observation on 11/29/2016 at 12:40 PM revealed that Resident #265 was served a wheat roll, chopped ham with gravy, mashed potatoes, mixed vegetables (peas, carrots, and lima beans), peaches, and nectar-thickened liquids. Certified Nursing Assistant (CNA) #2 was assisting with feeding the Resident and confirmed what was on the Residents tray. Observation on 11/30/2016 at 1:03 PM revealed Resident #265 was served rice, squash, coconut cake, nectar-thickened tea, and a white roll. CNA #1 was assisting with feeding the Resident and confirmed what was on the Residents tray. During an interview on 11/30/2016 at 1:15 PM CNA #1 pointed out dietary instructions for a low fiber diet for Resident #265 located in a notebook in the dining area. Dietary instructions included that the Resident was not to receive all beans, peas, whole wheat products, and coconut. | 2020-09-01 |
| 26 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 309 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure integration of Hospice and facility services to provide continuity of care for 1 of 1 sampled resident reviewed for Hospice. Complete documentation could not be found in Resident #265's medical record for Hospice services provided and there was no evidence of communication between Hospice and the facility to establish an agreed upon/coordinated plan of care. The findings include: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review on 11/29/2016 of Hospice documentation, kept in a separate notebook from the medical chart, revealed the Hospice Care Plan for Nurse visits weekly, Aide visits three times a week, Chaplin visits once a month, and Social Worker visits once a month. Record review on 11/29/2016 revealed incomplete documentation for Hospice Aide visits between 08/23/2016 and 11/17/2016, incomplete documentation for Chaplin visits for (MONTH) (YEAR), and incomplete documentation for Social Worker visits for (MONTH) (YEAR). During an interview on 11/29/2016 at 4:04 PM the Director of Social Services verified missing Hospice documentation. The Director of Social Services verified that at the time of services, Hospice notes were to be documented in Resident #265 ' s Hospice record. Review on 11/29/2016 of the Skilled Nursing Facility Service Agreement with the Hospice provider verified each party is responsible for documenting such communication in its respective clinical records to ensure that the need of hospice patients are met twenty-four hours per day. During an interview on 11/30/2016 at 12:15 PM revealed no evidence of care plan integration. Registered Nurse (RN) #1 verified that the facility staff did not review the Hospice care plan and that Hospice was only included in the facility care plan interventions under nutrition. RN #1 verified that Hospice services were not included in the interdisciplinary care plan and that Hospice did not attend the care plan meeting at the facility for Resident #265. There was no evidence that a Hospice representative reviewed the facility care plan. | 2020-09-01 |
| 27 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 323 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure that the planned fall prevention measures were in place and/or changed/added to prevent reoccurrence and minimize potential injury for 1 of 2 sampled Residents for accidents. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Review of fall risk assessment on 11/28/2016 revealed that Resident #265 was a high fall risk. Fall assessment dates and scores; 08/05/2016 score 10, 08/25/2016 score 10, 11/16/16 score 16. Review of Nurses notes, incident reports, and care plan revealed that Resident #265 had falls on the following dates: 9/28/16- Fall in bedroom. My knees are red but my ROM is WNL. Please place laser alarm on floor for poor safety awareness. 10/13/16- I lost balance in bathroom going into room CNA lowered me to floor. 10/23/16- Continue bed/chair alarms non skid socks. 10/28/16- Fall in bedroom Laser alarm by bed, re-educate on not turning off alarms and calling for assistance with any transfers. Nurses notes dated 10/28/2016 stated alarm not sounding r/t elder shuts it off. 11/8/16- I slid down to floor when trying to transfer self from WC to chair; no injury noted. 11/16/16- Slid out of bed onto floor with no injury noted. Implement fall mat, ensure alarms are functioning Q shift. 11/21/16- New alarms to bed and chair with no turn off switch. Observation on 11/28/2016 at 12:00 PM revealed no fall mat in Resident #265 ' s room, bed alarm with turn off switch, and laser alarm was turned off. The resident was lying in bed. Observation on 11/29/2016 at 12:35 PM revealed no fall mat in Resident #265 ' s room, and bed alarm with turn off switch. The resident was lying in bed. Observation on 11/30/2016 at 12:00 PM revealed no fall mat in resident #265 ' s room, bed alarm with turn off switch, and wheel chair alarm with turn off switch. Resident #265 was sitting in wheelchair in common area. The Director of Nursing (DON) and Regional Nurse Consultant verified that Resident #265's bed/chair alarm had a turn off switch and that a fall mat was not present in Resident #265's room. During an interview on 11/30/16 at 9:25 AM with Certified Nursing Assistant (CNA) #1 the CNA Care Plan was reviewed and did not have updated fall care plan information. CNA #1 provided the Master Copy of the CNA Care Plan. | 2020-09-01 |
| 28 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 329 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 of 1 sampled resident reviewed for Hospice had documented clinical reason for medication administration and/or were monitored for effectiveness of medication for Resident #265. Resident #265 was prescribed medication for which there was no documented evidence of clinical need. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Record review on 11/30/2016 at 9:30 AM revealed physician's orders [REDACTED]. 4 hours , [MEDICATION NAME] 0.5 mg tablet one tablet every 6 hours as needed , and Vitamin D3 1,000 units tablet 2 tablets daily . Continued review revealed no clinical indication for Vitamin D3 to treat the Resident's assessed condition. There were no laboratory reports to substantiate Vitamin D3 deficiencies or reason for continued use. No documented evaluation of the underlying cause of behaviors prior to the start of psychiatric medications. No pain measurement tool documented prior to [MEDICATION NAME] administration and after administration to measure effectiveness. No documentation of behaviors prior to administrating [MEDICATION NAME] and [MEDICATION NAME]. Review of the Medication Administration Records (MARs) revealed that from 09/01/2016 through 11/27/2016 Resident #265 received 18 doses of as needed [MEDICATION NAME] 0.5mg tab, 7 doses of as needed [MEDICATION NAME] 5mg/ml 0.5 ml, and 100 doses of as needed [MEDICATION NAME] 50 mg tab. Review of Progress Notes and MARs revealed that no reason for administration and/or effectiveness of PRN (as needed) medication were documented. Continued review revealed no evidence of evaluation of underlying cause of behaviors prior to starting routine psychiatric medications. During an interview on 11/30/2016 at 9:40 AM with the Director of Nursing (DON) information was requested to provide clinical reasons for the use of Vitamin D3. The DON stated they had reviewed the medical records and were unable to find any evidence of deficiency. She/He reviewed the record and was unable to provide additional information. | 2020-09-01 |
| 29 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 367 | D | 0 | 1 | OHU211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to assure that 1 of 1 sampled Residents reviewed for Hospice received the diet that was prescribed by the Physician. Resident #265 ' s physician's order [REDACTED]. The findings included: The facility admitted Resident #265 with [DIAGNOSES REDACTED]. Record review on 11/29/2016 revealed Physicians Orders for low fiber diet with ground meat and nectar liquids with no straws. Review on 11/29/2016 of nutrition care plan revealed approaches for a low fiber diet with ground meat and nectar-thickened liquids. Observation on 11/29/2016 at 12:40 PM revealed that Resident #265 was served a wheat roll, chopped ham with gravy, mashed potatoes, mixed vegetables (peas, carrots, and lima beans), peaches, and nectar-thickened liquids. Certified Nursing Assistant (CNA) #2 was assisting with feeding the Resident and confirmed what was on the Residents tray. Observation on 11/30/2016 at 1:03 PM revealed Resident #265 was served rice, squash, coconut cake, nectar-thickened tea, and a white roll. CNA #1 was assisting with feeding the Resident and confirmed what was on the Residents tray. During an interview on 11/30/2016 at 1:15 PM CNA #1 pointed out dietary instructions for a low fiber diet for Resident #265 located in a notebook in the dining area. Dietary instructions included that the Resident was not to receive all beans, peas, whole wheat products, and coconut. | 2020-09-01 |
| 30 | BRUSHY CREEK POST ACUTE | 425004 | 101 COTTAGE CREEK CIRCLE | GREER | SC | 29650 | 2016-12-01 | 371 | E | 0 | 1 | OHU211 | Based on observation and interview, the facility failed to assure foods were held at appropriate temperatures prior to serving in 2 of 2 cottages. In the Dogwood cottage, staff failed to calibrate the thermometer. In the Azalea cottage staff served foods that had been held at improper temperatures. Observation of the Azalea cottage at approximately 12:10 to 12:20 PM on 11/29/16 revealed Cook #1 measured the temperature of peaches, a cold food item, to be 49 degrees Fahrenheit. The cook did not alert the Certified Nursing Assistant (CNA) #3, who was serving, that the cold food item did not reach appropriate temperatures. Observation of the Azalea cottage at approximately 12:50 on 11/29/16 revealed that during the meal, the cold food item was held on the table without refrigeration or insulation. When CNA #3 plated four helpings of peaches and began serving, she was stopped and informed that they were not held at appropriate temperatures. Observation on 11/28/16 at 12:03 PM revealed Certified Nursing Assistant (CAN) #2 and Licensed Practical Nurse (LPN) #1 starting to plate lunch without taking food temperatures. When asked if food temperatures had been taken the staff were unaware that this had to be done. Observation on 11/28/2016 at 12:10 PM Dietary Aide #1 checked the temperature of the fish, without calibrating the thermometer. When asked Dietary Aide #1 stated that she/he calibrated the thermometer by placing it in ice water. When asked what temperature, the thermometer should be calibrated to she/he stated till it reads 0 degrees Fahrenheit. Cook #1 stated that after the thermometer was placed in ice water, it should read 32 degrees Fahrenheit. Observation on 11/28/2016 at 12:17 PM, Dietary Aide #1 filled a cup with ice and water and inserted the thermometer. When checked by Cook #1 the thermometer read 42 degrees Fahrenheit. She/He stated that the thermometer was calibrated earlier in the day and read 41.5 degrees Fahrenheit. Cook #1 stated that the Certified Dietary Manager (CDM) would need to be contacted about the thermometer not working properly but she/he did not know how to contact the CDM. LPN #1 contacted the CDM to assist with temping foods. The CDM was unable to turn on the thermometer. Cook #1 retrieved a working thermometer and began to calibrate it. At 12:22 PM the CDM stated that the thermometer should be calibrated to 0 degrees Fahrenheit. The temperature at which to calibrate the thermometer was clarified (32 F) and food temperatures were found to be within acceptable range. During an observation on 11/28/2016 at 12:40 PM, CNA #1 started to feed a resident a pureed diet from the warmer before it was temped. Food was taken back to the kitchen and temped. Temperature for the pureed green beans was 133.8 degrees Fahrenheit. An interview at this time revealed that Cook #1 did not know did not know the proper reheat temperatures. When asked where food temperatures were documented prior to beginning food service, Cook #1 called attention to a notebook where the last documented food temperatures were recorded on 11/21/2016. | 2020-09-01 |
| 31 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2020-01-29 | 759 | D | 1 | 1 | J64I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observation, interview, and review of the facility policy titled Enteral Tube Medication Administration, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 32 opportunities for error, resulting in a medication error rate of 6.25%. The findings included: ERROR #1-2: Observation of Licensed Practical Nurse(LPN) #1 on 1/28/20 at 12:10 PM revealed s/he crushed [MEDICATION NAME]/[MEDICATION NAME] 25/100 milligrams(mgs) and [MEDICATION NAME] [AGE] mg and placed each in the same cup. After entering Resident #118B's room, LPN #1 placed 30 cubic centimeters(cc) of water into each of two 30cc medication cups. LPN #1 placed approximately 10 cc of water from one of the medication cups containing water into the medicine cup containing the crushed medications. After checking and confirming placement of the [MEDEQUIP] tube([DEVICE]), LPN #1 placed approximately 20 cc of water into the [DEVICE]. Medications were placed in the [DEVICE], residual medication was observed and LPN #1 placed water from the second medication cup twice trying to administer all of the medication. During this time, a small amount of spillage was noted dripping off of LPN #1's glove. S/he placed the remaining water into the tube. Observation of the medication cup which contained the medications revealed medication was still in the bottom of the cup. LPN #1 confirmed the medication in the cup. LPN #1 stated s/he should have probably let the medicine sit a little longer to help the medications dissolve. Review of the facility policy titled Enteral Tube Medication Administration revealed the policy did not address residual medication. | 2020-09-01 |
| 32 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 159 | B | 1 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to to inform residents of balances in their personal funds for 2 of 12 residents interviewed.(Resident #48 & #46) The findings included: Record review of the Minimum Data Set(MDS) on 7/24/17 revealed Resident #48 had a Quarterly MDS dated [DATE] which listed the resident as having a 12 on the Brief Interview for Mental Status(BIMS). During an interview on 7/24/17 with Resident #48, he/she stated the facility did not inform him/her of the amount of money in his//her personal account. Record review of the MDS on 7/24/17 revealed Resident #46 had a Quarterly MDS dated [DATE] which listed the resident as having a 15 on the BIMS. During an interview on 7/24/17 with Resident #46, he/she stated the facility did not inform him/her of the amount of money in his/her personal account. During an interview with the Business Office Manager on 7/26/17 at 2:30 PM, he/she confirmed only a statement goes to the responsible party and not the resident. Information provided by the facility related to personal funds on 7/26/17 at 3:05 PM states the following: .A summary of activity is made available upon request and at least quarterly to each resident or resident representative . No additional information was presented as how the resident's knew they could request the balance of their personal account. | 2020-09-01 |
| 33 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 281 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Facility failed to follow procedures to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F333 and F425) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physician's order for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). [MEDICATION NAME] and [MEDICATION NAME] are common ingredients in both [MEDICATION NAME] and [MEDICATION NAME]. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving [MEDICATION NAME] for red eyes with itching. (cross reference F333 and F425) On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Resident 62 was admitted with a listed allergy to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) and multiple doses of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment were administered to Resident 62 between 1/27/11 and 7/24/17. (refer to F333) -A review of the Facility Policy and Procedures IB1: PRESCRIBER MEDICATION ORDERS states Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. and The prescriber is contacted to verify or clarify an order (e.g. (for example) when the resident has allergies [REDACTED]. The DON acknowledged in an interview on 7/24/17 at approximately 5:15 PM that the facility, pharmacy and nursing staff had failed to prevent Resident 62 from receiving multiple doses of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to which Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). He/she stated that the nursing staff should have detected the allergy issue each month before signing off on the physician orders and medication administration record. | 2020-09-01 |
| 34 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 333 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Facility failed to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F281 and F425) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physicians order for [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). [MEDICATION NAME] and [MEDICATION NAME] are common ingredients in both [MEDICATION NAME] and [MEDICATION NAME]. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving [MEDICATION NAME] for red eyes with itching. On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Physician order dated 1/27/12 (date of admission) listed [MEDICATION NAME] as an allergy. -Physician order dated 6/11/12 stated D/C (discontinue) [MEDICATION NAME] -Physicians order dated 8/23/12 stated [MEDICATION NAME] ung (ointment) sig (give) instill inside lower eye lids ou (both eyes) q PM (every evening) x 7 days and then use PRN (as needed) for itching. - MAR (medication administration record) review January- December, 2012 showed approximately 61 scheduled plus PRN doses of [MEDICATION NAME] Ophthalmic Ointment had been administered -Physician order dated 6/3/13 stated Add allergy to [MEDICATION NAME] and tenoretic. -MAR review [REDACTED]. -January - September, 2013 MAR indicated [REDACTED]. -Physician order dated 9/17/13 stated change [MEDICATION NAME] Oint (ointment) to q hs (every bedtime) -MAR review [REDACTED]. -MAR review [REDACTED]. -MAR review [REDACTED]. -Consultant Pharmacist Report dated 2-4,5-16 asked IS [MEDICATION NAME] OPHTH. OINT. still needed? The handwritten response on the report state Eyes are still red and the DON (Director of Nursing) stated on 7/24/17 at approximately 4:38 PM that he/she had written this response. -MAR review [REDACTED]. -MAR review [REDACTED]. A review of the Facility Policy and Procedures IB1: PRESCRIBER MEDICATION ORDERS states Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. and The prescriber is contacted to verify or clarify an order (e.g. (for example) when the resident has allergies [REDACTED]. The DON acknowledged in an interview on 7/24/17 at approximately 5:15 PM that the facility, pharmacy and nursing staff had failed to prevent Resident 62 from receiving multiple doses of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]) Ophthalmic Ointment to which Resident 62 was listed as allergic to [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]-[MEDICATION NAME]). | 2020-09-01 |
| 35 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 371 | E | 1 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility failed to ensure the cooktop was clean and free of grease build up, no dented cans in storage, the blades on the Buffalo Chopper and the Robo-coupe were free of dents and hazards, labeling and dating of raw chicken in the coolers and open packages of cookies, resident's food, use of pasteurized shell eggs, safe and clean storage ice in ice machines, removal of expired food in nutrition center refrigerator, clean and sanitary storage areas in nourishment center in 1 of 1 kitchen and 2 of 2 nourishment areas. The findings included: During initial tour on 7/23/17 at 10:45 AM, inside the walk-in refrigerator, a pan of cake covered with parchment paper and was not labeled or dated. The Assistant Dietary Manager said The cake is for lunch today. A can of pudding was also observed in the refrigerator with the lid partially cut open and still attached to the can and was not labeled or dated. Observed and verified by the Assistant Dietary Manager and the CDM was a larger plastic container which contained 3 whole chickens, and a bag of assorted chicken parts, which were not labeled or dated. Additionally, observed 1 Case of eggs in the shell from Glenview Farms, there was no indication on the box label and, the eggs did not have the stamp indicating that the eggs were pasteurized. The Assistant Dietary Manager and the CDM said the eggs are used for entrees and boiled eggs for the residents and h/she will check and see if the eggs are pasteurized. On 7/25/2017, the CDM provided a copy of the new product h/she will be ordering from foodservice vendor, to ensure that pasteurized eggs are used for the residents, Davidson's Pasteurized Eggs. The Policy and Procedures, Labeling and Dating, states, It is the Policy in the Dietary Department that all items upon delivery to storage area and freezer are labeled and dated. During initial tour on 7/23/2017 at approximately 11:00 AM of the dry storage room, observed 1 dented can of beets stored on the can rack. When the Assistant Dietary Manager was questioned regarding storage of dented cans, h/she said they are put on shelf outside storeroom and when asked, What do you do with the dented cans after you put them on the shelf? The Assistant Dietary Manager said, We use them. An interview on 07/23/2017 at 12:43 PM, with Certified Dietary Manager (CDM) h/she said dented cans are stored in his/her office and are used if the dent on the can is not on the seam of the can. The CDM's office contained multiple dented cans which h/she planned to obtain credit from the vendor. The CDM stated: The vendor does not pick up the dented cans, the vendor is now requiring that h/she make a picture of the dented cans to receive credit for the dented cans. The Policy and Procedures, Dented Cans states, If a can is dented, it is placed in the designated place for dented cans. During an observation on 07/25/2017 at 8:40 AM, the Buffalo Chopper's cutting blade had multiple cuts and missing pieces of metal on the cutting surface and this was verified by the CDM. Additionally, the Robot coupe blade had one nick in the blade and this was verified by the CDM. The CDM provided an invoice showing that replacement blades were ordered for both pieces of equipment on 7/25/2017. Observed both sides of grill top (the grill top was located in between the stove top and the deep fat fryer) had a substantial grease build on both sides and this was verified by the CDM. The CDM said the grill top it is on the cleaning schedule and the cook stated that h/she cleans the grill top every other week. The Cleaning schedule from July 16th to July 29th 2017 shows that the stoves/ovens/fryers all carts cleaned on 6/16, 6/17, 6/18 had employee initial indicating cleaned. The CDM said the grill top will be cleaned today. The grill was cleaned on 7/26/2017. Observations made on 07/26/2017 at 9:35 AM of the Nutrition Center located on the South Hall and were verified by the DON of the following items: 1) An open, expired container of CoffeeMate; expiration date of [DATE] located in the cabinet above the sink. 2) A second cabinet above the sink, had dried spilled brown substance and multiple soiled plastic containers, knives and forks, all stored behind the closed doors of the cabinet. 3) A sealed plastic box, located above the refrigerator labeled South contained 2 containers of chocolate chip cookies, one package was opened. 4) The interior of the Ice machine had brown spotting on the surface of the gray plastic gasket. On 07/26/2017 at 11:29 AM, an interview with the Director of Maintenance confirmed the brown spotting around the gasket which resulted in brown spotting imprinted on the stainless steel area where the brown spotted gasket had come in contact with the surface of the ice machine. The Director of Maintenance said and provided in writing, the dates which the Ice Machine was cleaned and sanitized: 6/26/17 North Ice Machine, 7/5/17 South Ice Machine, and 7/7/17 Dietary Ice Machine. H/She said the ice machines are emptied and sanitized quarterly throughout the building. Observations made on 07/26/2017 at 9:45 AM of the Nutrition Center located on the North Hall were verified by the DON of the following items: 1) a plastic trash can with food debris on the exterior, and labeled, Laundry. The DON and the CNA in the Nutrition Center both said that laundry is not stored in the Nutrition Center. 2) A plastic sealed container contained an open package of chocolate chip cookies which were not labeled. 3) A plastic container of peach cobbler which had not been labeled. The CNA #2 stated the resident's family had brought the peach cobbler for resident last night and we put in the refrigerator. H/She stated: We are supposed to label and date food when the family brings in and store in the refrigerator and we are supposed to throw away the next day. 4) Inside the refrigerator was a container of Mighty Shake manufacturer label stated: Use by date August 9. On 07/26/2017 at 11:07 AM the CDM said the Mighty Shake once pulled from the freezer for thawing are good for 14 days from the removal from the freezer. 5)The interior top of the Microwave oven had a buildup of a black substance and the white rim interior had spots of brown substance, and was verified by the DON. The Ice Chests and Machines Policy Statement, Ice Machines: .4.b. Thoroughly clean the machine and the parts. If build up of a sediment is noted, follow routine maintenance procedures for removing lime, rust or other elements. The Policy and Procedure titled, Food Brought into Resident's Room From Outside Sources states, Procedure: .2. Foods or Beverages brought in from the outside will be labeled with the Resident's name and room number and dated by nursing with the current date before putting in the refrigerator .3B. All cooked or prepared food brought in for a resident and stored in the unit's pantry refrigerator or personal room refrigerator will be dated when accepted and discarded after 72 hours .4. Nursing staff will monitor resident's room, unit pantry and refrigeration units for food and beverage disposal. An observation on 7/23/2017 at approximately 12:23 PM during the lunch meal service on the South Hall revealed Certified Nursing Assistant (CNA) #1 taking lunch trays in resident rooms without first cleansing/sanitizing his/her hands and setting up the trays without cleansing his/her hands and leaving resident rooms without first cleansing his/her hands on 1 of 2 halls. Review on 7/23/2017 at approximately 1:00 PM of the facility policy titled, Handwashing, states, All personnel working in the long-term care facility are required to wash their hands before and after resident contact, before and after performing any procedure, after sneezing or blowing noses, after using toilet, before handling food, and when hands are obviously soiled. | 2020-09-01 |
| 36 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 425 | E | 0 | 1 | LLSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, record reviews and interviews the Pharmacy failed to follow procedures to assure that Resident 62 was free of significant medication errors related to medicine to which allergic. The Facility admitted Resident 62 on 1/27/11 with [DIAGNOSES REDACTED]. (cross reference F281 and F333) The findings include: On 7/23/17 at approximately 1:57 PM during chart review it was noted that Resident 62 had a physicians order for Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment to be instilled inside lower lids of both eyes at bedtime and that Resident 62 was listed as allergic to Neosporin (Neomycin-Bacitracin-Polymyxin). Neomycin and Polymyxin are common ingredients in both Maxitrol and Neosporin. On 7/23/17 at approximately 2:05 PM LPN (Licensed Practical Nurse) # 2 stated that the Resident was receiving Maxitrol for red eyes with itching. On 7/24/17 at approximately 3:10 PM to 5:00 PM record reviews revealed the following: -Resident 62 was admitted with a listed allergy to Neosporin (Neomycin-Bacitracin-Polymyxin) and multiple doses of Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment were administered to Resident 62 between 1/27/11 and 7/24/17. (refer to F333) -A review of the Facility Policy and Procedures IB1: PRESCRIBER MEDICATION ORDERS states Any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. and The prescriber is contacted to verify or clarify an order (e.g. (for example) when the resident has allergies [REDACTED]. The DON acknowledged in an interview on 7/24/17 at approximately 5:15 PM that the facility, pharmacy and nursing staff had failed to prevent Resident 62 from receiving multiple doses of Maxitrol (Neomycin-Polymyxin-Dexamethasone) Ophthalmic Ointment to which Resident 62 was listed as allergic to Neosporin (Neomycin-Bacitracin-Polymyxin). The Consultant Pharmacist verified in an interview on 7/25/17 at approximately 12:05 PM that he/she had failed to detect and report the allergy to Neosporin when Maxitrol had been prescribed and in the succeeding months. | 2020-09-01 |
| 37 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 431 | D | 0 | 1 | LLSR11 | Based on observations, record reviews and interviews the facility failed to assure that sterile medications were properly stored in 1 of 4 medication carts and 1 of 2 treatment carts and that medications were securely stored on 1 of 4 medication carts. The findings include: On 7/23/17 at approximately 11:39 AM the medication cart # 2 on the North Unit was observed to be unattended and unlocked for approximately 6 minutes and one wandering resident in a wheelchair was touching and pulling on the cart. LPN (Licensed Practical Nurse) # 1 was informed of the observations on 7/23/17 at approximately 11:46 AM and he/she verified that the cart was had been left unlocked, unattended and that a wandering resident was in the area. On 7/23/17 at approximately 11:49 AM inspection of the top right hand drawer of medication cart # 2 on the North Unit revealed one opened bottle of Normal Saline USP (United States Pharmacopoeia) 100 ml (milliliter) by McKesson Lot # 20 which had been dated by the facility as opened on 7/21/17. The manufacturers label stated Single Patient Use, Sterile, 0.9% (percent) Sodium Chloride and contained about 80 ml. This finding was verified by LPN # 1 on 7/23/17 at approximately 11:53 AM. An observation on 7/25/2017 at approximately 10:50 AM, during wound care, revealed a 100 mg (milligram) bottle of Sterile Normal Saline-Single Use manufactured by McKesson with Lot # 10 with expiration date 5/11/2019 was opened and left on 1 of 2 treatment carts with other medications for resident use. After opened, the Sterile Normal Saline is no longer sterile. During an interview on 7/25/2017 at approximately 10:55 AM the Assistant Director of Nursing verified the findings and removed the bottle of Normal Saline from the treatment cart. | 2020-09-01 |
| 38 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2017-07-26 | 456 | D | 1 | 1 | LLSR11 | > Based on observations, interviews, and review of the facility policy titled, Description of Dryers, and Equipment Care, the facility failed to ensure a large build-up of lint was removed from the backs and upper sides of the lint traps in 2 of 6 clothes dryers. The four other clothes dryers were in use and the lint traps were not observed at this time. The findings included: An observation on 7/25/2017 at approximately 8:30 AM revealed 2 of 6 clothes dryers with a large build-up of lint in the backs and upper side in 2 of 6 clothes dryers. Four other clothes dryers were in use at this time and the lint traps were not observed. An interview on 7/25/2017 at approximately 8:30 AM with the Housekeeping Supervisor confirmed the findings and provided a copy of the facility policy titled, Description of Dryers, and Equipment Care. The policy titled, Description of Dryers, states, These lint screens MUST be brushed and cleaned every 2 loads. If not, the screen will become packed with lint. When this occurs, the warm air moving through the system is blocked, raising the temperature in the basket and causing a potentially dangerous situation -- one spark on lint can cause a fire. Review on 7/25/2017 at approximately 8:38 AM of the facility policy titled, Equipment Care, states, The equipment in the laundry consists of washing machines and dryers. These items need daily maintenance from laundry personnel and should have preventive maintenance performed by the maintenance department. It is your responsibility to see that the equipment is loaded and operated properly, and to be sure that the staff sets up an effective schedule to clean the lint filters on the dryers every two hours to save energy and to prevent fires. Review on 7/25/2017 at approximately 8:45 AM of a form titled, Lint Trap Schedule, for July 2017 was initialed by a laundry worker that the lint was removed at 8:00 AM on 7/25/2017, but 2 of 6 clothes dryers contained a large build-up of lint. Review on 7/25/2017 at approximately 10:15 AM of a form titled, Weekly Cleaning/Vacuuming Of Lint In/Around Dryers, was started on 11/1/2015 and was signed by the Maintenance Supervisor as completed. Further review on 7/25/2017 at approximately 1015 AM of the form revealed the next date logged was 6/20/2017 and was also signed by the Maintenance Supervisor. There was no consistency documented on the form to ensure the lint was cleaned and vacuumed weekly per the schedule. An interview on 7/25/2017 at approximately 10:40 AM with the Maintenance Supervisor confirmed the dryers were not vacuumed and cleaned out weekly. He/she went on to say the maintenance department does try to vacuum the clothes dryers out weekly but the log was pushed to the bottom of a stack of papers on his/her desk. He/she could not ensure that the dryers were cleaned/vacuumed out weekly and the build-up of lint removed. | 2020-09-01 |
| 39 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 567 | E | 0 | 1 | KNGB11 | Based on review of personal funds and interview, the facility failed to ensure that written authorization was obtained prior to disbursing monies from the account of one of one sampled resident reviewed for personal funds (Resident #23). The findings included: During an interview on 10/08/18 at 2:06 PM, Resident #23 stated s/he was not aware of the balance and did not receive statements from the facility regarding the status of her/his personal funds account. During an interview and review of the personal funds account with the Resident Financial Coordinator on 10/11/18 at 2:27 PM, multiple deductions (7/12/18, 7/31/18, 8/9/18, 8/24/18, and 9/7/18) were noted for the Beauty Shop for Resident #23. The invoices for the services provided were reviewed but no written authorizations were obtained from the resident/resident representative to deduct monies from the personal funds account. | 2020-09-01 |
| 40 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 568 | D | 0 | 1 | KNGB11 | Based on review of personal funds and interview, the facility failed to ensure that quarterly statements were provided to Resident #23, one of one sampled resident reviewed for personal funds. The findings included: During an interview on 10/08/18 at 2:06 PM, Resident #23 stated s/he was not aware of the balance and did not receive statements from the facility regarding the status of her/his personal funds account. The resident stated,My daughter might. Review of the 7/15/18 Significant Change in Status Assessment revealed the resident had a had a Brief Interview for Mental Status (BIMS) score of 15 indicating s/he was cognitively intact. During an interview on 10/11/18 at 2:27 PM, the Resident Financial Coordinator provided the last quarterly statement for Resident #23 for review. The Resident Financial Coordinator confirmed that the statement had been sent to the resident's daughter instead of to the resident. | 2020-09-01 |
| 41 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 607 | D | 1 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to develop and/or implement abuse reporting and investigation policies for 2 of 4 sampled residents reviewed for abuse/injuries of unknown origin. An allegation of abuse was not reported timely or thoroughly investigated for Resident #42. The finding included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Review of the investigation file on 10/10/18 at 4:04 PM revealed that on 8-14-18, a student in the Certified Nursing Assistant (CNA) training program reported that CNA #1 spoke about Resident #42's roommate and her/his personal information, made comments about the prior shift's lack of care of the resident, and handled Resident #42 roughly when assisting her/him out of bed to the bathroom. Another student's statement dated 8/16/18 indicated that (CNA #1) was forcefully pulling on (Resident #42's) right arm saying you have to go to the bathroom. During a telephone interview on 10/11/18 at 1:55 PM, Registered Nurse (RN) #1 stated a student reported the incident to her/him on the date of occurrence (8/14/18) before s/he left that evening. The RN obtained a written statement from the student. (CNA #2) was with me when we talked to the student and got her (his) statement. The nurse thought s/he put the statement in the Director of Nursing's box outside her/his office because s/he was not going to be at work the following day. S/he thought s/he might have given a copy to the Charge CNA (CNA #2) as well. Further review revealed that the facility did not report the allegation of abuse until the following day (8/15/18). During an interview on 10/11/18 at 12:45 PM, the DON stated s/he was aware of the 2 hour reporting requirements for allegations of abuse. S/he stated that s/he was not made aware of the allegation until 8/15/18. Review of the assignment sheet for 8/14/18, obtained from the Director of Nursing (DON), revealed that there were written statements obtained from the RN Supervisor, and 4 of the 5 CNAs on duty on the 100 Hall, including the alleged perpetrator. There were no statements from the two nurses on duty on the 100 Hall. All statements were either unwitnessed or witnessed by one individual. During an interview on 10/11/18 at 12:45 PM, when asked to describe a thorough investigation, the DON stated, You should talk to the resident, nurses, CNAs on the unit, visitors, and other people on duty at the time. The facility's abuse policies and procedures regarding reporting state: 7. E. Abuse, alleged or otherwise, will be reported within 2 hours or 24 hours. Appropriate agencies will be called . The facility's abuse policies and procedures regarding investigation state: D. 7. Develop a list of known and possible witnesses to the reportable incident. Interview staff, residents and/or visitors, or anyone who has or might have knowledge of the incident under investigation . 9. Obtain written signed, double witnessed or notarized statements from the reporter and all other identified witnesses . Statements taken from actual eyewitnesses should .contain the witness's name, address, and phone number. | 2020-09-01 |
| 42 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 609 | D | 1 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to report allegations timely to the State Agency for 2 of 2 allegations/incidents reviewed. Resident #42 had an allegation of physical and verbal abuse that was not reported to the state agency within the required timeframes. The facility failed to report an injury of unknown origin with major injury timely for Resident #37. The findings included: The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Observations during the survey revealed that the resident had a sad affect, was confused, answered questions inappropriately or not at all, had perseverating speech, and wandered aimlessly in the hallways. Review of the investigation file on 10/10/18 at 4:04 PM revealed that on 8-14-18, a student in the Certified Nursing Assistant (CNA) training program reported that CNA #1 spoke about Resident #42's roommate and her/his personal information, made comments about the prior shift's lack of care of the resident, and handled Resident #42 roughly when assisting her/him out of bed to the bathroom. Another student's statement dated 8/16/18 indicated that (CNA #1) was forcefully pulling on (Resident #42's) right arm saying you have to go to the bathroom. During a telephone interview on 10/11/18 at 1:55 PM, Registered Nurse (RN) #1 stated a student reported the incident to her/him on the date of occurrence (8/14/18) before s/he left that evening. The RN obtained a written statement from the student. (CNA #2) was with me when we talked to the student and got her (his) statement. The nurse thought s/he put the statement in the Director of Nursing's box outside her/his office because s/he was not going to be at work the following day. S/he thought s/he might have given a copy to the Charge CNA (CNA #2) as well. Further review revealed that the facility did not report the allegation of abuse until the following day (8/15/18). During an interview on 10/11/18 at 12:45 PM, the DON stated s/he was aware of the 2 hour reporting requirements for allegations of abuse. S/he stated that s/he was not made aware of the allegation until 8/15/18. The facility's abuse policies and procedures regarding reporting state: 7. E. Abuse, alleged or otherwise, will be reported within 2 hours or 24 hours. Appropriate agencies will be called . Reporting Requirements noted The facility must ensure that all allegations of abuse, neglect, injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility, the State Survey Agency, to other officials in accordance with state law . The facility admitted Resdient #37 on 11/04/13 with [DIAGNOSES REDACTED]. On 10/09/18 at 11:27 AM, review of the Reportable for a 09/01/18 incident revealed an Accident/Incident Report indicating the incident occurred at 06:25 AM on 09/01/18. Further review revealed the Initial 2/24-Hour Report dated 09/01/18 indicated it was a 2 hr (hour) initial report. Another Initial 2/24-Hour Report was dated 09/02/18. Review of the radiology report revealed it was faxed to the facility at 9:31 PM on 09/01/18 stating the resident had an incompletely characterized recent right proximal fracture with mild angular deformity and noted that the physician was notified at 11:01 PM. Additional review revealed it was reported to the Bureau of Certification on 09/02/18 at 9:40 AM. On 10/09/18 at 02:01 PM, review of the General Progress Notes revealed a note dated 09/01/18 and timed at 10:42 AM stating the resident had swelling to the right upper arm with bruising noted and the area was warm to touch. The resident was whimpering in pain when the arm was elevated. The physician was notified and orders received for an x-ray and a CBC (complete blood count). The Resident Representative was notified at 10:25 AM. The x-ray was done at 05:00 PM and the resident was started on [MEDICATION NAME] 500 mg (milligrams) for [MEDICAL CONDITION]. During an interview on 10/11/18, the Director of Nursing (DON) confirmed the dates on the Initial 2/24-Hour Report but stated that the x-ray results were received in the nursing office and that s/he was unsure when the nurse obtained the result from the office. The DON also confirmed the notation on the x-ray result indicating the physician was notified of the result at 11:01 PM pn 09/01/18 and that the incident was not reported timely. | 2020-09-01 |
| 43 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 610 | E | 1 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility admitted Resident #42 with [DIAGNOSES REDACTED]. Observations during the survey revealed that the resident had a sad affect, was confused, answered questions inappropriately or not at all, had perseverating speech, and wandered aimlessly in the hallways. Review of the investigation file on 10/10/18 at 4:04 PM revealed that on 8-14-18, a student in the Certified Nursing Assistant (CNA) training program reported that CNA #1 spoke about Resident #42's roommate and her/his personal information, made comments about the prior shift's lack of care of the resident, and handled Resident #42 roughly when assisting her/him out of bed to the bathroom. Another student's statement dated 8/16/18 indicated that (CNA #1) was forcefully pulling on (Resident #42's) right arm saying you have to go to the bathroom. During a telephone interview on 10/11/18 at 1:55 PM, Registered Nurse (RN) #1 stated a student reported the incident to her/him on the date of occurrence (8/14/18) before s/he left that evening. The RN obtained a statement from the student. (CNA #2) was with me when we talked to the student and got her (his) statement. The nurse thought s/he put the statement in the Director of Nursing's box outside her/his office because s/he was not going to be at work the following day. S/he thought s/he might have given a copy to the Charge CNA (CNA #2) as well. Further review revealed that CNA #1 was suspended during the investigation. Review of the assignment sheet for 8/14/18, obtained from the Director of Nursing (DON), revealed that there were written statements obtained from the RN Supervisor, and 4 of the 5 CNAs on duty on the 100 Hall, including the alleged perpetrator. There were no statements from the two nurses on duty on the 100 Hall. All statements were either unwitnessed or witnessed by one individual. During an interview on 10/11/18 at 12:45 PM, when asked to describe a thorough investigation, the DON stated, You should talk to the resident, nurses, CNAs on the unit, visitors, and other people on duty at the time. The facility's abuse policies and procedures regarding investigation state: D. 7. Develop a list of known and possible witnesses to the reportable incident. Interview staff, residents and/or visitors, or anyone who has or might have knowledge of the incident under investigation . 9. Obtain written signed, double witnessed or notarized statements from the reporter and all other identified witnesses . Statements taken from actual eyewitnesses should .contain the witness's name, address, and phone number. Based on record review and interview, the facility failed to thoroughly investigate an injury of unknown origin for Resident #37 and an allegation of abuse for Resident #42, 2 of 4 residents reviewed for reportable incidents. The findings included: The facility admitted Resdient #37 on 11/04/13 with [DIAGNOSES REDACTED]. On 10/09/18 at 11:27 AM, review of the reportable for a 07/14/18 incident revealed Resident #37 experienced a fall and sustained a Left Femoral Neck Fracture on 07/14/18. Further review revealed the resident was receiving a bath by the CNA (Certified Nursing Assistant) and when the CNA turned the resident on her/his side to wash the back, the resident slid out of bed to the floor on her/his knees. The Accident/Incident Report stated the CNA reported that s/he lost control of the resident and the resident slid to the floor. A statement was obtained from the CNA that was giving Resident #37 a bath but no other statements were obtained from any other staff on duty at the time. In addition, Resident #37 also sustained an incompletely characterized recent right proximal fracture with mild angular deformity on 09/01/18. Review of the reportable file revealed employee statements from the nurse on all 3 shifts on 08/31/18 and day shift on 09/01/18. Statements were also obtained from the CNA assigned to Mrs.[NAME]on the 3:00-11:00 PM and 11:00 PM-7:00 AM shift on 08/31/18 and the day and evening shift on 09/01/18. No statements were obtained from any other staff assigned to the unit during the 2 days. During an interview on 10/11/18 at 02:33 PM, the Director of Nursing (DON) stated Resident #37 did have side rails ordered at the time of the fall on 07/14/18. The DON confirmed there was no mention in the CNA's statement if the side rail was up and that s/he could not say for sure. The DON confirmed there was no documentation of an investigation and asked the Assistant Director of Nursing (ADON) if the side rail had been up when the resident fell . The ADON stated s/he did not recall asking and also confirmed the statement did not say if the side rails were in use. Both the DON and the ADON confirmed no statements had been obtained from any staff that had not been assigned to Resident #37 related to the 09/01/18 fracture and that a thorough investigation had not been done to rule out possible abuse. | 2020-09-01 |
| 44 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 623 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the required written notice of transfer to the resident/ resident representative for Resident #22, #19, # 57, #47 and #100 as soon as practicable of a facility initiated transfer. 5 of 5 reviewed for transfer to the hospital. The findings included: The facility admitted Resident #22 on 7/12/2018 with dignoses including, but not limited to, Muscle weakness, Acute and Chronic [MEDICAL CONDITION], unspecified with [MEDICAL CONDITION] or hypercapnia, Athscl [MEDICAL CONDITION] of native coronary artery without [MEDICAL CONDITION] pectoris, Heart Failure, [MEDICAL CONDITION] (chronic) (peripheral), Essential Hypertension, [MEDICAL CONDITION], Type II Diabetes Mellitus, Spinal Stenosis-lumbar region without [MEDICAL CONDITION] claudication, allergic rhinitis, [MEDICAL CONDITION] Stage 3, [MEDICAL CONDITION] disease, [MEDICAL CONDITION], Major [MEDICAL CONDITION], unspecified [MEDICAL CONDITION], unspecified hearing loss, nausea with vomiting, unspecified Dementia without behavioral disturbance, pressure ulcer right and left heel unstageable. Review of the medical record revealed that Resident #22 was transferred to the hospital on [DATE], 07/27/2018 and 08/22/2018, all were facility initiated with no documentation that written notice was provided to the resident and Resident Represenative (RR) of the transfer. During an interview on 10/09/2018 at approximately 12:30 PM, the Social Worker confirmed that the facility had not been providing written notification to the resident/ RR for hospital transfers. The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Record review on 10/09/18 at 11:59 AM revealed that the resident had multiple recent hospitalization s: (1) From 7/26/18 to 7/30/18 for Acute Hypoxic [MEDICAL CONDITION] and Exacerbation of [MEDICAL CONDITION], (2) From 8/14/18 to 8/17/18 for Shortness of Breath, Oxygen Saturation of 64% [MEDICAL CONDITION] Facial and Bilateral Lower Extremity [MEDICAL CONDITION], and [MEDICATION NAME]. (3) From 8/28/18 to 8/29/18 for Acute Hypoxic [MEDICAL CONDITIONS], Hypertensive Emergency, [MEDICAL CONDITIONS], Mitral Stenosis, and [MEDICAL CONDITION] Fibrillation. (4) From 9/11/18 to 9/12/18 for Acute Hypoxic [MEDICAL CONDITIONS], Hypertensive Emergency, [MEDICAL CONDITIONS], Mitral Stenosis, and [MEDICAL CONDITION] Fibrillation. (5) From 10/2/18 to 10/4/18 for Acute Hypoxic [MEDICAL CONDITIONS], Malignant Hypertension, Fluid Overload, and [MEDICAL CONDITION]. There was no evidence in the medical record of written notices to the resident's representative of the facility-initiated hospital transfers, including the reasons for the moves. The facility admitted Resident #100 with [DIAGNOSES REDACTED]. Review of Progress Notes on 10/10/18 at 8:40 AM revealed that the resident complained of hip pain after sustaining a fall on 6/14/18. Radiology reports showed no acute fractures at that time. The resident continued to complain of hip pain, and after an orthopedic consult, the facility was notified on 7/18/18 to send Resident #100 to the hospital for direct admission for treatment for [REDACTED]. There was no evidence in the medical record of written notices to the resident's representative of the facility-initiated hospital transfers, including the reasons for the moves. The facility admitted Resident #19 on 06/02/17 with [DIAGNOSES REDACTED]. On 10/08/18 at 03:01 PM, record review revealed the resident was hospitalized from [DATE] to 06/01/18 and from 06/22/18 to 6/29/18. Review of the general progress notes revealed no documentation that the facility provided a written notice of transfer to the resident or the resident representative. The facility admitted Resident #47 on 02/09/15 with [DIAGNOSES REDACTED]. On 10/08/18 at 01:13 PM, record review revealed the resident was hospitalized from [DATE] to 09/21/18. Review of the General Progress Notes on 10/10/18 revealed no documentation that the facility provided a written notice of transfer to the resident or the resident representative. During an interview on 10/10/18 04:09 PM, the Social Services Director confirmed the facility had not been providing written notices of transfer to the resident or resident representative when a resident was transferred to the hospital. | 2020-09-01 |
| 45 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 640 | B | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that required assessments were completed and/or transmitted as required for 4 of 4 residents reviewed for missing assessments. Four residents were noted with last transmission dates of greater than 120 days. Discharge assessments were not completed for three of these residents (Residents #315, #316, and #317). Resident #1 did not have a Quarterly Minimum Data Set (MDS) assessment transmitted. The findings included: Review of the MDS (Minimum Data Set) 3.0 Missing OBRA Assessment CASPER Report on 10/8/18 revealed the following: -The last assessment transmitted for Resident #317 was 4/1/18. -The last assessment transmitted for Resident #316 was 10/29/17. -The last assessment transmitted for Resident #315 was 10/15/17. -The last assessment transmitted for Resident #1 was 4/29/18. During an interview on 10/09/18 at 2:10 PM, the MDS Coordinator stated that Resident #317 was discharged on [DATE], #316 was discharged on [DATE], and #315 was discharged on [DATE]. No discharge assessments had been completed and transmitted for these residents. Additionally, s/he confirmed that the quarterly assessment for Resident #1 had an assessment reference date of 7/22/18 but had not been transmitted. | 2020-09-01 |
| 46 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 684 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to follow physician's orders for use of siderails and failed to follow standards of practice to address [MEDICAL CONDITION] for one of one sampled resident reviewed for range of motion (Resident #8). The findings included: The facility admitted Resident #8 with [DIAGNOSES REDACTED]. Multiple observations (on 10/08/18 at 7:59 AM, 10:07 AM, 10:51 AM, 1:11 PM, 3:39 PM, and 4:51 PM; on 10/08/18 01:03 PM; on 10/10/18 at 2:01 PM) revealed that the resident's right hand was [MEDICAL CONDITION], had a handroll in place, and was not kept elevated, both in and out of bed, to assist in decreasing the swelling. During an interview on 10/09/18 at 2:56 PM, Certified Nursing Assistant #2 verified the [MEDICAL CONDITION] of the right wrist and hand and that it had not been kept elevated. Record review on 10/09/18 at 3:02 PM revealed Physician's Orders for one siderail to be up. Multiple observations (on 10/08/18 at 7:59 AM, 10:07 AM, 3:39 PM, and 4:51 PM; on 10/10/18 at 2:01 PM) revealed the resident in bed with both half siderails elevated. During an interview on 10/09/18 at 3:49 PM, Licensed Practical Nurse #2 verified the Physician's Order and observed/confirmed that half rails were elevated on both sides of the bed. | 2020-09-01 |
| 47 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 698 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain consistent on-going communications with the [MEDICAL TREATMENT] center to ensure continuity of care for one of one sampled resident reviewed for [MEDICAL TREATMENT] (Resident #57). The findings included: The facility admitted Resident #57 with [DIAGNOSES REDACTED]. Review of Progress Notes on 10/09/18 at 2:31 PM revealed that on 8/14/18 at 4:14 AM, the resident was sent to the emergency room (ER) with shortness of breath and an oxygen saturation of 64% on 2 liters per minute. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . On 8/28/18, the resident was again sent to the ER with shortness of breath and an oxygen saturation of 77%. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . On 9/11/18, the resident was sent to the ER with shortness of breath and congestion. Oxygen saturation of 76%. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . On 10/2/18, Resident #57 was sent to the ER with shortness of breath, a feeling of heaviness in the chest, and an oxygen saturation of 74%. S/he was admitted to the hospital with [REDACTED]. There was no evidence in the record that the [MEDICAL TREATMENT] center was notified of the change in condition and hospitalization . Further review revealed no laboratory reports on file from [MEDICAL TREATMENT] since 4/18. Following a call from the facility, the [MEDICAL TREATMENT] center faxed 4/18 through 9/18 lab results which were provided by the Assistant Director of Nurses. Review of [MEDICAL TREATMENT] Flow Sheets from 7/3/18 through the dates of the survey revealed inconsistent and limited communication between the facility and the [MEDICAL TREATMENT] center. Pre- and post-[MEDICAL TREATMENT] weights were not provided by the [MEDICAL TREATMENT] facility to ensure accuracy in determination of weight loss. Two-way communication between the facility and [MEDICAL TREATMENT] did not include medication administration, new and discontinued medication, labs, resident compliance with food/fluid restrictions, [MEDICAL TREATMENT] treatment provided and the resident's response. During an interview on 10/09/18 at 3:28 PM, the Director of Nursing stated s/he expected communication from the [MEDICAL TREATMENT] center to include at least post-[MEDICAL TREATMENT] weights, what was done at [MEDICAL TREATMENT] (changes, labs drawn), and vital signs. | 2020-09-01 |
| 48 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 756 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the pharmacist failed to identify irregularities for 1 of 5 sampled residents reviewed for unnecessary medication. Resident #35 was on long-term [MEDICATION NAME] antibiotic therapy without documentation of physician recommendation regarding evaluation of risks versus benefits of continued use. The findings included: The facility admitted Resident #35 on 7-15-15 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at 11:53 AM revealed physician's orders [REDACTED]. Review of laboratory reports and Progress Notes on 10/10/18 at 12:43 PM revealed no evidence of active infection. Review of Physician's Progress Notes revealed no documentation of continued need or evaluation of risks versus benefits of long-term [MEDICATION NAME] antibiotic use. Review of the Medication Regimen Review reports on 10/11/18 at 1:31 PM revealed no references to long term use of [MEDICATION NAME] antibiotic therapy and inherent risk of antibiotic resistant bacterial infections. During an interview on 10/11/18 at 1:47 PM, the Pharmacist verified the physician's orders [REDACTED]. | 2020-09-01 |
| 49 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 757 | E | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow a procedure for 1 of 5 sampled residents reviewed for unnecessary medication to ensure that medication administered for excessive duration is reviewed for continued use. Resident #35 was on long-term [MEDICATION NAME] antibiotic therapy without documented evidence of evaluation of risks versus benefits. The findings included: The facility admitted Resident #35 on 7-15-15 with [DIAGNOSES REDACTED]. Record review on 10/10/18 at 11:53 AM revealed physician's orders [REDACTED]. Review of laboratory reports and Progress Notes on 10/10/18 at 12:43 PM revealed no evidence of active infection. Review of Physician's Progress Notes revealed no documentation of continued need or evaluation of risks versus benefits of long-term [MEDICATION NAME] antibiotic use. During an interview on 10/11/18 at 1:47 PM, the Pharmacist verified the physician's orders [REDACTED]. During an interview on 10/10/18 at 2:49 PM, when asked about the continued use of the antibiotic, the Assistant Director of Nurses stated that the resident had been admitted on an antibiotic for UTIs. S/he stated,We usually try cranberry and UTI Stat. I think we tried to take (the resident) off of it but the family wanted her (him) back on it. | 2020-09-01 |
| 50 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2018-10-11 | 761 | D | 0 | 1 | KNGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to dispose of expired medications in the North Unit medication room and the North 2 (N2) medication cart, 1 of 1 Unit reviewed. The findings included: Observation of the N2 unit medication cart on 10/10/18 at 08:43 AM revealed 1 vial of [MEDICATION NAME] 0.083% 2.5 mg (milligrams) per 3 ml (milliliters) with an expiration of September, (YEAR) and 1 473 ml bottle of [MEDICATION NAME] 160 mg per 5 ml Elixer with an expiration date of 08/18 which was close to full. Licensed Practical Nurse #3 confirmed the expiration dates at 08:50 AM on 10/10/18. | 2020-09-01 |
| 51 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 600 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, facility staff failed to ensure 1 of 24 sampled residents (Resident #17) was free from possible neglect. On 7/13/19, while performing peri-care on Resident #17, Certified Nursing Assistant (CNA) #6 turned the resident onto her side but failed to ensure the resident was safe from falling. As a result, Resident #17 fell from the bed and struck her head on the corner of a chair that was sitting next to the bed. The resident sustained [REDACTED]. The findings included: Review of the facility's policy entitled Perineal Care (Peri-care) (undated) revealed the following: Purpose: 1. To cleanse the perineum; 2. To prevent infection and odors. Equipment: 1. Soap and water; 2. Bath basin; 3. Washcloths and towel. Procedure: 1. Explain procedure to the resident and bring equipment to the bedside; 2. Provide privacy for the resident; 3. Assist the resident to void first if they need to; 4. Do perineal care at least one time a day with bath and PRN (as needed); 5. Cleanse the area with warm water and soap. When washing the area, always wash from the front to back (sic). Be careful not to pull the washcloth from the anal area to the vaginal area; 6. Rinse the area; 7. Towel blot dry the area; 8. Assist the resident to a comfortable position; 9. Return equipment to its proper area; 10. Wash hands; 11. Chart care rendered. Notify the appropriate person of any abnormal findings. The policy did not address adjustment of residents' bed heights, or the use of side rails during peri-care. Review of the facility's policy titled Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure effective date of 9/23/19 revealed Residents are to be free from verbal, sexual, physical and emotional/mental abuse; neglect; self-neglect; exploitation; deprivation; involuntary seclusion; and misappropriation of property at all times. Continued review noted neglect was defined as failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional, such as withholding or omitting care, or unintentional, where the caregiver should have known that care was needed, but it was not provided. This encompasses providing food, clothing, medicine, shelter, supervision, medical care and other services that a prudent person would deem essential for the well-being of the resident .If neglect is suspected, a determination is made as to what services were not provided and what physical harm, mental anguish, mental illness, or deterioration in the resident's mental or physical condition resulted. Neglect is also evaluated as a result of indifference, carelessness, or deliberate negligence. Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one (1) staff person for bed mobility, locomotion on and off the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one (1) staff person for transfers and had impairment to one (1) side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will not suffer injury related to falls (through review date 12/5/19). Interventions for this care area were initiated prior to the resident's fall from bed on 7/13/19 and included: 1. Monitor for safety and maintain safe environment; 2. Assist as needed in all ADLs (activities of daily living) areas; 3. Offer reminders not to arise unassisted as needed and transport to high visibility areas as needed; 4. Encourage to wear shoes with non-slip soles; 5. Maintain bed in low position while not rendering care. 6. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; 7. Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; 8. Notify Responsible Party and MD of all fall instances; 9. Monitor for s/sx (signs/symptoms) of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; 10. Provide diet per order, encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; 11. Strive to keep room free from clutter and pathway to bathroom clear, mop all spills; and 12. Administer med and monitor labs per MD orders. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will be clean and well-groomed by staff (through review date 12/5/19). Interventions for this care area were initiated prior to the resident's fall from bed on 7/13/19 and included: 1. Provide routine oral hygiene; 2. Clean and trim fingernails/toenails; Dress/undress appropriately and groom hair daily and as needed; 3. Offer toileting assistance every two hours and as needed in an effort to maintain some continence; 4. Provide incontinence skin care daily and as needed; 5. Turn and reposition every two (2) hours and as needed while in bed; 6. Transport to specific destinations once up; 7. Provide ROM (range of motion) exercises to all extremities throughout nursing care as tolerates; 8. Provide showers three (3) times weekly and sponge baths daily shampoo hair with shower unless other arrangements are made; 9. Spoon feed all meals by staff in an effort to ensure adequate nutritional intake; 10. Transfer from bed to geri-chair as tolerated; and 11. Perform treatments per MD orders. Review of Resident #17's Progress Notes revealed the following: 7/7/19 - Resident #17 Quietly resting in bed with eyes closed. (No added distress) NAD noted. Resp(irations) even and nonlabored. Total dependent care by staff. Kept clean, dry and comfortable in bed. 7/13/19 - CNA was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of Resident #17's Radiology report dated 7/13/19 revealed the resident's left shoulder was x-rayed and compared to an x-ray completed 12/12/17. According to the comparison there was no change in resident's status since prior x-ray. Results: Impacted fracture involving the humeral neck. The acromioclavicular and coracoclavicular joints are intact. Conclusion: Impacted humeral neck fracture (present prior to the fall from bed). The report also noted no fracture to the resident's left elbow. Review of the facility's Investigation Report dated 7/16/19 revealed on 7/13/19, Resident #17 rolled off bed during care. Laceration to left eyebrow and left upper cheek. (Resident) complained of left shoulder pain and elbow pain. X-ray ordered. According to the report, CNA #6 had Resident #17 facing her while the staff performed incontinent care, but when the aide moved to reach for the diaper located at the foot of the resident's bed, Resident #17 suddenly flipped over causing her to hit the left side of her face on the chair which was beside her bed then fell to the floor. Bed was in low position. Interventions by facility to prevent future injury/Alleged Abuse: Floor pads placed on floor resident is facing when she is in bed and make sure chair is not right beside bed. The facility summarized the incident, as follows: After investigation, facility concludes there was no abuse involved. Staff still unsure how resident rolled over that way but agrees that she should have all materials within easy reach. Continued review of the Investigation Report revealed CNA #6's witness statement dated 7/13/19 noted the following: I was changing (Resident #17) when she rolled off the side of the bed. She bumped her head on the corner of the chair as she went down. She was facing me and when I reached for the diaper, she all of a sudden rolled out of the bed and I could not catch her. The bed was in a low position the whole time. I called for the nurse right away as soon as this happened. All the nurses and CNAs came to help. Further review revealed RN (Registered Nurse) #2's witness statement dated 7/13/19 was documented, as follows: Called to res(ident's) room by CN[NAME] Res was lying on back on right side of bed. Resident noted to have laceration to left eyebrow and left upper cheek. Bleeding noted. ROM (range of motion) performed WNL (within normal limits) to lower extremities and right arm. C/O (complained of) pain to left arm. (Two) bruises noted to left elbow. Bleeding stopped and steri-strips applied to lacerations. Ice applied to lacerations and left arm. When asking CNA what happened she stated she was turning resident towards her (standing on right side of bed) and res slid between her and the bed and hit face and arm on chair as she fell . The witness statements detailed contradictory information. Review of CNA #6's Employee file revealed the Aide was hired on 7/18/08. On 7/15/19, CNA #6 received a Second Written Warning or Work Suspension Notice for negligence. The document noted the following: Negligence in assigned duties or overall resident care. CNA failed to follow proper turn and reposition. Not making sure resident is in the center of the bed before turning and repositioning. CNA was in-serviced 1:1 on turning and repositioning with charge aide. If it happens again - will terminate. The form was executed by both the Director of Nursing (DON) and the Assistant DON (ADON). The form noted that CNA #6 Refused to sign the document. Observation in the common TV area of North unit on 10/15/19 at 10:47 a.m. revealed Resident #17 was reclined in a Geri-chair with her bilateral (b/l) feet elevated. The resident's mouth was open throughout the observation and a blanket covered the resident's lower extremities from waist down and covered all of resident's b/l lower extremities. Continued observation revealed Resident #17 had a protruding tongue. The resident was able to nod yes or no to direct questions. Observation in Resident #17's room on 10/16/19 at 2:14 p.m. revealed that CNA #2 escorted Resident #17 to her room in order to transfer the resident from her Geri-chair to her bed. CNA #2 completed a one-person pivot transfer and placed the resident in the center of her bed, elevated the head of Resident #17's bed and then placed the bed in a low position. The transfer was completed safely without incident or injury. Interview on 10/15/19 at 10:47 a.m. with Resident #17 revealed the resident was able to answer Yes and No questions by nodding or shaking her head. When asked if the resident recalled having fallen from her bed in (MONTH) 2019, Resident #17 indicated No. When asked if the resident was experiencing any pain, Resident #17 stated, No. When the resident was asked if she had ever been neglected by staff, Resident #17 indicated, No. Interview on 10/16/19 at 1:57 p.m. with CNA #1 revealed CNA #6 was currently out of the country and on vacation. CNA #1 reported being on duty the day Resident #17 fell from bed. CNA #1 said she heard CNA #6 yelling out for help and she hurried to Resident #17's room and saw Resident #17 lying face down on the floor and positioned between the two (2) beds in the room. CNA #1 said that when she entered the room, she saw that Resident #17's bed was not in a low position and neither side rail was raised. CNA #1 explained that when providing resident care and moving residents from side to side, aides were to raise the side rail so that residents could hold onto the rails during care. CNA #1 said Resident #17 was not able to independently roll from side to side while in the bed. She said the resident was total assist and required assistance from staff to move in the bed. She said she did not understand how the resident could have rolled from bed. According to CNA #1, CNA #6 told her that while she (CNA #6) was providing care for Resident #17, she (CNA #6) had the resident on her side and facing her when CNA #6 reached for something and the resident fell . CNA #1 said she was not interviewed regarding the incident; however, she did complete and submit a witness statement. During an interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator, the DON confirmed that CNA #6 was currently out on vacation. The DON stated that the Assistant DON (ADON) conducted the investigation regarding Resident #17's fall from bed during peri-care. Interview on 10/17/19 at 11:50 a.m. with the facility's ADON, the nurse confirmed she completed the investigation regarding Resident #17's fall during peri-care. When asked about the position of residents' beds during peri-care, the ADON said the aides were to adjust residents' beds to a comfortable height in order to provide care. Upon completion of care, aides were to place the beds back in a lower position. The ADON said CNA #6 reported to her that Resident #17 was on her back and that when CNA #6 went to grab a diaper on the wheelchair, Resident #17 fell from the bed. The ADON said CNA #6 was written up because she performed peri-care incorrectly. The ADON said the resident's fall was not identified as a possible incident of neglect. Further interview revealed that CNA #1 told the ADON that she believed Resident #17 was too close to the edge of the bed, and that was the reason the resident fell . Telephone interview on 101/17/19 at 4:38 p.m. with RN #2 revealed the nurse did not recall well Resident #17's fall from bed during peri-care. RN #2 said the incident was so long ago. RN #2 said she did remember that CNA #6 told her that she (CNA #6) pulled Resident #17 towards her (CNA #6) and when she did this, Resident #17 slipped between her and the bed. RN #2 said she did not recall CNA #6 saying that she was reaching for a diaper (incontinent brief). RN #2 continued and said that she did not think CNA #6 could have done anything differently to prevent the incident from occurring. RN #2 said possible neglect was not considered because if CNA #6 had required more assistance to complete peri-care, then the aide would have asked her co-workers for help. The RN said it was possible for that type of thing to happen. | 2020-09-01 |
| 52 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 610 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, the facility failed to thoroughly investigate and prevent the possibility of further neglect from occurring for 1 of 24 sampled residents (Resident #17). On 7/13/19, while performing peri-care on Resident #17, Certified Nursing Assistant (CNA) #6 failed to ensure the resident was safe from falling and as a result, Resident #17 fell and sustained lacerations to the left eyebrow and left upper cheek. According to the facility's Investigation Report, only CNA #6 and the assessing Registered Nurse (RN) #2 were interviewed regarding the incident. In addition, CNA #6 was not suspended pending the outcome of the investigation. The findings included: Review of the facility's policy titled Abuse Prevention, Intervention, Investigation, and Reporting Policy and Procedure effective date of 9/23/19 revealed Residents are to be free from verbal, sexual, physical and emotional/mental abuse; neglect; self-neglect; exploitation; deprivation; involuntary seclusion; and misappropriation of property at all times. All reports of possible abuse are promptly and thoroughly investigated by facility management. Residents and staff are protected during incident investigation by ensuring reports are made without fear of retaliation and that anonymous reports are investigated. Continued review noted neglect was defined as failure to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect may be intentional, such as withholding or omitting care, or unintentional, where the caregiver should have known that care was needed, but it was not provided. This encompasses providing food, clothing, medicine, shelter, supervision, medical care and other services that a prudent person would deem essential for the well-being of the resident .If neglect is suspected, a determination is made as to what services were not provided and what physical harm, mental anguish, mental illness, or deterioration in the resident's mental or physical condition resulted. Neglect is also evaluated as a result of indifference, carelessness, or deliberate negligence .Completion of the following interviews: i. Person(s) reporting the incident; ii. Any witnesses to the incident (a) The resident (if appropriate); (b) The resident's roommate, family members and visitors (if applicable); (c) Staff members who have had contact with the resident during the period of the alleged incident. Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one staff person for bed mobility, locomotion on and off the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one staff person for transfers and had impairment to one side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Review of Resident #17's Progress Notes revealed the following: 7/13/19 - CNA was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of the facility's Investigation Report dated 7/16/19 revealed on 7/13/19, Resident #17 rolled off bed during care. Laceration to left eyebrow and left upper cheek. (Resident) complained of left shoulder pain and elbow pain. X-ray ordered. The facility summarized the incident, as follows: After investigation, facility concludes there was no abuse involved. Staff still unsure how resident rolled over that way but agrees that she should have all materials within easy reach. Continued review of the Investigation Report revealed CNA #6's witness statement dated 7/13/19 noted the following: I was changing (Resident #17) when she rolled off the side of the bed. She bumped her head on the corner of the chair as she went down. She was facing me and when I reached for the diaper she all of a sudden rolled out of the bed and I could not catch her. The bed was in a low position the whole time. I called for the nurse right away as soon as this happened. All the nurses and CNAs came to help. Further review revealed RN #2's witness statement dated 7/13/19 was documented, as follows: Called to res(ident's) room by CN[NAME] Res was lying on back on right side of bed. Resident noted to have laceration to left eyebrow and left upper cheek. Bleeding noted. ROM (range of motion) performed WNL (within normal limits) to lower extremities and right arm. C/O (complained of) pain to left arm. (Two) bruises noted to left elbow. Bleeding stopped and steri-strips applied to lacerations. Ice applied to lacerations and left arm. When asking CNA what happened she stated she was turning resident towards her (standing on right side of bed) and res slid between her and the bed and hit face and arm on chair as she fell . The witness statements detailed contradictory information. In addition, there were no other witness statements documented in the Investigation Report. Review of CNA #6's Employee file revealed the aide was hired on 7/18/08. On 7/15/19, CNA #6 received a Second Written Warning or Work Suspension Notice for negligence in reference to failing to follow proper turn and reposition technique. Observation in the common TV area of North unit on 10/15/19 at 10:47 a.m. revealed Resident #17 was reclined in a geri-chair with her bilateral (b/l) feet elevated. The resident's mouth was open throughout the observation and a blanket covered the resident's lower extremities from waist down and covered all of resident's b/l lower extremities. Continued observation revealed Resident #17 had a protruding tongue. Interview at this time with Resident #17 revealed the resident was able to answer Yes and No questions by nodding or shaking her head. When asked if the resident recalled having fallen from her bed in (MONTH) 2019, Resident #17 indicated No. When asked if the resident was experiencing any pain, Resident #17 stated, No. When the resident was asked if she had ever been neglected by staff, Resident #17 indicated, No. Interview on 10/16/19 at 1:57 p.m. with CNA #1 revealed CNA #6 was currently out of the country and on vacation. CNA #1 reported being on duty the day Resident #17 fell from bed. CNA #1 said she heard CNA #6 yelling out for help and she hurried to Resident #17's room and saw Resident #17 lying face down on the floor. CNA #6 told CNA #1 that she (CNA #6) had the resident on her side and facing her when CNA #6 reached for something and the resident fell . CNA #1 said she was not interviewed regarding the incident; however, she did complete and submit a witness statement. CNA #1 was not sure if CNA #6 was suspended during the investigation of the incident. During an interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator, the DON confirmed that CNA #6 was currently out on vacation. The DON stated that the Assistant DON (ADON) conducted the investigation regarding Resident #17's fall from bed during peri-care. According to the DON, a thorough investigation included interviewing the resident involved in the allegation (if possible), other residents, all pertinent staff/family/visitors (as applicable). When reviewing the witness statements from CNA #6 and RN #2, the DON confirmed that components of their statements were contradictory. The DON said when contradictory statements were obtained during an investigation, it was expected for the assigned Investigator to conduct follow-up interviews to obtain clarification. Interview on 10/17/19 at 11:50 a.m. with the facility's ADON, the nurse confirmed she completed the investigation regarding Resident #17's fall during peri-care. The ADON said that all witness statements (2) were included in the Investigation Report. In addition, the ADON said the resident's fall was not identified as a possible incident of neglect and CNA #6 was written up because she performed peri-care incorrectly. Continued interview with the ADON confirmed that the aide's failure to properly perform peri-care could be possible neglect that required investigation. Further interview revealed that CNA #6 was not suspended pending the outcome of the facility's investigation. | 2020-09-01 |
| 53 | CHERAW HEALTHCARE | 425005 | 400 MOFFAT ROAD | CHERAW | SC | 29520 | 2019-10-17 | 657 | D | 1 | 0 | NNBR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, clinical record review and review of facility policy, facility nursing staff failed to update 3 of 24 sampled residents' care plans (Residents #15, #16, and #17). The findings included: Review of the facility's Policy and Procedure for RAI (Resident Assessment Instrument)/Care Plans (not dated) revealed 3. Care plan team meets every Thursday to review care plan with family and residents who choose to attend unless arrangements are made for different time or date. Resident #15 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #15's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #15 exhibited no behaviors (i.e. no physical behaviors and no self-injurious behaviors) and no signs/symptoms of depression, during the assessment periods. According to the MDS, Resident #15 required the extensive assistance of one staff person for bed mobility, transfers, toileting, dressing, walking in the room, and locomotion on and off the unit. The Annual MDS assessment, noted Resident #15 had impairment to one side of lower extremities and utilized a wheelchair for mobility. Resident #15 had no falls during either MDS assessment period. Continued review of the MDS revealed Resident #15 was administered no anti-coagulant medications; however, the resident did receive antipsychotic medication for seven (7) days during the assessment period. Review of Resident #15's Progress Notes revealed the following: 11/11/8 - While the CNA had the resident in the bathroom, she noticed bruises on resident's left arm, reddish purple in color. The resident was not able to state what might have happened. No complaint of pain or sign or symptom of pain noted to left arm when touched. Resident was able to move bilateral upper extremities on her own without difficulties or distress noted. No swelling noted to left arm. Resident observed by nurse using bilateral arms to push herself up out of w/c without difficulties or distress noted. MD made aware, no new orders noted at this time. RR (Resident Representative) made aware and stated, She had bruises on her arm when I was down there on Monday, but I didn't recognize them as bruises, I just thought they were smudges. Review of the facility's Investigation Report dated 11/13/18 confirmed Resident #15 sustained unexplained bruising. Review of Resident #15's Comprehensive Care Plan revealed the following care areas were addressed: 8/1/19 - Problem: Resident at times may resist care or make physical contact with staff or other residents due to Dementia and [MEDICAL CONDITION]. Goal: Talk to resident in a calm, reassuring tone of voice (through review date 11/1/19). Interventions (all initiated before 11/22/18) : Talk to resident in a calm, reassuring tone of voice; explain all procedures to resident prior to assisting; If resident is resistant or combative with care, give her time to calm down and re-approach at a later time; Administer [MEDICATION NAME] per MD's (doctor's) orders; and family contacted/informed about drug use and possible side effects. 8/1/19 - Problem: Resident displays socially inappropriate/disruptive behaviors due to [MEDICAL CONDITION] Dementia. Goal: Decline in disruptive behaviors (through review date 11/1/19). Interventions (all initiated before 11/22/18): Place resident in area where constant observation when possible; Approach resident warmly and positively; Talk to resident in a calm voice when behaviors are recent; Remove resident from area when behaviors are unacceptable/disruptive; Offer food/drink when behaviors are present; Check to see if resident is soiled or cold; Administer [MEDICATION NAME] per MD orders. Monitor for effectiveness, for possible side effects or adverse reaction and report to MD as needed; and family informed/contacted about drug use and possible side effects. 8/1/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to left [MEDICAL CONDITION], Dementia, Urinary tract infection, Constipation,[MEDICAL CONDITIONS]. Goal: Resident will not suffer injury related to falls (through review date 11/1/19). Interventions (all initiated before 11/22/18) : Monitor for safety and maintain a safe environment; Assist as needed in all ADL (activities of daily living) areas; Offer reminders not to arise unassisted as needed and transport to high visibility area as needed; Encourage to wear shoes with non-slip soles; Keep room free from clutter and pathway to be clear. Mop up all spills promptly; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; Notify responsible party (RP) and MD of all fall instances; Monitor for signs and symptoms of [DIAGNOSES REDACTED], such as tingling of extremities, muscle cramps, twitching, stooped posture and brittle bones; Provide diet per order, encourage consumption of calcium rich foods, such as eggs, milk, cheese and other dairy products served within diet; and monitor labs per order. Report to MD as needed. 8/1/19 - Problem: Potential for skin tears and bruising related to fragile condition of skin. Goal: Skin tears will heal without complication (through review date 11/1/19). Interventions (all initiated before 11/22/18): Monitor for safety and maintain a safe environment. Handle gently and protect from injury; Provide treatment to skin tears per order. Monitor effectiveness of treatment and progression of healing; Monitor for s/sx (signs/symptoms) of infection, such as redness, warmth, pain, tenderness, [MEDICAL CONDITION] and purulent drainage; Have resident wear long sleeves/pants/geri-sleeves as needed to protect extremities (2/24/19); Provide adequate lighting to reduce the risk of bumping into furniture or equipment; offer fluids with medication pass, at meals and as needed between meals in an effort to ensure hydration; Apply lotions and moisturizers to skin as needed; Use a lift sheet to move and turn resident when in bed as needed; Pad wheelchair arms and leg supports as needed; Support dangling arms and legs with pillows and blankets as needed; and perform skin tear risk assessment initially upon admission and quarterly thereafter, as needed. 8/1/19 - Problem: Resident requires extensive to total assistance from staff for ADLs related to limited mobility and poor endurance related to history left [MEDICAL CONDITION], Dementia, UTI, Constipation,[MEDICAL CONDITIONS]. Goal: Resident will continue to participate in ADLs after set-up by staff (through review date 11/1/19). Interventions (all initiated before 11/22/18): Provide showers three times per week and sponge baths daily. Shampoo hair weekly with a shower unless other arrangements are made; Provide routine oral hygiene; Clean and trim fingernails/toenails as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide preventative skin care daily and as needed; Provide tray set up for meal consumption and assist with meals as needed in an effort to ensure adequate nutritional intake; Assist the resident to turn and reposition ever two hours and as needed while in bed; Assist to transfer from bed to wheelchair as tolerated; Transport to specific destinations once up; Provide Range of Motion (ROM) exercises to all extremities throughout nursing care as tolerated; and assist to dress/undress appropriately and groom hair daily and as needed. The comprehensive care plan was not updated after Resident #15 sustained unexplained bruising to her left arm on 11/11/18. 2. Review of Resident #16's clinical record revealed Resident #16 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored four (4) out of 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired and exhibited no behavioral symptoms. Continued review of the assessment noted the resident required the total assistance of one staff person for bed mobility, transfers, locomotion on and off the unit, dressing, toileting and bathing. Resident #16 had no impairment to upper and lower bilateral extremities and did not utilize a mobility device. During the assessment period, Resident #16 had no falls and received no therapy services. Review of Resident #16's Annual MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired and exhibited no behavioral symptoms during the assessment period. The Annual MDS noted Resident #16 required the total assistance of one staff person for bed mobility, transfers, locomotion off and on the unit, dressing, toileting, personal hygiene and bathing. Resident #16 had impairment of one side of lower extremity, and according to the MDS, the resident did not utilize a mobility device. During the assessment period, Resident #16 had no falls, was administered opioid medication for seven (7) days and received no therapy services. Review of Resident #16's Progress Notes revealed the following: 12/31/18 at 10:40 a.m. - Upon getting up this morning, resident complained (of) left leg pain. No swelling or bruise noted .when staff tries to push her to go to the activity she hollers and says that her leg is still hurt. When this nurse checked her leg once again, her leg just below the knee is swollen, tender to touch but not warm. No redness or bruise on the area. (MD) notified and made aware with no new order noted at this time. Continue monitoring resident condition. Review of Resident #16's Radiology report dated 12/31/18 revealed Resident #16 sustained an Acute proximal left lower leg fracture. Review of Resident #16's Care Plan revealed the following care areas were addressed: 9/12/19 - Problem: Requires extensive to total assistance from staff for ADLs (activities of daily living) related to limited mobility, poor endurance and intermittent episodes of confusion related to [MEDICAL CONDITIONS], Abnormality of Gait, Debility, [MEDICAL CONDITIONS], History of Pneumonia, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITIONS], Dysphasia, Hypertension, Obesity, Anxiety and Dementia. Goal: Resident will be cleaned and well-groomed by staff (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Clean and trim fingernails/toenails as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide incontinent skin care after each incontinent episode; Provide preventative skin care daily and as needed; Provide tray set up for meals. Monitor self- feeding performance and meal consumption and assist with meals as needed in an effort to ensure adequate nutritional intake; Transport to specific destinations once up; Provide range of motion (ROM) exercises to all extremities throughout nursing care as tolerated; Provide showers three times weekly and sponge baths daily as tolerated. Shampoo hair weekly with a shower unless other arrangements are made. Encourage to wash face, hands and upper body after set-up and cueing from staff. Monitor performance and assist as needed; Dress/undress appropriately and groom hair daily and as needed; Turn and reposition every two hours and as needed while in bed; Side rails up x 2 when in bed to assist with turning and repositioning. Check every 30 minutes and release every two hours. Allow free time during meals, care and family/social visits; Perform positioning assessment quarterly; and transfer from bed to chair with Hoyer lift or sit-to-stand. 9/12/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Cardiovascular Accident ([MEDICAL CONDITION]), Debility, Abnormal Gait, [MEDICAL CONDITIONS], Anxiety, Age-related [MEDICAL CONDITION] without current pathological fracture and intermittent episodes of confusion related to Dementia. Goal: Resident #16 will not suffer injury related to fall (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Monitor for safety and maintain a safe environment; Assist as needed in all ADL areas; Offer reminders not to arise unassisted as needed and transport to high visibility area as needed; Encourage to wear shoes with non-slip soles; Keep room free from clutter and pathway to bathroom clear. Mop up all spills promptly; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding factors and eliminate if possible; Notify responsible party (RP) and MD of all fall instances; Monitor for s/sx of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; Provide diet per order. Encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; and administer medications and monitor labs per MD orders. Report to MD as needed. 9/12/19 - Problem: Potential for pain or discomfort related to limited mobility and [MEDICAL CONDITION] and history of proximal left lower leg fracture. Goal: Resident #16 will obtain relief from pain/discomfort 30-60 minutes after medications/measures taken (through review date 12/12/19). Interventions (all interventions initiated as of 10/18/18): Monitor for s/sx of pain/discomfort such as verbal complaints, moaning, crying, facial grimace, loss of appetite, withdrawal and resistance to care; Maintain calm and reassuring environment. Avoid stressors; Position for comfort with pillow supports as needed; Provide diversionary activities so resident does not focus only on pain; Encourage and assist with exercise to tolerance within physical limitations within. Allow resident to guide pacing of movements and provide frequent rest periods; and administer medications per MD orders. The comprehensive care plan was not updated to address Resident #16's potential to sustain pathological fractures related to the [DIAGNOSES REDACTED]. 3. Record review revealed Resident #17 was admitted into the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of Resident #17's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired and exhibited no behavioral symptoms. Resident #17 required the total assistance of one staff person for bed mobility, locomotion on and off of the unit, dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one staff person for transfers and had impairment to one side of her upper extremities. Resident #17 utilized a wheelchair for mobility. According to the MDS, Resident #17 had no falls and received no therapy services, during the assessment period. Review of Resident #17's Progress Notes revealed the following: 7/13/19 - CNA (Certified Nursing Assistant) was in room providing care resident rolled off right side of bed and hit left side of face and shoulder on chair beside bed. Res(ident) noted to obtain laceration to left eyebrow and left upper cheek. Bruises noted to left elbow and upper elbow. [MEDICAL CONDITION] noted to left elbow. ROM (range of motion) within normal limits for lower extremities and right arm. C/O (complains of) pain to left shoulder and elbow . Review of the facility's Investigation Report dated 7/16/19 revealed the following interventions were to be added to Resident #17's fall care plan: Floor pads placed on floor resident is facing when she is in bed and make sure chair is not right beside bed. Review of Resident #17's Comprehensive Care Plan revealed the following care areas were addressed: 9/5/19 - Problem: Potential for falls resulting in injury related to limited mobility, poor endurance and poor judgement due to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fractures, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will not suffer injury related to falls (through review date 12/5/19). Interventions: Monitor for safety and maintain safe environment; Assist as needed in all ADLs (activities of daily living) areas; Offer reminders not to arise unassisted as needed and transport to high visibility areas as needed; Encourage to wear shoes with non-slip soles; Maintain bed in low position while not rendering care. Keep call light within reach at all times. Instruct/remind on use of system and answer promptly; Assess all falls and circumstances surrounding falls in an effort to determine cause or contributing factors and eliminate if possible; Notify Responsible Party and MD of all fall instances; Monitor for s/sx of [DIAGNOSES REDACTED] such as tingling of extremities, muscle cramps, twitching, stooped posture, and brittle bones; Provide diet per order, encourage consumption of calcium rich foods such as eggs, milk, cheese and other dairy products served within diet; Strive to keep room free from clutter and pathway to bathroom clear, mop all spills; and administer med and monitor labs per MD orders. 9/5/19 - Problem: Resident #17 requires total assist of staff for ADLs related to limited mobility and poor endurance related to Alzheimer's Dementia, [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], right humeral neck fracture, [MEDICAL CONDITION], Constipation, Depression, Loss of Appetite and [MEDICAL CONDITION]. Goal: Resident #17 will be clean and well-groomed by staff (through review date 12/5/19). Interventions: Provide routine oral hygiene; Clean and trim fingernails/toenails; Dress/undress appropriately and groom hair daily and as needed; Offer toileting assistance every two hours and as needed in an effort to maintain some continence; Provide incontinence skin care daily and as needed; Turn and reposition every two hours and as needed while in bed; Transport to specific destinations once up; Provide ROM (range of motion) exercises to all extremities throughout nursing care as tolerates; Provide showers three times weekly and sponge baths daily shampoo hair with shower unless other arrangements are made; Spoon feed all meals by staff in an effort to ensure adequate nutritional intake; Transfer from bed to geri-chair as tolerated; and perform treatments per MD orders. Resident #17's care plan was not updated to include the interventions to place floor pads on the floor and to make sure a chair was not right beside Resident #17's bed. Observation in Resident #17's room on 10/16/19 at 2:14 p.m. revealed a chair was placed next to the head of Resident #17's bed. Interview on 10/17/19 at 11:00 a.m. with the facility's Director of Nursing (DON) and the MDS Coordinator revealed residents' care plans were maintained in the electronic health record, and a hard copy was also maintained in the resident's paper chart. The MDS Coordinator said that nursing staff can update residents' hard copy care plans when needed by writing in newly developed interventions. The MDS Coordinator said that updated information documented on the hard copy care plans was formally added to residents' electronic care plans on a quarterly basis when care plan meetings were held. The DON and MDS Coordinator acknowledged that care plans for Residents #15, #16, and #17 were not updated; however, they should have been. | 2020-09-01 |
| 54 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2017-02-23 | 272 | C | 0 | 1 | 999W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review it was determined the facility failed to accurately assess a terminal prognosis for three (#s 45, 1 & 127) of three residents reviewed for hospice of the eight residents in the facility identified as receiving hospice services. Findings include: RESIDENT #45 The medical record for Resident #45 was reviewed on 02/21/17 at 1:29 p.m. The resident's care plan identified the resident received hospice care due to a terminal illness. A Hospice Certification and Plan of Treatment revealed the resident admitted to hospice on 11/01/16 due to a [DIAGNOSES REDACTED]. It was signed by a physician. The Minimum Data Set assessments, dated 01/05/17 and 11/04/16, were reviewed on 02/21/17 at 2:43 p.m. The assessments identified Resident #45 received hospice services while a resident at the facility (Section O0100k). These MDS assessments also indicated, in Section J1400, that the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. In an interview on 02/21/17 at 3:42 p.m., the Resident Assessment Coordinator, Registered Nurse #9, explained, according to the RAI (Resident Assessment Instrument) Manual, I have to have physician's documentation to support a terminal illness and I must not have (had it). When the Certification and Plan of Treatments were reviewed with the Resident Assessment Coordinator, Registered Nurse #9, she stated she did not know when those were put in the chart. The RAI manual's instructions, that read Under the hospice program benefit regulations, a physician is required to document in the medical record a life expectancy of less than 6 months, so if a resident is on hospice the expectation is that the documentation is in the medical record, were reviewed and the Resident Assessment Coordinator, Registered Nurse #9, verified the assessments were not completed accurately. RESIDENT #1 The medical record for Resident #1 was reviewed on 02/21/17 at 12:42 p.m. A Hospice Certification and Plan of Treatment indicated hospice was initiated 10/27/16 for [MEDICAL CONDITION]. The Minimum Data Set assessments, dated 11/05/16 and 02/05/17, were reviewed on 02/21/17 at 12:55 p.m. They identified the resident received hospice (Section O0100k) but did not have a terminal prognosis (Section J1400). The Resident Assessment Coordinator, Registered Nurse #9, in an interview on 02/21/17 at 3:47 p.m. verified the assessments did not accurately reflect the resident's terminal prognosis. RESIDENT #127 The medical record for Resident #127 was reviewed on 02/21/17 at 1:45 p.m. A Hospice Certification and Plan of Treatment indicated hospice was initiated on 06/05/14 for a [DIAGNOSES REDACTED]. In an interview on 02/21/17 at 3:50 p.m. the Resident Assessment Coordinator, Registered Nurse #9, verified the assessments did not accurately reflect the resident's terminal status. In an interview on 02/21/17 at 4:15 p.m., Director of Nursing Services, Registered Nurse #5, stated hospice was good about getting the Certification of Terminal Illnesses to the facility, and if needed, the nurse could call and get them faxed over to verify the prognosis. She stated if a resident was on hospice, the facility should have certification of the terminal prognosis. | 2020-09-01 |
| 55 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2017-02-23 | 371 | E | 0 | 1 | 999W11 | Based on observations and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service in one of two kitchens. Specifically, the facility failed to: -Ensure expired foods were disposed of; and -Ensure all foods were covered/ sealed. The findings included: [NAME] Expectations According to the 2013 Food Code from the U.S Department of Health and Human Services, page 92, Ready-to -eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment .and the day or date marked by the food establishment may not exceed a manufacturer's use-by date based on food safety. According to the 2013 Food Code from the U.S Department of Health and Human Services, pages 60 and 76, Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants .Food shall be protected from contamination by storing the food: where it is not exposed to splash, dust or other contamination. B. Facility Standards According to the storage of food policy provided by the dietary manager (DM) on 2/23/17 at 1:47 p.m., dated 9/2014, Store potentially hazardous foods under refrigeration at or below 41 degrees Fahrenheit for a maximum of 7 days, unless there is a different manufacturer's use by date specified .Discard food that has exceeded the expiration date . C. Observations The main kitchen was observed on 2/20/17 at 8:15 a.m. There were two containers of deluxe tuna salad observed in the walk-in refrigerator with a use-by date of 2/3/17. These containers were approximate five pound containers. (17 days) -One tray with 20 containers of fruit cocktail were observed in the walk-in refrigerator, uncovered. These containers were stored on the second shelf to the right with a box stored on the shelf above. -A five-pound container of pimento cheese was observed in the walk-in refrigerator as partially opened, not fully sealed. The main kitchen was observed on 2/23/17 at 1:03 p.m. A five-pound container of pimento cheese was observed in the walk-in refrigerator as partially opened, not fully sealed. D. Staff Interviews The registered dietitian (RD), DM and the nursing home administrator (NHA) were interviewed on 2/23/17 at 1:56 p.m. The DM said her staff was in charge of throwing out expired foods. She had completed monthly in-services with the staff. The DM also said this food item was thrown out that same day. She would ensure the above issues were addressed. | 2020-09-01 |
| 56 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2019-08-15 | 623 | D | 0 | 1 | RSRB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents and/or their representatives received in writing and in a language they could understand the reason for transfer to the hospital for 2 of 3 residents reviewed for hospitalization . The facility failed to provide a written Notice of Transfer that included the reason for transfer for Residents #7 and #65. The findings included: The facility admitted Resident #7 on 11/2/18 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 3/31/19 indicated the facility transferred Resident #7 to the emergency room due to pneumonia. The resident was hospitalized and re-admitted to the facility on [DATE]. Further review of the medical record revealed Resident #7 was admitted to the hospital on [DATE] due to [MEDICAL CONDITION] activity with re-admission to the facility on [DATE]. There was no documentation in the medical record to indicate the facility sent a written Notice of Transfer with the resident or sent a written notification for the reason for the transfer to the resident's representative at the time of the transfers and admissions to the hospital. The surveyor requested documentation related to the written Transfer Notices for the hospitalization s. The facility provided a copy of a form entitled, Facility Initiated Discharge Letter indicating Resident #7 would be discharged [DATE] and 7/28/19 respectively. The form indicated this was a Notice of Discharge. Review of the form indicated the reason for the resident's transfer to the hospital was not included on the form. During an interview on 8/14/19 at approximately 12:30 PM, the Director of Nursing and Business Office Manager reviewed the forms and confirmed that this was the form the facility sent upon transfer, and no other written Notice of Transfer was provided. The facility admitted Resident #65 on 4/12/19 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 5/28/19 revealed the facility transferred Resident #65 to the hospital due to decreased blood pressure and oxygen level with increased heart rate and temperature. The facility readmitted Resident #65 on 6/6/19. Further review of the medical record indicated Resident #65 was admitted to the hospital on [DATE] due to abnormal vital signs with re-admission to the facility on [DATE]. There was no documentation in the medical record to indicate the facility sent a written Notice of Transfer with the resident or sent a written notification for the reason for the transfer to the resident's representative at the time of the transfers and admissions to the hospital. The facility provided a copy of a form entitled, Facility Initiated Discharge Letter which indicated Resident #65 would be discharged from the facility 4/9/19 and 7/28/19 respectively. The form indicated this was a Notice of Discharge. Review of the form indicated the reason for the resident's transfer to the hospital was not included on the form. During an interview on 8/14/19 at approximately 12:30 PM, the Director of Nursing and Business Office Manager reviewed the forms and confirmed that this was the form the facility sent upon transfer, and no other written Notice of Transfer was provided. | 2020-09-01 |
| 57 | HEARTLAND OF COLUMBIA REHAB AND NURSING CENTER | 425008 | 2601 FOREST DRIVE | COLUMBIA | SC | 29204 | 2017-12-11 | 585 | D | 1 | 0 | CJTI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to resolve and/or notify the complainant timely for 1 of 1 grievances by a sampled resident. A grievance was initiated regarding care for resident #3, which was not resolved for eight (8) days. The findings included: In response to a complaint received in this office, review of the facility's grievance log was reviewed. During the review a grievance was noted for 1 of 4 sampled residents. The facility admitted resident #3 with [DIAGNOSES REDACTED]. On 10/1/17 a Concern Form was completed for a grievance regarding the resident's care. The grievance included a request for nursing to call a family member. Under the section Documentation of Facility Follow-up, the results of action taken stated: Staff inservice on call light response. Nurse returned call after admission director informed. There was no date as to when the family was called. Under the section, Resolution of Concern, Identify the method used to notify complainant of resolution, one to one discussion was checked and dated for 10/9/17. Per the Concern Form the complaint was not resolved for eight (8) days. Review of the Policy/Procedure for Concern Process stated, The assigned department head contacts the appropriate party once resolution has been completed. Once resolved, the concern form is updated with the resolution of the concern and returned to the Administrator of designee. There was no time schedule as to how long it should take to resolve an issue or notify the complainant of the resolution. On 12/11/17 at 11:35 AM the Administrator was interviewed by the surveyor. The Administrator stated the family was out of state and it was difficult to get in touch with them. | 2020-09-01 |
| 58 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-02-07 | 770 | D | 1 | 0 | SCLZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to obtain laboratory results timely for 1 of 3 residents reviewed for Diabetic Monitoring. Resident #1 did not have lab results available for eight days for an abnormal lab value. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. Review of the Nurse's Notes revealed a note written on 12/18/17 at 3:00 PM. Bloodwork collected collected (sic) for numerous labs ordered on [DATE] . Review of the facility investigation regarding the lab reports revealed the facility did not receive the lab reports until 12/28/17, after the resident was sent to the hospital for acute change in condition. The facility called the lab for the results when they reviewed the chart and noted there was no lab report from the ordered labs. The lab report stated the resident's Hemoglobin A1C was 12.5, noted to be high. The blood sample for the lab reports was noted to be drawn five days after the physician ordered the labs. The lab report was not available until eight days after the blood had been drawn. 2/7/18 at 1:30 PM the surveyor interviewed the Director of Nursing. When the resident was sent to the hospital we reviewed his/her chart and noted there was no report for the ordered labs. We called the lab and they faxed over the report. We did not get a call from the lab about the high A1C. | 2020-09-01 |
| 59 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-02-07 | 775 | D | 1 | 0 | SCLZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to maintain laboratory (lab) reports in the medical record for 1 of 3 residents reviewed for lab results. Resident #1 did not have lab reports in her/his medical record that were obtained on 12/18/17. The findings included: The facility admitted resident #1 with [DIAGNOSES REDACTED]. Review of the medical record revealed a physician's orders [REDACTED]. Review of the Nurse's Notes revealed a note written on 12/18/17 at 3:00 PM. Bloodwork collected collected (sic) for numerous labs ordered on [DATE] Review of the medical record revealed there were no lab reports for 12/18/17 available. The lab reports were requested from the Director of Nursing (DON). The DON supplied the lab report at the end of the day. Review of the lab report revealed the report had been faxed to the facility on [DATE] On 2/7/18 at 1:30 PM the surveyor interviewed the Director of Nursing. I am looking for the lab report. I know it is here or we wouldn't have known about the abnormal lab. | 2020-09-01 |
| 60 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 223 | J | 1 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to provide needed services to 1 of 3 residents reviewed for change in condition. Resident #48 had a change in condition that required respiratory assessment and treatment which the resident did not receive. In addition, based on observation, record review and interview the facility failed to ensure all residents with concerns with positioning for safe meal intake to avoid choking were given adequate assistance in set up at meal time. Three of 18 residents (Residents #6, #22 and #49) noted to have positioning concerns were found to be improperly positioned in bed to feed themselves effectively and safely. The Certified Nursing Assistant caring for Residents #22 and #49 residents had just been inserviced on how to provide assistance to residents with positioning for meal intake to ensure safety. The findings included: The facility admitted resident # 48 with [DIAGNOSES REDACTED]. Review of Nurses' Notes from [DATE] through [DATE] revealed resident was total care for all Activities of Daily Living (ADL's). S/He was in a persistent vegetative state. On [DATE] at 9:30 AM: resident lying in bed with eyes open, when breathes makes a gargling sound. resp even/unlabored. will continue monitoring. 10:20 AM called to room per Certified Nursing Assistant (CNA). Resident lying in bed with Head of bed (HOB) elevated ( ^) noted to have beige secretions coming out of mouth. No respirations noted. Code blue called &Cardiopulmonary Resuscitation (CPR) was initiated, no pulse, 911 called 10:30 AM Emergency Medical Services (EMS) here. took over CPR. To hospital via stretcher. Per Physician's Cumulative Orders for ,[DATE]-[DATE] an order for [REDACTED]. On [DATE] at 3:30 PM CNA # 44 was interviewed by the surveyor. The CNA had reported to the nurse the change in condition of the resident. In the morning s/he was coughing funny, making a strange noise. I told the nurse s/he needed to check on the resident, s/he was making a strange noise and needed to be suctioned. That was the first time. Don't remember the exact time. Somewhere between 7:30 and 8:00 AM. 2nd time the original aide heard her/him and went and told the nurse, s/he needed to check on the resident. I was standing there. We were getting the residents ready to eat. S/he (nurse) was standing outside the room, passing medicine. S/he heard us talking about telling her/him to come and check the resident. S/he came in the room and looked at him/her (resident). S/he said, 'yeah s/he do need to be suctioned. Around 10:30 the CNA (assigned to the resident) called me to come and look. S/he said s/he thought the resident was dead. I went into the room. His eyes was open and he had foam out is mouth. I called her/his name, I rubbed her/his chest, nothing. I ran up to the desk where the nurse was at. I yelled are you calling a code blue? S/he said she was about to. We tried to tell her that he was having a hard time breathing. We take care of these people every day. We know when something ain't right. On [DATE] at 8:30 AM, Registered Nurse (RN) #138 was interviewed via phone by surveyor. The RN stated the resident was gurgling during med pass. I went and found a suction machine, but it did not work. I never got a suction machine to work. The RN stated s/he had removed the suction machine from the crash cart. I think there are 3 crash carts. It was about 9:00 AM I can't remember exactly. I never had to suction her/him before. At 2:50 PM: CNA # 47 was interviewed by the surveyor. When I came in (,[DATE]), when I went to his room CNA # 44 was already in there. S/He (the resident) was making a noise like something was in her/his throat. CNA # 44 said s/he had already talked to the nurse. The nurse was outside the door with her/his med cart and said ok. Then the trays came out about 8:30 AM. The CNA and I were feeding two other residents (4 residents were in that room) and resident #48 was making noise again. I go and talked to the nurse and told her/him the resident needed to be suctioned. The nurse was a RN, I don't remember her/his name. I am prn (as needed). That time s/he came in and said, 'OK, I will suction her/him. When s/he (the nurse) came in s/he just looked at her/him (the resident). It was 10:00 something when I went and looked at her/him and s/he wasn't breathing. The other CNA was walking by and I called her/him in. The other CNA was in the room. I went to the desk and told the nurse to come and look, I didn't think s/he was breathing. S/he walked down to the room and looked at him. Again, didn't do anything. S/he left the room and got her/his chart. We asked her/him if s/he was going to call a code. S/he called the code and everyone came rushing into the room. They sent me to escort the ambulance. So I went outside and brought them in. The other CNA usually worked with the resident. Review of the facility investigation revealed the facility had obtained statements from the two Certified Nursing Assistants. There was no statement from the Registered Nurse. Review of the facility's summary of the investigation revealed, RN #138 stated when s/he entered the room the resident was unresponsive and s/he immediately reported to the nurse's station to call a code. She did not check vitals or pulse. S/he also stated s/he previously went into the room at 0900 and the resident sounded gargly but respirations were even and unlabored, there was no suction machine in the room at this time. The nurse was asked why s/he didn't suction in a timely manner and s/he stated that s/he could not find a suction machine on the crash carts. Other staff members were interviewed and it was determined that there were suction machines on each crash cart. The crash carts were located at each nurses station. During the survey, the crash carts were observed on ,[DATE], ,[DATE] and on [DATE]. Each observation the crash carts contained a suction machine as well as suction cannisters, suction tubing and suction catheters. On each crash cart was a check list which had been checked daily for required equipment. Record review for Resident #6 of physician progress notes [REDACTED].diabetes with peripheral circulatory disorders, type 1 .coronary [MEDICAL CONDITION] (hardening/narrowing of arteries) of unspecified type of vessel . On [DATE] at 12:57 PM Resident #6 was observed sitting very low in her bed, with the head of the bed raised causing her to to have her chin to her chest. Her tray of food was on the table and she was feeding herself. When asked if she is comfortable like that, she confirmed that she was not. On [DATE] at 12:37 PM during an observation, she is slouched in her bed, not at a 90 degree angle and tilted on her right side, and is feeding herself. A Certified Nurses Assistant (CNA) Staff #34 is currently in the room feeding another resident. The same CNA brought her food. Her call light is out of reach hanging on the other side of her bed. On [DATE] at 12:37 PM During an interview with the Resident #6, when asked if she still works with therapy, she stated that she does, when asked if she remembers what they tell her when she eats, she stated, yes, they tell me I am supposed to be sitting straight up so the food goes down into my stomach, not like this. On [DATE] 12:45 PM R#6 began yelling at Certified Nurse's Assistant (CNA) Staff #34, asking several times to put her head up, and CNA Staff #34 continued saying that the bed was all the way up. R#6 asks two more times, and CNA Staff #34 stated that her head is fine. CNA Staff #34 came to the edge of the bed and adjusted her tray, but did not put her head up or help her adjust in the bed. The resident remained in the same position, slouched and turned to the right side of the bed. On [DATE] at 12:47 PM during an interview with Resident #6, when asked if she is having trouble swallowing that way, she states,yes, everything is hard sitting like this. Resident #6 begins coughing, and coughed up coleslaw that she was eating. LPN (Licensed Practical Nurse) Staff #12 and LPN Staff #38 were in hall and were asked to come straighten up the resident and check on her. They came in and pulled her up in bed and repositioned her, but not in a 90 degree angle. She remained low in the bed and tilted to the right side. On [DATE] at 12:57 PM, during an interview with R#6, when asked if they always put her head up to eat, she stated no. She stated, this is better than when I am laying down, I cant eat like that. All residents were observed for proper positioning while in the bed feeding them self. During the extended survey observation was made of resident #22 on [DATE] at 5:15 PM and revealed she was observed to be served her meal and the nursing assistant elevated the head of her bed but she did not pull the resident up in the bed. Resident #22 remained slouched down in the bed and was in poor position to feed herself when her meal was served. The staff prepared her meal and left her to feed herself while she was still not positioned straight up in the bed as she was still noted to be slouched down in the bed. Resident #22 was observed to feed herself but was noted to struggle getting the food on her spoon and feeding herself without spilling the food on herself. During this observation the Social Service staff #108 walked by the room and observed Resident #22 in her bed positioned poorly and she entered the room and ask the resident why are you laying so far back in the bed trying to feed yourself. She began to reposition the resident and when doing so the resident began to cough/choke on the food that she had in her mouth. The Social Service staff #108 attempted to assist the resident by offering her a drink of water but the resident continued to cough and her eyes began to water and she was not able to speak. The Social Service staff #108 called for the nurse to come the the room and the nurse assessed Resident #22 and she was then able to drink water and she ceased coughing. Nurse #51 and Social Service Staff #108 pulled the resident up in bed and repositioned her in an adequate position so she could feed herself in an upright position and the resident was then able to feed herself her meal with no further concerns. Record review revealed Resident # 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum (MDS) data set [DATE] revealed she had no swallowing disorder and receives a therapeutic mechanically altered diet. She was noted to require the extensive assistance of two staff members to position her in bed, required eating supervision with oversight and encouragement/cueing and was a set up only with her meals. Review of Resident #22's current care plan dated [DATE] revealed interventions to include that staff are to assist her with eating, monitor for mastication difficulties, monitor her intake for safe swallowing and report any problems to the nurse. Review of Nurse Aide flow records for (MONTH) and (MONTH) (YEAR) revealed she requires the extensive assistance from staff to turn in bed. Her record was silent to any speech therapy orders or evaluations. During this same meal observation on [DATE] at 5:15 PM Resident #49 was also observed during the supper meal service. He was observed to be served his meal and nursing assistant #93 elevated the head of his bed but she did not pull the resident up in the bed to position him properly so he could feed himself safely. Resident #49 remained slouched down in the bed and he was leaning the to left against the bed rail. The Nurse Aide Staff #93 prepared his meal and left him to feed himself while he was not positioned straight up in the bed so he could eat without risk of choking and potential aspiration. The Social Service staff #108 walked by Resident 49's room and observed him slouched down in the bed, leaning to the left and attempting to feed himself. She repositioned the resident by pulling him up and over in the bed and placing pillows beside him for positioning so he could feed him self without risk of choking. When the Social Service Staff #108 repositioned him so he could feed himself safely he was not able to self assist with positioning. Interview with Nurse Aide #93 on [DATE] at 5:30 PM revealed she had been educated by the Speech Therapist when she arrived on shift on this date prior to the evening meal about how to properly position resident while they are eating in bed. She said she was in-serviced to elevate the head of the bed and to use pillows as needed to position the resident so they were in a safe position to feed them self. She stated she had never observed Resident #22 or #49 to have any issues feeding themselves in bed and had never observed them to choke. Review of the sign in sheet for the education/in-service provided by the Speech Therapist on [DATE] revealed Nurse Assistant #93 was present for the mandatory in-service on safe positioning of resident while eating. Review of the education that was provided to the staff during this mandatory in-service revealed they were educated on assisting residents with feeding and positioning, swallowing precautions and a review was done of swallowing guidelines for the patient and the caregiver. This in-service was to be provided to all staff on shift on [DATE] and to all staff who worked on the days following prior to them providing care until all the staff who assisted residents with meals had been in-serviced. The Corporate Nurse #134 was advised of the observation of Resident #22 being poorly positioned by Nurse Aide Staff #93 on [DATE] at 6 PM. At 6:10 PM she advised this surveyor that she had spoken with Nurse Aide #93 and the Nurse Aide had been suspended due to the poor positioning of Resident #22 during her meal after she had just been inserviced on how to properly position resident for safe eating while in bed. The corporate Nurse #134 verified Resident #22 had not had any previous speech evaluations and had not had any incidence of previous choking or coughing incidents while feeding herself. The staff failed to monitor Resident #22 for safe swallowing per her nutrition care plan and failed to position her in a safe manner in bed so she could eat her meal on [DATE] at 5:30 PM. The staff also failed to position Resident #49 in a position while in bed to promote safety while he was feeding himself in bed. Both residents were found by the Social Service Staff #108 to be poorly positioned and Resident #22 was observed to experience a coughing/choking episode while feeding herself in bed while being poorly positioned. Two additional residents were observed during the meal service on [DATE] as they were identified by the facility as being on swallowing precautions. At 5:05 PM Resident #1 who was identified by the facility as being on swallowing precautions was observed sitting in a wheelchair in the dining room feeding himself. He was observed eating a pureed diet and thick liquids and was observed to have no concerns while feeding himself. Resident #20 was also observed in the dining room in her wheelchair feeding herself and no concerns were noted as she fed herself a mechanical soft diet with chopped meats. On [DATE] at 2:10 PM, Corporate Nurse Staff #134, Regulation Specialist Staff #135, and Director of Nursing Staff #136 were notified that Immediate Jeopardy (IJ) began on [DATE] at 12:47 PM when Resident #6 was observed lying slouched down in her bed on her right side and began choking while feeding herself lunch after repeated requests from the resident to be placed in a position so she could feed herself safely. On [DATE] the Administrator was advised of a second Immediate Jeopardy that began on [DATE] when a resident had a change in condition related to respiratory issues that was not addressed by the nurse. The resident became unresponsive and was transported out of the facility to the hospital and expired. The facility's Allegation of Compliance (A[NAME]) to address the concerns with positioning of residents to prevent episodes of choking was received on [DATE] at 6:22 PM. The A[NAME] included: 1. Affected resident has been assessed by Speech Therapy and staff educated on proper positioning during meals. 2. Education provided to floor staff regarding proper positioning of residents who eat in bed by speech therapy and nursing management prior to dinner meal on [DATE]. 3. DON (Director of Nursing) or designee to visually check on residents during meal times to ensure proper positioning in bed at each meal x 7 days. 4. Speech Therapy will screen residents noted to have any difficulties with swallowing as reported by nursing on therapy referral form. 5. Residents noted for speech therapy screen will be reviewed in Q[NAME] (Quality of Care) meeting weekly beginning immediately. 6. Speech therapy to provide DON with copy of recommendations for processing to current orders or Kardex. 7. Staff that did not attend initial education on [DATE] will be educated on proper positioning and aspiration precautions before working the floor. The facility's Allegation of Compliance (A[NAME]) to address failure to assess and treat respiratory issues was submitted [DATE] to the surveyor and included the following: 1) Affected resident was transported to the hospital via 911 for evaluation and expired at the hospital. 2) Allegation of neglect was reported to the State Agency as required. 3) RN involved was suspended, terminated and reported to the SC Board of Nursing. 4) DON and Unit Managers to provide education on [DATE] to all nurses and Certified Nursing Assistants on neglect, oral suctioning procedure, location of suctioning equipment, recognizing change in condition and performing respiratory assessment. Inservice is mandatory and no one will be allowed to work until education is completed. 5) All resident's orders were audited by Nurse Management staff for identification of orders for advanced respiratory care/oxygen/suction. Findings were 2 residents in house with orders for continuous oxygen, 2 residents in house with orders for PRN (as necessary) oxygen and no residents in house with suction orders. 6) All respiratory care plans for affected residents have been reviewed and revised if needed on [DATE]. 7) Residents that have the potential for advanced respiratory care have been re-assessed for the need for suction on [DATE]. 8) Maintenance Director and Nursing verified that all 8 suction machines in the facility were functioning properly and central supply clerk verified that suction supplies are readily available on [DATE]. 9) A root cause analysis determined the nurse failed to respond to a change in condition of a resident and failed to respond appropriately to assess and treat. Equipment was available and functioning at the time of the incident. All staff including any new hires have been re-educated on neglect, respiratory assessment, equipment to use and location of equipment and recognizing change in condition. 10) The designated staff and DON will verify location of suction machines daily and nurses will check weekly their functionality. 11) This A[NAME] has been reviewed in an ad hoc QAPI meeting with the Medical Director's involvement and will be reviewed monthly at the QAPI meetings. The survey team completed record review, observation and interview to ensure the facility had implemented their A[NAME]. The Immediate Jeopardy at F279, F323 and F520 was removed on [DATE], but the citations remained at a lowered scope and severity of D. The Immediate Jeopardy citations at F223, F281 and F328 were removed on [DATE] after observations and interviews were completed to ensure the A[NAME] was in place and in practice. These citations remained cited at a lower scope and severity of D. | 2020-09-01 |
| 61 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 225 | D | 1 | 1 | J20Y11 | > Based on record review, interviews and review of facility files, the facility failed to obtain a statement from the alleged perpetrator for 1 of 3 residents reviewed for neglect. Resident #48 did not receive required care for respiratory difficulty. The findings included: Cross refer to F223 related to neglect of Resident # 48 and the incomplete investigation of the incident. Review of the facility investigation of the reported incident of Neglect revealed the facility did not have a written statement from the nurse who allegedly neglected resident #48. The facility had written statements of the Certified Nursing Assistants (CNA) who had witnessed the incident. There was no statement from the Nurse. The investigation was summarized with statements the nurse allegedly made, however there was no actual statement from the Nurse. The summary of the investigation revealed the nurse had stated s/he was unable to locate a suction machine and there was no suction machine on the crash cart. On 6/13/17 at 8:30 AM, Registered Nurse (RN) #138 was interviewed via phone by the surveyor. The RN stated the resident was gurgling during med pass. I went and found a suction machine, but it did not work. I never got a suction machine to work. The RN stated s/he had removed the suction machine from the crash cart. I think there are 3 crash carts. It was about 9:00 AM I can't remember exactly. I never had to suction her/him before. Review of the facility Policy and Procedure on Abuse/Neglect, under the section titled Investigation stated, Written summaries of interviews with individuals having first hand knowledge of the incident. NOTE: Employees/witnesses are not to write out statements. Employees/witnesses will be interviewed by designated facility staff and the interviewer will record all witness accounts in a document written, dated and signed by the interviewer. | 2020-09-01 |
| 62 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 244 | D | 0 | 1 | J20Y11 | Based on record review, staff and resident interview the facility failed to act promptly upon grievances from resident council meetings concerning issues of resident care and life in the facility regarding the lack of dental services. The facility was not able to demonstrate their response to resident requests for dental services. This involved 4 residents, #55, #10, # 52 and #29, who voiced requests to see the dentist during the resident council meetings. Findings include: During an interview with Resident #52 on 4/12/2017 at 2:10 PM the resident stated during the monthly resident council meeting residents have been voicing complaints about the lack of routine dental service. He stated in the last several meetings the residents have been asking when will they be provided a response to their request to see the demist. He stated a few residents have indicated they have broken dentures or do not have any dentures but would like to have dentures. Review of the resident council minutes on 4/11/2017 at 1:45 PM revealed in (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) the meeting minutes revealed documentation that several residents stated they would like to see the demist. The Activity Director informed the residents that she would obtain a list of names of which residents would like to see the dentists and she would attempt to get appointments set up for them. Interview with the Activity Director on 4/12/2017 at 10:05 AM reveled she did obtain a list of resident who would like to see the dentist in the (MONTH) (YEAR) resident counsel meeting and provided this survey the list. During this interview she verified as of this date the residents on the list have still not been scheduled for any dental care as they requested. She stated she had given the list of names to the Social Service staff but there has been no appointments made for these residents at this time. This was confirmed during an interview with the Social Service Director on 2/13/2017 at 11:08 AM. | 2020-09-01 |
| 63 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 248 | D | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide an individualized program for activities for 1 Resident, #110, of 1 resident reviewed for activities, by not providing activities of interest, or stimulation throughout the day. Findings include: Record review of History and Physical for Resident #110 dated 09/14/16 (from previous facility/hospital), revealed, Past Medical History: 1. [MEDICAL CONDITION] of the liver secondary to [MEDICAL CONDITION], 2. [MEDICAL CONDITION] 3. [MEDICAL CONDITION] infection, 4. Chronic pancreatitis, 5. [MEDICAL CONDITION] brain history with persistent [MEDICAL CONDITION], 6. Hepatic [MEDICAL CONDITION], 7. Recurrent [MEDICAL CONDITION], 8. Dysphagia, status [REDACTED].Review of Systems: Unable to obtain accurate review of systems as patient currently is alert and oriented X 0 with persistent [MEDICAL CONDITION] . Record review of Activities Progress Notes for Resident #110 dated 3/28/17 revealed the resident was new to the facility .Her family stated, she likes to listen to music, go outside, and being around people but she didn't attend church . Record review of the Care Plan for Resident #110 dated 03/28/17 revealed, Resident #110 is new to the facility and will be oriented and introduce to all the department managers and their departments. Her family states she likes to go outside and being around people, but she didn't attend church .Goal: Resident will express(verbally or showing signs of satisfaction with daily routine and leisure activities, in room and out of room activities. The staff were to involve the resident with those who have shared interest e.g. men/women's group, social parties, spiritual related, movies, and music, reminiscing and special events and to offer individualized care based on customary routine to keep them safe, stimulated and involved. Record review of Minimal Data Set (MDS) for Resident #110 dated 03/28/17 revealed, Section F Preferences for Customary Routine and Activities .The following boxes are checked: Family or significant other involvement for care decisions, Listening to music, Doing things with groups of people, spending time outdoors .Section G Functional Status indicates that the resident is dependent in all areas of care. Record review of CAA Summary Report for Resident #110 dated 03/31/15 revealed under communication the resident is non-verbal due to illness. Factors to include in care plan sensory deprivation, social isolation, mood/behavior disorder and has problems making self understood. Develop an individual care plan to help stimulate his/her cognitive, creative, social/converse/communication, independent, empowerment, sensory stimulation, spiritual and physical well being. On 04/11/17 at the following times, during observations, Resident # 110 was found in her bed, alone, facing the wall away from her roommates and the door with no music or television: 04/11/17 at 8:40 AM, 10:17 AM, 11:03 AM, 12:27 PM, 1:32 PM, 2:29 PM, and 3:06 PM, 4:54 PM, and 5:17 PM. On 04/12/17 at 7:42 AM and 8:44 AM during observations, she was in her bed, facing the wall away from her roommates and the door with no music or television. On 04/12/17 during the following times, she was up in her chair in her room, alone: 10:39 AM, 1:19 PM, and 2:40 PM. On 04/12/17 at 3:37 PM during an interview Licensed Practical Nurse Staff #66, when asked if there is any reason that Resident #110 doesn't come out of her room, she stated, She comes out during meals. When asked if she comes out for all meals, she confirmed that she did. When asked why she had not been out for the past two meals observed by this surveyor, she confirmed that she should have been out and that she had not been. She stated, She isn't supposed to be around them other residents when they are eating because its a dignity issue. On 04/12/17 at 4:39 PM during an interview with the Assistant Director of Nursing Staff #3, when asked how many people worked in activities, she confirmed there are three, but before they got the third person, there were only two. When asked if three people doing the activities for that building was enough, she confirmed that it is not. When asked if they work seven days per week, she stated that she did not think so. When asked if there were any residents that could not get up for activities on the A/B Hall, she confirmed that there isn't. She stated, They (A/B hall) don't really have activities back there, so they have to come up to the front. When asked if there is any reason why staff cannot take Resident #110 out of the room, she stated, They would have to make sure it is ok with the nurse, as well as activities. On 04/12/17 at 3:24 PM during an interview with the Activities Director Staff #9, when asked if an individual can't get to activities by themselves, what is offered to them, she stated, We go in their rooms, ask them what they want to do and they may want to listen to music or watch TV. We have other residents that are bed ridden, and we have 1:1 (one on one individual activities) two times a week. We do some type of stimulation like hand massage, head massage, or some type of stimulation. When asked how activities knows what the resident preferences are if they are unable to voice them, she stated, When asked if they had a meeting with Resident #110's family about preferences, she confirmed that they had and stated, When we spoke to her father, he told me that she liked to listen to music, and she never attended church services. We sometimes come in with our phone or a radio and play some music for a short period of time. Sometimes she will open her eyes and move her body so we know she knows someone is with her. When asked if there is anywhere to take people if they want to go outside, or if they want to watch TV outside of their room, she stated, With the structure of out facility, we have most of our activities in the dining room. When asked if Resident #110 comes out of her room, she confirmed that she does not. When asked if the staff was able to take her to watch TV somewhere else besides her room, she confirmed that they could. When asked if the CNA's (Certified Nurse's Assistant) could get her up to have activities somewhere else besides her room, she confirmed that they could. When asked why she stays in her room if she has the opportunity to leave it, she stated, I don't know, that would be up to the nurse, and they would tell the CN[NAME] On 04/13/17 at 7:44 AM during an interview with the Interim Administrator Staff # 23 When asked if there is any reason someone wouldn't be taken out of their room sometime during the day to work with activities, or to be provided stimulation, she confirmed that there is no reason that should happen. When asked if one day of 1:1 activities per week was enough for someone that is totally dependent, and cannot express their concerns, she stated, It needs to be more often. When asked who brings the residents to activities, she confirmed that activities does that. When asked if activities is unable to get someone up, who gets the residents to activities, she confirmed that the CNAs should help get them up. On 04/13/17 at 8:17 AM, during an interview with Unit Manager Staff #45, she was brought to Resident #110's room and asked if there is a reason she is facing the wall or why she doesn't come out of her room, she stated confirmed that she did not know. She stated, In her 72 hour meeting, her dad stated that she likes to watch TV, so maybe that is why (The residents area is observed to have no TV). When asked if they could turn her around to face her roommates side of the room directly behind her so that she can see the TV that is on in the room, she stated, I am not sure. On 04/13/17 at 8:23 AM, during an interview with Minimum Data Set (MDS) Nurse Staff #99, she was brought to Resident #110's room and was asked why the resident's bed is facing the wall, away from her roommates and the door, she stated, I don't know why she would be like that. On 04/13/17 8:55 AM during an interview with the Administrator Staff #43, she confirmed that the staff is now turning her bed around to face her roommates, and the door. Record review of Activity Policies and Procedures dated 07/01/16 revealed, Policy: The Activity/Recreation Director and staff will provide for ongoing Activity/Recreation programs. Purpose: To provide programs to address the abilities, needs and interests of the patients/residents. This would include large groups, small groups, individual and independent opportunities. Programs take place mornings and afternoons, seven days a week to include holidays and evening and take place in various areas, both inside and outside of the Facility. | 2020-09-01 |
| 64 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 253 | E | 0 | 1 | J20Y11 | Based on observation and staff interview the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for residents in the facility. This involved resident rooms and common areas in the facility. Findings include: During Stage 1 the following observations were made: Room 8 B Skilled on 4/10/2017 10:31 AM the closet doors were noted to be marred with chipped paint the bathroom floor had a build up of dirt around the edges of room. There was a urinal hanging on handrail by the commode, the walls were noted with chipping paint on them build up of dirt around cove molding in bedroom. Room AB 6 A on 4/10/2017 at 11:29 AM was noted to have a privacy curtain falling off the ceiling and the hooks were broken. The walls were noted to be dirty with the paint chipping off the walls. Room Skilled 2 B on 4/10/2017 at 10:41 AM was noted to have walls and closet doors with chipped paint. There was a build up dirt around the entrance into the room and the cove base through out the room. Room Skilled 13 B on 4/10/2017 at 10:09 AM the closet doors were noted with marred and chipped paint and the bathroom floor was very dirty with buildup of dirt around the edges all walls. The overbed table was observed to have a very rusty metal base. Room Skilled 12 B on 4/10/2017 at 1:01:20 AM was observed to have a build up dirt at the entry to room and on the bathroom floor around cove base. Room Skilled 18 B on 4/10/2017 at 10:02 AM the closet doors were noted to be marred with chipped paint. The bathroom floor was very dirty with buildup of dirt around the edges all walls. There were three urinals hanging on handrail by the commode. The overbed table base was rusty and the handle on bathroom sink was broken off and laying on the sink. Room AB 1 A on 4/10/2017 at 9:58 AM brown substance was observed to be smeared on wall. Room Skilled 6 A on 4/10/2017 at 10:36 AM the door to the room was noted with chipped paint on the wall behind the bed and there was chipping paint on the closet doors. Room Skilled 11 B on 4/10/2017 at 11:04 AM there was a build up dirt at the entry to room and the closet doors were noted with chipped paint. Room Skilled 21 A on 4/10/2017 at 9:39 AM the walls were noted with chipped paint in room and bathroom. The bathroom floor had a buildup around the cove base. Room Skilled 5 A on 4/10/2017 at 10:56 AM there was a build up of dirt around floor at the entry into the room and the bathroom walls behind toilet was noted to have smears of brown substance on the walls. Room Skilled 9 A on 4/10/2017 at 10:54 AM there was chipped paint on closets and a build up of dirt throughout the room around the cove base. Room C 5 A on 4/10/2017 at 9:55 AM the door frame into room was scraped with chipped paint. Room Skilled 4 A on 4/10/2017 at 10:41 AM there was a build up of dirt on floor and around cove base in the room and the walls in room and closet doors were noted with chipped paint. These observations were shared and verified with the Maintenance Director on 4/12/2017 at 1:20 PM. He stated the building was in the process of selling and he was not able to get any supplies for any repairs so he does the best he can with what he has. He verified he did not currently have a schedule in place to begin any repairs. These findings were also shared with the Administrator and corporate staff on 4/12/2017 at 3:05 PM. | 2020-09-01 |
| 65 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 278 | D | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the the current status for 3 residents, #77 for anti-psychotic medications, # 94 for Hospice care and Resident #16 for pressure ulcers. MDS data was reviewed for 18 residents in Stage 2. Findings include: 1. Record review for Resident #77 revealed the quarterly MDS dated [DATE] was silent to coding identifying the resident had a current [DIAGNOSES REDACTED]. This was verified by the MDS Nurse ##99 on 4/10/2017 at 1:30 PM. 2. Record review for Resident #94 revealed a physicians verbal order dated 3/8/2017 documenting the physician certified that Resident #94's prognosis was that he had less than six months to live if his disease runs it's normal course. The record review also revealed the resident was currently receiving Hospice services. Review of Resident #94's most recent MDS dated [DATE] revealed it was silent to the fact the resident was receiving Hospice services and was also silent to his [DIAGNOSES REDACTED]. The inaccurate MDS was verified by the MDS nurse #99 on 4/11/2017 at 2:20 PM. 3. The quarterly 02/22/17 Minimum Data Set (MDS) assessment for Resident #16 was reviewed on 04/11/17 at 9:39 a.m. and identified the resident with two unstageable pressure ulcers. One pressure ulcer was noted to be unstageable due to a non-removable dressing and one was noted to be unstageable due to slough/eschar. According to Wound Clinic documentation, reviewed on 04/11/17 at 9:06 a.m., by 02/22/17 the resident had only one unstageable pressure ulcer (to the left lateral heel.) In an interview on 04/12/17 at 9:28 a.m., MDS Coordinator Staff #99 reviewed the MDS and stated only one unstageable pressure ulcer should have been coded. She acknowledged it was an error to code two. | 2020-09-01 |
| 66 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 279 | J | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a comprehensive person-centered care plan for each 2 of 18 residents whose care plans were reviewed in Stage 2. This involved Resident #6 for nutrition/swallowing precautions which resulted in an Immediate Jeopardy when the resident became choked during a meal after asking for and not receiving assistance from staff with positioning. In addition, Resident #77 had no care plan to address the use of anti-psychotic medications. Findings include: 1. Record review for Resident #6 of physician progress notes [REDACTED].diabetes with peripheral circulatory disorders, type 1 .coronary [MEDICAL CONDITION] (hardening/narrowing of arteries) of unspecified type of vessel .[MEDICAL CONDITION] (lacking control) bladder, CKD ([MEDICAL CONDITION]) stage IV (4), [MEDICAL CONDITION] . Record review of the Therapy Screening Form dated 01/19/17 revealed, Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy: Difficulty with mobility, bed mobility .difficulty turning to assist with ADL's (Activities of Daily Living). Record review of the Functional limitations Assessment by OT (Occupational Therapy) dated 01/25/17 revealed, Pt evaluation this date and is presently at 90% impairment to do self feeding, ADLS and bed/chair positioning requiring increased assist from care givers. Record review of Speech Therapy (ST) Plan of Care dated 01/30/17 revealed, .During routine screen, ST noted increased coughing during PO (by mouth) consumption .Therapy necessary for increased upper airway protection. Without therapy patient at risk for aspiration . Record review of Minimum Data Set ((MDS) dated [DATE] revealed, Section G-Functional Status-Bed mobility: total dependence, one person physical assist .Section K Swallowing/Nutritional Status- Swallowing disorder-Z. None of the above. Record review of ST daily treatment note dated 03/13/17 revealed, Swallowing functional limitation, current status has been documented based on clinical judgment;pt able to follow safe swallow strategies with min cues to increase upper airway protection. Education provided to the resident on the importance of sitting upright in 90 degree position for all oral intake . Record review of ST -Therapist Progress & Discharge Summary dated 04/07/17 revealed, .The patient will perform pharyngeal elevation/excursion (specific phases of swallowing) exercise given 30% visual and verbal instruction/cues to increase pharyngeal squeeze to decrease aspiration risk exhibiting mild impairment (25-50% impairment;risk of aspiration on liquids; mild oral residue and may need meats ground or chopped; cueing and intermittent supervision for carry-over. Record review of OT (Occupational Therapy) daily treatment record dated 03/30/17 revealed, OT supervisory visit completed .OT saw patient in her room initially for using ADL (Activities of Daily Living) training. OT pulled her up in edge then set up her lunch tray. Patient stayed up to complete her meal with 20% spillage .the resident transition from supine (lying face up) to sit EOB (edge of bed) with max (maximum) A (assist). resident was then taken to rehab gym .to work on arm strength to assist with bed/chair mobility/positioning . Record review of Nursing Policies and Procedures for Aspiration Precaution Guidelines dated 07/01/16 revealed, Follow protocols/guidelines developed by speech and/or occupational therapists. Remember mealtime strategies should always be individualized. Every precaution should be communicated to all staff. These may include: Position the resident at a 90 degree angle or as upright as possible while eating or taking oral medications; .Avoid positioning the resident in a flat position . Record review of Aspiration Precautions Sheet for Resident #6, with no date revealed, 1. upright in chair for all meals . Record review of Kardex (CNA communication/task sheet) with no date for Resident #6 revealed, Eating- Independent/Set-up, Activity/Mobility- out of bed/wheelchair/mechanical lift ., no further indication of positioning. On 04/10/17 at 12:57 PM Resident #6 was observed sitting very low in her bed, with the head of the bed raised causing her to to have her chin to her chest. Her tray of food was on the table and she was feeding herself. On 04/11/17 at 12:37 PM during an observation, she is slouched in her bed, not at a 90 degree angle and tilted on her right side, and is feeding herself. A CNA (Certified Nurses Assistant) Staff #34 is currently in the room feeding another resident. The same CNA brought her food. Her call light is out of reach hanging on the other side of her bed. On 04/11/17 at 12:37 PM During an interview with the Resident #6, when asked if she still works with therapy, she stated that she does, when asked if she remembers what they tell her when she eats, she stated, yes, they tell me I am supposed to be sitting straight up so the food goes down into my stomach, not like this. On 04/11/17 12:45 PM Resident #6 began yelling at CNA Staff #34, asking several times to put her head up, and CNA Staff #34 continued saying that the bed was all the way up. Resident #6 asked two more times, and CNA Staff #34 stated that her head is fine. CNA Staff #34 came to the edge of the bed and adjusted her tray, but did not put her head up or help her adjust in the bed. The resident remained in the same position, slouched and turned to the right side of the bed. On 04/11/17 at 12:47 PM during an interview with Resident #6, when asked if she is having trouble swallowing that way, she states,yes, everything is hard sitting like this. Resident #6 begins coughing, and coughed up coleslaw that she was eating. LPN (Licensed Practical Nurse) Staff #12 and LPN Staff #38 were in hall and were asked to come straighten up the resident and check on her. They came in and pulled her up in bed and repositioned her, but not in a 90 degree angle. She remained low in the bed and tilted to the right side. On 04/11/17 at 12:57 PM, during an interview with Resident #6, when asked if they always put her head up to eat, she stated no. She stated, this is better than when I am laying down, I can't eat like that. On 04/11/17 at 1:03 PM, during an interview with the ST (Speech Therapist) Staff #125 that wrote recommendations for Resident #6, she was brought to the room to see the positioning for Resident #6. She was asked if this was the correct positioning for her to eat in, and she verified that it is not. She asked Resident #6 why she was sitting that way, and the resident stated, I asked for help, but they wont help me. ST Staff #125 asked if she knows where she should be, and the resident confirmed that she should be straight up in the bed. ST Staff #125 asked Resident #6 what CNA was working with her, and the resident stated, I don't remember her name but it is someone who works with me a lot. ST Staff #125 stated that she discharged her from her service last week, or the week before and she used to come in before meals to help get her positioned with help from a CN[NAME] She stated that she has done education many times with Resident #6, and she knows where she should be positioned. ST Staff #125 walked down the hall to find the CNA that was working with her and found CNA Staff #34. ST Staff #125 asked CNA #34 if she had helped the resident position herself, and CNA #34 confirmed that she helped her with her tray and raised the head of her bed. CNA #34 then stated that the nurses came in later to reposition her. ST Staff #125 asked CNA #34 if she understands how she should be positioned, and she confirmed that she did. On 04/11/17 1:28 PM during an interview with LPN Staff #38, when asked how Resident #6 is supposed to be positioned when eating, she responded She should be on her back, but she has an area on her bottom, so she has to be on her side. We try to get her straight up on her back, but she turns every two hours. When we do pull her up, she slides back down in the bed. When asked if Resident #6 will let staff know if she needs readjusted, she confirmed that she will. When asked if Resident #6 will get up in a chair, she stated, Yes, she will get up for therapy for a little while, and she wants right back in the bed. If she needs anything, she will let you know. On 04/11/17, in the evening, the most current and complete care plan for Resident #6 was requested from Corporate Nurse Staff # 134. It was received in the morning of 04/11/17 with no indication of a swallowing or positioning care plan. 2. Record review for Resident # 77 revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The resident was noted to be receiving Risperidol 2 milligrams two times a day for [MEDICAL CONDITION]. Review of the Most recent Minimum Data Set ((MDS) dated [DATE] documented the resident was receiving an anti-psychotic medication 7 days a week. Review of the current care plan revealed the care plan was silent to the use of the anti-psychotic medication. There were no individual person centered care plan goals or interventions noted regarding the use of the anti-psychotic medication or any behaviors the resident exhibits in regards to the use of this anti-psychotic medication. Interview with the MDS nurse #99 on 4/11/2017 at 1:30 PM verified there was not a current comprehensive care plan in place to address Resident #77s [MEDICAL CONDITION] diagnosis, her use of anti-psychotic medications or current goals and interventions to direct her care in regards to the anti-psychotic medication. On 04/11/17 at 2:10 PM, Corporate Nurse Staff #134, Regulation Specialist Staff #135, and Director of Nursing Staff #136 were notified that Immediate Jeopardy (IJ) began on 04/11/17 at 12:47 PM when Resident #6 was observed lying slouched down in her bed on her right side and began choking while feeding herself lunch after repeated requests from the resident to be placed in a position so she could feed herself safely. The facility's Allegation of Compliance (A[NAME]) was received on 04/11/17 at 6:22 PM. The A[NAME] included: 1. Affected resident has been assessed by Speech Therapy and staff educated on proper positioning during meals. 2. Education provided to floor staff regarding proper positioning of residents who eat in bed by speech therapy and nursing management prior to dinner meal on 04/11/17. 3. DON (Director of Nursing) or designee to visually check on residents during meal times to ensure proper positioning in bed at each meal x 7 days. 4. Speech Therapy will screen residents noted to have any difficulties with swallowing as reported by nursing on therapy referral form. 5. Residents noted for speech therapy screen will be reviewed in Q[NAME] (Quality of Care) meeting weekly beginning immediately. 6. Speech therapy to provide DON with copy of recommendations for processing to current orders or Kardex. 7. Staff that did not attend initial education on 04/11/17 will be educated on proper positioning and aspiration precautions before working the floor. The survey team completed record review and interview to ensure the facility had implemented their A[NAME]. The Immediate Jeopardy at F279 was removed on 4/13/2017, but the citation remained at a lowered scope and severity of D. | 2020-09-01 |
| 67 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 280 | D | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure care plans were reviewed and revised by the interdisciplinary team for 2 of 18 residents whose care plans were reviewed in Stage 2. Findings include: The Activity Care Plan for Resident #23, updated 03/15/17, and reviewed on 04/11/17 at 2:55 p.m., listed a Problem Start Date of 09/23/15. The identified problem indicated the resident is new to the facility, she/he will be orient, introduce, greet and meet staff members, the different department managers and the different department. In an interview on 04/12/17 at 9:30 a.m., MDS Coordinator Staff #99 stated the problem should have been updated to reflect the resident's current status. She acknowledged the resident had been in the facility over a year and a half and was no longer considered new. 2. Resident' #73's comprehensive care plan was reviewed on 04/11/17 at 2:34 p.m. The Potential [MEDICAL CONDITION] related to hx (history) of stroke care plan included the goal, Resident will participate in self care activities to the highest possible level as evidenced by: ___ (specify). One of the approaches was Allow sufficient time to complete self care. According to the 01/31/17 Minimum Data Set, reviewed on 04/11/17 at 10:27 a.m., Resident #73 was totally dependent on staff for all care needs. In an interview on 04/12/17 at 9:15 a.m., MDS Coordinator #99 stated the care plan should have had a specific goal included. She stated it was an oversight. She also stated the resident could not complete self care and that approach should have been updated to accurately reflect this resident's specific care needs. In addition, the Falls care plan, reviewed on 04/11/17 at 2:36 p.m. identified approaches that included mat on both sides of bed and padded headboard and footboard. Observation on 04/11/17 at 3:32 p.m. revealed Resident #73 in bed. The bed was against the wall, with only one mat on the floor. The bed did not have a padded headboard or footboard. In an interview on 04/12/17 at 9:15 a.m., MDS Coordinator Staff #99 stated the Falls care plan should have been updated to accurately reflect the current interventions in place. | 2020-09-01 |
| 68 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 281 | J | 1 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews and review of facility files, the facility failed to provide respiratory assessment and care to meet the residents needs for 1 of 3 residents reviewed for neglect. Resident #48, in a persistent vegetative state was gurgling. The resident's condition was reported to the nurse, but she/he did not assess or provide intervention of suctioning. The findings included: Cross refer to F223 Neglect of resident by failure not to assess or intervene with an identified change in respiratory condition. The facility admitted resident #48 with [DIAGNOSES REDACTED]. Review of Nurses' Notes from [DATE] through [DATE] revealed resident was total care for all Activities of Daily Living (ADL's). S/He was in a persistent vegetative state. On [DATE] at 9:30 AM: resident lying in bed with eyes open, when breathes makes a gurgling sound. resp even/unlabored. will continue monitoring. 10:20 AM called to room per Certified Nursing Assistant (CNA). Resident lying in bed with Head of bed (HOB) elevated ( ^) noted to have beige secretions coming out of mouth. No respirations noted. Code blue called &Cardiopulmonary Resuscitation (CPR) was initiated, no pulse, 911 called 10:30 AM Emergency Medical Services (EMS) here. took over CPR. To hospital via stretcher. Per Physician's Cumulative Orders for ,[DATE]-[DATE] an order for [REDACTED]. Review of the medical record revealed the resident was noted at 9:30 AM to have a gurgling sound when breathing. There was no indication the resident was assessed. No vital signs were available. There was no notation of the resident's breath sounds, no auscultation of the lungs. No evidence of any assessment of the resident's respiratory condition. At approximately 10:30 AM the resident was noted to be without respirations. Again, there was no evidence the resident had been assessed for vital signs before CPR was began. Interviews with the two Certified Nursing Assistants (Cross Refer to F223) revealed the nurse did not assess the resident at any time, from the time they first reported the resident's noisy breathing until the code was called and CPR started. On [DATE] the Administrator was advised of a second Immediate Jeopardy that began on [DATE] when a resident had a change in condition related to respiratory issues that was not addressed by the nurse. The resident became unresponsive and was transported out of the facility to the hospital and expired. The facility's Allegation of Compliance (A[NAME]) to address failure to assess and treat respiratory issues was submitted [DATE] to the surveyor and included the following: 1) Affected resident was transported to the hospital via 911 for evaluation and expired at the hospital. 2) Allegation of neglect was reported to the State Agency as required. 3) RN involved was suspended, terminated and reported to the SC Board of Nursing. 4) DON and Unit Managers to provide education on [DATE] to all nurses and Certified Nursing Assistants on neglect, oral suctioning procedure, location of suctioning equipment, recognizing change in condition and performing respiratory assessment. Inservice is mandatory and no one will be allowed to work until education is completed. 5) All resident's orders were audited by Nurse Management staff for identification of orders for advanced respiratory care/oxygen/suction. Findings were 2 residents in house with orders for continuous oxygen, 2 residents in house with orders for PRN (as necessary) oxygen and no residents in house with suction orders. 6) All respiratory care plans for affected residents have been reviewed and revised if needed on [DATE]. 7) Residents that have the potential for advanced respiratory care have been re-assessed for the need for suction on [DATE]. 8) Maintenance Director and Nursing verified that all 8 suction machines in the facility were functioning properly and central supply clerk verified that suction supplies are readily available on [DATE]. 9) A root cause analysis determined the nurse failed to respond to a change in condition of a resident and failed to respond appropriately to assess and treat. Equipment was available and functioning at the time of the incident. All staff including any new hires have been re-educated on neglect, respiratory assessment, equipment to use and location of equipment and recognizing change in condition. 10) The designated staff and DON will verify location of suction machines daily and nurses will check weekly their functionality. 11) This A[NAME] has been reviewed in an ad hoc QAPI meeting with the Medical Director's involvement and will be reviewed monthly at the QAPI meetings. The Immediate Jeopardy citations at F223, F281 and F328 were removed on [DATE] after observations and interviews were completed to ensure the A[NAME] was in place and in practice. These citations remained cited at a lower scope and severity of D. | 2020-09-01 |
| 69 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 282 | D | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to implement the care plan for 3 (Resident #110, # 22 and #66) of 18 residents whose care plans were reviewed in Stage 2. This involved lack of a therapy evaluation, for Resident #110, pressure ulcer care for Resident #66 and positioning while eating for Resident #22. Findings include: 1. Record review of the admission nurses note for Resident #110 dated 3/22/17 at 6:00 PM, revealed, .Body assessment completed . Bilat (bilateral) lower extremities contracted .resident requires total assistance and care with all needs . Record review of Care Plan for Resident #110 dated 03/22/17 revealed, Resident is limited in range of motion R/T (related to) contractures of the upper and lower extremities .Goal Resident's joint contractures will be free from injury and skin breakdown Perform a contracture assessment .Staff to perform PROM (passive range of motion) during ADLs (activities of daily living)/care as tolerated . Record review of Minimal Data Set (MDS) for Resident #110 dated 03/28/17 revealed, Section G Functional Status indicates that the resident is dependent in all areas of care. On the following dates and times during observations, the Resident # 110 was found in her bed, with bilateral contractions to her legs, positioned on her back, no splints, and towel rolls in her hand: 04/11/17 at 8:40 AM, 10:17 AM, 11:03 AM, 12:27 AM, 1:32 AM, 2:29 AM, and 3:06 AM, 4:54 AM, and 5:17 AM. 04/12/17 at 7:42 AM and 8:44 AM. On 04/12/17 she was up in her chair at 10:39 AM, 1:19 AM, and 2:40 PM, tilted to her left side with no support, splints, or other interventions for contractures. On 04/12/17 at 11:39 am during an interview with Occupational Therapists Staff #127, when asked if residents get screened when they are admitted , to decide whether they need therapy, she confirmed that they are. When asked if there is a reason why someone would not be screened, she confirmed that sometimes, only a screen is appropriate and therapy will not pick them, up but they should be screened right away. When asked who decides when a resident may need a therapy evaluation, she stated, It is a multi-tier decision. I have had nurses, therapists, or other coworkers ask for screenings. When asked if someone contracted, what interventions are normally recommended, or how would the process begin, she stated, Anyone that comes to this facility should be evaluated based on how they will be, here. You go through the same process with everyone. For contractures, you would do passive range of motion and try to find the most appropriate splint, then decide how long they should wear it, then DC (discontinue) the resident from therapy and they go to restorative (nursing). Then it is a nursing decision. When asked who provides the therapy recommendations if a splint is required or passive range of motion, she confirmed that nursing will provide those interventions after the therapy evaluation. When asked if there would be any situation where a resident with contractures would not receive some type of intervention, she stated, pain may be an issue, its situational . On 04/12/17 at 11:46 AM during an interview with Physical Therapy Assistant Staff # 123, when asked if Resident #110 has been evaluated by therapy, he stated, We don't have a full-time OT (occupational therapist), so she is awaiting an eval (evaluation) on Thursday (04/13/17). When asked where this information is documented, he confirmed it should be in her chart . On 04/12/17 at 2:48 PM during an interview with Licensed Practical Nurse #66, when asked if there was anyone that she is taking care of today that receives range of motion from nursing, she stated, No, restorative does that. They (CNA's) may walk them and things like that. The CNA's aren't told to do it (ROM), they do get them up and do ADL's (activities of daily living). Record review of Restorative Nursing Policies and Procedures dated 12/01/14 revealed, Subject: Joint Mobility/Range of Motion (ROM) Program and Splinting - Initiating the Program Policy: Patients/residents will be assessed for joint mobility limitation upon admission, re-admission, quarterly, annually, and with significant changes .A restorative program will be implemented through the care plan to increase, maintain, or prevent deterioration of joint mobility and to maximize physical function when referral to therapy is not indicated .Orthotic, assistive, or prosthetic devices will be provided if indicated .Procedures: 2. The problems, goals, target dates and approaches are documented on the patients/residents care plan .Candidates: Appropriate candidates for the Nursing Restorative ROM (Range of motion) Program may include, but are not limited to, patients/residents with the following conditions: contractures, decreased AROM (active range of motion), Decreased PROM (passive range of motion) . On 04/12/17 at 3:08 PM, during an interview with Restorative Aide Staff #99, when asked if Resident #110 was on restorative services such as range of motion, she confirmed that therapy have not given recommendations for her for any restorative services. 2. Resident # 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION]. Review of the most recent Minimum (MDS) data set [DATE] revealed she had no swallowing disorder and receives a therapeutic mechanically altered diet. She was noted to require the extensive assistance of two staff members to position her in bed, required eating supervision with oversight and encouragement/cueing and was a set up only with her meals. Review of her current care plan dated 3/1/2017 revealed interventions to include that staff are to assist her with eating, monitor for mastication difficulties, monitor her intake for safe swallowing and report any problems to the nurse. Review of Nurse Aide flow records for (MONTH) and (MONTH) (YEAR) revealed she requires the extensive assistance from staff to turn in bed. Her record was silent to any speech therapy orders or evaluations. Observation of resident #22 on 4/11/2017 at 5:15 PM revealed she was observed to be served her meal and the nursing assistant elevated the head of her bed but she did not pull the resident up in the bed. Resident #22 remained slouched down in the bed and was in poor position to feed herself when her meal was served. The staff prepared her meal and left her to feed herself while she was still not positioned straight up in the bed as she was still noted to be slouched down in the bed. Resident #22 was observed to feed herself but was noted to struggle getting the food on her spoon and feeding herself without spilling the food on herself. During this observation the Social Service staff #108 walked by the room and observed Resident #22 in her bed positioned poorly and she entered the room and ask the resident why are you laying so far back in the bed trying to feed yourself. She began to reposition the resident and when doing so the resident began to cough/choke on the food that she had in her mouth. The Social Service staff #108 attempted to assist the resident by offering her a drink of water but the resident continued to cough and her eyes began to water and she was not able to speak. The Social Service staff #108 called for the nurse to come the the room and the nurse assessed Resident #22 and she was then able to drink water and she ceased coughing. Nurse #51 and Social Service Staff #108 pulled the resident up in bed and repositioned her in an adequate position so she could feed herself in an upright position and the resident was then able to feed herself her meal with no further concerns. The staff failed to monitor Resident #22 for safe swallowing per her nutrition care plan during her meal on 4/11/2017 at 5:30 PM. She was found by the Social Service Staff #108 to be poorly positioned and experienced a coughing/choking episode while feeding herself in bed. 3. Resident #66 was admitted to the facility on [DATE]. She was noted to have a current [DIAGNOSES REDACTED]. Review of her most recent Minimum (MDS) data set [DATE] revealed she required the extensive assistance of 2 staff for bed mobility and eating. She was noted to have a pressure ulcer to her right heel and had pressure reduction for bed and was receiving pressure ulcer care. Review of her current pressure ulcer care plan dated 10/24/2016 revealed she was at risk for pressure ulcers due to impaired mobility. The current interventions included to avoid shearing, conduct skin assessment per facility protocol, encourage and assist with turning and to report any signs of skin breakdown. On 12/24/2016 new orders were noted for the resident to wear heel protectors at all times and to float her heels. Observations of Resident #66 on 4/11/2017 7:40 AM she was observed to be in bed with heel protectors on but her heels were noted to resting on the bed. On 4/12/2017 at 8:40 AM she was observed to be in bed with heel protectors on but her heels were not being floated per her current orders. Observation again on 4/13/2017 at 8:32 AM revealed Resident #60 was observed in the bed with heel protectors on both her feet but her feet were laying on the bed and not floated per orders. These concern were shared with the Administrative staff on 4/12/17 at 11 AM. The facility failed to implement the care plan interventions for Resident #66 in regards to promoting healing of her current pressure ulcer. | 2020-09-01 |
| 70 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 314 | E | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure that interventions to support healing and prevention of pressure ulcers were being implemented for 3 (Resident #60, #66 and #110) of 4 resident reviewed for pressure ulcers in Stage 2. Findings are: 1. Record review for Resident #60 of physicians progress note dated 12/14/17 revealed,72 yo (year old) F (female), who was admitted to secondary to gradual functional decline over several weeks. Prior to admission, pt (patient)resided at an Intermediate Care Facility (ICF)) for 15yrs (years) and steadily became incapable of caring for herself and was incontinent of bowel and bladder per prior documentation at . She had also begun to pocket her food. The pt (patient) is wheelchair-bound at baseline. Record review of Minimum Data Set ((MDS) dated [DATE] revealed, Section G Functional Status- resident is dependent with one person assist for all areas including bed mobility, transfer, personal hygiene .Skin Conditions: Number for untraceable pressure ulcers: 1, Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar: Pressure ulcer length: 4.5 cm, width: 2.1, depth: 3.1. Record review of Care Plan date 01/01/17 revealed, Problem: Pressure Ulcer .Goal: Residents skin will remain intact .Approach: Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible .turn and reposition every ___(frequency) (section left blank) . On the back of the care plan were wound measurements, on 03/30/17 the documentation revealed, .Left buttock stage 3 CCTX (Continue current treatment) 0.2cmx 0.2cm x 0.2 cm. Record review of Care Plan dated 01/05/17 revealed, Problem: Pressure Ulcer Resident is at risk for skin breakdown R/T incontinence and impaired mobility .Goal: Residents skin will remain intact .Approach: Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible . Observations on 04/11/17 during the following times, the resident was observed positioned on her right side in her bed: 8:25 AM, 8:45 AM, 10:18 AM, 11:02 AM, 12:26 PM, 1:33 PM, 2:30 PM, 3:01 PM, 4:53 PM, and 5:17 PM. On 04/12/17 during the following times, the resident was observed positioned on her right side in her bed: 8:44 AM, 9:18 AM, 10:45 AM, 1:20 PM, and 2:43 PM. On 04/12/17 at 1:22 PM, during an interview with Unit Manager Staff #45, when asked when Resident #60's pressure ulcer was first identified, she stated, It was acquired in-house on 10/4/16. On 04/12/17 at 1:36 PM during an interview with Licensed Practical Nurse #54 while doing wound care for Resident #60 during observation of wound care, when asked if Resident #60 has an air mattress, she confirmed that she does. When asked how often nurses do skin checks, she stated, Once a week, and the CNA's (Certified Nurses Assistant) check their skin once a day. When asked how often the resident goes to the wound clinic, she confirmed that she used to go once a week, but now she goes once every three weeks because the wound is healing. When asked if Resident #60 is ever is disagreeable about getting out of bed, or being moved, she stated, Every once in a while, but not often. On 04/12/17 at 3:53 PM, during an interview with Licensed Practical Nurse Staff # 54, when asked if there is a reason resident #60 is not getting turned, she stated, I was just in the room and helped the CNA (Certified Nurse's Assistant) turn her, and she has an air mattress anyway. When asked if that was the first time that she assisted today with turning R #60, she would not answer the question. When asked why she is not getting out of bed, she stated, I don't know that she isn't getting out of the bed. She has a high-back chair she can get up into. She used to get up everyday, before we (morning shift) came in. She was also going to therapy. She started getting these areas on her butt and started breaking down a lot., When asked if she has pain, she confirmed that she does not appear to be in pain, but she does have Tylenol ordered if she did. 2. Record review of the care plan for Resident #110 dated 3/22/17 revealed, Problem: Pressure Ulcer Resident at risk of pressure ulcer due to friction and shear .Goal: Intact skin without evidence of redness, irritation, maceration, or open areas through next review .Approach: Minimum or 2 people plus draw sheet to lift resident while in bed .Skin assessment and inspection every shift with close attention to heels . On the care plan the following notes were added: 04/08/2017 Open area to right buttock with DWC (wound cleanser). Apply hydrogel and dry dressing BID (twice a day) until healed .4/11/2017 per Nurses note R (right) buttocks measurements are 0.4 cm , width 0.5 cm . Record review of Minimum Data Set (MDS) for Resident #110 dated 03/28/17, revealed, Section G Functional Status indicated that resident is dependent with one person assist with all function, including bed mobility. Section M Skin Conditions revealed that R #110 is at risk for pressure ulcers. On 04/10/17 at 4:00 PM, during a family interview with Resident #110's father, when asked if had any concerns with the care that his daughter receives in the facility, he stated, I do have a concern that she has a gray area on her buttocks now. In the last place that she was, they were turning her often, and she did not have any skin problems, but now she does. I don't feel like they are turning her enough. On 04/11/17 during observations at the following times, the resident was positioned on her back: 8:40 AM, 10:17 AM, 11:03 AM, 12:27 PM, 1:32 PM, 2:29 PM, 3:06 PM, 4:54 PM, and 5:17 PM. On 04/13/17 at 8:10 AM during an interview with Certified Nurse's Assistant (CNA) Staff #116, when asked how she knows if a resident needs specific positioning, she stated, I would look in the Kardex. When asked if there is a place for documenting turning, she confirmed that there is not. When asked how often R #110 was repositioned, she confirmed it was every two hours. When asked if she has any other interventions, she stated, Yes, she has heel protectors. Record review of Resident #110's Kardex with no date, revealed, no indication of positioning. On 04/12/17, in the afternoon during an interview with Corporate Nurse Staff #134, when asked if the facility uses air mattresses, she stated, Only for stage four's (pressure ulcers), we just don't have another option. When asked how turning schedules are relayed to CNA's, she stated, That is a standard of care that we teach . Record review of Performance Improvement Projects (PIPs) dated 2/10/17 revealed, Issues Identified: Facility is over stated average for wounds, wound documentation is not accurate and staging is not correct. Accurate information was not coded correctly on MDS (Minimum Data Set) which lead to QM (Quality Measures) % increasing .Wounds were not being staged correctly and wound sheets were not filled out correctly which lead to inaccurate coding and wound worsening due to improper treatment. Wound measuring not accurate, turn schedule not being performed in timely manner, no assisted devices to heels and other areas of concern .Action #2 Facility wide turn schedule to be implemented. Labs to be obtained and tests to be ordered for other types of wounds, staff education provided on 2/20/17 .Action #4 DON(Director of Nursing)/ADON(Assistant Director of Nursing)/Wound nurse and Unit Managers to monitor for turn schedule, skin sheets, and frequent incontinent care provided to residents . On 04/13/17 at 7:44 AM during an interview with the Administrator Staff #43, when asked if she if familiar with the residents in the facility, she stated, I am not familiar with a lot of them. When asked if the facility has a positioning protocol, she stated, We are working on that. We were going to do a turning and repositioning thing and they got clocks and received the clocks on 3/21 and need to implement the program. When asked if there are alerts for the staff now for positioning, she stated, If the CNA's (Certified Nurse's Assistants) have someone, they turn them. When asked if it is a standard practice that the facility staff turns residents every two hours, she confirmed that it is. When asked if there is a place to document positioning and turning, she stated, am not sure. I know that there are some things that need to get addressed here, I need to get order and time to do it.' 3. Resident #66 was admitted to the facility on [DATE]. Her record revealed she had a current pressure ulcer to her right heel. Review of the residents most recent Minimum (MDS) data set [DATE] revealed she required the extensive assistance of 2 staff for bed mobility. The MDS also reflected documentation of a current pressure ulcer to her right heel and was noted to have a pressure reduction mattress for her bed and was receiving pressure ulcer care. Review of her current pressure ulcer care plan dated 10/24/2016 revealed Resident #66 was at risk for pressure ulcers due to impaired mobility. The current interventions included that staff were to avoid shearing, conduct skin assessment per facility protocol, encourage and assist the resident with turning and to report any signs of skin breakdown. On 12/24/2016 new orders were noted for the resident to wear heel protectors at all times and to float her heels off the bed to promote healing of her pressure ulcer to her right heel. Observations were made of Resident #66 on 4/11/2017 7:40 AM and she was observed to be in bed with heel protectors on but her heels were noted to resting on the bed. On 4/12/2017 at 8:40 AM she was observed to be in bed with heel protectors on but her heels were not being floated per orders. Observation on 4/13/2017 at 8:32 AM revealed Resident #60 was observed in the bed with heel protectors on both her feet but her feet were not floated per current orders. These concerns were shared with the Administrative staff on 4/12/17 at 11 AM. The facility failed to implement the floating of Resident #60's heels to assist in the promotion of healing of her current pressure ulcer to her right heel. | 2020-09-01 |
| 71 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 318 | D | 0 | 1 | J20Y11 | Based on observation, record review and interview, the facility failed to ensure that range or motion services were provided for 1 (Resident #110) of 3 residents reviewed in Stage 2 for range of motion. The findings included: Record review for Resident #110 of Restorative Nursing Policies and Procedures dated 12/01/14 revealed, Subject: Joint Mobility/Range of Motion (ROM) Program and Splinting - Initiating the Program Policy: Patients/residents will be assessed for joint mobility limitation upon admission, re-admission, quarterly, annually, and with significant changes .A restorative program will be implemented through the care plan to increase, maintain, or prevent deterioration of joint mobility and to maximize physical function when referral to therapy is not indicated .Orthotic, assistive, or prosthetic devices will be provided if indicated .Procedures: 2. The problems, goals, target dates and approaches are documented on the patients/residents care plan .Candidates: Appropriate candidates for the Nursing Restorative ROM (Range of motion) Program may include, but are not limited to, patients/residents with the following conditions: contractures, decreased AROM (active range of motion), Decreased PROM (passive range of motion) . Record review of the admission nurses note for Resident #110 dated 3/22/17 at 6:00 PM, revealed, .Body assessment completed . Bilat (bilateral) lower extremities contracted .resident requires total assistance and care with all needs . Record review of Care Plan for Resident #110 dated 03/22/17 revealed, Resident is limited in range of motion to R/T (related to) contractures of the upper and lower extremities .Goal Resident's joint contractures will be free from injury and skin breakdown Perform a contracture assessment .Staff to perform PROM (passive range of motion) during ADLs (activities of daily living)/care as tolerated . Record review of Minimal Data Set (MDS) for Resident #110 dated 03/28/17 revealed, Section G Functional Status indicates that the resident is dependent in all areas of care. On the following dates and times during observations, the Resident # 110 was found in her bed, with bilateral contractions to her legs, positioned on her back, no splints, and towel rolls in her hand: 04/11/17 at 8:40 AM, 10:17 AM, 11:03 AM, 12:27 AM, 1:32 AM, 2:29 AM, and 3:06 AM, 4:54 AM, and 5:17 AM. On 4/12/17 at 7:42 AM and 8:44 AM. On 04/12/17 she was up in her chair at 10:39 AM, 1:19 AM, and 2:40 PM, tilted to her left side with no support, splints, or other interventions for contractures. On 04/12/17 at 11:39 am during an interview with Occupational Therapy's Staff #127, when asked if residents get screened when they are admitted , to decide whether they need therapy, she confirmed that they are. When asked if there is a reason why someone would not be screened, she confirmed that sometimes, only a screen is appropriate and therapy will not pick them, up but they should be screened right away. When asked who decides when a resident may need a therapy evaluation, she stated, It is a multi-tier- decision. I have had nurses, therapists, or other coworkers ask for screenings. When asked if someone contracted, what interventions are normally recommended, or how would the process begin, she stated, Anyone that comes to this facility should be evaluated based on how they will be, here. You go through the same process with everyone. For contractures, you would do passive range of motion and try to find the most appropriate splint, then decide how long they should wear it, then DC (discontinue) the resident from therapy and they go to restorative (nursing). Then it is a nursing decision. When asked who provides the therapy recommendations if a splint is required or passive range of motion, she confirmed that nursing will provide those interventions after the therapy evaluation. When asked if there would be any situation where a resident with contractures would not receive some type of intervention, she stated, pain may be an issue, its situational . On 04/12/17 at 11:46 AM during an interview with Physical Therapy Assistant Staff # 123, when asked if Resident #110 has been evaluated by therapy, the stated, We screened off on her. We don't have a full-time OT (occupational therapist), so she is awaiting an eval (evaluation) on Thursday .When asked where this information is documented, he confirmed it should be in her chart . On 04/12/17 at 2:48 PM during an interview with Licensed Practical Nurse #66, when asked if there was anyone that she is taking care of today that receives range of motion from nursing, she stated, No, restorative does that. They (CNA's) may walk them and things like that. The CNA's aren't told to do it (ROM), they do get them up and do ADL's (activities of daily living). On 04/12/17 at 3:08 PM, during an interview with Restorative Aide Staff #99, when asked if Resident #110 was on restorative services such as range of motion, she confirmed that therapy have not given recommendations for her for any restorative services. | 2020-09-01 |
| 72 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 323 | J | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to keep two resident's, #6 and #22, out of 18 residents identified for dependant eating, free from choking due to improper positioning while eating. This resulted in Immediate Jeopardy (IJ) for 2 residents (Resident #6, and #22). The sample was expanded to include Resident #1 and #20 who were identifed to be on swallowing precautions by the facility during the extended survey. The facility identified that the total number of residents that required assistance with meal service was 18. In addition, the facility failed to ensure handrails in the hallways did not have rough and splintered areas making them a hazard to residents when used. Findings include: Record review for Resident #6 of physician progress notes [REDACTED].diabetes with peripheral circulatory disorders, type 1 .coronary arteriosclerosis (hardening/narrowing of arteries) of unspecified type of vessel .Neurogenic (lacking control) bladder, CKD (Chronic Kidney Disease) stage IV (4), [DIAGNOSES REDACTED] . Record review of Therapy Screening Form dated 01/19/17 revealed, Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy: Difficulty with mobility, bed mobility .difficulty turning to assist with ADL's (Activities of Daily Living) . Record review of Functional limitations Assessment by OT (Occupational Therapy) dated 01/25/17 revealed, Pt evaluation this date and is presently at 90% impairment to do self feeding, UB ADLS and bed/chair positioning requiring increased assist from care givers . Record review of Speech Therapy (ST) Plan of Care dated 01/30/17 revealed, .During routine screen, ST noted increased coughing during PO (by mouth) consumption .Therapy necessary for increased upper airway protection. Without therapy patient at risk for aspiration . Record review of Minimum Data Set ((MDS) dated [DATE] revealed, Section G-Functional Status-Bed mobility: total dependence, one person physical assist .Section K Swallowing/Nutritional Status- Swallowing disorder-Z. None of the above. Record review of ST daily treatment note dated 03/13/17 revealed, Swallowing functional limitation, current status has been documented based on clinical judgment;pt able to follow safe swallow strategies with min cues to increase upper airway protection. Education provided to pt on importance of sitting upright in 90 degree position for all oral intake . Record review of ST -Therapist Progress & Discharge Summary dated 04/07/17 revealed, .The patient will perform pharyngeal elevation/excursion (specific phases of swallowing) exercise given 30% visual and verbal instruction/cues to increase pharyngeal squeeze to decrease aspiration risk exhibiting mild impairment (25-50% impairment;risk of aspiration on liquids; mild oral residue and may need meats ground or chopped; cueing and intermittent supervision for carry-over . Record review of OT (Occupational Therapy) daily treatment record dated 03/30/17 revealed, OT supervisory visit completed .OT saw pt (patient) in her room initially for using ADL (Activities of Daily Living) training. OT pulled pt up in edge then set up her lunch tray. Pt stayed up to complete her meal with 20% spillage .Pt transition from supine (lying face up) to sit EOB (edge of bed) with max (maximum) A (assist). Pt then taken to rehab gym .to work on arm strength to assist with bed/chair mobility/positioning . Record review of care plan for Nutritional Status for R#6 edited on 11/02/16 with long term goal target date: 4/30/17 revealed, Resident receives CCHA, NAS, Renal Mechanical Soft with ground meats diet .Resident will ave (average) nutritional needs met qd by weight remaining stable within +/- 5% each month through next review period .Monitor for needed assistance with meals and notify nurse and dietary manager .notify nursing staff immediately if resident shows any signs or symptoms of difficulty swallowing . Record review of Nursing Policies and Procedures for Aspiration Precaution Guidelines dated 07/01/16 revealed, Follow protocols/guidelines developed by speech and/or occupational therapists. Remember mealtime strategies should always be individualized. Every precaution should be communicated to all staff. These may include: Position the resident at a 90 degree angle or as upright as possible while eating or taking oral medications; .Avoid positioning the resident in a flat position . Record review of Aspiration Precautions Sheet for Resident #6, with no date revealed, 1. upright in chair for all meals . Record review of Kardex (CNA communication/task sheet) with no date for R #6 revealed, Eating- Independent/Set-up, Activity/Mobility- out of bed/wheelchair/mechanical lift ., no further indication of positioning. On 04/10/17 at 12:57 PM Resident #6 was observed sitting very low in her bed, with the head of the bed raised causing her to to have her chin to her chest. Her tray of food was on the table and she was feeding herself. When asked if she is comfortable like that, she confirmed that she was not. On 04/11/17 at 12:37 PM during an observation, she is slouched in her bed, not at a 90 degree angle and tilted on her right side, and is feeding herself. A Certified Nurses Assistant (CNA) Staff #34 is currently in the room feeding another resident. The same CNA brought her food. Her call light is out of reach hanging on the other side of her bed. On 04/11/17 at 12:37 PM During an interview with the Resident #6, when asked if she still works with therapy, she stated that she does, when asked if she remembers what they tell her when she eats, she stated, yes, they tell me I am supposed to be sitting straight up so the food goes down into my stomach, not like this. On 04/11/17 12:45 PM R#6 began yelling at Certified Nurse's Assistant (CNA) Staff #34, asking several times to put her head up, and CNA Staff #34 continued saying that the bed was all the way up. R#6 asks two more times, and CNA Staff #34 stated that her head is fine. CNA Staff #34 came to the edge of the bed and adjusted her tray, but did not put her head up or help her adjust in the bed. The resident remained in the same position, slouched and turned to the right side of the bed. On 04/11/17 at 12:47 PM during an interview with Resident #6, when asked if she is having trouble swallowing that way, she states,yes, everything is hard sitting like this. Resident #6 begins coughing, and coughed up coleslaw that she was eating. LPN (Licensed Practical Nurse) Staff #12 and LPN Staff #38 were in hall and were asked to come straighten up the resident and check on her. They came in and pulled her up in bed and repositioned her, but not in a 90 degree angle. She remained low in the bed and tilted to the right side. On 04/11/17 at 12:57 PM, during an interview with R#6, when asked if they always put her head up to eat, she stated no. She stated, this is better than when I am laying down, I cant eat like that. On 04/11/17 at 1:03 PM, during an interview with the ST (Speech Therapist) Staff #125 that wrote recommendations for R#6, she was brought to the room to see the positioning for R#6. She was asked if this was the correct positioning for her to eat in, and she verified that it is not. She asked Resident (R)#6 why she was sitting that way, and the resident stated, I asked for help, but they wont help me. ST Staff #125 asked if she knows where she should be, and the resident confirmed that she should be straight up in the bed. ST Staff #125 asked R#6 what Certified Nurse's Assistant (CNA) was working with her, and the resident stated, I don't remember her name but it is someone who works with me a lot. ST Staff #125 stated that she discharged her from her service last week, or the week before and she used to come in before meals to help get her positioned with help from a CN[NAME] She stated that she has done education many times with R#6, and she knows where she should be positioned. ST Staff #125 walked down the hall to find the CNA that was working with her and found CNA Staff #34. ST Staff #125 asked CNA #34 if she had helped the resident position herself, and CNA #34 confirmed that she helped her with her tray and raised the head of her bed. CNA #34 then stated that the nurses came in later to reposition her. ST Staff #125 asked CNA #34 if she understands how she should be positioned, and she confirmed that she did. On 04/11/17 1:28 PM during an interview with Licensed Practical Nurse (LPN) Staff #38, when asked how Resident #6 is supposed to be positioned when eating, she responded She should be on her back, but she has an area on her bottom, so she has to be on her side. We try to get her straight up on her back, but she turns every two hours. When we do pull her up, she slides back down in the bed. When asked if Resident #6 will let staff know if she needs readjusted, she confirmed that she will. When asked if Resident #6 will get up in a chair, she stated, Yes, she will get up for therapy for a little while, and she wants right back in the bed. If she needs anything, she will let you know. On 04/11/17, in the evening, the most current and complete care plan for Resident #6 was requested from Corporate Nurse Staff # 134. It was received in the morning of 04/11/17 with no indication of a swallowing or positioning care plan. 2. During the extended survey process all residents were observed for proper positioning while in the bed feeding them self. During the extended survey observation was made of resident #22 on 4/11/2017 at 5:15 PM and revealed she was observed to be served her meal and the nursing assistant elevated the head of her bed but she did not pull the resident up in the bed. Resident #22 remained slouched down in the bed and was in poor position to feed herself when her meal was served. The staff prepared her meal and left her to feed herself while she was still not positioned straight up in the bed as she was still noted to be slouched down in the bed. Resident #22 was observed to feed herself but was noted to struggle getting the food on her spoon and feeding herself without spilling the food on herself. During this observation the Social Service staff #108 walked by the room and observed Resident #22 in her bed positioned poorly and she entered the room and ask the resident why are you laying so far back in the bed trying to feed yourself. She began to reposition the resident and when doing so the resident began to cough/choke on the food that she had in her mouth. The Social Service staff #108 attempted to assist the resident by offering her a drink of water but the resident continued to cough and her eyes began to water and she was not able to speak. The Social Service staff #108 called for the nurse to come the the room and the nurse assessed Resident #22 and she was then able to drink water and she ceased coughing. Nurse #51 and Social Service Staff #108 pulled the resident up in bed and repositioned her in an adequate position so she could feed herself in an upright position and the resident was then able to feed herself her meal with no further concerns. Record review revealed Resident # 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum (MDS) data set [DATE] revealed she had no swallowing disorder and receives a therapeutic mechanically altered diet. She was noted to require the extensive assistance of two staff members to position her in bed, required eating supervision with oversight and encouragement/cueing and was a set up only with her meals. Review of Resident #22's current care plan dated 3/1/2017 revealed interventions to include that staff are to assist her with eating, monitor for mastication difficulties, monitor her intake for safe swallowing and report any problems to the nurse. Review of Nurse Aide flow records for (MONTH) and (MONTH) (YEAR) revealed she requires the extensive assistance from staff to turn in bed. Her record was silent to any speech therapy orders or evaluations. During this same meal observation on 4/11/2017 at 5:15 PM Resident #49 was also observed during the supper meal service. He was observed to be served his meal and nursing assistant #93 elevated the head of his bed but she did not pull the resident up in the bed to position him properly so he could feed himself safely. Resident #49 remained slouched down in the bed and he was leaning the to left against the bed rail. The Nurse Aide Staff #93 prepared his meal and left him to feed himself while he was not positioned straight up in the bed so he could eat without risk of choking and potential aspiration. The Social Service staff #108 walked by Resident 49's room and observed him slouched down in the bed, leaning to the left and attempting to feed himself. She repositioned the resident by pulling him up and over in the bed and placing pillows beside him for positioning so he could feed him self without risk of choking. Record review for Resident #49 revealed he was not on any swallowing precautions and his care plan was silent to any special interventions regarding swallowing. Review of Resident 49's most recent MDS dates 1/17/2017 revealed he required the extensive assistance of staff for bed mobility. When the Social Service Staff #108 repositioned him so he could feed himself safely he was not able to self assist with positioning. Interview with Nurse Aide #93 on 4/11/2017 at 5:30 PM revealed she had been educated by the Speech Therapist when she arrived on shift on this date prior to the evening meal about how to properly position resident while they are eating in bed. She said she was in-serviced to elevate the head of the bed and to use pillows as need to position the resident so they were in a safe position to feed them self. She stated she had never observed Resident #22 or #49 to have any issues feeding themselves in bed and had never observed them to choke. Further interview with Nurse Aide staff #97 and #102 at this time also revealed they had been educated on how to position residents in bed to ensure they are safe to feed themselves in bed to prevent any choking hazards. They both also stated they had never known Resident #22 or #49 to have any issues with feeding themselves while in bed and had not known either of them to choke while feeding themselves in bed. Review of the sign in sheet for the education/in-service provided by the Speech Therapist on 4/11/2017 reveled Nurse Assistant #93. #97,and #102 were all present for the mandatory in-service on safe positioning of resident while eating. Review of the education that was provided to the staff during this mandatory in-service reveled they were educated on assisting residents with feeding and positioning, swallowing precautions and a review was done of swallowing guidelines for the patient and the caregiver. This in-service was to be provided to all staff on shift on 4/11/2017 and to all staff who worked on the days following prior to them providing care until all the staff who assisted residents with meals had been in-serviced. The Corporate Nurse #134 was advised of the observation of Resident #22 being poorly positioned by Nurse Aide Staff #93 on 4/11/2017 at 6 PM. At 6:10 PM she advised this surveyor that she had spoken with Nurse Aide #93 and the Nurse Aide had been suspended due to the poor positioning of Resident #22 during her meal after she had just been inserviced on how to properly position resident for safe eating while in bed. The corporate Nurse #134 verified Resident #22 had not had any previous speech evaluations and had not had any incidence of previous choking or coughing incidents while feeding herself. The staff failed to monitor Resident #22 for safe swallowing per her nutrition care plan and failed to position her in a safe manner in bed so she could eat her meal on 4/11/2017 at 5:30 PM. The staff also failed to position Resident #49 in a position while in bed to promote safety while he was feeding himself in bed. Both residents were found by the Social Service Staff #108 to be poorly positioned and Resident #22 was observed to experience a coughing/choking episode while feeding herself in bed while being poorly positioned. Two additional residents were observed during the meal service on 4/11/2017 as they were identified by the facility as being on swallowing precautions. At 5:05 PM Resident #1 who was identified by the facility as being on swallowing precautions was observed sitting in a wheelchair in the dining room feeding himself. He was observed eating a pureed diet and thick liquids and was observed to have no concerns while feeding himself. Resident #20 was also observed in the dining room in her wheelchair feeding herself and no concerns were noted as she fed herself a mechanical soft diet with chopped meats. 3. During the environmental tour observations were made of the handrails in the hallway on all 4 units that were noted to have rough and splintered areas along the edges and along the lengths of the handrails. The Maintenance Director who was present during this tour verified the splintered areas on the handrails and indicated he had repaired some of them in the past with wood putty but verified there were still many areas that still needed to be repaired. He advised this surveyor that they need to replace all of the handrails but the building is in the process of being sold and he has not been given any funds to do any repairs in the building in a very long time so he does the best he can do. He stated all he can do at this time is to put blue tape on all of the splintered areas until he is given funds to do repairs. On 04/11/17 at 2:10 PM, Corporate Nurse Staff #134, Regulation Specialist Staff #135, and Director of Nursing Staff #136 were notified that Immediate Jeopardy (IJ) began on 04/11/17 at 12:47 PM when Resident #6 was observed lying slouched down in her bed on her right side and began choking while feeding herself lunch after repeated requests from the resident to be placed in a position so she could feed herself safely. The facility's Allegation of Compliance (A[NAME]) was received on 04/11/17 at 6:22 PM. The A[NAME] included: 1. Affected resident has been assessed by Speech Therapy and staff educated on proper positioning during meals. 2. Education provided to floor staff regarding proper positioning of residents who eat in bed by speech therapy and nursing management prior to dinner meal on 04/11/17. 3. DON (Director of Nursing) or designee to visually check on residents during meal times to ensure proper positioning in bed at each meal x 7 days. 4. Speech Therapy will screen residents noted to have any difficulties with swallowing as reported by nursing on therapy referral form. 5. Residents noted for speech therapy screen will be reviewed in Q[NAME] (Quality of Care) meeting weekly beginning immediately. 6. Speech therapy to provide DON with copy of recommendations for processing to current orders or Kardex. 7. Staff that did not attend initial education on 04/11/17 will be educated on proper positioning and aspiration precautions before working the floor. The survey team made observations, record review and interview to ensure the facility had implemented their A[NAME]. The Immediate Jeopardy and Substandard Quality of Care at F-323 was removed on 4/13/2017, but the citation remained at a lowered scope and severity of D. | 2020-09-01 |
| 73 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 328 | J | 1 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to provide respiratory care/suctioning to 1 of 3 residents reviewed for neglect. Resident #48 did not receive suctioning for an extended period of time, became unresponsive and was transported out of the facility to the hospital. The findings included: Cross refer to F223- Neglect, Resident #48 was identified with respiratory difficulty which was reported to the nursing staff with no interventions taken. The facility admitted resident #48 with [DIAGNOSES REDACTED]. Review of Nurses' Notes from [DATE] through [DATE] revealed resident was total care for all Activities of Daily Living (ADL's). S/He was in a persistent vegetative state. On [DATE] at 9:30 AM: resident lying in bed with eyes open, when breathes makes a gurgling sound. resp even/unlabored. will continue monitoring. 10:20 AM called to room per Certified Nursing Assistant (CNA). Resident lying in bed with Head of bed (HOB) elevated ( ^) noted to have beige secretions coming out of mouth. No respirations noted. Code blue called & Cardiopulmonary Resuscitation (CPR) was initiated, no pulse, 911 called 10:30 AM Emergency Medical Services (EMS) here. took over CPR. To hospital via stretcher. Per Physician's Cumulative Orders for ,[DATE]-[DATE] an order for [REDACTED]. On [DATE] Registered Nurse, (RN) #138 was interviewed via phone by surveyor at 8:30 AM. The RN stated the resident was gurgling during med pass. S/he stated s/he went and found a suction machine on the crash cart but it was not working. S/he did state suction machines were located on each crash cart. The RN stated s/he never suctioned the resident before. On [DATE] the Administrator was advised of a second Immediate Jeopardy that began on [DATE] when a resident had a change in condition related to respiratory issues that was not addressed by the nurse. The resident became unresponsive and was transported out of the facility to the hospital and expired. The facility's Allegation of Compliance (A[NAME]) to address failure to assess and treat respiratory issues was submitted [DATE] to the surveyor and included the following: 1) Affected resident was transported to the hospital via 911 for evaluation and expired at the hospital. 2) Allegation of neglect was reported to the State Agency as required. 3) RN involved was suspended, terminated and reported to the SC Board of Nursing. 4) DON and Unit Managers to provide education on [DATE] to all nurses and Certified Nursing Assistants on neglect, oral suctioning procedure, location of suctioning equipment, recognizing change in condition and performing respiratory assessment. Inservice is mandatory and no one will be allowed to work until education is completed. 5) All resident's orders were audited by Nurse Management staff for identification of orders for advanced respiratory care/oxygen/suction. Findings were 2 residents in house with orders for continuous oxygen, 2 residents in house with orders for PRN (as necessary) oxygen and no residents in house with suction orders. 6) All respiratory care plans for affected residents have been reviewed and revised if needed on [DATE]. 7) Residents that have the potential for advanced respiratory care have been re-assessed for the need for suction on [DATE]. 8) Maintenance Director and Nursing verified that all 8 suction machines in the facility were functioning properly and central supply clerk verified that suction supplies are readily available on [DATE]. 9) A root cause analysis determined the nurse failed to respond to a change in condition of a resident and failed to respond appropriately to assess and treat. Equipment was available and functioning at the time of the incident. All staff including any new hires have been re-educated on neglect, respiratory assessment, equipment to use and location of equipment and recognizing change in condition. 10) The designated staff and DON will verify location of suction machines daily and nurses will check weekly their functionality. 11) This A[NAME] has been reviewed in an ad hoc QAPI meeting with the Medical Director's involvement and will be reviewed monthly at the QAPI meetings. The Immediate Jeopardy citations at F223, F281 and F328 were removed on [DATE] after observations and interviews were completed to ensure the A[NAME] was in place and in practice. These citations remained cited at a lower scope and severity of D. | 2020-09-01 |
| 74 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 329 | D | 0 | 1 | J20Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review it was determined the facility failed to ensure two (#s 113 & 94) of five residents reviewed for unnecessary medications were free from unnecessary medications. Failure to adequately monitor behaviors, attempt non-drug interventions prior to the use of as needed anti-anxiety medication, and administration of pain medication and anti-anxiety medication at the same time for Resident #113, and failure to ensure a proper [DIAGNOSES REDACTED].#94 placed these residents at risk to receive an unnecessary medication. Findings include: 1. Review of the most current physician's orders [REDACTED]. In an interview on 04/12/17 at 1:47 p.m., Licensed Nurse #51 explained when a nurse administered a prn medication, they would complete the behavior monitoring form and/or document in the nurse's notes what staff attempted prior to administering the medication (non-drug interventions), what behaviors the resident exhibited that required the interventions and if the medication was effective. Review of the Medication Administration Record (MAR) on 04/12/17 at 1:54 p.m. revealed no behavior monitoring forms for this resident. The front of the MAR indicated the resident received prn [MEDICATION NAME] on 12 or 13 occasions (unable to decipher handwriting) from 04/04/17 through 04/12/17. Only five of the administrations were listed on the back of the MAR with the reason for giving yelling & screaming each time and that the dose was effective. There were no non-drug interventions (NDIs) identified for any of those doses. Review of the nurse's notes, at 04/12/17 at 2:07 p.m., revealed no mention of the resident's behaviors or the administration of the medication on ten of the occasions the resident received the medication (04/04, 06, 07, 08, or 09/17 at 5:00 a.m.) The nurse's note on 04/09/17 at 11:00 p.m. and 04/11/17 at 12:30 p.m. identified the resident's behaviors and attempted NDIs prior to administration of the medication. Entries on both 04/10/17 at 11:00 p.m. and 04/11/17 at 11:00 p.m. revealed the resident was administered prn pain medication and prn [MEDICATION NAME] at the same time, without mention of NDIs and without consideration that if the pain was treated perhaps the anxiety would also be managed without medication. In an interview on 04/12/17 at 2:11 p.m., Licensed Nurse #70 reviewed the MAR. She stated she could not determine if the prn [MEDICATION NAME] was administered 12 or 13 times due to the handwriting, Maybe twice on 04/07/17, not sure. She looked at the back of the MAR and commented, Oh, they aren't writing it on the back. She acknowledged there was no behavior monitoring form. 2. Review of physician's orders [REDACTED]. The listed [DIAGNOSES REDACTED]. According to the (YEAR) Nursing Drug Handbook, [MEDICATION NAME] is used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder. Behaviors is not a recognized [DIAGNOSES REDACTED]. | 2020-09-01 |
| 75 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 353 | E | 0 | 1 | J20Y11 | Based on observation, interview and record review it was determined the facility failed to ensure nursing staff provided services each resident was assessed to require. This failed practice was evidenced by residents reporting extended wait times for assistance to be provided and observations revealed staff failing to respond to residents requests for assistance. Findings include: During Stage 1 interviews, four (#s 80, 6, 55 & 57) of 13 residents answered No when asked Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time? For example, in an interview on 04/10/17 at 11:03 a.m., Resident #6 stated, I have to wait a long time. In an interview on 04/10/17 at 11:19 a.m., Resident #55 stated, for all care including bathroom and just overall care needs. All shifts had a lot of people (staff) quit. In an interview on 04/12/17 at 1:20 p.m. Registered Nurse #3 stated a lot of the residents were high acuity, either due to physical or cognitive/mental needs, and that staffing was based on census not acuity. In an interview on 04/13/17 at 7:59 a.m., Staff Scheduler #107 stated staffing was based on the census and not acuity of resident's care needs. She also stated the facility only had one Registered Nurse to work the floor and that it was sometimes difficult to schedule enough nurse aides. Failed practice was determined during the survey related to a lack of nurse aide in-services; failure to utilize a Registered Nurse seven days per week; failure to ensure proper positioning of dependent residents during meals to prevent aspiration; lack of appropriate interventions to prevent / treat pressure ulcers; failure to provide range of motion services a resident was assessed to require and a failure to ensure residents received dental services. The facility's failure to ensure staff provided the care residents were assessed to require in a timely manner placed all residents at risk for unmet care needs. | 2020-09-01 |
| 76 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 354 | D | 0 | 1 | J20Y11 | Based on staff interview and record review it was determined the facility failed to ensure the services of a Registered Nurse (RN) were used at least eight consecutive hours a day, seven days a week. This failure placed residents at risk to not have their care needs met due to a lack of qualified nursing staff. Findings include: In an interview on 04/12/17 at 4:25 p.m., Assistant Director of Nursing (Registered Nurse) #3 explained she worked Monday through Friday, supervising staff and ensuring care needs were met. She also explained the facility employed three RNs who worked the floor. At 4:30 p.m., review of staffing schedules for 03/25/17 through 04/02/17 revealed on Saturday (03/25/17 and 04/08/17) and Sunday (03/26/17 and 04/09/17) the facility had no RN coverage. At 4:35 p.m., Assistant Director of Nursing 3 stated If that is what it says, then that is what it is. In an interview on 04/13/17 at 7:57 a.m., Scheduler #107 explained the facility previously had three RNs, however two recently quit and so there was only one currently on the schedule. She explained she was not aware of the requirement to have an RN scheduled every day. I just schedule what I have. | 2020-09-01 |
| 77 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 371 | E | 0 | 1 | J20Y11 | Based on observation and staff interview it was determined the facility failed to ensure staff completed proper glove changes and handwashing as required while preparing food. This placed residents at risk for foodborne illness. Findings include: Observation of lunch meal preparation on 04/12/17 from 10:00 a.m. to 11:15 a.m. revealed improper hand hygiene. Cook #86 was observed making sandwiches. Wearing gloves, she placed ham on slices of bread that had been laid out on a cooking sheet. She then picked up a plastic bag of eggs, removed a marker from her pocket, wrote the date on the bag, opened the fridge, put the bag of eggs in the fridge, put the marker back in her pocket, and returned to the sandwiches, placing a slice of bread on each sandwich, wearing the same gloves. She was observed to touch a cart, obtain two loaves of bread, open a cabinet, retrieve a pan of food from the stove, retrieve a strainer and food processor from the sink area, turned on the sink faucet and then returned to place pickles on the sandwiches, using the same gloved hands. Using a knife, she opened a cheese wrapper and sliced some cheese. She then put turkey and cheese slices on the sandwiches. She obtained a cutting board and placed it on a counter, then placed the top slice of bread on more of the sandwiches. She proceeded to slice some ham and then chopped it, ripped open a bread wrapper and continued to put the top slice of bread on the sandwiches, without handwashing or glove change. These observations were shared with Dietary Manager #114 at 10:25 a.m. who spoke to the staff member about the need for handwashing and glove changing when moving between tasks. At 10:40 a.m. Dietary Aide #61 was observed making pureed apples. Wearing gloves, she put the food processor together, turned on and off the food processor several times, used a spatula to check the consistency of the apples, obtained a bowl and then, using the same gloved hands, reached into the food processor and scooped apples out of the food processor. These observations of a lack of handwashing / glove change when preparing / touching food items and potentially contaminated objects during lunch meal preparation on 04/12/17 were discussed with Dietary Manager #114 and Corporate Regulatory Specialist #135 on 04/12/17 at 4:20 p.m. Both expressed an understanding of these issues. | 2020-09-01 |
| 78 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 412 | D | 0 | 1 | J20Y11 | Based on observation, interview and record review it was determined the facility failed to ensure two (#s 34, 23) of three residents reviewed for dental services received routine dental services. Failure to offer dental services and assist residents with locating a dentist, obtaining appointments and arranging for transportation placed residents at risk for unmet dental needs. Findings include: In an interview on 04/10/17 at 12:05 p.m., Resident #34 stated he had no teeth and would like to see a dentist to obtain dentures. He stated he did not like an altered texture diet and so received a regular diet, at his request, which could sometimes be difficult to chew. He stated the facility had not offered to assist him in locating a dentist or arranging an appointment for dental services. Observation of the resident at this time revealed the resident had no teeth, nor dentures. The Nutrition Risk Assessment, dated 11/23/13, and reviewed on 04/11/17 at 12:58 p.m., identified the resident as edentulous (without teeth). The Annual Minimum Data Set (MDS) assessment, dated 10/06/16, reviewed on 04/13/17 at 8:58 a.m. identified the resident was edentulous. The Care Area Assessment identified the Resident is edentulous. He is impaired physically on his right side due to a stroke. He will need to be assisted with oral care by staff to prevent ulcers of his mouth. Care plan will be developed to prevent ulcers for the resident to receive oral care. There was no indication the offer of a dental visit for dentures was considered or made. In an interview on 04/11/17 at 6:10 p.m., Social Services Staff #27 explained the wheelchair lift in the facility's van had been broken for an extended period of time. She stated the facility arranged with a local transportation company to take residents who required the use of a wheelchair to the dentist, however they did not return at the end of appointments promptly and so the dentist wanted them to remain with the resident. The transportation company refused and so the dentist would no longer see the residents. In an interview on 04/12/17 at 8:14 a.m., Social Services Staff #27 was asked if Resident #34 had been seen by a dentist, or offered and refused, since admission in 2013. She stated she was not sure if that had occurred and that she would check. As of 04/13/17 at 11:00 a.m., no further information was provided. 2. Observation on 04/10/17 at 11:49 a.m. revealed Resident #23 appeared to have some missing and broken teeth. He had white debris / build-up along his lower gum. The resident was unable to respond to any questions due to cognitive loss. Record Review, conducted on 04/11/17 at 8:30 a.m., revealed the resident admitted to the facility 09/16/15. A Nursing Data Collection Form, dated 03/15/17, identified the resident was missing some teeth. A Dietary Data Collection / Evaluation Nutritional form, dated 09/15/16, revealed the resident had his own teeth, condition / missing. Social Service Progress Reviews, dated 03/15/17, 12/13/16, 09/15/16 and 06/16/16 all indicated Dental care: Provided by facility. Review on 04/12/17 at 5:39 p.m. of the 09/15/16 Annual Minimum Data Set assessment identified the resident had Obvious or likely cavity or broken natural teeth. The associated Care Area Assessment identified the Resident has several missing teeth and very poor dentition. It indicated see care plan. The Care Plan, reviewed on 04/11/17 at 2:53 p.m. identified the resident was At risk for mouth or facial pain related to decaying (cavity) and/or broken natural teeth. One of the identified approaches was for staff to Consult with dentist and follow recommendations. In an interview on 04/12/17 at 8:14 a.m. Social Service Staff #27 was asked if Resident #23 had been seen by a dentist, or offered and refused, since admission. She was unable to provide any evidence the resident was seen or dental services were offered and refused. | 2020-09-01 |
| 79 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 498 | D | 0 | 1 | J20Y11 | Based on interview and record review it was determined the facility failed to ensure all nurse aides received at least 12 hours of in-service training per year. This placed residents at risk to not have their care needs met due to insufficiently trained staff. Findings include: Upon request, the facility provided a list of all currently employed, active staff members. On 04/12/17 at 10:30 a.m. a random review of five on-call nurse aides (Nurse Aides 4, 22, 32, 44 & 46) revealed none received 12 hours of in-service education from 01/01/16 through 04/12/17. The facility's documentation of the in-service hours received revealed Nurse Aide #4 had 10.25 hours; Nurse Aide #22 had 7 hours 10 minutes; Nurse Aide #32 had no hours; Nurse Aide #44 had 9.25 hours; and Nurse Aide #46 had 2 hours 50 minutes. In an interview on 04/12/17 at 3:14 p.m., Assistant Director of Nursing #3 explained the facility used computer based in-service training as well as person led in-services. She reviewed the computer system for these five staff and verified the above hours. She stated on-call staff were invited to the live in-services and it was their responsibility to get the 12 hours of in-service education. She was unable to explain why these staff did not receive the required education. | 2020-09-01 |
| 80 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2017-06-14 | 520 | J | 0 | 1 | J20Y11 | The facility failed to identify quality deficiencies and develop and implement plans of action to correct the quality deficiencies. This includes monitoring the effect of implemented changes and making needed revisions to action plans. This involved accident hazards regarding positioning of residents during meals which resulted in Immediate Jeopardy and Substandard Quality of Care. In addition, lack of dental service, pressure ulcer wound tracking, housekeeping and maintenance and lack of the required 8 hours coverage of an Registered Nurse in the building 7 days a week. Findings include: During the survey from 4/10/2017 through 4/13/2017 care area concerns were noted in the provision of care for the residents by the facility in the areas of accident hazards regarding positioning of residents during meals, lack of dental services, pressure ulcer wound tracking, housekeeping and maintenance, and lack of the required coverage of a Registered Nurse in the building for 8 hours every day. An interview was conducted with the Administrator Staff #23 on 4/13/2017 at 9:05 AM. This surveyor shared with the Administrator the noted concerns in the areas of accident hazards regarding positioning of residents during meals, dental services, pressure ulcer wound tracking, housekeeping and maintenance, and lack of the required coverage of a Registered Nurse in the building for 8 hours every day. She stated their Quality Assurance team meets monthly and none of these care area concerns had been identified in any of their meetings. In the area of accidents hazards the Administrator verified the Quality Assurance team had not identified any concerns with residents not being positioned in bed while feeding themselves in a manner to prevent potential choking and aspiration. Refer to F323. She stated during a meeting a few months ago they had discussed concerns with personalized care plans and updating care plans in the facility but this was after it was brought to their attention in a recent complaint survey. She was not able to produce any documentation to address how they were correcting the care plan concerns identified back in (MONTH) (YEAR). She stated they currently have an Interim Director of Nursing and she is not able to produce a lot of the documentation and monitoring being requested because she is not sure where the previous DON has put things. She stated the previous DON left the faciity on in (MONTH) (YEAR). The Administrator later provided this surveyor with a copy of a Performance Improvement Plan (PIP) for Pressure ulcers dated 2/10/2017. This document revealed the facility had identified a concern with wounds not being staged correctly, residents not being turned timely, wound sheets not being filled out correctly and wound measurements not being done correctly. The action plan indicated the facility would hire a new wound nurse, they would establish a facility wide turn schedule, staff education would be provided on wounds and the Director of Nursing/Wound Care Nurse and Unit Managers were to monitor for turn schedules, skin sheets and frequent incontinence care to residents. The facility was not able to produce any education that had been provided to the staff, nor documentation on any monitoring conducted as stated on the action plan and they did not currently have a wound nurse. The Administrator was not able to produce any further meeting minutes from this PIP to address the progress of the corrective action in this area. Refer to F314. In the area of Dental services that Resident Council meeting minutes had identified in January, (MONTH) and (MONTH) (YEAR) the residents complained about the lack of dental services and several residents were requesting to be able to see the dentist. The Administrator was not aware of this concern and the Quality Assurance team had not addressed the ongoing lack of dental services for residents in the facility. Refer to F244 and F312. In the area of Housekeeping and Maintenance she verified there was not plan in place to address any of the observed findings identified during the survey from 4/10/2017 through 4/13/2017. Refer to F253. She also verified the lack of Registered Nurse coverage and stated this had not been addressed through their current Quality Assurance process. Refer to F354. On 04/11/17 at 2:10 PM, Corporate Nurse Staff #134, Regulation Specialist Staff #135, and Director of Nursing Staff #136 were notified that Immediate Jeopardy (IJ) began on 04/11/17 at 12:47 PM when Resident #6 was observed lying slouched down in her bed on her right side and began choking while feeding herself lunch after repeated requests from the resident to be placed in a position so she could feed herself safely. The facility's Allegation of Compliance (A[NAME]) was received on 04/11/17 at 6:22 PM. The A[NAME] included: 1. Affected resident has been assessed by Speech Therapy and staff educated on proper positioning during meals. 2. Education provided to floor staff regarding proper positioning of residents who eat in bed by speech therapy and nursing management prior to dinner meal on 04/11/17. 3. DON (Director of Nursing) or designee to visually check on residents during meal times to ensure proper positioning in bed at each meal x 7 days. 4. Speech Therapy will screen residents noted to have any difficulties with swallowing as reported by nursing on therapy referral form. 5. Residents noted for speech therapy screen will be reviewed in Q[NAME] (Quality of Care) meeting weekly beginning immediately. 6. Speech therapy to provide DON with copy of recommendations for processing to current orders or Kardex. 7. Staff that did not attend initial education on 04/11/17 will be educated on proper positioning and aspiration precautions before working the floor. The survey team made observations, record review and interview to ensure the facility had implemented their A[NAME]. The Immediate Jeopardy at F520 was removed on 4/13/2017, but the citation remained at a lowered scope and severity of F. | 2020-09-01 |
| 81 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-09-07 | 550 | D | 0 | 1 | NUHA11 | Based on observations, and interview, the facility failed to maintain the dignity of residents during med pass on 1 of 3 units. The Nurse did not knock before entering Resident #30's room on the Skilled West Unit. The findings included: On 9/5/18 at approximately 5:15 PM, an observation during Resident #30's medication administration, Licensed Practical Nurse (LPN) #1 entered the residents' room without knocking to obtain a finger stick blood sugar sample. Following the sample LPN #1 left the room for approximately 3 minutes and returned to Resident #30's room and entered the room again without knocking or asking permission to enter. On 9/5/18 at approximately 5:25 PM, in an interview with LPN #1, s/he verified the s/he entered Resident #30's room without knocking or asking permission to enter. | 2020-09-01 |
| 82 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-09-07 | 638 | B | 0 | 1 | NUHA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete an MDS (Minimal Data Set) Assessment within 92 days of the prior MDS assessment for Resident #10, 1 of 4 residents reviewed for hospitalization . The findings included: The facility admitted Resident #10 on 08/14/17 with [DIAGNOSES REDACTED]. On 09/05/18 at approximately 2:35 PM, review of the State Agency MDS data base revealed an Annual MDS assessment dated [DATE]. Further review revealed a discharge MDS assessment dated [DATE] and a Re-entry MDS dated [DATE]. No Quarterly MDS Assessment, with an Assessment Reference Date no later than 08/11/18 was noted. During an interview on 09/05/18 at approximately 4:30 PM, MDS Coordinator #1 stated a Quarterly MDS had been started but confirmed it was not completed and that s/he would investigate why the assessment wasn't completed. During an interview on 09/07/18 at 08:55 AM, MDS Coordinator #1 again confirmed the MDS was not done and stated another MDS Coordinator had reported that s/he thought it had been completed. | 2020-09-01 |
| 83 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-09-07 | 732 | C | 0 | 1 | NUHA11 | Based on record review and interview, the facility failed to clearly identify on the daily Staff posting how many Registered Nurses and how many Licensed Practical or Licensed Vocational Nurses were working each shift on 25 of 30 days reviewed. The findings included: On 09/06/18 at 01:11 PM, observation of the Staff Posting in the front lobby revealed 1 number posted for the category of Licensed staff. The total number and the actual hours worked by the categories of Registered Nurses and Licensed practical nurses or licensed vocational nurses was not differentiated. Further review of the Staff Posting for the last 30 days revealed no differentiation of licensed staff on 25 days. During an interview on 09/06/18 at 02:19 PM, the Nursing Home Administrator (NHA) confirmed the staff was not differentiated on the Staff Posting. The NHA confirmed that a single number listed in the box for licensed staff did not clearly identify how many of the number of nurses listed were Registered Nurses and how many were Licensed Practical or Licensed Vocational Nurses. | 2020-09-01 |
| 84 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2018-09-07 | 760 | D | 0 | 1 | NUHA11 | Based on observations, interview, and review of the facility policies and the Humalog KwikPen manufacture recommendations, the facility failed to administer the correct amount of insulin for 1 of 1 resident reviewed for insulin administration. Staff did not follow an established procedure to deliver the correct amount insulin to Resident #30. The findings included: On 9/5/18 at 5:15 PM, during an observation of Resident #30's medication administration on the Skilled West Unit, Licensed Practical Nurse (LPN) #1 checked Resident #30's blood sugar (BS) which was 224. The physician's orders stated, Resident #30 is to receive 4 units of Humalog insulin via the KwikPen for a BS between 200-249. LPN #1 attached a needle to the KwikPen and without priming the KwikPen, selected 4 units on the dose knob dial. LPN #1 proceeded to administer the insulin by putting the KwikPen needle onto Resident #30's left upper arm and pressed the dose knob administration button. Following the administration LPN #1 verified s/he did not prime the Humalog KwikPen prior to administration. LPN #1 was asked, Were you trained in using insulin pens? LPN #1 stated, No, I never heard of priming before. Review of the facility policy Medication Management Program, states under procedure (11. N.) Follow manufactures guidelines for medication pen-style delivery devices for priming and air shots. Review of the Humolog KwikPen manufactures recommendations reveals under, Priming your HUMALOG KwikPen. Step (4) states, Prime before each injection. Priming ensures the Pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin. | 2020-09-01 |
| 85 | FAITH HEALTHCARE CENTER | 425009 | 617 WEST MARION STREET | FLORENCE | SC | 29501 | 2019-12-22 | 679 | D | 0 | 1 | WNXB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, it was determined the facility failed to provide meaningful activities to two (#15 and #21) of two sampled residents reviewed for activities on the AB hall. The facility identified 34 residents who resided on AB Hall. The findings include: The facility's activity calendar for (MONTH) 2019 documented the following activities were to be provided: 12/20/19: 10:30 AM Reverend (name redacted); 2:00 PM Exercise; 2:30 Puzzles; 3:30 PM Music and Table Top Games. 12/21/19: 10:30 AM Christmas Movies/Arts and Crafts; 3:00 PM Church. 1. Resident #15 had [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS), dated [DATE], documented the resident's cognition was severely impaired and required total assistance from staff for activities of daily living skills such as transfers and locomotion. A care plan, last updated 10/14/19, documented the resident enjoyed family visits, reading the bible, watching TV, listening to music, church, flower/plants and having snacks between meals. The documented interventions included to provide the resident with verbal reminders of the activities. The resident's current physician's orders [REDACTED]. On 12/20/19 at 9:45 AM, the resident was observed up in her wheelchair in her room. The room was dark, and the resident had no television in her room or radio to play music. On 12/20/19 from 9:45 AM to 10:35 AM, the resident remained in her room with the lights off. There were no stimulating activities provided to the resident while she was in the room. The resident was observed with her eyes closed on and off during this time. On 12/20/19 at 10:30 AM, there was a church service provided in the main dining room. No staff was observed letting the resident know of the activity or took her to the activity. On 12/20/19 from 10:30 AM to 12:45 PM, the resident again remained in her room with the lights off. She was observed on multiple occasion in the dark room, with her head hung low and eyes closed. The resident was not provided any stimulating activities during this time. On 12/20/19 at 2:00 PM, the resident was observed asleep in her wheelchair in her room. The lights were off, and the room was dark. There were no meaningful activities being provided to the resident. On 12/20/19 at 2:00 PM, an activity of exercise occurred. At 2:30 PM, residents were putting puzzles together, and at 3:30 PM music was provided. All activities were in the main dining room. Resident #15 remained in her room, with the lights off and was not offered to attend and/or taken to the activities in the main dining room. There were no meaningful activities being provided to the resident. On 12/21/19 from 8:51 AM to 12:00 PM, the resident was observed in her room in her wheelchair. She sat at an overbed table at the foot of her roommate's bed. There were no activities in the room being provided and the resident was not taken to the morning activities of Christmas Movies/Arts and Crafts at 10:30 AM in the main dining room. On 12/21/19 at 1:10 PM, the Activity Director (AD) and Assistant Activity Director (AAD) were interviewed regarding Resident #15. They both agreed it was the activity department's responsibility to make sure the residents were provided a meaningful program of activities. They stated the residents were logged in on an attendance record for group activities and a separate sheet for one-on-one activities. They indicated Resident #15 was quiet and liked to listen to Gospel music and attend religious activities to hear about the Bible. They both stated the resident was dependent on staff to tell them when the activities were going on and required assistance to get to and from the activities. The AD and AAD stated they needed to monitor the residents better to make sure they are coming to activities and provide them with one-on-one activities of their likings. On 12/21/19 at 3:01 PM, Certified Nurse Aide #135 stated it was all the staff's responsibility to make sure residents were aware of and taken to activities. She then stated residents that do not go to group activities should have room visits or one-on-one activities provided. She stated Resident #15 enjoyed television and music, but there was nothing in the room to provide them. She then stated the resident did not always like to go to group activities. She then acknowledged the resident did not attend and was not taken to any activities on the previous day or during the morning of 12/21/19. She stated the resident had not been provided much for activities and more should be provided. 2. Resident #21 had [DIAGNOSES REDACTED]. A quarterly (MDS), dated [DATE], documented the resident's cognition was severely impaired and required total assistance from staff for activities of daily living skills such as transfers and locomotion. The current physician's orders [REDACTED].activities as tolerated . An activity progress note, dated 10/05/19, documented, .She attends group activities also gets activities in AB hall lobby . This was the last documented activity progress note in the clinical record. The resident's care plan, last updated 11/13/19, documented, Problem .is receiving hospice services .she continues to attend our activities 1-2x's a week. She prefers to watch tv/movies/news, attending spiritual socials and food related events. She is able to make her simple needs and wants yes and no question .Interventions encourage to become involved with activities out of their room [ROOM NUMBER]x's a week or offer entertainment in their room . On 12/20/19 at 9:45 AM, the resident was observed up in her geri-chair in the common area of the AB hall. The resident was facing a white wall, away from the television that was on. On 12/20/19 from 9:45 AM to 12:05 PM, the resident was observed in the common area facing away from the television at a white wall. There were no meaningful activities for the resident, and she was observed with her eyes closed while in the room. On 12/20/19 at 12:05 PM, the resident was taken to her room, provided care and then taken back out and placed across from the nurses' station. The resident was not taken to the morning activities. On 12/20/19 at 10:30 AM, there was a church service provided in the main dining room. No staff was observed letting the resident know of the activity and/or taking her to the activity. On 12/21/19 from 8:51 AM to 12:00 PM, the resident was observed in her room in bed. There were no activities being provided in the room. A roommate's television was on, but it was behind the center privacy curtain at the resident's head of the bed and Resident #21 could not see it from her bed. The resident was not taken to the morning activities of Christmas Movies/Arts and Crafts at 10:30 AM in the main dining room. On 12/21/19 at 1:10 PM, the Activity Director and Assistant Activity Director were interviewed regarding Resident #21. They indicated it was the activity department's responsibility to make sure residents were provided with a meaningful activity program. They stated the residents are logged in on an attendance record for group activities and a separate sheet for one-on-one activities. The AD and AAD indicated Resident #21 liked to listen to music, reading and religious activities. They also indicated the resident enjoyed watching television and listening to music relaxed her. They stated the resident was totally dependent on staff to assist with and provide activities. They both stated they needed to monitor the residents better to make sure they are coming to activities and provide them with one-on-one activities of their likings. On 12/21/19 at 3:01 PM, Certified Nurse Aide (CNA) #135 stated it was all the staff's responsibility to make sure residents were aware of and taken to activities. She then stated residents that do not go to group activities should have room visits or one-on-one activities provided. CNA #135 stated Resident #21 enjoyed television, music and conversations with others. She then acknowledged the resident did not attend and was not taken to any activities on the previous day or during the morning of 12/21/19. She stated the resident had not been provided much for activities and more should be provided. | 2020-09-01 |
| 86 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-01-23 | 610 | D | 1 | 0 | S6DX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated. Resident #1 was noted with a fracture of unknown origin. The facility failed to interview all staff involved with the resident's care around the time the fracture was identified. The facility failed to clarify staff statements related to care provided to Resident #1 around the time the fracture was identified. One of three residents reviewed for abuse/neglect. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 10/19/17. The CNA (certified nurse aide) observed the resident's right lower leg to be swollen and warm to the touch. Resident #1 had a history of [REDACTED]. The physician was notified and a venous Doppler was ordered. The Doppler results were negative and the physician was notified. An x-ray was ordered and revealed a tiny cortical fracture in proximal tibia. Resident #1 was a stand assist transfer with stand up lift. Review of Resident #1's Nurse's Progress Note dated 10/18/17 at 9:50 AM revealed the CNA and nurse reported the resident having a swollen, discolored area to the right lower leg (shin area). The physician was called and notified with a new order for ultrasound of the right lower leg related to [MEDICAL CONDITION] and discoloration. On 10/18/17 at 4:47 PM the Doppler results were received and were negative for blood clot. The Nurse's Progress Note dated 10/18/17 at 5:37 PM indicated Resident #1's daughters requested the resident receive an x-ray of the leg. The nurse informed them that the physician would be in the facility and would look at the resident then. The resident's daughters insisted on an x-ray. The nurse called the nurse practitioner and left a message. Review of the Nurse's Progress Note dated 10/18/17 at 6:00 PM revealed received a call back from the nurse practitioner and an x-ray of the right leg was ordered. There were no Nurse's Progress Notes between 9/29/17 and 10/18/17 at 9:50 AM. Review of Resident #1's Physician's Progress Note dated 10/19/17 revealed the resident was seen for right leg pain and swelling. The note indicated the other day the resident began to experience swelling and pain in the right lower extremity. They were unable to determine any specific traumatic event or problem which occurred. Unfortunately due to the resident's dementia, s/he could not provide any reliable history. Review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed the resident's Brief Interview for Mental Status score was 7, which indicated the resident was non-interviewable. The surveyor requested a copy of the facility's complete investigation into the injury of unknown origin. Review of the facility's investigation revealed there was no statement from the nurse assigned to Resident #1 on the 7:00 PM - 7:00 AM shift on 10/17/17 and 10/18/17. There was also no statement from the nurse assigned to the resident on the 7:00 PM - 7:00 AM shift on 10/15/17 or the nurse assigned to the resident on 7:00 AM-7:00 PM shift on 10/16/17. There were also no statements from the CNAs that were assigned to Resident #1 on 10/15/17 on the 7:00 AM -7:00 PM shift and the 7:00 PM-7:00 AM shift. There was no statement from the CNA that was assigned to Resident #1 on 10/16/17 on the 7:00 AM- 7:00 PM shift. There was no statement from the CNA that was assigned to the resident on 10/17/17 on the 7:00 AM-7:00 PM shift. There was no statement from the CNA that was assigned to Resident #1 on 10/18/17 on the 7:00 AM - 7:00 PM shift. CNA #1's facility-obtained statement dated 10/19/17 revealed on Tuesday night (10/17/17) on the 7:00 PM- 7:00 AM shift s/he put Resident #1 to bed., pivot to stand. Resident #1 was able to stand and was transferred to bed with no complaints of pain. CNA #1 immediately called LPN (Licensed Practical Nurse) #1 to the room to assure the resident that s/he was on the bed and not on the floor. LPN #1 came in and assured Resident #1 that everything was okay and that s/he was on the bed. LPN #1's facility-obtained statement dated 10/19/17 indicated s/he was called to Resident #1's room by CNA #1 on 10/17/17. The CNA stated Resident #1 was really confused and kept asking the CNA to get him/her out of the floor but the resident was in the bed. LPN #1 walked over to the resident and told him/her that s/he was in the bed and not in the floor. Resident #1 stated No I am not, I am in the floor. The resident was redirected that s/he was in bed and not on the floor. In an interview with the surveyor on 1/23/18 at approximately 12:05 PM, the DON (Director of Nursing) stated s/he completed the investigation into Resident #1's injury of unknown origin. The DON stated for an injury of unknown injury, they interview everyone who worked with the resident for 24-48 hours prior to the identification of the injury. That would include nurse aides, nurses, and anyone else who may have been involved with the resident. The DON confirmed the investigation did not include statements from all staff who worked with Resident #1 prior to the identification of the injury. In a telephone interview with the surveyor on 1/23/18 at approximately 12:45 PM, CNA #1 confirmed s/he transferred Resident #1 as a stand and pivot per his/her statement. CNA #1 stated Resident #1 was a one person assist, which means s/he was a stand and pivot transfer. CNA #1 stated that was the information on Resident #1's CNA information sheet. CNA #1 stated the paperwork in Resident #1's room and in the PCR (patient care record) book both said one person assist and not sit to stand lift. In an interview with the surveyor on 1/23/18 at approximately 12:55 PM, the DON stated s/he talked with CNA #1 and s/he said s/he used a lift and pivoted the resident. The DON did not have CNA #1 clarify his/her statement related to how Resident #1 was transferred or make a note that they talked with CNA #1 to clarify the statement related to him/her pivoting the resident. | 2020-09-01 |
| 87 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-01-23 | 656 | G | 1 | 0 | S6DX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to develop and implement a comprehensive person-centered care plan that included the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of Resident #1's care plan and Nurse Aide Information Sheet revealed the resident's transfer status was not identified. One of three residents reviewed for care plans. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 10/19/17. The CNA (Certified Nurse Aide) observed the resident's right lower leg to be swollen and warm to the touch. Resident #1 had a history of [REDACTED]. The physician was notified and a venous Doppler was ordered. The Doppler results were negative and the physician was notified. An x-ray was ordered and revealed a tiny cortical fracture in proximal tibia. Resident #1 was a stand assist transfer with stand up lift. Review of Resident #1's (MONTH) (YEAR) physician's orders [REDACTED]. Review of Resident #1's care plan revealed resident needs assist with ADL's due to decreased cognition and decreased mobility was identified as a problem area. Interventions and approaches were listed on the care plan and included transfers with mechanical lift and sling lift pad in wheelchair for positioning. There was no indication what type of lift the resident required. A copy of the Nurse Aide's Information Sheet for Resident #1 was included in the facility's investigation file. Review of the form revealed the resident's status was noted as lift to chair with two assist. Review of Resident #1's Nurse Aide's Information Sheet revealed nothing that indicated the resident required a lift for transfers. There was no additional information related to transfers on the form. Review of Resident #1's Nurse's Progress Note dated 10/18/17 at 9:50 AM revealed the CNA and nurse reported resident having swollen, discolored area to the right lower leg (shin area). Called the physician and reported with new order for ultrasound of the right lower leg related to [MEDICAL CONDITION] and discoloration. On 10/18/17 at 4:47 PM the Doppler results were received and were negative for blood clot. The Nurse's Progress Note dated 10/18/17 at 5:37 PM indicated Resident #1's daughters requested the resident receive an x-ray of the leg. The nurse informed them that the physician would be in the facility and would look at the resident then. The resident's daughters insisted on x-ray. The nurse called the nurse practitioner and left a message. The Nurse's Progress Note dated 10/18/17 at 6:00 PM indicated received a call back from the nurse practitioner and an x-ray of the right leg was ordered. CNA #1's facility-obtained statement dated 10/19/17 revealed on Tuesday night (10/17/17) on the 7:00 PM- 7:00 AM shift s/he put Resident #1 to bed., pivot to stand. Resident #1 was able to stand and was transferred to bed with no complaints of pain. CNA #1 immediately called LPN #1 to the room to assure the resident that s/he was on the bed and not on the floor. LPN (Licensed Practical Nurse) #1 came in and assured Resident #1 that everything was okay and that s/he was on the bed. LPN #1's facility-obtained statement dated 10/19/17 indicated s/he was called to Resident #1's room by CNA #1 on 10/17/17. The CNA stated Resident #1 was really confused and keeps asking the CNA to get him/her out of the floor but the resident was in the bed. LPN #1 walked over to the resident and told him/her that s/he was in the bed and not in the floor. Resident #1 stated No I am not I am in the floor. The resident was redirected that s/he was in bed and not the floor. In an interview with the surveyor on 1/23/18 at approximately 11:50 AM, CNA #3 stated s/he had worked at the facility almost 3 years. CNA #3 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR (patient care record) book. It's the same information, they have it in two places. CNA #3 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 11:55 AM, CNA #4 stated s/he had worked at the facility almost 6 months. CNA #4 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR book. CNA #4 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 12:05 PM, the DON (Director of Nursing) stated the CNAs look at the Nurse Aide Information sheet which is in the PCR book and the wall locker in the resident's rooms. The DON confirmed Resident #1's Nurse Aide Information sheet indicated two assist, but did not have information that the resident required a lift for transfers. The DON stated Resident #1 had been back and forth between the sit to stand lift and the total lift. Resident #1 required a sit to stand lift at the time the fracture was identified. The DON stated the nurses and the unit coordinator (RN (Registered Nurse) supervisor) are responsible for updating the care plan when there are changes in care. If the care plan says mechanical lift it is a generic term, it could be different types of lifts. They have sit to stand, hoyer, and a steady lifts that will go all the way to the floor to pick residents up. The DON stated it should be on the CNA Information Sheet what type of lift is required. | 2020-09-01 |
| 88 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2018-01-23 | 689 | G | 1 | 0 | S6DX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 was noted with a fracture of unknown origin. Resident #1 was transferred as a stand and pivot, the CNA (certified nurse aide) did not use the sit to stand lift the resident required. The resident's Nurse Aide Information sheet did not contain accurate information related to the resident requiring a lift for transfers. One of three residents reviewed for accidents. The findings included: The facility reported an injury of unknown source to the State Agency for Resident #1 on 10/19/17. The CNA observed the resident's right lower leg to be swollen and warm to the touch. Resident #1 had a history of [REDACTED]. The physician was notified and a venous Doppler was ordered. The Doppler results were negative and the physician was notified. An x-ray was ordered and revealed a tiny cortical fracture in proximal tibia. Resident #1 was a stand assist transfer with stand up lift. Review of Resident #1's (MONTH) (YEAR) physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Radiology Report dated 10/19/17 revealed the resident had a tiny proximal tibial metaphyseal cortical fracture. Review of Resident #1's care plan revealed resident needs assist with ADL's (activities of daily living) due to decreased cognition and decreased mobility was identified as a problem area. Interventions and approaches were listed on the care plan and included transfers with mechanical lift and sling lift pad in wheelchair for positioning. There was no indication what type of lift the resident required. A copy of the Nurse Aide's Information Sheet for Resident #1 was included in the facility's investigation file. Review of the form revealed the resident's status was noted as lift to chair with two assist. Review of Resident #1's Nurse Aide's Information Sheet revealed nothing that indicated the resident required a lift for transfers. There was no additional information related to transfers on the form. Review of Resident #1's Nurse's Progress Note dated 10/18/17 at 9:50 AM revealed the CNA and nurse reported the resident having a swollen, discolored area to the right lower leg (shin area). The physician was called and notified with a new order for ultrasound of the right lower leg related to [MEDICAL CONDITION] and discoloration. On 10/18/17 at 4:47 PM the Doppler results were received and were negative for blood clot. The Nurse's Progress Note dated 10/18/17 at 5:37 PM indicated Resident #1's daughters requested the resident receive an x-ray of the leg. The nurse informed them that the physician would be in the facility and would look at the resident then. The resident's daughters insisted on an x-ray. The nurse called the nurse practitioner and left a message. Review of the Nurse's Progress Note dated 10/18/17 at 6:00 PM revealed received a call back from the nurse practitioner and an x-ray of the right leg was ordered. There were no Nurse's Progress Notes between 9/29/17 and 10/18/17 at 9:50 AM. Review of Resident #1's Physician's Progress Note dated 10/19/17 revealed the resident was seen for right leg pain and swelling. The note indicated the other day the resident began to experience swelling and pain in the right lower extremity. They were unable to determine any specific traumatic event or problem which occurred. Unfortunately due to the resident's dementia, s/he could not provide any reliable history. Review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed the resident's Brief Interview for Mental Status score was 7, which indicated the resident was non-interviewable. CNA #1's facility-obtained statement dated 10/19/17 revealed on Tuesday night (10/17/17) on the 7:00 PM- 7:00 AM shift s/he put Resident #1 to bed., pivot to stand. Resident #1 was able to stand and was transferred to bed with no complaints of pain. CNA #1 immediately called LPN (Licensed Practical Nurse) #1 to the room to assure the resident that s/he was on the bed and not on the floor. LPN #1 came in and assured Resident #1 that everything was okay and that s/he was on the bed. LPN #1's facility-obtained statement dated 10/19/17 indicated s/he was called to Resident #1's room by CNA #1 on 10/17/17. The CNA stated Resident #1 was really confused and kept asking the CNA to get him/her out of the floor but the resident was in the bed. LPN #1 walked over to the resident and told him/her that s/he was in the bed and not in the floor. Resident #1 stated No I am not, I am in the floor. The resident was redirected that s/he was in bed and not on the floor. In an interview with the surveyor on 1/23/18 at approximately 11:50 AM, CNA #3 stated s/he had worked at the facility almost 3 years. CNA #3 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR (patient care record) book. It's the same information, they have it in two places. CNA #3 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 11:55 AM, CNA #4 stated s/he had worked at the facility almost 6 months. CNA #4 stated residents' transfer status is on a care plan sheet in the resident's closet and also the PCR book. CNA #4 reviewed the Nurse Aide information sheet for Resident #1 and stated s/he would not use a lift for the resident because it was not indicated on the form. In an interview with the surveyor on 1/23/18 at approximately 12:05 PM, the DON (Director of Nursing) stated the CNAs look at the Nurse Aide Information sheet which is in the PCR book and the wall locker in the resident's rooms. The DON confirmed Resident #1's Nurse Aide Information sheet indicated two assist, but did not have information that the resident required a lift for transfers. The DON stated Resident #1 had been back and forth between the sit to stand lift and the total lift. Resident #1 required a sit to stand lift at the time the fracture was identified. The DON stated the nurses and the unit coordinator (RN (Registered Nurse) supervisor) are responsible for updating the care plan when there are changes in care. If the care plan says mechanical lift it is a generic term, it could be different types of lifts. They have sit to stand, hoyer, and a steady lifts that will go all the way to the floor to pick residents up. The DON stated it should be on the CNA Information Sheet what type of lift is required. In a telephone interview with the surveyor on 1/23/18 at approximately 12:45 PM, CNA #1 confirmed s/he transferred Resident #1 as a stand and pivot per his/her statement. CNA #1 stated Resident #1 was a one person assist, which means s/he was a stand and pivot transfer. CNA #1 stated that was the information on Resident #1's CNA information sheet. CNA #1 stated the paperwork in Resident #1's room and in the PCR book both said one person assist and not sit to stand lift. | 2020-09-01 |
| 89 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 253 | D | 1 | 1 | SD8911 | > Based on observation and interview the facility failed to maintain a clean and functional environment for 2 of 2 units. The findings included: The Environmental Tour was conducted with the Environmental Services Room 1 Areas of paint were noted to be rubbed away from the dry wall; the baseboard was pulled away from the wall near the bathroom. Room 53Odors were noted in the restroom; urine was noted in and around the toilet; the restroom floor was wet and discolored. Room 54 The countertop near the hot water faucet was chipped; baseboard under the sink was pulled away from the wall; discolored floor tiles were noted beneath the sink counter and in the restroom. Room 58 The sink fixture was loose; the fixture was noted to vibrate when turned on; a wheelchair was stored in the restroom; brown build up was noted at the base of the toilet. Room 59 The headboard was bruised on Bed A - nearest to the door; paint was scratched away from the drywall; soap film build up was noted around the sink faucets; 1 unlabeled bed pan noted in the restroom; a wired rack; over the commode seat had some rust on the legs; wood on door leading into Room 59 was splintered above the metal plate. Room 62 There was noted odor in the restroom; two uncovered bed pans (gray and pink) in the restroom; black build up on the bathroom floor. These concerns were noted during the first two days of the survey and reviewed and confirmed with the maintenance manager and environmental services manager on 5-10-17 at 2:11 p.m. | 2020-09-01 |
| 90 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 274 | D | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to identify a change in status and conduct a Significant Change in Status Assessment (SCSA) as required for Resident #96, 1 of 3 residents reviewed with a significant change in status. The findings included: The facility admitted Resident #96 with [DIAGNOSES REDACTED]. On 05/09/2017 at 2:34 PM, comparison of the Admission MDS (Minimal Data Set) assessment dated [DATE] to the Quarterly MDS assessment dated [DATE] revealed the resident declined in cognition from a BI[CONDITION] (Brief Interview for Mental Status) score of 15 to a BI[CONDITION] score of 7, indicating the resident declined from cognitively intact to severely impaired. Further review revealed the resident's eating declined from supervision to total dependence. In addition, Resident #96 was receiving intermittent catheterizations on the Admission MDS but had an indwelling catheter on the Quarterly MDS Assessment. Continued review also revealed the resident had a significant weight loss from 249 pounds to 217 pounds, a weight loss of 12.[AGE]% resulting in a decline in a total of 4 areas: cognition, eating, placement of indwelling catheter, and weight loss. During an interview on 05/10/2017 at 4:20 PM, the RN (Registered Nurse) MDS Coordinator #1, confirmed declines in cognition, eating, continence and weight and that a SCSA should have been completed. | 2020-09-01 |
| 91 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 278 | D | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to assure that 1 of 5 sampled residents reviewed for unnecessary medications and one of 1 sampled resident reviewed for hospice services received accurate assessments. Resident #26 had a Minimum Data Set (MDS) assessment completed with inaccurate data related to skilled speech and physical therapy services. Resident #122 had a MDS assessment completed with inaccurate data for item J1400 addressing resident prognosis. The findings included: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Record review on 5/10/17 at 8:43 AM revealed that Resident #26 had a Physician Telephone Order dated 4/17/17 for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) to evaluate and treat. Further review revealed a clarification telephone order written on 4/18/17 for .skilled PT services 5 times a week for four weeks . and an additional telephone order written for Patient to participate in skilled ST services 5 times a week .for 30 days . Additional review of section O-Special Treatments, Procedures and Programs, Items 0400A1-3A (ST treatment minutes) and O400C1-3A (PT treatment minutes) and O0420 (distinct calendar days of therapy) revealed that all were all answered with a 0 with 0400A4-6 (ST treatment days/ dates) and O400C4-6 (PT treatment days/ dates) were all blank with no information entered on the Admission Comprehensive MDS with Assessment Reference Date (ARD) of 4/25/2017. Further Record review of ST and PT treatment records for the dates of 4/19/17 through 4/25/17 provided on 5/10/17 at 1:30 PM by COTA #1 revealed that Resident #26 received skilled PT individual treatments on 4/19/17, 4/20/17, 4/21/17, 4/24/17, and 4/25/17 as well as skilled ST individual treatments on 4/19/17, 4/21/17, 4/24/17, and 4/25/17. COTA #1 verified during interview that Resident #26 received skilled ST and PT services during the assessment period of 4/19/17-4/25/17. During interview with MDS Nurse #1 on 5/11/17 at approximately 10:18 AM, s/he verified that the Admission Comprehensive MDS with ARD of 4/25/17 did not accurately reflect the skilled ST and PT services that Resident #26 received during the assessment period. MDS Nurse #1 further verified that the coding for section O items 0400A, 0400C and O0420 were all incorrectly coded and additionally reported that s/he only counted therapy if a resident was receiving skilled therapy services for short term rehabilitation (rehab) under Medicare Part A. MDS Nurse #2 was present during interview and supported this statement by further verifying that both MDS Nurses have historically only code skilled therapy services for those residents identified as short term rehab or Medicare A. | 2020-09-01 |
| 92 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 309 | D | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, the facility failed to obtain weekly weights as ordered for one of one resident reviewed for dental status. The findings included: Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review on 5/11/2017 at 2:00 PM revealed that a clarification order was written on 3/1/17 to continue weekly weights. Further review of Resident #92's weight sheet revealed that weights were recorded as follows: 3/2/17: 138.0 pounds 3/13/17: 141 pounds 3/29/17: no information entered 4/5/17: line struck through, no information entered 4/24/17: 143 pounds Further review of weekly nursing summaries from 2/2017 to 5/2017 revealed that there were no weights recorded anywhere on the forms. During interview on 5/11/17 at 3:06 PM with DON, s/he verified that there was a clarification order written on 3/1/17 for weekly weights and that the weekly weight sheet did not have weekly weights recorded as ordered on a consistent basis since 3/1/17. Additionally, the DON verified that there were no weights documented on any of the weekly summaries completed by nurses from 2/2017 through 5/2017. When asked, the DON stated that the only two places the weights would have been recorded would have been the weight sheet or the weekly nurse summary form. The DON verified that the order for weekly weights was not followed as ordered. | 2020-09-01 |
| 93 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 315 | D | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to ensure there was medical justification for a foley catheter for Resident #24, 1 of 3 residents reviewed with a catheter. The findings included: The facility admitted Resident #24 with [DIAGNOSES REDACTED]. On 05/11/2017 at 12:29 PM, review of the Facility History and Physical dated 4/13/17 revealed a statement from the physician stating I believe this patient has the Foley catheter in place to help promote proper wound healing regarding his sacral pressure ulcer which is being addressed and surveilled by the wound care nurse. On 05/11/2017 at 12:38 PM, RN (Registered Nurse) #3 confirmed the Stage II on the sacrum was healed at the time of admission. S/he further confirmed the History and Physical indicated the Foley was in place to promote healing of the pressure ulcer and that the resident had a Foley for a month without a justification. | 2020-09-01 |
| 94 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 329 | E | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the Registered Pharmacist (RPH) failed to identify irregularity for two consecutive months related to the approved gradual dose reduction (GDR) of antipsychotic medication for 2 of 5 residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #120 2/3/17 with [DIAGNOSES REDACTED]. Record review on 5/10/17 at approximately 1:49 PM revealed a Pharmacist recommendation dated 2/23/17 for Physician to please re-evaluate the need for continued use of ziprasidone, perhaps considering a gradual dosage reduction to 20 milligrams (mg) by mouth daily for delusions associated with [MEDICAL CONDITION], with the end goal of discontinuation of therapy if possible. Physician approved this request by checking the response I accept the recommendation(s) above, please implement as written with a signature date of 3/2/17. Further review of physicians orders initiated on 3/2/17 reveal the order change [MEDICATION NAME] to 0.25 mg tabs-take 1 tab by mouth four times daily (QID) which was signed by the Nurse Practitioner on 3/6/17. Additional review of the monthly physician orders [REDACTED]. During interview with MD#1 and DON on 5/11/17 at 10:00 AM, MD#1 verified that s/he did approve the GDR for ziprasidone on 3/2/17 that was recommended by the RPH during February 2017 MMR. MD#1 and DON then reviewed Resident #120's medical record during interview after which both verified that the pharmacy recommendation for GDR of ziprasidone that was approved on 3/2/17 had not been initiated as ordered with 2 subsequent RPH monthly MMR's on 3/9/17 and 4/13/17 that did not identify the irregularity. DON and MD both verified that Resident #120 should have been receiving ziprasidone 20 mg capsule by mouth once daily since 3/2/2017. DON and MD #1 both verified that for 71 days, Resident #120 received a daily unnecessary dose of ziprasidone for a total of 71 doses. At the conclusion of the interview, MD #1 initiated an order to decrease the ziprasidone from 20 mg twice daily to 20 mg once daily to begin on 5/11/17. The facility admitted Resident #31 with [DIAGNOSES REDACTED]. Review of Resident #31's record on 5-10-17 at 4:07 p.m. revealed that a repeated pharmacy recommendation from 2-23-17 stated to add an appropriate [DIAGNOSES REDACTED]. The physician indicated to discontinue the medication and signed the pharmacy recommendation on 4-20-17. The order to discontinue the medication was not written until 4-25-17, as evidenced by the 'Physicians Order Form'. The initial pharmacy recommendation was signed by the physician on 3-1-17 but did not indicate a response from the physician regarding the recommendation. Review of the resident's Medication Administration Record [REDACTED]. The records were reviewed by the Director of Nursing DON on 5-11-17 at 12:28 p.m. and confirmed that an order should have been written and the ordered should have been discontinued prior to 4-25-17. | 2020-09-01 |
| 95 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 332 | E | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview the facility failed to ensure the medication error rate was less than 5%. The facility had 3 errors of 27 opportunities resulting in a medication error rate of 11.11%. The findings included: On 05/10/2017 at 9:01 AM, LPN #1 was observed during the medication pass. LPN #1 administered 24 units of [MEDICATION NAME] [MED] to Resident #5. Observation revealed the vial of [MED] was opened on 04/11/2017. During an interview on 05/10/2017 at 2:04 PM, LPN #1 confirmed the medication should have been discarded 28 days after opening, on 5/8/17. The LPN also confirmed the resident received 5 doses of [MEDICATION NAME] after day 28. During the medication pass observation of LPN #4 on 05/11/2017 at 9:28 AM, the LPN administered [MEDICATION NAME] that was not completely dissolved via the PEG (Percutaneous Endoscopic Gastrostomy) tube which clogged the tube. While attempting to de-clog the tube, the LPN poured the medication back into the medicine cup but several large pieces of the medication remained in the tube. Using a clean washcloth, LPN #4 removed pieces of the tablet from the connector and discarded them. In addition, while administering the [MED], the connection between the syringe and the tube came loose and a portion of the medication flowed out of the syringe onto the towel. The LPN confirmed the resident did not receive the full dose of the 2 medications. | 2020-09-01 |
| 96 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 333 | E | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, the facility failed to ensure that expired medication was not administered to Resident #5, 1 of 1 resident observed for [MED] administration. The findings included: On [DATE] at 9:01 AM, LPN #1 was observed during the medication pass. LPN #1 administered 24 units of [MEDICATION NAME] [MED] to Resident #5. Observation revealed the vial of [MED] was opened on [DATE] and would have expired on 5//,[DATE]. On [DATE] at 2:04 PM, LPN #1 confirmed the medication should have been discarded 28 days after opening. The LPN also confirmed the resident received 5 doses of [MEDICATION NAME] after day 28. | 2020-09-01 |
| 97 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 371 | F | 1 | 1 | SD8911 | > Based on observation and interview, the facility failed to properly store and label food items in both the reach-in and walk-in coolers. In addition, the cook failed to have foods at the appropriate temperature before serving. The findings included: During initial tour of the kitchen on 5/8/2017 at approximately 3:30 pm, observation of the walk-in cooler revealed 3 large bags of expired salad, stored in a box dated use by 4/30/2017. There was also an additional label on the box dated use by 5/3/2017. The tour also revealed 2 bags of unlabeled and undated shredded cheese in the walk- in cooler. At approximately 4:00 pm on 5/8/17, tour of the reach-in cooler revealed 2 peanut butter and jelly sandwiches with a use by date of 5/3/17 and 1 pimento cheese sandwich with a use by date of 5/6/17. Additional tour of the kitchen showed the ice scoop to have been left inside of the ice machine. Review of the facility's policy on Food Storage stated, Scoops are not to be stored in food or ice containers, but are kept covered in a protected area near the containers. An interview with the Certified Dietary Manager on 5/8/17 at approximately 4:15 pm revealed there were expired and unlabeled items in both the walk-in and reach-in coolers. The facility also failed to properly prepare food items to be served at proper temperatures. During an observation of the temping of the lunch tray line on 5/10/17 at approximately 10:56 am, it was revealed the potato salad to be served was not a proper temperature. The cook who took the temperatures found the first bowl of potato salad to be at 50 degrees Fahrenheit. A second bowl was then obtained and found to be at [AGE] degrees Fahrenheit. The temperatures of the fried chicken wings were shown to be at 120 degrees Fahrenheit. During an interview on 5/10/17 at 11:15 am, the cook stated that s/he allows reheated items to reach a temperature of 1[AGE] degrees Fahrenheit. Review of the facility's policy on Reheated Foods, states All parts of the food must reach an internal temperature of 165 degrees Fahrenheit with a minimum holding time at the specified temperature for 15 seconds and a maximum time of 2 hours. The policy also states cold food items must maintain a temperature of 41 degrees Fahrenheit and below for safe consuming. | 2020-09-01 |
| 98 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 428 | D | 1 | 1 | SD8911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the Registered Pharmacist (RPH) failed to identify irregularity for two consecutive months related to the approved gradual dose reduction (GDR) of antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #120 2/3/17 with [DIAGNOSES REDACTED]. Record review on 5/10/17 at approximately 1:49 PM revealed a Pharmacist recommendation dated 2/23/17 for Physician to please re-evaluate the need for continued use of ziprasidone, perhaps considering a gradual dosage reduction to 20 milligrams (mg) by mouth daily for delusions associated with alcohol abuse, with the end goal of discontinuation of therapy if possible. Physician approved this request by checking the response I accept the recommendation(s) above, please implement as written with a signature date of 3/2/17. Further review of physicians orders initiated on 3/2/17 reveal the order change clonazepam to 0.25 mg tabs-take 1 tab by mouth four times daily (QID) which was signed by the Nurse Practitioner on 3/6/17. Additional review of the monthly physician orders [REDACTED]. During interview with MD#1 and DON on 5/11/17 at 10:00 AM, MD#1 verified that s/he did approve the GDR for ziprasidone on 3/2/17 that was recommended by the RPH during February 2017 MMR. MD#1 and DON then reviewed Resident #120's medical record during interview after which both verified that the pharmacy recommendation for GDR of ziprasidone that was approved on 3/2/17 had not been initiated as ordered with 2 subsequent RPH monthly MMR's on 3/9/17 and 4/13/17 that did not identify the irregularity. | 2020-09-01 |
| 99 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-05-11 | 431 | E | 1 | 1 | SD8911 | > Based on observation and interview, the facility failed to label medications with the date opened and/or failed to discard expired medications on 2 of 4 medication carts and in 1 of 2 medication rooms observed. The findings included: During review of the unit 2 medication carts on 5/9/17, 2 bottles of ophthalmic drops were observed on cart 1 with no open date: Artificial Tears 15 ml (milliliters) and Brimonidine Tarrate 0.2 % 5 ml. Review of the American Academy of Ophthalmology recommendations revealed A good rule of thumb is to throw away any opened bottle of eye drops after 3 months. Further review revealed a bottle of [MED] 0.005% 2.5 ml with an open date of 3/19/17. The pharmacy label stated to discard 6 weeks after opening. During an interview on 05/09/2017 at 12:04 PM, RN (Registered Nurse) #2 confirmed the findings and stated the policy is to discard 30 days after opening. On 05/10/2017 at 2:44 PM, review of the Unit 1 medication carts revealed Brimonidine Tarrate 0.2 % 5 ml 2 bottles with no open date, Timolol Maleate 0.5% 5 ml bottle with no open date, Olopatadine Hydrochloride 0.2% 2.5 ml bottle with no open date, and [MED] 0.005% 2.5 ml bottle with no open date. In addition, review of the cart revealed 2 Nicotine Transdermal Patches 7 mg (milligrams) that expired February, 2017. During an interview on 05/10/2017 3:00 PM, LPN (Licensed Practical Nurse) #1 confirmed the findings. Review of the facility's policy for Recommended Minimum Medication Storage Parameters for Ophthalmic, Otic, and Topical Medications on 5/11/17 revealed the recommendation for Ophthalmic preparations was to Refer to manufacturer's recommendations. Review of the online manufacturer's recommendations revealed Artificial Tears are stable for 90 days after opening, On 05/10/2017 at 9:01 AM, LPN #1 was observed during the medication pass. LPN #1 administered 24 units of Novolog [MED] to Resident #5. Observation revealed the vial of [MED] was opened on 04/11/2017. On 05/10/2017 at 2:04 PM, LPN #1 confirmed the medication should have been discarded 28 days after opening. The LPN also confirmed the resident received 5 doses of Novolog after day 28. 05/10/2017 3:03:38 PM, review of the Unit 1 medication room revealed 1 open bottle of Vitamin B-1 100 mg that expired 01/17. The finding was confirmed by LPN #2. | 2020-09-01 |
| 100 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 157 | D | 1 | 0 | MGP911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to inform the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. Resident #1 and Resident #3 were both noted to have a change in condition. Review of the resident's medical records revealed no documentation that the physician was notified of the residents' change in condition. Two of three residents reviewed for change in condition. The findings included: Review of Resident #1's medical record revealed Nurses' Progress Notes dated 8/2/17 indicated called to room by Certified Nursing Assistant (CNA) to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. Registered Nurse (RN) supervisor (RN #1) notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted weekly summary and body audit completed. The next note after the 8/2/17 entry was noted as a late entry for 8/1/17 and indicated the resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] was noted, daughter present. Daughter stated possible the footrest (missing) may have caused pain and [MEDICAL CONDITION]. Replaced footrest. Reported to nurse to get something for pain and monitor. The note was completed by RN #1. The Nurses' Progress Note dated 8/3/17 at 3:00 AM indicated the resident had complaints of pain and swelling to the right knee and warm to touch. Ice pack applied and elevated. As needed Tylenol given related to pain. On 8/3/17 at 5:00 AM the Nurses' Note indicated Tylenol was effective. Resident states My knee still hurts but feels a lot better since that ice. Ice appears to be effective. Swelling slightly reduced in size and less warm to touch. Resident now resting quietly. At 10:10 AM the note indicated the physician was asked to see the resident related to right knee pain. X-ray and CBC ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no documentation that the physician was notified of Resident #3's complaints of pain on 8/1/17 or 8/2/17. Review of Resident #1's (MONTH) Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his knee with some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Resident #1 was sent out to the hospital and noted to have a fracture. Review of Resident #3's medical record revealed the Nurse's Progress Note dated 6/19/17 at 9:55 AM indicated the nurse practitioner rounded and new orders were written for hospice to evaluate and treat the resident related to [MEDICAL CONDITION]. On 6/19/17 at 2:00 PM the Nurse's Note indicated Resident #3 had two bowel movements that were black, sticky and had blood clots in them. Resident resting in bed. On 6/19/17 at 6:00 PM the Nurses' Note indicated the resident was in bed with black blood and clots pouring out from rectum as quick as it can be wiped up. Still alert and awake at present. Review of the Nurses' Note dated 6/19/17 at 8:00 PM revealed the resident was constantly trying to get out of bed. Staff redirected resident with ease after attempt #4. Notified supervisor of actions. Supervisor reported to nurse practitioner who gave order for [MEDICATION NAME] 0.5 mg every 6 hours as needed related to agitation. Resident is alert with confusion. Black tarry blood still noted coming out of rectum. Review of the resident's Nurses' Notes from 6/1/17-6/19/17 revealed no prior documentation related to the resident having blood and clots coming from rectum. There was no documentation that the physician was notified related to the resident's change in condition. Review of Resident #3's medical record revealed the resident was admitted to hospice on 6/21/17. In an interview with the surveyor on 8/16/17 at approximately 1:10 PM, the Director of Nursing (DON) stated s/he would check on physician notification related to resident with blood clots from the rectum. The DON returned and had no documentation that the physician was notified of Resident #3's change in condition. The DON stated s/he thinks the nurses did not notify the physician because they were waiting on hospice, didn't want to be aggressive. | 2020-09-01 |
| 101 | ELLEN SAGAR NURSING CENTER | 425012 | 1817 JONESVILLE HIGHWAY | UNION | SC | 29379 | 2017-08-16 | 225 | G | 1 | 0 | MGP911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving abuse or neglect were reported immediately, but not later than 2 hours after the allegation was made. The facility also failed to have evidence that all alleged violations were thoroughly investigated. Resident #1 was noted to have complaints of pain on 8/1/17 and the allegation of neglect was not reported to the State Agency until 8/3/17. Review of the facility's investigation revealed statements from three staff members, the Registered Nurse (RN) Supervisor on the unit (RN #1), the wound care nurse (RN #3) and Certified Nursing Assistant (CNA) #1. It was noted on the Daily Assignment Sheet for 8/1/17 that CNA #1 was not assigned to Resident #1. There were no statements from the staff assigned to care for the resident on the days surrounding the incident. One of two residents reviewed for reportable incidents. The findings included: The facility reported an allegation of neglect to the State Agency for Resident #1 by CNA #1 on 8/3/17. Review of the facility's Five-Day Follow-Up Report dated 8/8/17 indicated after investigation, Resident #1 was found to have right knee fracture from attempted transfer to wheelchair without lift or two-person assist. The Initial 24-hour Report dated 8/3/17 revealed Resident #1 stated that while being pivoted by CNA #1, the CNA assisted him/her to slide to the floor and at that time his/her right knee popped. Further review of the medical record revealed the Annual Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status score of 6. The Quarterly MDS dated [DATE] coded the resident as having a Brief Interview for Mental Status score of 5. The Quarterly MDS coded Resident #1 as totally dependent for transfers. Review of the care plan revealed resident needs moderate to max assistance with ADLs was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included resident transfers with assist of mechanical lift. Review of the Nurses' Progress Notes dated 8/2/17 indicated called to room by CNA to look at resident's leg. Right leg is swollen. States had pain in leg while receiving peri-care. RN supervisor notified who also looked at leg. Resident's socks removed and legs elevated. The previous note was dated 7/21/17 and noted weekly summary and body audit completed. The next note was noted as a late entry for 8/1/17 and indicated resident complained in wheelchair that right knee popped while being transferred to bed. Some slight [MEDICAL CONDITION] noted, daughter present. Daughter stated possible the footrest (missing) may have caused pain and [MEDICAL CONDITION]. Replaced footrest. Reported to nurse to get something for pain and monitor. The note was completed by RN #1. The Nurses' Progress Note dated 8/3/17 at 3:00 AM indicated the resident had complaints of pain and swelling to the right knee and warm to touch. Ice pack applied and elevated. As needed Tylenol given related to pain. On 8/3/17 at 5:00 AM the Nurses' Note indicated Tylenol was effective. Resident states My knee still hurts but feels a lot better since that ice. Ice appears to be effective. Swelling slightly reduced in size and less warm to touch. Resident now resting quietly. At 10:10 AM the note indicated the physician was asked to see the resident related to right knee pain. X-ray and CBC ordered stat. The Nurses' Progress Note dated 8/3/17 at 6:40 PM indicated the nurse practitioner was notified of the x-ray results and a new order was received to send the resident to the emergency room for evaluation and treatment related to complaints of pain. There was no additional documentation related to monitoring the resident for complaints of pain or assessing the resident's knee. Review of Resident #1's (MONTH) Medication Administration Record [REDACTED]. The resident did not receive the as needed medication any other time during the month of August. Resident #1 received scheduled Tylenol 2 tablets (650 mg) three times daily for pain at 8:00 AM, 4:00 PM, and 8:00 PM. Review of the physician progress notes [REDACTED]. Apparently the other day during the transfer his/her knee was some way twisted. The exact mechanism of action was unknown, and from conversation with the facility staff history does not seem to be consistent with another. Resident #1 is a poor historian. The physician ordered an x-ray. The note was signed 8/3/17 at 4:24 PM. Review of the Mobilex Radiology Report dated 8/3/17 revealed the conclusion was noted as possible non-displaced fracture through the medial femoral condyle. Further evaluation with oblique views was recommended. RN #1's facility-obtained statement dated 8/1/17 indicated at approximately 8:40 AM, resident's niece reported that the resident's right leg hurt and that s/he needed his/her foot rest on the wheel chair. RN #1 assessed the resident's right and left legs. Resident stated hurts more with movement, grimaced. Resident also reported it happened while being put to bed. Niece stated she felt like it was because the resident had been up in wheelchair without a foot rest. RN #1 and CNA #1 found the foot rest. CNA #1 replaced them on the wheelchair. RN #1 reported to the primary nurse and asked if resident could get something for pain and to continue to monitor his/her leg. RN #1's facility-obtained statement dated 8/4/17 indicated when s/he arrived to work on 8/3/17 s/he was made aware that Resident #1 was in the hospital with a fracture. It had been reported to another RN that CNA #1 had dropped the resident while transferring without a lift. When CNA #1 was called to the office to investigate the incident, s/he stated s/he never lifted the resident without a lift. CNA #1 did observe the resident in the wheelchair without a foot rest with the resident's leg stuck behind the front wheel and had to lift the chair up and get the resident's leg free. RN #1 explained to CNA #1 that this was considered an incident and should have been reported to the primary nurse. RN #1's facility-obtained statement dated 8/7/17 indicated upon entering Resident #1's room since return from the hospital s/he asked the resident how s/he hurt his/her leg. Resident #1 replied That (boy/girl) holding me up made me slide into the floor. Asked how s/he had picked the resident up and if s/he had used the lift. Resident #1 replied no, s/he had him/her under his/her arms. Resident #1 stated (s/he) picked me up under my arms and put me in the chair. In an interview with the surveyor on 8/15/17 at approximately 2:20 PM, RN #1 stated s/he is the unit manager for Unit 1. RN #1 stated that the resident's niece said his/her leg was hurting out in the lobby. RN #1 went and assessed the resident's leg and it was painful. Resident #1 didn't have petals on his/her wheelchair and his/her niece felt that may be what was causing the resident's leg to hurt. Normally the resident had petals but staff said they couldn't find them that day. RN #1 walked down the hall and found them on another wheelchair. The CNA said they looked like the resident's and the CNA checked and they fit Resident #1's wheelchair. The petals were on an extra wheelchair that was on the hall. Resident #1's knee had slight [MEDICAL CONDITION]. RN #1 stated s/he had the resident's nurse give the resident his/her pain medication. RN #1 stated s/he was not assigned to the resident, s/he was on as unit manager. The niece thought the resident's leg might be bothering him/her because it was not supported by the petal. RN #1 told the resident's nurse to monitor the resident's leg and let him/her know if there were any additional complaints of pain. RN #1 stated s/he did not hear anything else about the resident's leg until s/he heard the resident went out to the hospital with a fracture. RN #1 works days Monday-Friday. RN #1 stated Resident #1 was a total lift prior to the incident. RN #3's facility-obtained statement dated 8/1/17 indicated on 8/1/17 at 8:45 AM, the resident's niece reported to RN supervisors, RN #3 and RN #1, the resident complained of pain to the right knee. Resident states It happened when I was put back to bed. Assessment findings of slight [MEDICAL CONDITION] noted to right knee and pain with movement. Niece states It might be from sitting up in wheelchair without a foot rest. Foot rest placed by CNA, RN to monitor. In an interview with the surveyor on 8/15/17 at approximately 2:35 PM, RN #3 stated s/he is the wound care nurse. RN #1 stated the resident's niece told them about the resident complaining of pain. RN #1 stated s/he does not remember anything about the incident. In an interview with the surveyor on 8/15/17 at approximately 2:45 PM, Licensed Practical Nurse (LPN) #1 stated the resident's family member stated the resident was complaining his/her leg hurt. LPN #1 stated s/he gave him some Tylenol. The resident doesn't usually complain about anything. Resident #1 said s/he was hurting. LPN #1 didn't look at the resident's leg. LPN #1 worked 7 AM-7 PM. CNA #1's facility-obtained statement dated 8/4/17 indicated on the afternoon of 8/1/17 at approximately 11:30 AM, Resident #1 was transferred from the bed to the chair using the lift. Resident #1's wheel chair only had one left pedal attached to it. When the resident was in the hallway his/her right leg twisted under the chair. Resident #1 called out and said that his/her leg was stuck. CNA #1 then began to undo the resident's leg. RN #1 walked up and said that Resident #1 needed two pedals on his/her wheelchair. They began to look throughout the facility for another pedal to add to the resident's wheelchair. After they found a right pedal that would fit, RN #1 and CNA #1 put the pedal on the right side of the wheelchair. The day in question, the resident did not complain of any pain or discomfort and his/her leg was not swollen. After Resident #1's wheelchair was adjusted his/her sister took over and pushed the resident to the lobby. In an interview with the surveyor on 8/16/17 at approximately 10:15 AM, RN #2 (Director of Education) stated the only registry verification for CNA #1 was the one checked on 7/10/17. CNA #1's date of hire was 7/5/17. RN #2 confirmed the registry verification was done after the employee's date of hire. In an interview with the surveyor on 8/16/17 at approximately 1:50 PM, the Director of Nursing (DON) stated s/he was not at the facility when the incident happened with Resident #1. The DON stated s/he usually goes back to interview staff who worked with the resident prior to the incident. The DON stated s/he would have looked back to try to find out when the pain started. The DON stated Resident #1 did not usually complain of pain. The DON stated the resident could tell you what happened. The DON stated s/he would expect the nurses to monitor a resident for a new complaint of pain. Review of the Disciplinary Action Form dated 8/4/17 revealed the facility placed CNA #1 on administrative leave pending results of investigation for resident care. Review of an email dated 8/14/17 from Spartanburg Regional to staffing agency that CNA #1 was employed by revealed due to the current issue involving (CNA #1), managers are terminating his/her contract effective immediately. There was no documentation in any emails provided that the facility notified the staffing agency about the incident that led to the termination of CNA #1's contract. | 2020-09-01 |