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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 952 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 623 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review and interview, the facility failed to give the resident and the resident representative in writing a notice of transfer in a language understood for 1 of 3 residents reviewed for hospitalization . Resident #78 admitted to hospital with no evidence of notice of transfer given to resident and resident representative. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Record review on 1/8/20 at 5:43 PM revealed the resident was transferred to the hospital on [DATE], 10/14/19, 10/23/19, [DATE], and 1/7/20. Further review of the medical record revealed there was no documentation the resident or the resident representative received a written notice of transfer. During an interview with the Director of Nursing on [DATE] at approximately 11:00 AM, s/he confirmed the transfer forms were not issued to the resident or the resident representative. | 2020-09-01 |
| 953 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 625 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review and interview, the facility failed to issue a bed hold notice to the resident representative upon discharge for 1 of 3 residents reviewed for hospitalization . Resident #78 admitted to hospital with no evidence a bed hold notice was issued. The findings included: The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Record review on 1/8/20 at 5:43 PM revealed the resident was transferred to the hospital on [DATE], 10/14/19, 10/23/19, [DATE], and 1/7/20. Further review of the medical record revealed there was no documentation the resident representative received a bed hold notice. During an interview with the Director of Nursing on [DATE] at approximately 11:00 AM, s/he stated a bed hold notice was not issued due to the resident being private pay. Review of the facility bed detail revealed all [AGE] beds were certified. | 2020-09-01 |
| 954 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 658 | E | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on observations, record reviews and interviews the facility failed to assure that care and services were provided according to accepted standards of clinical practice for 1 of 5 residents reviewed for unnecessary medications. Resident #12 had two different physician orders [REDACTED]. An interview with the Director of Nursing (DON) revealed that the nursing staff providing care to Resident #12 failed to realize there were two different orders in place for finger stick blood sugar testing resulting in additional finger sticks. An interview with Licenses Practical Nurse (LPN) #3 revealed that s/he was aware that the orders were confusing but failed to report this to the DON. The findings included: Resident #12 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/08/20, at approximately 3:47 PM, a random medical record observation revealed that Resident #12 had two different physician orders [REDACTED]. On 1/8/20 at approximately 4:04 PM, LPN #3 stated that the orders were confusing and that he/she had been intending to report this to the DON (Director of Nursing) but had not done so. On 1/8/20 at approximately 4:37 PM, the Surveyor made the DON aware of the finger stick blood sugar testing concerns related to Resident #12. On 1/8/10 at approximately 5:20 PM, a review of physician's orders [REDACTED]. The first was an opened ended physician order [REDACTED]. Blood Sugar is less than [AGE], Call MD. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, Give 6 Units. If Blood Sugar is 301 to 350, Give 8 Units. If blood Sugar is 351 to 400, give 10 Units. If Blood Sugar is greater than 400, call MD. Three times a Day; 07:30 AM, 11:30 PM, 05:30 PM. After reviewing Resident #12's medical record it revealed that Resident #12 was being tested ,[DATE] times daily for blood sugar levels. On 1/8/20 at approximately 5:40 PM, the DON stated that Resident #12 was being tested too frequently, and that the resident had been in and out of the hospital due to [MEDICAL CONDITION] and agreed to generate all physician orders [REDACTED]. On 1/8/20 at approximately 5:55 PM the DON stated that somewhere along the way three different nurses had failed to realize that there were two different orders in place for finger stick blood sugar testing and that the resident was definitely getting stuck to many times per day. On 1/8/20 at approximately 5:45 PM the DON (Director of Nursing) provided a report quantifying the number of unnecessary finger stick per day since October 2019 that had been performed on Resident # 12. There was a total of 121 extras finger sticks performed 10/20/19 through 1/8/20 and they occurred as follows: October 2019 = 11, November 2019 = 28, December 2019 = 61, January 2020 = 21. On 1/9/20 at approximately 10:15 AM, these numbers were confirmed by the DON. | 2020-09-01 |
| 955 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 732 | E | 1 | 1 | S0WQ11 | > Amended February 11, 2020 Based on record review and interview, the facility failed to post accurate daily staffing postings for 31 of 31 days reviewed. Postings observed with incomplete census and/or staff and inaccurate total number of hours worked. The findings included: Review of the facility postings on [DATE] at 11:00 revealed the following: 12/1-31/ 2019-all with inaccurate total of number of hours worked; 12/1, 3, 6, 7, 9, 15, 17, 19, 20, 22, 25, 27, 28, 29, 30, 31/2019- census not documented each shift; 12/1, 3, 6, 19, 20, 22/ 2019 licensed and non- licensed staff incomplete ; 12/1, 9, 22/ 2019-shift supervisor not documented. During an interview with the Director of Nursing on [DATE] at 8:15 AM, s/he confirmed the postings were incomplete and the total number of hours worked had not been calculated. S/he stated during the week the Unit Managers were responsible for ensuring correct information was documented on the postings and the week-end supervisors were responsible to place the correct information on the posting form on the week-ends. | 2020-09-01 |
| 956 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 761 | D | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and interviews the facility failed to assure that opened, single use only sterile medications, used for treatments, were removed from 2 of 6 medication carts. The findings included: On 1/07/20 at approximately 12:16 PM, inspection of the Hall 200 Treatment Cart revealed one opened, folded shut foil package of Curad (Xeroform Petroleum Dressing) Sterile 5 (inch) x 9 labeled by the manufacturer Single Use Only. Do Not Reuse stored in the bottom drawer. On 01/07/20 at approximately 12:20 PM LPN (Licensed Practical Nurse) #1 verified the manufacturer's labeling and that the package had been opened and stored for reuse. On 1/07/20 at approximately 12:32 PM inspection of the Hall 100 Treatment Cart revealed one opened tube of [MEDICATION NAME] Wound and Burn Dressing 1.5 oz. (ounce) labeled Sterile and Tube Sterility guaranteed in unopened, undamaged package was stored in the top drawer. On 01/07/20 at approximately 12:44 PM, LPN #2 verified the manufacturer's labeling related to single use only for sterility and that the package had been opened and stored for reuse. On 01/07/20 at approximately 2:18 PM LPN #1 stated that he/she did not realize that the manufacturer had labeled the [MEDICATION NAME] as sterile and for single use only and verified that it had been stored for reuse. | 2020-09-01 |
| 957 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 806 | D | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure Resident #52, 1 of 1 with Food Allergy, did not receive food items to which s/he was allergic. The findings included: The facility admitted Resident #52 with [DIAGNOSES REDACTED]. During meal observation on 01/07/19 at approximately 12:50 PM, Resident #52 was served a salmon croquette. The Resident Representative for Resident #52 was present and sent the plate back to the kitchen for a substitute. The tray card stated No seafood but listed the pureed salmon croquette as a meal item. During Record review on [DATE] at approximately 4:03 PM, a dietary order dated 11/26/19 stated Regular Diet, Pureed consistency, allergic to seafood, was noted. In an interview on 01/07/20, the Dietary Manager confirmed that the resident received fish today. S/he also reviewed the tray card and confirmed that when it states no seafood it means no fish also. Stated the tray should be checked to make sure the resident does not receive any food to which s/he is allergic. Also confirmed that the resident had received seafood/ fish previously and the family had returned it to the kitchen. In an interview on 0[DATE] at approximately 12:38 PM the Director of Nursing confirmed that the staff needs to come up with a plan to make sure it does not happen again. | 2020-09-01 |
| 958 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2020-01-10 | 880 | D | 1 | 1 | S0WQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Amended February 11, 2020 Based on record review, observation, interview, and review of facility policies titled Infection Control-Linen and Laundry, Infection Control Prevention and Control Activities, Infection Control-Linen and Laundry and information from ECOLAB, the facility failed to ensure infection control procedures were adhered to for one of one laundry observation and 2 of 2 handwashing observations. During observation of the laundry, staff was observed to carry a soiled gown close to his/her uniform, no separation between clean and soiled items in the personal laundry room. In addition, two observations were made of staff entering a soiled utility room and exiting without washing or sanitizing his/her hands. The findings included: During observation of the laundry on [DATE] at 8:30 AM, Laundry Staff #1 was observed after removing a soiled gown to hold it close to his/her uniform. Observation of the laundry for personal care items revealed one door entering into a small laundry room. To the right of the door soiled items and washers were observed. To the left of the door clean items and dryers were observed. Staff was observed entering the laundry with the soiled bin and clean, uncovered items were stored within 6 inches of the doorway. Measurements from the dirty laundry bin to the clean items was approximately 7 feet 2 inches. Due to the proximity and crowded area in the laundry, Laundry Staff were asked how did s/he manage to get clean items into the dryer. S/he stated the laundry racks were moved back. This placed the clean racks midway and very close to the soiled side of the room. In addition, Laundry Staff was observed to obtain the water temperature of the washer which was 125 degrees. S/he tested the pH of the linen and stated some days it is yellow and some days it is green. When Laundry Staff #1 was asked what the parameters for the water temperature and pH should be, s/he was unable to tell the surveyor. On [DATE] at 11:04 AM, after observing pressure ulcer treatment, Licensed Practical Nurse #1 washed his/her hands, entered the soiled utility room and placed items in receptacles. S/he exited the soiled utility room without evidence of washing or sanitizing his/her hands. During an interview with the Director of Nursing on [DATE] at 4:24 PM, s/he stated staff should wash or sanitize hands after placing items in the soiled utility. Review of the facility policy titled Infection Control-Linen and Laundry revealed the following under Section 2300- Water Supply, Hygiene, and Temperature Control-D. Hot water provided for washing linen and clothing shall not be less than one hundred sixty (1[AGE]) degrees Fahrenheit. Should chlorine additives or other chemicals that contribute to the margin of safety in disinfecting linen and clothing be a part of the washing cycle, the minimum hot water temperature shall not be less than one hundred ten(110) degrees Fahrenheit, provided hot air drying is used. Review of the Fabric pH indicator by ECOLAB revealed instructions for determining the pH from a range of 4-12+ with the number 7 and 8 circled. Written instructions states if color is green or yellow that indicates a good pH. Review of the facility policy titled Infection Control Prevention and Control Activities revealed the following under the Hand Washing section: 2. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Hands will be washed immediately after gloves are removed, between patient contact, equipment handling and when otherwise indicated to wash hands between tasks:. Review of the facility policy titled Infection Control-Linen and Laundry revealed the following: 5. Laundry Process a. Soiled laundry i. The soiled laundry area is to be clearly separate from the clean laundry area. Resident #62 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of the pressure ulcer dressing change on 0[DATE]20 at 10:53 AM, Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) # 1 entered the resident's room and both washed hands and donned gloves. The RN #1 removed the soiled dressing, washed her hands with soap/water, and donned new gloves. The RN #1 measured the pressure ulcer 1.13 cm x 0.1 cm x 0.7 cm, then washed hands with soap/water. The LPN #1 washed hands and donned new gloves, cleaned wound with wound cleanser, washed hands with soap/water, and donned new gloves. The LPN #1 applied calcium alginate dressing to sacrum. The RN #1 and LPN # 1 pulled up Resident #62 in the bed, collected the trash and both washed their hands. The LPN #1 then took the trash down the hall to the soiled utility room, entered the soiled utility room and placed the trash in the bin. After leaving the soiled utility room, LPN # 1 did not wash hands with soap or water or appear to sanitize with an alcohol based rub. During an interview with the Director of Nursing on 0[DATE]20 AT 4:16 PM, the concerns about handwashing were mentioned and she confirmed that the LPN should have washed hands after placing trash in the soiled utility. A review of the facility policy titled Infection Control Prevention and Control Activities revealed that 1.) Hands should be washed often. 2.) Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Hands will be washed immediately after gloves are removed, between patient contact, equipment handling and when otherwise indicated to wash hands between tasks. | 2020-09-01 |
| 959 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 157 | D | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's Change in Condition Policy, the facility failed to notify the family of significant changes in the resident's condition requiring potential physician intervention for one of one sampled resident reviewed for notification. The family of Resident #22 was not notified of falls that occurred on 3/22/17 and 4/30/17. The findings included: The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Review of Nurse's Notes and Incident Reports on 05/04/2017 at 2:34 PM revealed that Resident #22 fell in the hallway on 3/22/17. On 4/30/17, s/he was found sitting on the floor after attempting to go to the bathroom unassisted. There was no evidence located that the family was notified of the falls. During an interview on 05/05/2017 2:36 PM, the Director of Nursing (DON) reviewed the medical record and incident reports and verified there was no evidence that the family had been notified. On 5/5/17 at 3:44 PM, the DON stated, All I have is what's on the incident report. Review of the facility's Change in Condition Policy revealed no reference to family notification. | 2020-09-01 |
| 960 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 241 | D | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility policy titled, Educating & Promoting Patient/Resident Rights, the facility failed to promote care for Resident #87, #85 and resident #72 in a manner and in an environment that maintains or enhances the resident's dignity and respect for 3 of 3 residents reviewed for Dignity. The findings included: The facility admitted Resident #87 with [DIAGNOSES REDACTED]. An observation on 5/3/2017 at approximately 11:48 AM revealed Resident #87 lying in bed and wearing a hospital gown. Review on 5/4/2017 at approximately 10:27 AM of the plan of care for Resident #87 made no mention of Resident #87's preference to wear a hospital gown daily. Review on 5/4/2017 at approximately 10:29 AM of a form titled, Nursing Monthly Observation Form, dated 1/3/2017 states, Daily Decision Making Skills, are consistent and reasonable. No mention was made on the form that Resident #87 prefers to wear a hospital gown daily. Review on 5/4/2017 at approximately 10:32 AM of the nurses notes from 1/11/2017 through 4/28/2017 made no mention that Resident #87 prefers to wear a hospital gown daily. An observation on 5/4/2017 at approximately 11:30 AM revealed Resident #87 sitting up in bed wearing a hospital gown. During an interview on 5/4/2017 at approximately 3:11 PM with Certified Nursing Assistant (CNA) #4 stated, It is definitely this resident's preference to wear a hospital gown daily. Review on 5/5/2017 at approximately 8:50 AM of a form titled, Social Services Progress Notes Form. dated 5/4/2017 at 7:15 PM included an interview with the Social Services Director and reads, In speaking with Resident #87, he/she stated, .I prefer to wear gowns, it is more comfortable. If I am going out of the building, I want to wear clothes. No documentation could be found in Resident #87's medical record to ensure wearing a hospital gown daily was his/her preference. Review on 5/5/2017 at approximately 9:10 AM of the facility policy titled, Educating and Promoting Patient/Resident Rights, states, It is the Pruitt Corporation companies' policy that the individual rights of patients/residents will be protected and safeguarded by all partners. The right to be treated with dignity. The facility admitted Resident #72 with [DIAGNOSES REDACTED]. An observation on 5/2/2017 at approximately 2:43 PM of Resident #72 revealed his/her name written with a permanent marker on the outside aspect of the collar of his/her shirt. A second observation on 5/2/2017 at approximately 3:20 PM revealed Resident #72 sitting at the nurses desk in a wheel chair and a Certified Nursing Assistant referred to him/her as grandpa on two different occasions. Review on 5/5/2017 at approximately 9:15 AM of the plan of care made no mention of a preference by Resident #72 to be called grandpa. During an interview on 5/5/2017 at approximately 10:45 AM with Licensed Practical Nurse (LPN) #2, he/she confirmed that the name was written on the outside aspect of Resident #72's shirt collar. LPN #2 also was not aware of a nickname or a preferred name that Resident #72 wished to be called other than his/her given name. During an interview on 5/5/2017 at approximately 10:50 AM with Certified Nursing Assistant (CNA) #2 he/she stated. I am not aware of any other name other than the given name for this resident. An interview on 5/5/2017 at approximately 10:55 AM confirmed that CNA #5 was not aware of a nickname or any other name other than Resident #72's given name that he/she wished to be called. During an interview on 5/5/2017 at approximately 10:55 AM with the Social Service Director, he/she was not aware of any other name than Resident #72's given name as a preference to be called when addressing him/her. The Social Service Director went on to say that he/she did not know who had written the resident's name on the outside of his/her shirt across the collar. The facility admitted Resident #85 with [DIAGNOSES REDACTED]. A random observation on 5/2/2017 at approximately 4:48 PM revealed Resident #85 asleep in bed, lying on his/her right side, with door open, the privacy curtain was not pulled and his/her torso and brief were exposed to the hallway with visitors and staff walking by the room. Review on 5/5/2017 at approximately 9:10 AM of the facility policy titled, Educating and Promoting Patient/Resident Rights, states, It is the Pruitt Corporation companies' policy that the individual rights of patients/residents will be protected and safeguarded by all partners. The right to be treated with dignity and the right to Privacy | 2020-09-01 |
| 961 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 253 | E | 0 | 1 | P4RY11 | Based on observations and interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior on 1 of 2 Units. The findings included: Observations made on 5/2/2017 and 5/3/2017 during visits to resident rooms on the 100 Hall revealed the following. Room #102 B - 1. Geri chair with spills along the side. 2, Bottom mattress visible at the head of bed of 102 B. 3. Dried tube feeding at the head of the bed on the floor and on the pole holding tube feeding pump. 4. Dried brown/yellow substance on the wall at the bed, 5. Privacy curtain with reddish/pink stains. 6. Privacy curtain of 102 A stained. 7. Base of toilet in the bathroom has a brown substance. 8. A urinal in the bathroom was uncovered and unlabeled. Room #103 A 1. Ceiling patched but not painted. 2. Scuffed walls in need of paint. Room #104 B 1. Paint peeling on door. 2. Walls scuffed and in need of paint. 3. Three drawer handles loose and one missing on the dresser. 4. Dried spills on the drawers of the dresser. 5. Spider web above the window curtain. 6. Soiled chair seat with large brown stain visible. 7. Trash noted under the bed. 8. Wall damaged behind the bed in need of repair. 9. Ceiling with stains. 10. Two fall mats on the floor one is ripped and the second has visible stains. Room #107 B 1. Wall behind the bed is scuffed and in need of repair. Room #118 P 1. The air conditioner not working and has not worked for a period of time. Room #128 1. Large bug crawling about in the bathroom. Further observations made on the 200 Hall included: Room #208 B 1. Bathroom floor has dark stains. 2. Baseboards in the bathroom are soiled and stained. 3. Base of the commode has rusty/dirty substance. Room #218 A 1, Bathroom floor is dirty. 2. Bucket and grey pan sitting on the bathroom floor. 3. Privacy curtain with stains. 4. The elevated toilet seat has rust stains. During rounds on 5/5/2017 at approximately 8:00 PM the Administrator and the Housekeeping Supervisor verified the above findings. | 2020-09-01 |
| 962 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 256 | D | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure adequate and comfortable lighting in 3 resident rooms on the 100 Hall of 1 of 2 units. The findings included: During observations on 5/2/2017 and 5/3/2017 revealed the following: 1. Two lights out in room [ROOM NUMBER] on the 100 Hall. 2. room [ROOM NUMBER] on the 100 Hall the light is out over the sink in the room and the light is out in the bathroom and has a cracked cover. 3. room [ROOM NUMBER] on the 100 Hall has the light out in the bathroom. During rounds on 5/5/2017 at approximately 8:00 PM the Administrator and the Housekeeping Supervisor verified the findings on the 100 Hall. | 2020-09-01 |
| 963 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 278 | D | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately ensure the Minimum Data Set (MDS) was accurate for 1 of 3 for pressure ulcers, 1 of 3 for nutritional status, and 1 of 5 for medications. Resident #22's (MDS) was inaccurate related to medications, Resident #27's MDS was inaccurately coded for nutritional status, Resident #95's MDS inaccurately reflected pressure ulcer staging. The findings included, Resident #27 was admitted with [DIAGNOSES REDACTED]. Record review on [DATE] at 2:30 PM Resident #27's Quarterly MDS dated [DATE] revealed that Section K was incorrectly documented a therapeutic diet and should have been documented as a Mechanically Altered diet. Record review on [DATE] at approximately 2:00 PM revealed current physician's orders [REDACTED]. Further review of the Annual MDS dated [DATE] revealed weight loss had been incorrectly coded. On [DATE] at 3:30 PM, an interview with the MDS coordinator verified that Section K on MDS dated [DATE] was incorrectly coded for therapeutic diet and that the Section K on the MDS dated [DATE] was coded incorrectly for physician prescribed weight loss regimen. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Record review at 12:54 PM on [DATE] revealed that the [DATE] Admission Assessment noted open areas present on the sacrum, buttocks, and toe. The [DATE] Body Audit Form noted Pressure ulcer to sacrum + L(eft) buttock and R(ight) great toe amputation (with) scab @ surgical site. No measurements or staging of the wounds were recorded until [DATE], 3 days later. Further review revealed weekly wound assessments were not completed. On [DATE] at 5:06 PM, review of Wound Observation and Assessment forms revealed that on [DATE], the pressure ulcer on the left buttock was noted as a Stage 2 measuring 4 centimeters (cm) length x 2.5 cm width x 0.1 cm depth with 100% granulation tissue and light serosanguinous-sanguinous drainage. Surrounding skin showed maceration, [DIAGNOSES REDACTED], and unexplained other. The pressure ulcer on the sacrum was noted as a Stage 4 measuring 6 cm length x 5.8 cm width x 2.6 cm depth with tunneling from ,[DATE] at 4 cm and a moderate amount of serosanguinous drainage. Surrounding skin showed maceration, [DIAGNOSES REDACTED], and unexplained other. These were the only recorded wound assessments in the record until the resident expired on [DATE]. On [DATE] at 1:45 PM, Licensed Practical Nurse (LPN) #2 provided additional information from a [DATE] wound care center appointment which noted that the sacral pressure ulcer measurements were 9 cm length x 11 cm width x 3.3 cm depth, with an area of 99 sq (square) cm and a volume of 326.7 cubic cm. Muscle and bone are exposed. Undermining has been noted at 9:00 and ends at 3:00 with a maximum distance of 4.7 cm .large amount of serosanguinous drainage .yellow slough, ,[DATE]% bright red granulation .Right Great Toe is an Unstageable Pressure Injury. Obscure full thickness skin and tissue loss Pressure Ulcer .Wound bed is ,[DATE]% dry, black eschar .Left Medial Buttock is a Stage 3 Pressure Injury Pressure Ulcer .measurements are 3.5 cm length x 2.5 cm width x 0.1 cm depth .scant amount of yellow drainage .Wound bed is ,[DATE]% granulation . Review of the [DATE] Admission MDS on [DATE] at 1:05 PM revealed that the resident was coded as having one Stage 2 and one Stage 4 pressure ulcer. Measurements reflected those taken in the facility on [DATE] as opposed to those provided by the wound center on [DATE]. During an interview on [DATE] at 2:08 PM, the MDS Coordinator reviewed the [DATE] wound center report and verified s/he should have coded a Stage 3 and a Stage 4 instead of a Stage 2 and a Stage 4 as per the report confirmed as received on [DATE]. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Review of the [DATE] Quarterly Minimum Data Set (MDS) Assessment Section N-Medication revealed that an anticoagulant was coded as having been received 5 days and an antibiotic was coded as not having been received during the 7 day look back period. Record review on [DATE] at 4:14 PM revealed [DATE] physician's orders [REDACTED]. No orders were found for anticoagulant use. Review of the ,[DATE] Medication Administration Record [REDACTED]. During an interview on [DATE] at 2:01 PM, Registered Nurse #1 reviewed the record and verified that the information was entered incorrectly. | 2020-09-01 |
| 964 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 280 | D | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure the plan of care was reviewed and revised to include Resident #87's refusal to turn and reposition to prevent decline in skin integrity and to include Resident #87's choice to wear hospital gowns daily for 1 of 3 residents reviewed for pressure Ulcers. The facility further failed to ensure that all disciplines participated in the care planning process for Resident #95 for 1 of 31 care plans reviewed. The findings included: The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Observations made on 5/2/2017, 5/3/2017 and 5/4/2017 revealed Resident #87 wearing a hospital gown daily. Review on 5/4/2017 at approximately 10:27 AM of the plan of care for Resident #87 made no mention of Resident #87's preference to wear hospital gowns daily. Review on 5/4/2017 at approximately 12:40 PM of the nurses notes revealed notes dated 3/15/2017 through 3/27/2017 in which Resident #87 refused to turn and reposition. A second review on 5/4/2017 at approximately 1:00 PM of the plan of care for Resident #87 revealed no revision of the plan of care to include Resident #87's refusal to turn and reposition. During an interview on 5/4/2017 at approximately 1:28 PM with Registered Nurse (RN) #1, the Care Plan Coordinator confirmed that the care plan did not include Resident #87 choosing to wear a hospital gown daily and the his/her refusal to turn and reposition. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Care Plan review at 1:09 PM on 05/04/17 revealed that only the Activities Director and MDS Coordinator participated in the 12-2-16 Care Plan Conference Meeting. There was no evidence of participation by Social Services, Dietary, or the Certified Nursing Assistant. According to facility documentation, problems included a Stage 2 pressure ulcer on the left buttock and a Stage 4 on the sacrum. During an interview at 1:11 PM on 5-5-17, the Director of Nursing stated that an X on the form initially indicated that the staff member attended the meeting. Then, the policy changed to indicate that the x completion of the assigned sections of the MDS and staff had to physically sign the form to indicate care plan meeting participation. The DON reviewed the Care Plan form and confirmed that only the MDS Coordinator and Activities participated. | 2020-09-01 |
| 965 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 282 | D | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that residents received appropriate care according to the current care plan for 1 of 3 residents reviewed for range of motion services. Resident #77 did not receive consistent range of motion services. The findings included: The facility admitted Resident #77 with a [DIAGNOSES REDACTED]. A review of the care plan for Resident #77 on 5/5/2017 at approximately 5:30 PM, revealed a Problem/Need for activities of daily living which included impaired mobility with an intervention for AROM/PROM (Active Range of Motion/Passive Range of Motion) with daily care as tolerated which was initiated on 9/24/2014. On 5/5/2017 at approximately 6:30 PM a review of the resident's Care Task Documentation revealed no documentation on these dates for AROM/PROM: 2/5/17, 2/6/17, 2/9/17,3/5/17, 3/23/17,4/2/17, 4/3/17, 4/417, 4/5/17 4/8/17, 4/12/17 4/1617, 4/17/17, 4/19/17,4/22/17 ,4/26/17,4/27/17, 4/29/17 and 4/30/17. Interview with the MDS Coordinator on 5/5/2017 at approximately 7:00 PM verified inconsistent documentation of AROM/PROM for resident #77. | 2020-09-01 |
| 966 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 309 | D | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews and review of the facility's agreement with Hospice titled, Hospice Nursing Home Agreement, the facility failed to ensure coordination of care for Resident #68 between the facility and United Hospice of the Midlands for 1 of 1 resident reviewed for Hospice Care and Services. The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 7:00 PM of the Hospice notebook for Resident #68 revealed, the hospice care plan has not been updated since [DATE]. The Certification period for Hospice was expired [DATE]. The Certified Nursing Assistant (CNA) visit documentation was not in the Hospice notebook nor the facility for Resident #68 to ensure coordination of care. During an interview on [DATE] at approximately 7:00 PM with the Licensed Practical Nurse (LPN) #3, Unit Manager verified the findings and stated, the CNA visits Resident #68 for care as ordered and we sign their form and they take it with them. They do not leave a copy with us. Review on [DATE] at approximately 7:15 PM of the facility policy titled, Hospice Nursing Home Agreement, states under, Section VI. Records, a. Compilation of Records: i. Preparation: . Each Residents clinical record shall completely, promptly and accurately document all services provided to, and events concerning each Residential Hospice Patient and that all services are provided pursuant to this Agreement including, evaluations, treatments, progress notes, authorizations to admission to Hospice and/or facility and physician orders [REDACTED]. Facility and Hospice shall cause each entry made for services provided hereunder to be signed by the person providing the services. Each clinical record shall document all services provided and the events occurring to Hospice patients, periodic reassessments of the Hospice Patient/Family unit, coordination of care between the Hospice and the Facility . : | 2020-09-01 |
| 967 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 314 | D | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure Resident #87's and Resident #95's pressure ulcers were measured and staged in a timely manner for 2 of 3 residents reviewed for Pressure Ulcers. The findings included: The facility admitted Resident #87 with [DIAGNOSES REDACTED]. Review on [DATE] at approximately 3:37 PM of a form titled, Wound observation and Assessment Form, revealed Resident #87 was in the hospital from [DATE] through [DATE] and was admitted back into the facility on [DATE]. Licensed Practical Nurse (LPN) #2 assessed the pressure ulcers on admission on [DATE]. The Wound Nurse was not available until 4 days later to actually measure and stage the pressure ulcers. An interview on [DATE] at approximately 3:40 PM with Registered Nurse (RN) #2, Wound Care Nurse, confirmed Resident #87 returned from the hospital on [DATE], but he/she was not working until [DATE] and pressure ulcers were not measured and staged until his/her return to work on [DATE]. RN #2 went on to say that all wounds/pressure ulcers are measured on Thursdays. This surveyor then asked, If a resident is admitted any other day of the week other than Thursday did the wounds/pressure ulcers not get assessed, measured and staged by an RN, until the wound nurse returns to work and he/she stated, yes. During an interview on [DATE] at approximately 4:45 PM the Director of Nursing, (DON) verified Resident #87 returned for the hospital on [DATE] and the pressure ulcers were not measured and staged by the wound nurse until [DATE]. This surveyor asked if the DON would expect a newly admitted resident with wounds/pressure ulcers to be assessed, measured and staged in a timely manner and he/she stated, I think it is best if only one nurse measures and stages the wounds/pressure ulcers. The wound nurse will measure the wounds/pressure ulcers when he/she returns to work. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Record review at 12:54 PM on [DATE] revealed that the [DATE] Admission Assessment noted open areas present on the sacrum, buttocks, and toe. The [DATE] Body Audit Form noted Pressure ulcer to sacrum + L(eft) buttock and R(ight) great toe amputation (with) scab @ surgical site. No measurements or staging of the wounds were recorded until [DATE], 3 days later. Further review revealed weekly wound assessments were not completed. On [DATE] at 5:06 PM, review of Wound Observation and Assessment forms revealed that on [DATE], the pressure ulcer on the left buttock was noted as a Stage 2 measuring 4 centimeters (cm) length x 2.5 cm width x 0.1 cm depth with 100% granulation tissue and light serosanguinous-sanguinous drainage. Surrounding skin showed maceration, [DIAGNOSES REDACTED], and unexplained other. The pressure ulcer on the sacrum was noted as a Stage 4 measuring 6 cm length x 5.8 cm width x 2.6 cm depth with tunneling from ,[DATE] at 4 cm and a moderate amount of serosanguinous drainage. Surrounding skin showed maceration, [DIAGNOSES REDACTED], and unexplained other. These were the only recorded wound assessments in the record until the resident expired on [DATE]. On [DATE] at 1:45 PM, Licensed Practical Nurse (LPN) #2 provided additional information from a [DATE] wound care center appointment which noted that the sacral pressure ulcer measurements were 9 cm length x 11 cm width x 3.3 cm depth, with an area of 99 sq (square) cm and a volume of 326.7 cubic cm. Muscle and bone are exposed. Undermining has been noted at 9:00 and ends at 3:00 with a maximum distance of 4.7 cm .large amount of serosanguinous drainage .yellow slough, ,[DATE]% bright red granulation .Right Great Toe is an Unstageable Pressure Injury. Obscure full thickness skin and tissue loss Pressure Ulcer .Wound bed is ,[DATE]% dry, black eschar .Left Medial Buttock is a Stage 3 Pressure Injury Pressure Ulcer .measurements are 3.5 cm length x 2.5 cm width x 0.1 cm depth .scant amount of yellow drainage .Wound bed is ,[DATE]% granulation . Based on this information, compared to the [DATE] assessment/measurements, the sacral wound increased in size, depth, tunneling, and amount of drainage. There was little change in the buttock ulcer size, but it worsened to a Stage 3. The [DATE] wound center noted an unstageable area to the great toe (in addition to the surgical/amputation site) that the facility failed to identify and measure. During an interview on [DATE] at 1:24 PM, the Minimum Data Set (MDS) Coordinator stated that the resident's admitted was on a Friday. The Director of Nurses stated it was the practice of the facility to measure pressure ulcers on Mondays when the admission was on Friday. LPN #2 confirmed that the only weekly measurements/staging were those noted on [DATE]. Record review on [DATE] at 2:09 PM revealed Physician order [REDACTED]. Pat dry. Apply Chlorpactin 4 gm (grams). Cover (with) dry dsg (dressing) tid (three times daily) + PRN (as needed). (2) Clean L(eft) buttock (with) NS. Pat dry. Apply Chlorpactin 4 gm. Cover (with) dry dsg tid + PRN. (3) Skin Prep to R(ight) great toe amputation daily. Review of the ,[DATE] Treatment Administration Record on [DATE] at 5:00 PM revealed treatments were not done as ordered. The sacral and left buttock wound treatments were not initialed as completed 15 times from ,[DATE] through [DATE]. During an interview on [DATE] at 1:28 PM, when advised of the omissions, the Director of Nurses (DON) stated s/he expected physician's orders [REDACTED]. Review of Nurse's Notes on [DATE] at 4:14 PM revealed that the resident developed a new Stage 2 pressure ulcer on the left upper buttock on [DATE]. Review of the [DATE] Admission MDS on [DATE] at 1:05 PM revealed that the resident was coded as having one Stage 2 and one Stage 4 pressure ulcer. Measurements reflected those taken in the facility on [DATE] as opposed to those provided by the wound center on [DATE]. During an interview on [DATE] at 2:08 PM, the MDS Coordinator reviewed the [DATE] wound center report and verified s/he should have coded a Stage 3 and a Stage 4 instead of a Stage 2 and a Stage 4 as per the report confirmed as received on [DATE]. Care Plan review at 1:09 PM on [DATE] revealed that only the Activities Director and MDS Coordinator participated in the [DATE] Care Plan Conference Meeting. There was no evidence of participation by Social Services, Dietary, or the Certified Nursing Assistant. Problems included a Stage 2 pressure ulcer on the left buttock and a Stage 4 on the sacrum. During an interview at 1:11 PM on [DATE], the DON stated that an X on the form initially indicated that the staff member attended the meeting. Then, the policy changed to indicate completion of the assigned sections of the MDS and staff had to physically sign the form to indicate care plan meeting participation. The DON reviewed the Care Plan form and confirmed that only the MDS Coordinator and Activities participated. | 2020-09-01 |
| 968 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 315 | E | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the facility policy titled, Handwashing, and Indwelling Urinary Catheter (Foley) Care and Management, the facility failed to ensure Resident #113 received proper foley catheter care for 1 of 2 residents reviewed with a foley catheter. The facility further failed to provide care with interventions for Resident #78 to improve or prevent further decline in urinary incontinence. And the facility additionally failed to ensure Resident #72 received the proper incontinent care for 2 of 2 residents reviewed for urinary incontinence. The findings included: The facility admitted Resident #113 with [DIAGNOSES REDACTED]. An observation on 5/4/2017 at approximately 9:07 AM of Foley catheter care for Resident #113 went as follows: Resident #113 was on contact isolation for an infection. The Certified Nursing Assistant (CNA) #3 applied Personal Protective Equipment (PPE) outside the room before entering and this surveyor did also. CNA #3 knocked on the door with gloved hands. The procedure was explained to Resident #113 and this surveyor asked for permission to observe the CNA performing the catheter care and he/she stated it was ok. Using the same gloved hands raised the bed, pulled the privacy curtains, moved the bedside table away from the bed and pulled down the bed linens and removed his/her brief. The CNA was not observed removing his/her gloves and washing his/her hands prior to starting the catheter care. The CNA used the same gloved hands to retrieve a pre moistened wipe from a pack of wipes and swiped down one time on either side of the groin area and then threw the wipe in the trash. The CNA then retrieved another wipe and secured the tubing and held the wipe over the tubing and cleansed down the tubing. He/she did not cleanse the insertion site of the foley catheter. He/she then refastened the brief, using the same gloved hands, checked to make sure the tubing was not kinked , lowered the bed, took a clean brief from the bedside table and placed it in a closet, arranged the overbed table for the resident's convenience, pushed a straight chair closer to the bed. The resident asked the CNA to lower the bed further and to raise the head of the bed and the CNA used the same gloved hands to perform all these task and never removed the gloves nor did he/she remove the gloves and wash his/her hands. The CNA then pulled the privacy curtains back from around the bed and went over to the biohazard bins and raised the bin lid with his/her same gloved hands and removed the gloves and the gown and placed them in the bin and used her ungloved hand to close the bin and not the foot pedal to open and close the bin. Then he/she went into the resident restroom to wash his/her hands. During an interview on 5/4/2017 at approximately 9:20 AM with CNA #33 confirmed that he/she had not washed his/his hands and had used the same gloved hands used to perform the cath care that he/she used to pull the privacy curtains, raise the bed, move the furniture, and unfasten and fasten the brief. He/she also confirmed that he/she had not cleaned the insertion site of the foley catheter. Review on 5/4/2017 at approximately 9:45 AM of the facility policy titled, Handwashing, states under the Policy Statement: It is the policy of PruittHealth to prevent the spread of bacteria which may lead to foodborne illness by using proper hand washing techniques. Review on 5/4/2017 at approximately 10:00 AM of the facility policy titled, Indwelling Urinary Catheter (Foley) Care and Management, states under implementation, Gather the equipment and supplies at the patient's bedside. Perform hand hygiene. Provide Privacy and explained the procedure to the patient. Perform hand hygiene. Put on gloves and other personal protective equipment (PPE). Provide routine hygiene for meatal care. :Remove and discard your gloves and any other PPE if worn and perform hand hygiene. The facility admitted Resident #78 with [DIAGNOSES REDACTED]. Review on 5/5/2017 at approximately 8:16 AM of the Admission Nursing Observation Form for Resident #78 states, resident on admission (12/29/2016) was continent of bowel and bladder. Review on 5/5/2017 at approximately 8:18 AM of the Plan of Care for Resident #78 included a problem onset dated 12/29/2016 and reads, Resident has physical limitations and cognitive deficits that render the resident with impaired mobility to perform ADLs (Activities of Daily Living) and requires 1 to 2 persons to assist to meet ADL needs with a [DIAGNOSES REDACTED]. Resident #78 does have daily use of a diuretic. No other documentation could found in the medical record for Resident #78 to indicate that he/she was incontinent when admitted to the facility. Review on 5/5/2017 at approximately 8:38 AM of the Nursing Monthly Observation Form states Resident #78 is continent of bowel and bladder. Review on 5/5/2017 at approximately 8:40 AM of a form titled, Bowel/Bladder Elimination Program Assessment Form. reads resident has no history of incontinence and uses the bedside toilet without difficulty. No documentation could be found in the medical record to ensure Resident #78 would not benefit and would not be able to participate in a bowel and bladder training program. Review on 5/5/2017 at approximately 8:42 AM of the Minimum Data Set (MDS) assessment dated [DATE], Section H - Bowel and Bladder under H0300 - Urinary continence is coded with a 1, as occasionally incontinent of bladder and Section H0400 is coded with a 2, frequently incontinent of bowel. Section H also includes a section which asks if a bowel and bladder toileting program has been attempted and the questions was answered with a, No. During an interview on 5/5/2017 at approximately 8:45 AM with the Director of Nursing (DON) confirmed that Resident #78 was continent on admission but since then has had incontinent episodes and also confirmed that a bowel and bladder toileting program had not been attempted for Resident #78. During observation of incontinent care at 2:40 PM on 5-3-17, Certified Nursing Assistant (CNA) #1 gowned and gloved in the hall. When asked why the resident was on isolation precautions, s/he stated,[MEDICAL CONDITIONS]. Resident #72 was transported from the hall to the bathroom in his room. After removing the seatbelt and locking the wheelchair, the CNA assisted the resident to stand using the grab bar. The CNA pulled his pants and brief down and assisted him to sit on the toilet. S/he removed the wet brief. The CNA used the soap from the hand dispenser at the sink to add soap to a periwipe from a container on the back of toilet. S/he proceeded to cleanse the right groin and penis twice, wiping toward the urethra, then wiped around the urethra with the same side of cloth. S/he did not rinse the soap off. CNA #1 said,I know I did that wrong. The CNA assisted the resident to stand and cleansed the perianal area with another disposable cloth, front to back, changing sides of cloth. S/he did not cleanse the left groin or scrotum. CNA #1 stated,Oh, I didn't bring in any gloves as s/he pushed the resident's wheelchair up to the sink. The CNA removed the soiled gloves, put them in the trash in the bathroom, and washed her/his hands. After assisting the resident to wash his hands, s/he removed her/his isolation gown and disposed of it by opening the isolation bin with her/his hands instead of using the foot pedal. The CNA then pushed the resident out of the bathroom and exited the room after opening the door to the hallway without using any type of barrier. S/he did not wash her/his hands before leaving the room and pushing the resident into and down the hall. During an interview immediately following the procedure, CNA #1 verified s/he touched the top of the disposal bin and opened the door without a barrier. On 5-5-17 at 1:02 PM, the corporate consultant provided a copy of the table used for training and return demonstration, Perineal Care. Review of the table listing the procedure to follow for perineal care included: Apply soap to wet washcloth. Wash the perineal area. Wipe in only one direction, from front to back and from center to thighs Male: .Wash and rinse the tip of the penis using a circular motion beginning at the urethra. Continue washing down the penis to the scrotum and inner thighs. With fresh water and a clean washcloth, rinse the area thoroughly with the same [MEDICAL CONDITION]. | 2020-09-01 |
| 969 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 318 | D | 0 | 1 | P4RY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that residents received appropriate care according to the current care plan for 2 of 3 residents reviewed for restorative services. Resident #77 did not receive consistent range of motion services and resident #22 did not receive restorative services to assist with ambulation daily per physician orders. The findings included: The facility admitted Resident #77 with a [DIAGNOSES REDACTED]. A review of the care plan for Resident #77 on 5/5/2017 at approximately 5:30 PM, revealed a Problem/Need for activities of daily living which included impaired mobility with an intervention for AROM/PROM (Active Range of Motion/Passive Range of Motion) with daily care as tolerated which was initiated on 9/24/2014. On 5/5/2017 at approximately 6:30 PM a review of the resident's Care Task Documentation revealed no documentation on these dates for AROM/PROM: 2/5/17, 2/6/17, 2/9/17,3/5/17, 3/23/17,4/2/17, 4/3/17, 4/417, 4/5/17 4/8/17, 4/12/17 4/1617, 4/17/17, 4/19/17,4/22/17 ,4/26/17,4/27/17, 4/29/17 and 4/30/17. Interview with the MDS Coordinator on 5/5/2017 at approximately 7:00 PM verified inconsistent documentation of AROM/PROM for Resident #77. The facility admitted Resident #22 with [DIAGNOSES REDACTED]. Record review on 5/3/17 at 4:14 PM revealed a physician's orders [REDACTED]. Restorative Nursing Flow Record Forms provided on 5/5/2017 at 2:34 PM revealed that restorative was to,Increase mobility AEB (as evidenced by) the ability to ambulate at least 100 feet with RW (rolling walker) daily through next review. Services were not provided as ordered between (MONTH) and (MONTH) (YEAR) on the following dates: 2/4/17, 2/5/17, 2/7/17, 2/11/17, 2/12/17, 2/16, 2/17/17, 2/18/17, 2/20/17, 2/21/17, 2/24/17, 2/26/17, 2/27/17, 3/4/17, 3/8/17, 3/9/17, 3/10/17, 3/21/17, 3/23/17, 3/26/17, 4/8/17, 4/10/ 17, 4/12/17, 4/13/17, 4/16/17, 4/18/17, 4/22/17, 4/23/17, 4/27/17 and 5/1/17. During an interview on 05/05/2017 at 2:45 PM, Certified Nursing Assistant (CNA) #2 stated the blanks in the documentation meant that s/he had been pulled off restorative to handle patient assignments. S/he stated, If Restorative is pulled to the floor, there is no coverage. The CNA assigned to the resident on restorative services does not provide it. | 2020-09-01 |
| 970 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 431 | D | 0 | 1 | P4RY11 | Based on observations, record reviews, interviews the facility failed to assure that medications were stored properly and that expired medications were not in use in 1 of 2 medication rooms and 1 of 2 treatment carts. The findings included: On 5/2/2017 at approximately 10:00 AM inspection of the 100 Hall Medication Room Refrigerator revealed 1 unlabeled, 1 cc (cubic centimeter) syringe containing .1 ml (milliliter). LPN #3, when questioned stated h/she did not know what it was and removed the syringe. On 5/2/17 at approximately 10:10 AM inspection of the 100 Unit treatment cart revealed in the 2nd drawer of the right front storage compartment, one opened 4 ounce tube of Remedy Antifungal Cream (Active ingredient is miconazole nitrate 2%) 1/5th full, expiration 2/2015, and one unopened tube of Remedy Antifungal Cream (Active ingredient is miconazole nitrate 2%), Expiration 2/2015. On 5/2/17 at 10:15 am , the finding was verified by by LPN #4 and h/she stated that no residents were receiving. On 5/2/17 at approximately at 10:20 AM an inspection of the 100 Unit treatment cart revealed a container of Cavilon Durable Barrier Cream 1 oz, Active Ingredient Dimethicone 1.3% Half full expiration, (YEAR)-03 On 5/2/17 at 10:20 AM, the finding was verified by LPN #4. | 2020-09-01 |
| 971 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2017-05-05 | 441 | F | 0 | 1 | P4RY11 | Based on observation and interview, the facility inappropriately handled soiled laundry in 1 of 1 laundry room. The laundry aide was noted to use protective clothing that did not prevent contact with soiled linen when sorting soiled laundry. The findings included: On 05/05/2017 at 9:31 AM, Laundry Aide #1 was observed sorting soiled laundry with the following protection over her uniform; an apron and wrist length disposable gloves. Laundry Aide #1 reached into the soiled laundry container and her/his bare arms and the sleeve and side of her/his uniform touched the soiled laundry and the inside of the soiled laundry container multiple times throughout the sorting process. On 5/05/2017 at approximately 10:00 AM, Laundry Aide #1 was observed during the process of placing the soiled laundry into the front loading washing machines. Again, Laundry Aide #1 was observed reaching into the soiled laundry containers with bare arm, sleeve and side of uniform touched the soiled linen and interior of soiled linen container. On 05/05/2017 at approximately 10:30 AM, during an interview with the Director of Maintenance and Housekeeping he/she said that the facility had long gloves for protection of the arms, but they are not used because the gloves irritated the arms of staff wearing the gloves. On 5/05/2017 at approximately 11:30 AM a review of the facility policy and procedure titled Infection Control-Linen and Laundry Services states: Policy Statement: It is the policy of this facility to provide a clean supply of linens and protect partners who handle and process the linen. The Policy and Procedure further states, Procedure: Routine Handling of Soiled Linen: 2. Soiled linen should be handled as little as possible and with a minimum of agitation to prevent gross microbial contamination of the air and of persons handling the linen. Standard precaution will be used by staff handling the linen. | 2020-09-01 |
| 972 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 568 | D | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of quarterly statements and interviews, the facility failed to provide quarterly statements to the Resident Representative for 1 of 1 sampled resident reviewed for funds (Resident #68). The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. During an interview on 9/09/18 at 2:43 PM, the resident representative stated s/he had not received the last quarterly statement. During an interview on 9/20/18 at 2:28 PM, the Business Office Manager reviewed her/his records and stated that the facility was representative payee and that the quarterly statement had been sent to the resident at the facility even though s/he was incapable of receipt. | 2020-09-01 |
| 973 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 569 | D | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Trust Fund and interviews, the facility failed to provide evidence of Resident Representative notification of account balances greater than that allowable for Medicaid for 1 of 1 sampled resident reviewed for funds (Resident #68). The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review of Resident #68's account revealed that the balance had been greater than $2000 since 12/17. During an interview on 9/20/18 at 2:28 PM, the Business Office Manager (BOM) stated s/he had contacted the Resident Representative to spend down the monies. The BOM stated s/he had not sent the notification in writing to the Representative and was unable to state when s/he had contacted her/him because s/he kept no records of the conversation. | 2020-09-01 |
| 974 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 575 | C | 0 | 1 | F5OV11 | Based on observation and interviews, required postings were not available and/or readily accessible to residents and visitors on 2 of 2 units. The findings included: Observations throughout the survey revealed that the contact information for the Ombudsman and protection and advocacy agency was not readily accessible to wheelchair-bound residents. There was also no information posted about contacting the State licensure or State Survey agencies or the Medicaid Fraud Control Unit to file complaints. During a tour of the facility to observe postings on 9/20/18 at 9:29 AM, the Director of Nursing verified the above. | 2020-09-01 |
| 975 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 577 | C | 0 | 1 | F5OV11 | Based on observation and interview, the results of the survey were not readily available to residents and visitors of the facility. There were no available postings to indicate the location of survey results on 2 of 2 units. The findings included: Observations throughout the survey revealed that the survey was located in a wooden box in the hallway near the 100 Hall nursing station on the back of the entry wall. Only residents and visitors passing this area would notice the wooden box with a small (less than 3 inches by 1 inch) attached sign indicating its contents. There were no signs at any of the 4 visitor entrances to indicate the location of previous survey results. The only residents and visitors passing the wooden box would be those accessing from one of the entrances and proceeding down one of the 4 resident halls or those standing at the 100 Hall nursing station. During a tour of the facility to observe postings on 9/20/18 at 9:29 AM, the Director of Nursing and Administrator verified the above. | 2020-09-01 |
| 976 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 584 | D | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to maintain a clean environment in 2 of 4 rooms reviewed with feeding machines. Rooms 104A and 105A had tube feeding spatter on walls, floor equipment, also walls, handles and furniture were in disrepair. The findings included: 09/19/18 11:30 AM an observation with the House Keeping Supervisor revealed: room [ROOM NUMBER]A had tube feeding spatter on the wall, floor, machine, pole, and base of the pole. room [ROOM NUMBER]A had tube feeding spatter on the wall, floor, machine, pole, and base of the pole. Also, the walls were scuffed, 2 handles (closet and drawer) were broken, and the bed stand furniture was damaged and in disrepair. Furthermore, the suction machine was uncovered, and the tubing was between the drawers. Following the observations of room [ROOM NUMBER]A and 105A, the House Keeping Supervisor verified the tube feeding spatter, and disrepair of the walls, handles, band stand, and suction machine. | 2020-09-01 |
| 977 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 585 | C | 0 | 1 | F5OV11 | Based on observations and interview, the facility failed to support the residents' right to voice grievances by failure to post the grievance policy/procedure including how to contact the grievance official for residents and/or their representatives on 2 of 2 units. The findings included: Observations throughout the survey revealed that the grievance policy/procedure was not readily accessible to residents and/or resident representatives. It was not posted anywhere in the facility. During an interview on 9/18/18 at 4:40 PM, the Director of Nurses stated that the grievance policy was only reviewed with the family on admission. S/he was unaware if posted in the facility so as to be accessible following the admissions process. During an interview on 9/18/18 at 5 PM, the Administrator verified that the grievance policy/procedure was not posted and readily accessible to residents and their representatives. | 2020-09-01 |
| 978 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 637 | D | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review the facility failed to complete a significant change in status assessment after Resident #47 was admitted to hospice. Resident #47 was 1 of 1 resident sampled for Hospice. The findings included: Resident #47 was admitted with Partial traumatic amputation between shoulder and elbow, muscle weakness, [MEDICAL CONDITION] and pressure ulcer. The resident was admitted to hospice effective 9/5/18. Review of the Minimum Data Set (MDS) on 9/19/18 revealed no Significant Change in Status assessment had been completed. Review of the RAI manual related to hospice election states, A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. It must be within 14 days from the effective date of the hospice election. | 2020-09-01 |
| 979 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 644 | D | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a Level 2 screening was done as required for one of 3 sampled residents reviewed for PASARR (Pre-Admission Screening and Resident Review). The facility readmitted Resident #68 following hospitalization with a new mental health [DIAGNOSES REDACTED]. The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Further review revealed a [DIAGNOSES REDACTED]. No recent hospitalization records were noted in the record. During an interview on 9/20/18 at 10:28 AM, the Minimum Data Set (MDS) Coordinator reviewed the record with the surveyor and verified that the resident did not have the [DIAGNOSES REDACTED]. On 9/20/18 at 12:25 PM, after additional review, the MDS Coordinator affirmed that the resident did not have the stated [DIAGNOSES REDACTED]. S/he stated s/he was not aware of the [DIAGNOSES REDACTED]. | 2020-09-01 |
| 980 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 645 | D | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, a Level II Preadmission Screening and Resident Review (PASARR) was not completed on admission for 1 of 3 residents reviewed for PASARR. Resident #24 was admitted with a mental illness [DIAGNOSES REDACTED]. The findings included: Resident #24 was admitted on [DATE] with [DIAGNOSES REDACTED].#24 had a psychiatric hospitalization within the previous two years. Further review revealed no further evaluation was recommended. Interview with the facility Administrator on 09/18/18 at 12:15 PM revealed Resident #24 was not having any problems adjusting so a Level II PASARR was not completed; however, record review revealed the PASARR Level I Screening Form was completed on 6/20/18 but the resident was not admitted until 6/25/18. | 2020-09-01 |
| 981 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 655 | D | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and family interview the facility failed to complete and share with the resident/resident's responsible party a baseline care plan. Resident #44 had a care plan completed but there was no evidence it was shared with the resident and resident #47 had a baseline care plan completed but the responsible party stated during interview that she/he had not received the care plan or had a discussion with anyone about a care plan. Two of 4 residents sampled for baseline care plans. The findings included: Resident #47 was admitted with Partial traumatic amputation between shoulder and elbow, muscle weakness, [MEDICAL CONDITION] and pressure ulcer. During an interview with the resident's responsible party she/he revealed that the facility had not discussed a care plan with her/him since admission. She/he had not seen a copy of her/his mother's plan of care at any time. During a review of the resident's record there was a care plan completed but no documentation that it was reviewed with the resident's responsible party. Resident #44 was admitted with a pressure ulcer and indwelling catheter. A review of the resident's record revealed a baseline care plan completed timely but no documentation it was reviewed with the resident or his/her spouse. There was an area specifically set aside for the date and signature of when the baseline care plan was shared with the resident or responsible party, but it was blank and not signed off. | 2020-09-01 |
| 982 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 656 | E | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to develop and/or implement care plan interventions for turning and positioning for 3 of 8 sampled residents reviewed for pressure ulcers (Residents #26, #29, #68) and 1 of 6 sampled residents reviewed for activities (Residents #68). Additionally, measures were not implemented to minimize fall injuries per the care plan for 1 of 5 sampled residents reviewed for accidents (Resident #29) and the Care Plan was not followed related to use of devices/splints for 1 of 6 sampled residents reviewed for range of motion (Residents #68). The findings included: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Review of the 7-10-18 Quarterly Minimum Data Set (MDS) Assessment on 9/10/18 at 10:15 PM revealed that the resident was totally dependent on staff for bed mobility. Record review on 9/19/18 at 1:26 PM revealed physician's orders [REDACTED]. Review of the Care Plan on 9/19/18 at 3:01 PM revealed interventions for decreased mobility included turning and positioning every 2 hours. Multiple observations revealed Resident #26 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 10:28 AM, 12:15 PM, and 2:12 PM; on 9/10/18 at 8:43 AM, 9:30 AM, 11:03 AM, 12:37 AM, 2:16 PM, and 4:02 PM; on 9/18/18 at 9:31 AM, 11 AM, 12:31 PM, 2:15 PM, and 4:18 PM), indicating s/he had not been turned and positioned every 2 hours. During all observations, a positioning wedge was noted on the bedside table. No pillows or positioning devices were noted in the bed with the resident. During an observation and interview on 9/19/18 at 8:36 AM, the Director of Nurses (DON) verified that the resident was positioned on his/her back. S/he stated, He (she) should be turned every 2 hours and the wedge used for positioning. The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review of the 7-13-18 Quarterly MDS Assessment on 9/10/18 at 9:25 PM revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating a moderately impaired cognitive status. S/he experienced inattention, disorganized thinking, and trouble concentrating. The resident required extensive assistance for bed mobility and was totally dependent for transfers. The MDS noted a fall with minor injury had occurred since the previous assessment. A 11-5-17 significant change in status assessment noted the resident with a stage 3 pressure ulcer. Record review on 9/18/18 at 10:12 AM revealed physician's orders [REDACTED]. Review of the Care Plan on 9/18/18 at 12:47 PM revealed interventions for decreased mobility and skin breakdown included turning and positioning every 2 hours. Interventions for fall risk included a 5-25-18 entry for a Floor mat to right side (of) bed. Multiple observations revealed Resident #29 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 11:48 AM, 1:55 PM, and 3:59 PM; on 9/10/18 at 8:24 AM, 9:45 AM, 11:13 AM, and 12:47 PM; on 9/18/18 at 9:25 AM, 11:04 AM, 12:05 PM, 2:10 PM, 2:25 PM and 4:13 PM), indicating s/he had not been turned and positioned every 2 hours. No pillows or positioning devices were noted in the bed with the resident except to prop up [MEDICAL CONDITION] right arm. Multiple observations on 9/18/18 also revealed Resident #29 in bed without the floor mat in place as ordered and care planned (at 9:25 AM, 11:04 AM, 12:05 PM, 2:10 PM, and 2:25 PM). During an interview and observation on 09/18/18 at 2:25 PM, Licensed Practical Nurse (LPN) #3 verified that the mat was folded and leaning against the bedside table. S/he stated, That mat should be down. During an interview and observation on 9/19/18 at 8:43 AM, the DON verified the resident's positioning. S/he stated that the resident should be turned and positioned every 2 hours. Regarding the mat, the DON stated that it should be in place at all times. The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review of the 8-16-18 Quarterly MDS Assessment on 9/10/18 at 7:21 PM revealed that the resident required extensive assistance of staff for bed mobility, had impaired ROM in both upper and lower extremities, and had a stage 4 pressure ulcer. Record review on 9/18/18 at 3:21 PM revealed physician's orders [REDACTED]. resting hand splints 6-8 hours daily as tolerated. Review of the Care Plan on 09/19/18 at 8:50 PM revealed interventions for decreased mobility and skin breakdown included a turning and positioning program. Interventions for multiple contractures included Bilateral elbow & wrist braces as tolerated. During an interview on 9/09/18 at 2:36 PM, Resident #68's family asked, When does that (positioning) wedge go on? We never see it used. (Resident #68) is always on her (his) back when we're here. They also stated that facility staff used to put splints on but couldn't get it uncontracted. They never put splints on or rolls in her (his) hands. Multiple observations revealed Resident #68, with bilateral upper extremity contractures, positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 10:36 AM, 12:24, 2:19 PM, and 4:17 PM; on 9/18/18 at 9:32 AM, 11:30 AM, 2:17 PM, and 5:47 PM), indicating s/he had not been turned and positioned every 2 hours. During all observations, a positioning wedge was noted in the chair. No pillows or positioning devices were noted in the bed with the resident. No devices/splints were in place to prevent further decline in ROM and no splints were visible in the room until 9/18/18 at 11:30 AM, when one resting hand splint was noted on the left upper extremity. During an interview on 9/19/18 at 9:23 AM, the DON stated, They should turn her (him) every 2 hours and use the wedge. During an interview on 9/18/18 at 4:24 PM, LPN #4 verified that only the left resting hand splint was in place. S/he searched the room and was unable to locate any other splints. LPN #4 stated that the Certified Nursing Assistant was responsible for splint application. During an interview and observation on 9/19/18 at 9:23 AM, while Resident #68 was at [MEDICAL TREATMENT], the DON confirmed 2 resting hand splints on the cabinet next to the television. S/he did not know how long the splints had been missing. During an interview on 9/19/18 at 12:21 PM, after review of the therapy notes, the Rehab Coordinator stated that Resident #68 had been discontinued from skilled therapy on 3-9-17 with splints after caregiver education. S/he further stated, We will need to do a new evaluation since the elbow splints are missing to determine if contractures are worse. On 9/19/18 at 2:49 PM, the Occupational Therapist verified the physician's orders [REDACTED]. Additionally, observations on all days of the survey revealed that the resident was either in bed or out to [MEDICAL TREATMENT]. No activities were observed other than the television being on in the room. During an interview on 9/09/18 at 2:34 PM, Resident #68's family members expressed concern that they never saw her/him out of bed and would like to see her/him attend activities and get out of the room on days s/he didn't have [MEDICAL TREATMENT]. When asked, they stated they had expressed this to facility staff. They stated that Resident #68 had previously been very active individually (always on the go), in community groups, and had attended church every Sunday. Review of the 12-29-17 Annual MDS Assessment on 9/10/18 at 7:21 PM revealed that books, magazines, newspapers, music, news, groups, and religious services were very important to the resident. Section G noted that the resident transferred from bed only 1-2 times during the 7-day look-back period. Review of the Care Plan on 09/19/18 at 8:50 PM revealed that Resident needs one on one activities in room when not up and out of bed. (MONTH) also attend activities of interest out of room as tolerated. The goal was limited to one on one in room activities and did not address group activities. Although the resident was unable to communicate and only made eye contact, interventions included to Ask Resident about activity preferences and help plan. The plan did not include resident representatives' concerns. On 9/20/18 at 9:59 AM, review of One-to-One/Small Group Attendance Record Forms for 6/18 through 9/18 with the Activity Director (AD) revealed no attendance at group activities of any kind. During an interview on 9/19/18 at 11:38 AM, the Activity Director stated, The resident is not up and out to come to group. Basically, s/he's always in bed. That's why we do 1:1. The Activity Director reviewed the (MONTH) calendar and noted multiple events the resident would have enjoyed based on her/his noted interests, but that s/he had not been out of bed. S/he stated, We (Activities) can't get her (him) up but we would be glad to bring her (him) to programs. | 2020-09-01 |
| 983 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 657 | D | 0 | 1 | F5OV11 | Based on observation, record review, and interview, the facility failed to update Care Plans for 1 of 5 residents reviewed for accidents. The Care Plan for Resident #50 was not updated related to wanderguard placement. The findings included: Observation of Resident #50 on 09/18/18 at 06:18 PM revealed the resident sitting in the TV room by the nurse's station. A wanderguard was observed on the right ankle. Observation on 09/19/18 at 08:37 AM revealed Resident #50 in bed eating breakfast. Staff entered the room and used a device to check for placement and function of the wanderguard, which was on the resident's right ankle. Record review of a 8/21/18 Nurse's Note revealed, Resident noted to be outside on premises. Wanderguard not in place. Resident assisted back inside by staff. Another 8/21/18 Nurse's Note stated Wanderguard placed to residents R (right) leg. Review of the Care Plan for Resident #50 revealed Resident is an elopement risk and requires the use of a wanderguard. Further review revealed this Care Plan was not updated following the incident on 8/21/18. Interview with the Director of Nurses on 09/19/18 at 09:45 AM confirmed the 8/21/18 Nurse's Note that Resident #50 was found outside. Interview with Licensed Practical Nurse #3 on 09/19/18 at 10:45 AM revealed Resident #50 was able to get the wanderguard off his/her wrist, so they started applying it to his/her ankle though this was not indicated on the Care Plan. Interview with MDS (Minimum Data Set) Care Plan Coordinator #1 on 09/19/18 at 10:47 AM confirmed the Care Plan was not updated with the change in wanderguard placement following this incident. | 2020-09-01 |
| 984 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 679 | D | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to provide opportunities to attend group activities and/or provide individualized activities based on the resident's previous lifestyle and preferences for 1 of 6 sampled residents reviewed for activity participation (Residents #68). The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Observations on all days of the survey revealed that the resident was either in bed or out to [MEDICAL TREATMENT]. No activities were observed other than the television being on in the room. During an interview on 9/09/18 at 2:34 PM, Resident #68's family members expressed concern that they never saw her/him out of bed and would like to see her/him attend activities and get out of the room on days s/he didn't have [MEDICAL TREATMENT]. When asked, they stated they had expressed this to facility staff. They stated that Resident #68 had previously been very active individually (always on the go), in community groups, and had attended church every Sunday. Review of the 12-29-17 Annual Minimum Data Set (MDS) Assessment on 9/10/18 at 7:21 PM revealed that books, magazines, newspapers, music, news, groups, and religious services were very important to the resident. Section G noted that the resident transferred from bed only 1-2 times during the 7-day lookback period. Review of the Care Plan on 09/19/18 at 8:50 PM revealed that Resident needs one on one activities in room when not up and out of bed. (MONTH) also attend activities of interest out of room as tolerated. The goal was limited to one on one in room activities and did not address group activities. On 9/20/18 at 9:59 AM, review of One-to-One/Small Group Attendance Record Forms for 6/18 through 9/18 with the Activity Director (AD) revealed no attendance at group activities of any kind. During an interview on 9/19/18 at 11:38 AM, the Activity Director stated, The resident is not up and out to come to group. Basically, s/he's always in bed. That's why we do 1:1. The Activity Director reviewed the (MONTH) calendar and noted multiple events the resident would have enjoyed based on her/his noted interests, but that s/he had not been out of bed. S/he stated, We (Activities) can't get her (him) up but we would be glad to bring her (him) to programs. | 2020-09-01 |
| 985 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 686 | E | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to provide care and services to prevent development of pressure ulcers in high risk residents and promote healing of existing pressure ulcers for 3 of 8 residents reviewed with pressure ulcers. Residents #68, #29, and #26 were not turned and positioned every 2 hours per physician's orders [REDACTED]. In addition, the nurse failed to cleanse the scissors prior to cutting a dressing to be used as wound packing on a stage 4 pressure ulcer for Resident #68. The findings included: The facility admitted Resident #26 with [DIAGNOSES REDACTED]. Review of the 7-10-18 Quarterly Minimum Data Set (MDS) Assessment MDS on 9/10/18 at 10:15 PM revealed that the resident was totally dependent on staff for bed mobility. Record review on 9/19/18 at 1:26 PM revealed physician's orders [REDACTED]. Review of the Care Plan on 9/19/18 at 3:01 PM revealed interventions for decreased mobility included turning and positioning every 2 hours. Multiple observations revealed Resident #26 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 10:28 AM, 12:15 PM, and 2:12 PM; on 9/10/18 at 8:43 AM, 9:30 AM, 11:03 AM, 12:37 AM, 2:16 PM, and 4:02 PM; on 9/18/18 at 9:31 AM, 11 AM, 12:31 PM, 2:15 PM, and 4:18 PM), indicating s/he had not been turned and positioned every 2 hours. During all observations, a positioning wedge was noted on the bedside table. No pillows or positioning devices were noted in the bed with the resident. During an observation and interview on 9/19/18 at 8:36 AM, the Director of Nurses (DON) verified that the resident was positioned on his/her back. S/he stated, He (she) should be turned every 2 hours and the wedge used for positioning. The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review of the 7-13-18 Quarterly Minimum Data Set (MDS) Assessment MDS on 9/10/18 at 9:25 PM revealed that the resident required extensive assistance of 2 staff members for bed mobility. A 11-5-17 significant change in status assessment noted the resident with a stage 3 pressure ulcer. Record review on 9/18/18 at 10:12 AM revealed physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Care Plan on 9/18/18 at 12:47 PM revealed interventions for decreased mobility and skin breakdown included turning and positioning every 2 hours. Multiple observations revealed Resident #29 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 11:48 AM, 1:55 PM, and 3:59 PM; on 9/10/18 at 8:24 AM, 9:45 AM, 11:13 AM, and 12:47 PM; on 9/18/18 at 9:25 AM, 11:04 AM, 12:05 PM, 2:10 PM, 2:25 PM and 4:13 PM), indicating s/he had not been turned and positioned every 2 hours. No pillows or positioning devices were noted in the bed with the resident except to prop up [MEDICAL CONDITION] right arm. During an interview and observation on 9/19/18 at 8:43 AM, the DON verified the resident's positioning. S/he stated that the resident should be turned and positioned every 2 hours. The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review of the 8-16-18 Quarterly Minimum Data Set (MDS) Assessment MDS on 9/10/18 at 7:21 PM revealed that the resident required extensive assistance of staff for bed mobility and had a stage 4 pressure ulcer. Record review on 9/18/18 at 3:21 PM revealed physician's orders [REDACTED]. Review of the Care Plan on 09/19/18 at 8:50 PM revealed interventions for decreased mobility and skin breakdown included a turning and positioning program. During an interview on 9/09/18 at 2:36 PM, Resident #68's family asked, When does that (positioning) wedge go on? We never see it used. (Resident #68) is always on her (his) back when we're here. Multiple observations revealed Resident #68 positioned on his/her back with the head of the bed elevated at least 30 degrees (on 9/09/18 at 10:36 AM, 12:24, 2:19 PM, and 4:17 PM; on 9/18/18 at 9:32 AM, 11:30 AM, 2:17 PM, and 5:47 PM), indicating s/he had not been turned and positioned every 2 hours. During all observations, a positioning wedge was noted in the chair. No pillows or positioning devices were noted in the bed with the resident. During an interview on 9/19/18 at 9:23 AM, the DON stated, They should turn her (him) every 2 hours and use the wedge. During observation of the stage 4 sacral pressure ulcer treatment on 9/18/18 at 11:30 AM, Licensed Practical Nurse #5 removed a pair of scissors from her/his pocket and cut the silver alginate dressing with which the wound was to be packed. Before application, the surveyor stopped the nurse and asked about cleansing the implement. The nurse stated s/he had cleaned it earlier with a Clorox Wipe. The Lippincott Procedures for alginate dressing application provided by the facility at 10:23 AM on 9-20-18 stated to Cut the dressing to the size of the wound using sterile scissors . | 2020-09-01 |
| 986 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 688 | E | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide services as ordered to prevent further decline in mobility for 1 of 6 sampled residents reviewed for range of motion (R0M). Resident #68 did not have splints applied as ordered. The findings included: The facility admitted Resident #68 with [DIAGNOSES REDACTED]. Review of the 8-16-18 Quarterly Minimum Data Set (MDS) Assessment on 9/10/18 at 7:21 PM revealed that the resident had impaired ROM in both upper and lower extremities. Record review on 9/18/18 at 3:21 PM revealed physician's orders [REDACTED]. resting hand splints 6-8 hours daily as tolerated. Review of the Care Plan on 09/19/18 at 8:50 PM revealed interventions for multiple contractures included Bilateral elbow & wrist braces as tolerated. During an interview on 9/09/18 at 3:05 PM, Resident #68's family members stated that facility staff used to put splints on but couldn't get it uncontracted. They never put splints on or rolls in her (his) hands. Multiple observations revealed Resident #68 with bilateral upper extremity contractures without any devices/splinting in place to prevent further decline in ROM (on 9/09/18 at 10:36 AM, 12:24, 2:19 PM, and 4:17 PM; on 9/18/18 at 9:32 AM). No splints were visible in the room. On 9/18/18 at 11:30 AM, one resting hand splint was noted for the first time on the left upper extremity. During an interview on 9/18/18 at 4:24 PM, Licensed Practical Nurse (LPN) #4 verified that only the left resting hand splint was in place. S/he searched the room and was unable to locate any other splints. LPN #4 stated that the Certified Nursing Assistant was responsible for splint application. On 9/19/18 at 9:23 AM, while Resident #68 was at [MEDICAL TREATMENT], 2 resting hand splints were noted on the cabinet next to the television. During an interview at this time, the Director of Nurses (DON) checked the Medication Administration Record [REDACTED]. The DON stated, The nurse should circle their initials and document why the splints were not on. S/he did not know how long the splints had been missing. During an interview on 9/19/18 at 12:21 PM, after review of the therapy notes, the Rehab Coordinator stated that Resident #68 had been discontinued from skilled therapy on 3-9-17 with splints after caregiver education. S/he further stated, We will need to do a new evaluation since the elbow splints are missing to determine if contractures are worse. On 9/19/18 at 2:49 PM, the Occupational Therapist verified the physician's orders [REDACTED]. | 2020-09-01 |
| 987 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 689 | E | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide a fall mat as ordered to minimize injury in the event of falls for one of five sampled residents reviewed for accidents (Resident #29). The findings included: The facility admitted Resident #29 with [DIAGNOSES REDACTED]. Review of the 7-13-18 Quarterly Minimum Data Set (MDS) Assessment on 9/10/18 at 9:25 PM revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 9, indicating a moderately impaired cognitive status. S/he experienced inattention, disorganized thinking, and trouble concentrating. The resident required extensive assistance for bed mobility and was totally dependent for transfers. The MDS noted a fall with minor injury had occurred since the previous assessment. Record review on 9/18/18 at 10:12 AM revealed physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Care Plan on 9/18/18 at 12:47 PM revealed interventions for fall risk included a 5-25-18 entry for a Floor mat to right side (of) bed. Multiple observations on 9/18/18 revealed Resident #29 in bed without the floor mat in place as ordered and care planned (at 9:25 AM, 11:04 AM, 12:05 PM, 2:10 PM, and 2:25 PM). During an interview and observation on 09/18/18 at 2:25 PM, Licensed Practical Nurse (LPN) #3 verified that the mat was folded and leaning against the bedside table. S/he stated, That mat should be down. During an interview regarding the mat on 9/19/18 at 8:43 AM, the Director of Nurses stated that it should be in place at all times. | 2020-09-01 |
| 988 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 730 | E | 0 | 1 | F5OV11 | Based on review of inservice records and interviews, the facility failed to ensure that 8 of 20 Certified Nursing Assistants (CNAs) received 12 hours of continuing education on an annual basis as required. This has the potential to affect patient care rendered to all residents to whom they are assigned. The findings included: Review of the facility's inservice records on 9-20-18 revealed that 8 of the 20 CNAs employed greater than one year had not completed their 12 hours of continuing education as required to maintain their certification. During an interview on 9-20-18 at 4:30 PM, this requirement was explained to the Director of Nurses. No further documentation was provided. | 2020-09-01 |
| 989 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 770 | E | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure labs were done timely and/or done as ordered for 4 of 8 residents reviewed for unnecessary medications. Labs for Residents #24, #7, #60, #74 were not done timely and/or done as ordered with two resulting in delay of treatment. The findings included: Record review of the 7/4/18 Physician's Interim Order for Resident #24 revealed an X-ray to bilateral ribs (3 views) STAT (immediately) was ordered related to a fall. Review of another 7/4/18 Physician's Interim Order revealed: U/A (urinalysis) with C&S (culture and sensitivity) per family request to rule out UTI (Urinary Tract Infection). Review of the 7/14/18 Physician's Interim Order revealed: D/C'd (discontinued) U/A with C&S dated 7/5/18, U/A with C&S 7/15/18. Further review revealed a 7/16/18 Physician's Interim Order [MEDICATION NAME] mg (1) tab PO (by mouth) BID (twice daily) x 7 days for UTI and a 7/18/18 Physician's Interim Order to D/[MEDICATION NAME] start [MEDICATION NAME] 100 mg 1 tab PO BID x 10 days for UTI. Interview with the Director of Nurses (DON) on 09/18/18 at 04:24 PM revealed the U/A with C&S was ordered on [DATE] but no requisition was sent so it was reordered on [DATE]. S/he provided the (MONTH) (YEAR) Daily Laboratory Draw Form, which listed the U/A with C&S for Resident #24. The form indicated no requisition. Further interview with the DON on 09/18/18 at 05:57 PM revealed the requisition was located but the lab never received it. A copy of this was provided with a collection date of 7/5/18. The DON stated at some point it was discovered that the lab was not completed so the previous order was discontinued and the lab was reordered. The facility admitted Resident #7 with [DIAGNOSES REDACTED]. Record review on 9/19/18 at 9:55 AM revealed physician's orders [REDACTED]. Continued review revealed that the last lipid panel in the medical record was dated 1/8/18. During an interview on 9/19/18 at 2:29 PM, the Minimum Data Set (MDS) Coordinator #1 verified that the lipid panel had not been done as ordered with the other labs scheduled for every 6 months. S/he reviewed the record and confirmed that the lab order had been signed by the physician monthly from 6/18 through the dates of the survey (4 months). During an interview on 9/19/18 at 4:10 PM, MDS Coordinator #2 and Licensed Practical Nurse (LPN) #6 stated that the facility policy had changed in 10/17 to do the lipid profile annually. Review of the Lab Book revealed that the lipid profile had been crossed out on the lab form. Both nurses verified the physician's orders [REDACTED]. No order could be found changing the timeframes for the lab draws. The facility admitted Resident #60 with [DIAGNOSES REDACTED]. Record review on 9/19/18 at 3:31 PM revealed 7-26-18 physician's orders [REDACTED]. Lab results were reviewed on 9/19/18 at 4:37 PM and no results could be located for the Lipid Profile. During an interview on 9/19/18 at 5:35 PM, the Director of Nurses (DON) stated that the labs had been done at the consultant physician's office, but these were not available on the record for review. The lab results were faxed to the facility on [DATE], but did not include the Lipid Profile. During an interview at 9:15 AM on 9-20-18, the DON verified that the Lipid Profile results were not included in this information. At 9:31 AM, the DON stated that the lipid profile had not been done because the resident was not fasting. The facility admitted Resident #74 with [DIAGNOSES REDACTED]. Record review on 9/20/18 at 10:30 AM revealed physician's orders [REDACTED]. Review on 9/20/18 at 11:12 AM revealed the only lab results in the record consistent with this order were completed in 3/18. No results were located for 9/17. Further review revealed physician's orders [REDACTED]. Review of labs revealed that the physician reviewed the 9-6-18 monthly results and ordered that the test be repeated in one week. No results were noted in the medical record. During an interview on 9/20/18 at 1:06 PM, the MDS Coordinator verified the physician's orders [REDACTED]. The lab results, faxed to the facility on [DATE], noted that the PT/INR had been drawn and reported on 9-13-18. The Nurse Practitioner did not review the lab until 9-20-18 which resulted in a delay in treatment. After review, s/he increased the resident's [MEDICATION NAME] dose to 9 mg daily. During an interview on 9/20/18 at 3:53 PM, the DON confirmed that the lab results had been faxed to the facility that morning and medication orders were changed, resulting in delay of treatment. No lab results were provided for 9/17. | 2020-09-01 |
| 990 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 779 | D | 0 | 1 | F5OV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have signed and dated diagnostic reports available for review in the clinical record as required to maintain continuity of care for one of 8 sampled residents reviewed for unnecessary medications (Resident #60). The findings included: The facility admitted Resident #60 with [DIAGNOSES REDACTED]. Record review on 9/19/18 at 3:31 PM revealed 7-26-18 physician's orders [REDACTED]. Lab and Diagnostic results were reviewed on 9/19/18 at 4:37 PM and no results could be located for these diagnostic tests. During an interview on 9/19/18 at 5:35 PM, the Director of Nurses (DON) stated that the diagnostic tests had been done at the consultant physician's office, but these were not available on the record for review. | 2020-09-01 |
| 991 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2018-09-20 | 812 | F | 0 | 1 | F5OV11 | Based on observation, interview, and review of the facility policies, the facility failed to prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchens reviewed and has the potential to affect 73 of 73 residents with ordered diets as evidenced by failing to do the following: Clean vents, pans, cooler, and air-dry pans. The findings included: On 9/18/18 at 4:45 PM, during an observation in the main kitchen of the dinner line plating revealed (3) vents above the steam table, (1) vent above the food preparation area across from the stove, and (1) vent in the dishwashing area had a large build-up of dust. Also, below the steam table and on the dry pan rack, a stack of (4) full pans, (7) 1/6 pans, and (4) 1/3rd pans were stacked wet and had food debris on them. On 9/19/18 at 9:10 AM, an observation of the main kitchen with The Certified Dietary Manager (CDM) revealed (3) vents above the steam table, (1) vent above the food preparation area across from the stove, and (1) vent in the dishwashing area had a large build-up of dust. Also, the door and base board of the cooler were rusted showing holes through the outer layer of steel. On 9/19/18 at 9:15 AM, during an interview with the CDM, s/he verified pans were stacked wet and had food debris on them, also the vents above the steam table, food preparation area and in the dishwashing area had a large build-up of dust, furthermore the door and base of the cooler were rusted. Review of the facility policy entitled, Dishwashing, revealed under procedure (8.) Allow all items to thoroughly air dry before unloading racks or storing items. | 2020-09-01 |
| 4363 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2016-07-15 | 205 | C | 0 | 1 | 2DDJ11 | Based on record review and interview, the facility failed to provide a notice that specified the duration of the bed-hold policy during which the resident is permitted to return and the nursing facility's policies regarding bed-hold period for Resident #35, 1 of 1 resident reviewed for bed hold. The findings included: During a family interview for Resident #35 on 7/12/16, the Responsible Party (RP) stated that the resident had been hospitalized in the last several months. The RP also stated that a Bed Hold notice was not provided that stipulated the duration of the Bed Hold. On 07/12/2016 at 9:05 PM, review of the admission records for the resident and interview with the Admissions Coordinator revealed Resident #35's Responsible Party was informed of the Bed Hold Policy upon admission. Record review revealed no documentation that the bed hold policy had been provided to the RP or sent to the hospital at the time of transfer. Review of the Acute Care Transfer Document Checklist revealed a copy of the facility's bed hold policy was not included. Review of the bed-hold policy revealed that any resident transferred/ discharged from the healthcare center be allowed to be readmitted unless the healthcare center believes it will be unable to treat the resident. The policy further stated that the bed hold policy will be provided on admission and at the time of any transfer. The policy also stated that in cases of emergency, at the time of transfer means within 24 hours of the transfer. The policy further states that if the resident's copy of the bed hold notice is sent with other papers accompanying the resident to the hospital, the requirement is met. During an interview on 07/13/2016 at 11:18 AM, Licensed Practical Nurse (LPN) #3 confirmed that the policy stated a second notice which specified the duration of the bed hold policy, would be issued at the time of transfer. The LPN confirmed a Bed Hold notice is not included in the packet sent to the hospital when a resident is transferred and that a notice specifying the duration of the bed hold is not provided by the facility. The LPN further stated that the Transition Nurse, a facility Employee, or Case Manager, from the hospital, provided that information and that no one at the facility kept track of the notification. S/he also stated that the Transition Nurse travels and does not have an office at the facility and was not sure if s/he had an office at the hospital. | 2020-02-01 |
| 4364 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2016-07-15 | 253 | E | 0 | 1 | 2DDJ11 | Based on observation and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 2 of 2 observed units. The findings included: During initial tour at approximately 11:45 AM on 7/11/2016, observations revealed the following housekeeping and maintenance concerns. These concerns were confirmed during a tour with the Maintenance Supervisor at approximately 4:05 PM on 7/14/2016. 100 Hall 1. Spa #3 contained the following: discolored grout in the corner of the shower; black/rust discoloration on the shower hose; and a privacy curtain dragging along the floor. 2. Spa #4 contained the following: discolored grout in the shower; black film/residue on the wall of the shower traveling up a foot; and a wet spot/discoloration on the ceiling tiles near the toilet. 3. Rooms 101, 103, 104, 106, 107, 108, 117, 120, 124, and 126 had stained floor tiles and discolored, warped, and/or separated baseboards beneath the sinks. 4. Room 101 had a rusty vent. 5. Room 115 contained food particles littered throughout its baseboard and walls. 6. The dining room had the following: wallpaper splits in several locations; 1 out of 4 of the tables were loose and unstable; black spotted substance was found around the air vent and ascended to the ceiling; and a loose and stained ceiling tile. 7. A blackened ceiling tile was directly above the med cart near the nurse's station. 8. The entrance lobby contained a stain of 1 foot in diameter and rust stains beneath the table. 200 Hall 1. Shower #1 contained yellowish-brownish discoloration of grout 1.5 feet from floor. 2. Shower #2 contained a rusty shower frame and floor; yellowish-brownish discoloration of grout. 3. Rooms 209 and 215 had loose baseboards. 4. Room 212 had a buildup of dirt and debris along the corners and edges by the bathroom. 5. Room 216 had a buildup of dirt and debris along the corners and edges of the room. 6. Room 218 had five inches of the veneer strip missing from the side edge of the bedside table. 7. Dining room contained overbed table with worn edges exposed and bugs in the light fixtures. | 2020-02-01 |
| 4365 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2016-07-15 | 274 | D | 0 | 1 | 2DDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the CMS ' s (Centers for Medicare/Medicaid) RAI (Resident Assessment Instrument) Version 3.0 Manual, the facility failed to identify a significant change and conduct a Significant Change in Status Assessment for Resident #67, 1 of 1 resident reviewed with a Significant change in condition. The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Resident #67 was re-admitted on [DATE] with additional [DIAGNOSES REDACTED]. At 9:20 AM on 07/14/2016, review of the MDS (Minimal Data Set) assessments revealed an Admission assessment dated [DATE] and a Quarterly assessment dated [DATE]. The assessments indicated a decline in cognition/ decision making with the BIMS (Brief Interview for Mental Status) score decreasing from a score of 13, cognitively intact, to a score of 11,moderately cognitively impaired. The assessment also indicated the resident declined from limited assistance to extensive assistance in eating, a decline in continence from frequently to always incontinent. In addition, the MDS coded the resident as having had a significant weight loss form 149 pounds to 120 pounds. Review of the 5/14/16 discharge summary indicated the [DIAGNOSES REDACTED]. Review of the RAI Manual, Chapter 2, page 2-21 revealed A SCSA (Significant Change in Status Assessment) is appropriate when: - There is a determination that a significant change (either improvement or decline) in a resident ' s condition from his/her baseline has occurred as indicated by comparison of the resident ' s current status to the most recent comprehensive assessment and any subsequent Quarterly assessments; and - The resident ' s condition is not expected to return to baseline within two weeks. In addition, the RAI manual defines a decline in status as a Decline in two or more of the following: - Resident ' s decision-making changes; - Presence of a resident mood item not previously reported by the resident or staff and/or an increase in the symptom frequency (PHQ-9(C)), e.g., increase in the number of areas where behavioral symptoms are coded as being present and/or the frequency of a symptom increases for items in Section [NAME] (Behavior); - Any decline in an ADL (Activity of Daily Living) physical functioning area where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment; - Resident ' s incontinence pattern changes or there was placement of an indwelling catheter; - Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days); - Emergence of a new pressure ulcer at Stage II or higher or worsening in pressure ulcer status; - Resident begins to use trunk restraint or a chair that prevents rising when it was not used before; and/or - Overall deterioration of resident ' s condition. Further review of the Manual, Chapter 3, page 3-14 revealed a BIMS score of 13-15 was considered cognitively intact, a score of 8-12: moderately impaired cognition and a score of 0-7: severe impairment of cognition. During an interview at 07/14/2016 10:10:14 AM, the MDS Coordinator stated the system doesn't usually flag for a significant change for a 2 point decline in the BIMS score and that Dietary addressed the weight loss. The Coordinator stated s/he would look into the decline in ADLs. On 07/14/2016 at 12:52 PM, the MDS Coordinator confirmed the resident had declined in cognition, eating, and continence on the 6/6/16 Quarterly MDS assessment. The MDS Coordinator stated the weight loss was anticipated due to diuretic therapy and multiple medication changes for [MEDICAL CONDITION] and Diabetes Mellitus. In addition, the MDS Coordinator confirmed that a 2 point decline in cognition would constitute a significant decline if the change indicated the resident went from cognitively intact to moderately impaired and that was part of what would be at the discretion of the IDT (Interdisciplinary Team). The Coordinator indicated that the resident was sick on admission and sick after returning from the hospital so the IDT had not been able to determine what the resident's baseline was but when asked if the resident was the same person on the Quarterly assessment as he/she was at the time of the Comprehensive Assessment and formulation of the care plan, s/he confirmed the resident was not the same. The Coordinator confirmed a Significant Change in Status Assessment should have been conducted. | 2020-02-01 |
| 4366 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2016-07-15 | 332 | D | 0 | 1 | 2DDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the manufactures recommendations, the facility failed to maintain a medication rate of less than 5%. There were 2 errors out of 28 opportunities for error, resulting in a medication error rate of 7.1%. The findings included: Error #1 On [DATE] at approximately 8:00 AM, during an observation of Resident #58's medication administration, Licensed Practical Nurse (LPN) #1 removed an [MEDICATION NAME] Diskus ,[DATE] inhaler from the pharmacy packaging that had a hand written date of [DATE], also the inhaler had a hand written date of [DATE], LPN #1 then attempted to administer the medication. Following the observation of the [MEDICATION NAME] Diskus ,[DATE] inhaler dated [DATE], LPN #1 verified the inhaler was expired on [DATE] per manufacture box instructions. Review of the manufacture recommendations on the box and insert revealed instructions that state, Discard [MEDICATION NAME] Diskus 1 month after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first. Also, the box insert states under How should I store [MEDICATION NAME] Diskus? Safely throw away [MEDICATION NAME] Diskus in the trash 1 month after you open the foil pouch or when the counter reads 0, whichever comes first. Review of the facility policy, Medication Storage and Expiration located in the Medication Administration Record [REDACTED] On [DATE] at 12:00 PM, during an interview with the facility pharmacy consultant, s/he provided, Supplemental Stability Information that states, GlaxoSmithKline has a stability database for the commercially supplied [MEDICATION NAME] Diskus products (strengths ,[DATE], ,[DATE] and ,[DATE] mcg per blister) when stored at 25 degrees C (77degrees F) and 75% relative humidity without overwrap for up to 3 months. These data indicate that the typical product performance is acceptable when used up to 3 months after storage at 25 degrees C and 75% relative humidity without overwrap, but not beyond the expired date of the [MEDICATION NAME] Diskus product. Also, Data Regarding [MEDICATION NAME] Diskus When Stored at Higher Than Recommended Temperatures, revealed under summery bullet (3) states, Results of supplemental stability testing of [MEDICATION NAME] Diskus at 40 degrees C 75% relative humidity for 6 months, both within and outside the foil overwrap, showed the product was within acceptable limits for the measures evaluated at 1 month. However, at 3 and 6 months, failures were observed with respect to drug-related impurities and fine particle mass. Following review of the supplemental stability information the facility pharmacy consultant was asked to provide a storage temperatures and relative humidity logs for the storage of the [MEDICATION NAME] Diskus. The facility could not provide the information requested. Error #2 On [DATE] at 8:40 AM, during an observation of Resident #52 ' s medication administration, LPN #2 administered [MEDICATION NAME] XR ,[DATE] tablet crushed to Resident #52. Review of the facility policy, Medication administration: Oral Medications, states under Special Consideration: (1) Refer to Crush List prior to crushing any medication for assurance that it can be pulverized safely. Review of the [MEDICATION NAME] XR manufacture recommendations reveals under, How should I take Junumet XR? Bullet (5) states, Take [MEDICATION NAME] XR tablets whole. Do not break, cut, crush, dissolve, or chew [MEDICATION NAME] XR tablets before swallowing. If you cannot swallow [MEDICATION NAME] XR tablets whole, tell your doctor. On [DATE] at 12:00 PM, during an interview with the facility pharmacy consultant, s/he verified the manufacture recommendation that [MEDICATION NAME] XR ,[DATE] should not be crushed. | 2020-02-01 |
| 4367 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2016-07-15 | 371 | D | 0 | 1 | 2DDJ11 | Based on observation, and interviews, the facility failed to prepare, distribute, and serve food under sanitary conditions for 2 of 2 units and has the potential to effect 71 of 71 residents with ordered diets as evidenced by staff touching residents food during meal. The finding included: On 7/11/16 at 1:15 PM, during lunch observation on the 200 unit, Certified Nursing Assistant (CNA) #1 delivered Resident #72 ' s tray and reached in a bag grabbing bread with her/his bare hand and placed the bread on the residents plate. Following the observation CNA verified s/he did remove the resident bread with his/her hand and stated, I was trained to shake bread out of bag and not to touch it. On 7/11/16 at 12:51 PM, during a random observation of Resident in room 108, Certified Nursing Assistant (CNA) #2 delivered the resident's tray, reached in the bag and removed the bread with her/his hand and placed the bread on the resident's plate. Following the observation CNA #2 verified s/he did remove the resident bread with her/his hand and stated I know I wasn't supposed to touch the bread. | 2020-02-01 |
| 5404 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2015-03-19 | 253 | E | 0 | 1 | 4CJS11 | Based on observations and interviews, the facility failed to provide effective housekeeping and maintenance services in resident's rooms and shower/spa areas as evidenced by furniture and tile in disrepair. The findings included: On 3/16/15 at approximately 10:50 AM, during initial tour, multiple random observations of warped bed side tables were bubbled, cracked, with peeled vinyl and broken plastic that showed the particle board beneath. Also, in the upper 100 unit spa, the tile was cracked with rust stains and a brown/black substance on the grout of the shower room floor. On 3/18/15 at approximately 9:45 AM, a walk-through of the facility with the Maintenance Director revealed warped bed side tables in 25 rooms (101, 103, 104, 114, 116, 121, 123, 125, 127, 128, 129, 203, 204, 205, 211, 212, 213, 214, 215, 217, 218, 219, 220, 221, 226). Also, in the upper 100 unit spa. the tile was cracked with rust stains and a brown substance on the grout of the shower. Following the observation, the Maintenance Director verified the observations of the bed side tables and spa/shower area and stated I was aware of this and they need to be fixed and replaced . | 2018-12-01 |
| 5405 | PRUITTHEALTH- BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2015-03-19 | 333 | D | 0 | 1 | 4CJS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy, the facility failed to administer the correct amount of Diabetes Mellitus (DM) medication ordered by the physician for 1 of 2 residents reviewed for Diabetic medication administration. Resident #93 did not receive the correct amount of physician ordered [MEDICATION NAME] during medication administration. The findings included: The facility admitted Resident #93 with [DIAGNOSES REDACTED]. On 3/17/15 at 5:12 PM, during an observation of medication pass, Registered Nurse (RN) #1 crushed a [MEDICATION NAME] 1000 milligram (mg) tablet and placed the medication in a medication cup with approximately 15 milliliters(ml) of water. RN #1 then administered the contents of the medication cup into a syringe connected to Resident #93's percutaneous endoscopic gastrostomy (PEG) tube. The [MEDICATION NAME] 1000 mg. tablet did not dissolve and a significant amount of the medication remained at the bottom of the syringe and in the medication cup. Following the administration, RN #1 went to the sink and attempted to clean out the syringe. RN #1 was then asked to examine the contents at the bottom of the syringe and medication cup. RN #1 verified there was a significant amount of the [MEDICATION NAME] 1000 mg's remaining and stated, I should give her/him another pill because I don't think she/he got any. RN #1 then indicated that she/he did not adequately crush the medication into a powder before mixing with water. On 3/18/15 at 12:00 PM, a review of the facilities policy entitled Gastrostomy tube during drug instillation, long term care, revealed under Implementation, bullet (9.) which stated Request liquid forms of medications if available. If a liquid form of a medication isn't available and the medication is an immediate-release tablet, crush the prescribed dose of each medication separately into a fine powder in a cup or plastic bag designed for this purpose using a mortar and pestle or other pill-crushing device. If you 're administering more than one medication, administer each medication separately and flush the tube with sterile water after administering each medication. | 2018-12-01 |
| 6784 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2014-09-30 | 282 | D | 1 | 0 | LP5311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to follow the plan of care for Resident #1 related to weekly weights (1 of 4 residents sampled for weight loss) The findings included: The facility admitted Resident #1 with a [DIAGNOSES REDACTED]. A review of the medical record on 9/30/14 at 10:32 AM, revealed that Resident #1 was alert and comprehended conversation, but was confused. S/he required total assist with activity of daily living (ADLs) due to recent fracture and the placement of a leg immobilizer. S/he was continent of bowel and bladder at home prior to fall, but had declined to wearing briefs since hospital admission. A review of the care plan related to nutrition and/ or hydration documented as an approach to obtain weekly weights on admission times 4 weeks. A review of the weight record for Resident #1 on 9/30/14 at 10:35 AM, revealed that Resident #1 was weighed on admission on 1/31/14 with a weight of 129 pounds and then again on 2/11/14 with a weight of 120 pounds. The weight should have been obtained per the care plan for 2/7/14 (weekly weight due) it was not available. An interview with the Director of Nursing (DON) on 9/30/14 at 3:50 PM revealed that the care plan should read weekly weights for new admission for 4 weeks. The DON attempted to locate the 2/7/14 weight, but was unsuccessful. | 2017-09-01 |
| 6785 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2014-09-30 | 325 | D | 1 | 0 | LP5311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain parameters of nutritional status, weekly weights were not done per the plan of care on a newly admitted resident. Resident #1 (1 of 4 residents reviewed for weight loss) was identified with a significant weight loss on day 11 of his/her admission. The findings included: The facility admitted Resident #1 with a [DIAGNOSES REDACTED]. A review of the medical record on 9/30/14 at 10:32 AM, revealed that Resident #1 was alert and comprehended conversation, but was confused. S/he required total assist with activity of daily living (ADLs) due to recent fracture and the placement of a leg immobilizer. S/he was continent of bowel and bladder at home prior to fall, but had declined to wearing briefs since hospital admission. A review of the medical record revealed that Resident #1 had a poor appetite, but was able to feed his/herself with a tray set up. The admission weight for Resident #1 on 1/31/14 was 129 pounds and his/her height was 5 foot 6 inches. The usual body weight for Resident #1 was recorded as 130-140 pounds with an ideal body weight of 130 +/- 10 %. Upon admission Resident #1 was started on a regular diet. On 2/4/14 the diet was down graded to a no fried foods-mechanical soft with ground meats. On 2/7/14 the speech therapist changed her/his diet to pureed due to poor intake and swallowing; his/her poor oral intake continued. Resident #1 at this time required the assistance of staff with meals. The Certified Dietary Manager (CDM) made a notation on 2/11/14 regarding the resident's significant weight loss of 6.9% (9 pounds) from 129 pounds on 1/31/14 to 120 pounds on 2/11/14. The recommendations from the CDM were to add the resident to the red napkin program, do weekly weights, add whole milk three times a day with meals, add ice cream at supper and rice; start Standard 2.0 supplement at 120 milliliters three times a day, and request an appetite stimulant from the physician. The resident had 2 stageable pressure ulcers. The responsible party (RP) and physician were notified of the significant weight loss. A review of the care plan related to nutrition and/ or hydration documented as an approach to obtain weekly weights on admission times 4 weeks. A review of the weight record for Resident #1 on 9/30/14 at 10:35 AM, revealed that Resident #1 was weighed on admission on 1/31/14 with a weight of 129 pounds and then again on 2/11/14 with a weight of 120 pounds. The weight should have been obtained per the care plan for 2/7/14 (weekly weight due) was not available. An interview with the Director of Nursing (DON) on 9/30/14 at 3:50 PM, revealed that the care plan should read weekly weights for new admission for 4 weeks. The DON attempted to locate the 2/7/14 weight, but was unsuccessful. S/he stated, I don't see the weight. The DON did state that the resident went out to the wound center on 2/7/14 and the weight must have gotten missed. The CDM was not available for interview. A review of the Weight Monitoring Program revealed that under Procedure: *Weight Frequency 2. New Admissions. New admissions will be weighed weekly for a period of four weeks. Initial weight and height will be obtained within 24 hours of admission to the healthcare center. | 2017-09-01 |
| 7985 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2012-08-01 | 157 | D | 0 | 1 | WJTJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview, and review of Clinical Nursing Skills & Techniques, 7th Edition, pages 90 and 98, the facility failed to notify the physician of changes in the resident's condition requiring physician intervention for 1 of 10 sampled residents reviewed for notification. The facility failed to notify the physician of elevated blood pressures for Resident #10 which resulted in changes in medication regimen. The findings included: On 7/30/12 at 4:15PM, record review revealed Resident #10 was admitted with a [DIAGNOSES REDACTED]. The prescribed [MEDICATION NAME] was discontinued on 7/19/12. Review of 6/8/12 Daily Skilled Nurses Notes revealed a N(ight) shift untimed blood pressure (BP) of 176/94, and a 6/11/12 note with a N shift untimed BP of 158/91. A 7/23/12 Vital Sign sheet for 11PM to 7AM noted a 10PM BP of 170/111 and an 11PM BP of 147/97, and a 7/25/12 Vital Sign sheet for A(M) shift untimed BP of 159/94. A 7/25/12 Daily Skilled Nurses documented a N shift untimed BP of 157/98. The Vital Signs Sheet had a statement of Notify nurse of any abnormals immediately please: BP less than 90/60 or greater than 140/90. There was no evidence found in the record that the physician was notified of the elevated BPs. During an interview on 7/31/12 at 10:40AM, Licensed Practical Nurse (LPN) #1 explained the procedure in the event that the staff obtained elevated blood pressure readings. She stated that the BP was rechecked on the opposite arm manually. If it continued to be high, medication parameters were checked. If there were no parameters in place, the physician should be notified. Record review revealed no physician's orders for BP parameters related to notification. Interview and review of the Daily Skilled Nurses Notes and Vital Signs with LPN #1, Registered Nurse (RN) #2, and the 100 Hall Unit Manager revealed that the physician had not been notified for the five episodes of recorded elevated blood pressure. Clinical Nursing Skills & Techniques, 7th Edition, page 90 noted hypertension stage 1 systolic of 140 - 159 or diastolic of 90 - 99. Hypertension stage 2 systolic greater than or equal to 160 or diastolic greater than or equal to 100. Review of the reference page 98 noted interventions for blood pressure is above acceptable range to have another nurse repeat measurement in 1 to 2 minutes, and to report blood pressure to nurse in charge or health care provider to initiate appropriate evaluation and treatment. On 7/31/12, after the failure to notify the physician of elevated BP was acknowledged by staff, the physician was notified and new orders were received by phone for [MEDICATION NAME] 25mg PO (by mouth) TID (three times a day). | 2016-09-01 |
| 7986 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2012-08-01 | 253 | D | 0 | 1 | WJTJ11 | On the days of the survey, based on observation, interview, and review of the Joerns Healthcare User-Service Manual, the facility failed to provide services necessary to maintain a sanitary environment for 1 of 1 sampled residents with a low air loss mattress. The facility failed to cleanse/sanitize a visibly soiled Therapy Pad for Resident #1 with a *** Healthcare Low Airless Mattress. The findings included: Resident #1 was admitted with multiple pressure wounds and bilateral upper and lower extremity contractures. Observation of wound treatment, on 7/31/12, revealed Resident #1 had a heavily soiled Therapy Pad on his Low Air Loss Mattress. Stains and dried spills were observed on multiple areas of the surface on the first two days of the survey. During an interview on 7/31/12 at 9:30AM, Certified Nursing Assistant (CNA) #1 (assigned to care for this resident) confirmed the soiled Therapy Pad. When asked how the Therapy Pad was cleaned and how often it was changed, she stated that she didn't know. Concurrent interview with the Wound Nurse confirmed the soiled Therapy Pad. When asked, she stated that she didn't know the cleaning or changing procedure. Review of the *** Healthcare User-Service Manual page 12 noted the therapy pad can be wiped down with a disinfectant solution or a mild detergent with a damp cloth. If heavily soiled, the therapy pad can be laundered in a washer and dryer with warm water (no more than 120 degrees Fahrenheit). A non-bleach detergent should be used sparingly. Wipe dry or allow to air dry. On 7/31/12, after the failure to maintain a clean Therapy Pad was acknowledged by staff, the facility contacted the supplier to change and clean the low air loss mattress therapy pads. On 7/31/12 at 10:40AM the wound nurse stated, Now I know where to get the special bed sheets - we need to keep some on hand. | 2016-09-01 |
| 7987 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2012-08-01 | 318 | D | 0 | 1 | WJTJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, record review, and interview, the facility failed to give appropriate treatment and services to prevent further decrease in range of motion to 1 of 2 sampled residents with contratures. The facility failed to provide range of motion and positioning to Resident #1 to prevent further contracture and to prevent skin breakdown. The findings included: Resident #1 was admitted with bilateral upper and lower extremity contractures and multiple pressure wounds. Observation on 7/30/12 at 12:55PM revealed the resident lying in bed, right leg severely contracted toward buttock, and prevalon boots on both feet. A Hospice Certified Nursing Assistant (CNA) completed his bed bath, positioned the resident on his back, and elevated the head and foot of the bed. There were no positioning devices or pillows noted in place. At 1:55PM and 3:40PM the resident was observed in the same position and continued without positioning devices or pillows. At 4:45PM, the resident was observed in bed with a pillow behind his back propping him toward his left side. However there were no positioning devices or pillows between his knees, between his right leg and buttock, or at his right arm contracture. On 7/31/12 at 8:45AM, Resident #1 was observed on his back with the head of the bed elevated. A pillow was observed on top of the resident. No other positioning devices were observed. Observation and interview conducted during wound treatment on 7/31/12 at 9:15AM revealed a stage II pressure ulcer at the resident's right elbow, not previously noted with a current treatment order. The wound care nurse stated, It opens and has healed several times. Record review on 7/31/12 at 1:40PM revealed physician's orders [REDACTED]. Documentation of Wound Observation and assessment dated [DATE] stated R elbow has abrasion where res.(resident) scrubs about in bed with elbow. The Documentation of Wound Observation and assessment dated [DATE] stated Res. uses elbow to scoot self slightly in bed. Will be difficult to heal and remain healed. On 7/31/12 at 2:30PM, record review revealed Interdisciplinary Referral to Rehab Screening form dated 4/19/12 for Range of motion/contractures B (bilateral) lower ext/ (extremities). Rehab Screening Results and Recommendations signed 4/23/12 recommended Pt (patient) was on hospice prior to admission to facility. Due to current end of life status no skilled physical therapy needs at this time. An Interdisciplinary Referral to Rehab Screening form dated 5/11/12 referring the resident to rehab for Range of motion/contractures Rehab Screening Results and Recommendations signed 5/11/12 stated Eval (evaluation) completed for measurement of LE (left extremity) contracture - nursing staff to continue with routine ROM (range of motion)/ positioning. An undated Interdisciplinary Referral to Rehab Screening without a complaint checked for referral had a Rehab Screening Results and Recommendations signed 5/11/12 that stated Nursing staff to perform gentle PROM (passive range of motion) with ADLs (activities of daily living) per OT (Occupational Therapy) inservice - position with pillows as needed for comfort. An interview on 7/31/12 at 4:20PM with the Director of Rehab revealed that the resident had been evaluated for PT (Physical Therapy) and OT and that his contractures were too severe for therapy. She stated that an inservice was conducted with all staff for ROM during ADLs concerning this specific resident. Record review 7/31/12 at 4:25PM revealed the Plan of Care for PT and OT noted the resident's Rehab Potential as poor. OT evaluated the resident to require total care for ADLs. PT measured the resident's contractures revealing that his R knee - 120 decrees full knee ext with fairly fixed contracture. Record review and interview with the Director of Nursing (DON) on 7/31/12 at 5:00PM revealed CNA Care Interventions Record Form with no evidence of instruction for any ROM to be provided during care. Observation and interview on 7/31/12 at 4:30PM with the 100 Hall Unit Manager (UM) confirmed the resident's positioning without pillows/devices. She stated that position changes were to take place every two hours to include pillows and devices. The 100 Hall UM confirmed the severity of the contractures and named devices that could be used with nursing discretion for positioning and wound prevention. | 2016-09-01 |
| 9028 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2012-04-11 | 278 | D | 1 | 0 | GOSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint survey, the facility failed to accurately assess 1 of 3 residents reviewed for assessment. Resident #3 was blind, and a deaf-mute. The facility failed to thoroughly assess the resident's communication abilities. The care plan stated that the resident was blind and a deaf/mute, however, the approaches included speaking to the resident, explaining to the resident, providing large print books, a communication board and the resident reading lips. There was no mention of the resident using sign language or gestures to communicate. The staff failed to know what his signs/gestures meant. The findings included: The facility admitted Resident #3 with [DIAGNOSES REDACTED]. Review of the resident's Admission MDS (Minimum Data Set) dated 8/19/11 and his Quarterly MDS dated [DATE] revealed he was coded as having highly impaired hearing. His speech was coded as no speech and his vision was coded as highly impaired. Review of his Care Plan dated 8/22/11 and updated on 2/3/12 revealed a problem for "at Risk for impaired communication related to rarely or never understands, rarely or never able to make understood". The goal was listed, "Demonstrate ability to communicate by reading lips and using communication board". One of the approaches included; "Speak in a manner that can be understood." A problem of Impaired Vision, Blind, Deaf and Mute was included in the plan of care. The approaches included, "Use large- print material with patient. Inform patient of intended action/procedure". Review of the Hospice Nursing Visit Record Form dated 4/5/12, stated, "In gerichair seated in dining room. Pt. deaf & mute but can communicate by gesture. Has not attempted to make eye contact..." In an interview with the surveyor on 4/10/12, at 3:00 PM the MDS nurses and the Director of Health Services (DHS) failed to know if the resident was legally blind or totally blind. They stated they thought at one time he had a communications board but did not think he could use it. They were unable to say if the resident was born a deaf/mute or if something happened after birth. They were not aware if he used true sign language or gestures to communicate. The resident was observed on 4/11/12 at 8:35 AM in the dining room. The surveyor said good morning. The resident held up 10 fingers, facing the surveyor, and motioned with hands in a circular motion (gestures similar to pedaling a bicycle) and pointed at the surveyor. The resident was attempting to communicate. A CNA (certified nurse aide) was at the resident's side. She did not know what the gestures meant. On 4/11/12 at 8:35 AM, CNA #2 was interviewed regarding communicating with the resident. She stated, "I don't understand sign language. I just know he needs more food. He will start to move his chair towards the table." On 4/11/12 at 8:50 AM, CNA #1 was interviewed regarding communicating with the resident. She stated, "He uses sign language. If you stand directly in front of him it is like he can read your lips. You may have to repeat a few times... He doesn't make words, just gestures." | 2015-08-01 |
| 9029 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2012-04-11 | 274 | G | 1 | 0 | GOSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint inspection, based on record reviews, observations and the Guidelines for Determining the Need for a SCSA for Residents with Terminal Conditions CMA ' s RAI Version 3.0 Manual, chapter 2: Assessments for the RAI, page 2, the facility failed to identify a significant change in one of one resident with a significant change. Resident #2 declined in all areas of Activities of Daily Living, and had a significant weight loss but was not assessed for a significant change in his condition. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the resident's Admission and Quarterly Minimum Data Set (MDS) revealed, the Admission MDS dated [DATE] coded the resident as requiring limited assistance with walking, locomotion, dressing and hygiene. The resident was coded as requiring supervision with meals. He was coded as continent of bowel and occasional incontinence of bladder. His weight was recorded as 174 pounds. Review of Resident #2's referral admission history and physical dated 11/14/11 documented, "...73 y/o (year old) ... the general health status is good. Review of symptoms negative. VSS (vital sign), though orthostatic readings are in the 70's. Pt (patient) is alert to self only... Assessment: Pt is continuing with dementia as expected recent addition of [MEDICATION NAME]. He has become increasing difficult for family to manage at home. Pt has two respite stays during his hospice certifications. He is wandering throughout the neighborhood and is not sleeping throughout the night. It is expressed to me today that the family wishes to admit to the... for long term placement. This means they have no choice to revoke hospice as this team will not be allowed to continue care for patient in new setting..." The Quarterly MDS dated [DATE] indicated the resident declined in his activities of daily living (ADLs). He was documented as requiring extensive assistance with transfers and eating. He was coded as not ambulating, and requiring total assistance with locomotion, dressing and hygiene. His elimination was coded as incontinent of bowel and frequently incontinent of bladder. His weight was recorded as 150 pounds. Review of the Hospice Nursing Visit Record Form: 12/27/11 stated, "...frail weak, total care. Increased sleep 2nd decline..." 1/5/12 Pt with increased agitation which is relieved with transfer to geri chair and or/ repositioning. S/Sx (signs and symptoms) of decline due to decrease overall status. The resident had a significant change in his over all condition between his admission assessment and his quarterly assessment, and was not assessed for a significant change. Observation of the resident on 4/11/12 at 8 AM, revealed the resident lying in the bed in a fetal position. There was no response to his name or knocking on the door; two CNA's entered the room and were observed pulling the resident up in the bed, turning and positioning him. Review of the Guidelines for Determining the Need for a SCSA for Residents with Terminal Conditions states, "The key in determining if a SCSA is required for individuals with a terminal condition is whether or not the change in condition is an expected, well-defined part of the disease course and is consequently being addressed as part of the overall plan of care for the individual. If a terminally ill resident experiences a new onset of symptoms or a condition that is not part of the expected course of deterioration and the criteria are met for a SCSA, a SCSA assessment id required..." | 2015-08-01 |
| 9030 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2012-04-11 | 280 | G | 1 | 0 | GOSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the inspection survey, based on record reviews, observations, and interviews, the facility failed to revise care plans to show the actual condition for 2 of 3 residents reviewed for care plans. Residents #2 and #3's care plans did not reflect the condition of the resident. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the resident's Admission and Quarterly Minimum Data Set (MDS) revealed, the Admission MDS dated [DATE] coded the resident as requiring limited assistance with walking, locomotion, dressing and hygiene. The resident was coded as requiring supervision with meals. He was coded as continent of bowel and occasional incontinence of bladder. His weight was recorded as 174 pounds. The Quarterly MDS dated [DATE] indicated the resident had declined in his activities of daily living (ADLs). He was documented as requiring extensive assistance with transfers and eating. He was coded as not ambulating and as requiring total assistance with locomotion, dressing and hygiene. His elimination was coded as totally incontinent of bowel and frequently incontinent of bladder. His weight was recorded as 150 pounds. Review of the Physician's Telephone Orders revealed: 2/12/12 Contact Precautions/ Isolation Precautions... [MEDICATION NAME] DS two tabs by mouth twice a day times 10 days. 3/8/12 "D/C (discontinue) contact & isolation precautions. Change diet to Mech (Mechanical) Soft." Review of Nurse's Notes dated 1/10/12 at 3:00 PM stated, "NO (new order) - noted to D/C (discontinue Wandergard/Resident displays 0 (no) action r/t (related to) leaving facility. Review of the Hospice Visit of 4/5/12 and The Hospice Interdisciplinary Group Care Plan Review/Comprehensive Assessment Update dated 3/28/12, stated, "beginning to become contracted". Review of a Change of Condition Nurses Note dated 2/3/12, documented the resident had a [MEDICAL CONDITION] episode. Review of the "Plan of Care: Facility Addendum Form dated 11/18/11, from hospice, identified a problem of "Alterations in Nutritional Status Diet: Regular, Actual weight loss. The goal was to provide assistance with meals. The Goal checked was "Eat to satisfaction x (times) 5 days". Review of the care plan originally dated 11/28/11, and updated 2/20/12 revealed the facility failed to have a care plan for potential for or actual weight loss. The care plan identified as a problem Wandering with the potential for elopement. The Wandergard was discontinued on 1/10/12. On 12/23/11 a care plan for the potential for injury from falls related to the resident "falling on floor' was initiated. Review of the nurse's notes documented falls on 11/22/11, 11/27/11, 12/2/11, 12/23/11 and 1/11/12. The care plan addressed the 12/23/11 fall but failed to include the other falls or an intervention to prevent further falls. The care plan failed to address the resident's Syncopal event documented in the change of condition nurse's note dated 2/3/12. The care plan identified a problem with ADL Function that stated, "Need assistance with ADLs" failed to show the change in the resident's ability to perform ADLs. Review of the MDS dated [DATE] and 2/15/12 indicated the resident deteriorated from limited assistance to extensive/total assistance. Review of the ADL Care Plan Record, dated 11/16/11 documented the resident as continent of bowels and occasional incontinence of bladder. He was documented as receiving a Regular diet and requiring set up only with meals. Review of the Hospice Nursing Visit Record Form dated 3/8/12 stated, "Patient has been refusing to eat... Patient is having difficulty chewing on regular diet... order to be written to change diet to Mechanical Soft". Physician's Telephone Orders for 3/8/12 changed diet to Mechanical Soft. On 4/5/12 there was an order to change diet to Pureed. The ADL Care Plan dated 11/16/11 indicated Resident #2 was independent with bed mobility and independent with ambulation. Review of the MDS dated [DATE] and observations on 4/10/12 revealed the resident was not ambulatory and required total care with bed mobility. Resident #2 was observed on 4/10/12 at approximately 9:40 AM in bed with a bed alarm in place. He failed to response when he name was called. On 4/11/12 at approximately 8:00 AM the resident was observed in bed on his left side, in a fetal position with his eyes closed. There was no response to a knock on door or when his name was called. At 8:25 AM the resident was observed receiving his breakfast tray. Two Certified Nurse Aides (CNA) pulled the resident up in the bed and repositioned him; the CNAs fed the resident a pureed breakfast. In an interview with the surveyor on 4/10/12 at 3:00 PM the MDS nurses stated they were not sure why there was not a care plan for weight loss. They stated, "The nurses are responsible for making changes in the care plans". MDS nurse #1 stated, "We thought the care plan for ADLs would cover the changes." The facility admitted resident #3 with [DIAGNOSES REDACTED]. Review of the resident's care plan revealed an identified problem with Activities. One of the goals was for the resident to read lips and communicate with a communication board. One of the approaches was "give patient verbal reminders of Activity prior to start". A problem was identified for ADL Function. One of the approaches was, "Explain what you are going to do prior to start". A problem was identified that the resident was at risk for weakness and fatigue due to diagnoses. Approaches included to encourage the resident to eat all meals and encourage to take rest periods. A problem was identified as "at Risk for impaired communication related to Rarely or never understands, rarely or never able to make understood". The goal was listed, "Demonstrate ability to communicate by reading lips and using communication board". One of the approaches included; "Speak in a manner that can be understood." A problem identified as Impaired Vision, Blind, Deaf and Mute was included in the plan of care. The approaches included, "Use large- print material with patient. Inform patient of intended action/procedure". During an interview with the MDS nurses and the Director of Health Services (DHS) on 4/10/12, at 3:00 PM, they failed to know if the resident was legally blind or totally blind. They stated they thought at one time he had a communications board but did not think he could use it. The resident was observed on 4/11/12 at 8:35 AM in the dining room. The surveyor said good morning. The resident held up 10 fingers, facing the surveyor, and motioned with hands in a circular motion (gestures similar to pedaling a bicycle) and pointed at the surveyor. The resident appeared to attempt to communicate. A CNA was at the resident's side. She was unable to say what the gestures meant. On 4/11/12 at 8:35 AM, CNA #2 was interviewed regarding communicating with the resident. She stated, "I don't understand sign language. I just know he needs more food. He will start to move his chair towards the table." On 4/11/12 at 8:50 AM, CNA #1 was interviewed regarding communicating with the resident. She stated, "He uses sign language. If you stand directly in front of him it is like he can read your lips. You may have to repeat a few times... He doesn't make words, just gestures." The care plan stated that the resident was blind and deaf/mute, however, the approaches included speaking to the resident, explaining to the resident, providing large print books, a communication board and the resident reading lips. There was no mention the resident would use sign language or gestures to communicate. The staff did not know what his signs/gestures meant. | 2015-08-01 |
| 9031 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2012-04-11 | 310 | G | 1 | 0 | GOSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the complaint survey, based on record reviews, observations and interviews, the facility failed to provide services to ensure that a resident's abilities in activities of daily living do not diminish. Resident #2 declined following admission with no interventions to maintain or decrease the deterioration of the resident. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of the resident's Admission and Quarterly Minimum Data Set (MDS) revealed the Admission MDS dated [DATE] coded the resident as requiring limited assistance with walking, locomotion, dressing and hygiene. The resident was coded as requiring supervision with meals. He was coded as continent of bowel and occasional incontinence of bladder. His weight was recorded as 174 pounds. Review of Resident #2's referral admission history and physical dated 11/14/11 documented, "...73 y/o (year old) ... the general health status is good. Review of symptoms negative. VSS (vital sign), though orthostatic readings are in the 70's. Pt (patient) is alert to self only... Assessment: Pt is continuing with dementia as expected recent addition of [MEDICATION NAME]. He has become increasing difficult for family to manage at home. Pt has two respite stays during his hospice certifications. He is wandering throughout the neighborhood and is not sleeping throughout the night. It is expressed to me today that the family wishes to admit to the... for long term placement. This means they have no choice to revoke hospice as this team will not be allowed to continue care for patient in new setting..." The Quarterly MDS dated [DATE] indicated the resident declined in his activities of daily living (ADLs). He was documented as requiring extensive assistance with transfers and eating. He was coded as not ambulating and requiring total assistance with locomotion, dressing and hygiene. His was totally incontinent of bowel and frequently incontinent of bladder. His weight was recorded as 150 pounds. Review of the Social Services Progress Notes dated 11/18/11 stated, "...admitted from home. He is alert, talkative, confused and enjoys walking." 11/22/12: "Resident does walk about the facility without purpose..." The resident was observed on 4/10 and 4/11/12 in the bed, lying in a fetal position. On 4/11/12 at 8:25 AM, he was observed repositioned in the bed totally by staff and spoonfed by the staff. At the time of the survey the resident was total care for all of his ADLs. Review of the Nurse's Notes revealed: 11/16/12 Admission nurses note stated, "Resident is alert and oriented to self and place at times. Ambulating independently. Able to relay needs but depends on staff for ADL's - bathing & assist c (with) dressings... wears pull ups for occ (occasional) incont..." 11/23/11 ...ambulating in hallway earlier in shift.... 11/27/11 "...res observed per environmental svc (service) staff laying on floor @ foot of bed... AROM (active range of motion) per resident with verbal cuing... Resident had urinated between the bed and wall but he was on the floor at foot of bed. Assisted up & to geri-chair per nse (nurse) and CNA..." 11/29/11 ...attempts to transfer without assistance. On 11/29/11 the resident was checked for incontinence of bowel and bladder. 12/2/11 Checked for incontinence of bowel and bladder 12/3/11 "Resident requires assistance with dressing & toileting. Once food tray is set up resident can feed himself... kept trying to climb out of chair." 12/4/11 "Resident requires assistance with toileting & grooming x 1. Can feed self once tray has been set up...attempted to go out of facility. Wanderguard in place. Able to make needs known..." Change of Condition Nurses Notes dated 2/3/12: "...resident slow to respond, VS (vital signs) checked within normal limits. Review of the Hospice Nurse visits, revealed: 12/22/11: Staff reports increased time in bed. Overall increase weakness. 12/27/12: Frail weak, total care patient. Increase sleep secondary to decline. 1/5/12: CNA (Certified Nursing Assistant @ SNF (skilled nursing facility) reports that pt. is sleeping more and has good (50%+) po (by mouth) intake of meals. Pt. with increased agitation, which is relieved with transfer to geri chair and/or repositioning. Signs/symptoms of decline due to decrease in overall status. 2/27/12: ...According to LTC (long term care) staff, family made aware of weight loss from November 2011 to February 2012. 3/8/12 Patient has been refusing to eat, ate about 50% and 25% of meals. Patient is having difficulty chewing on regular diet. HRN (Hospice Registered Nurse) spoke with Unit Manager order to be written to change diet to Mechanical Soft, if still having difficulty, then to pureed diet... 3/26/12 Under evidence of decline/disease progression: Continuous weight loss, ADL Dependence total... 4/5/12: Bilateral legs beginning to contract. Legs stretched out as far as possible and supported with pillows. In an interview with the surveyor on 4/11/12 at 1:45 PM the DHS (Director of Health Services) regarding the decline in Resident #2 she stated there was nothing obvious with the decline. "He didn't have a stroke or anything like that. If they (resident) are hospice we have to get hospice approval for a screen or evaluation. If hospice made a referral hospice nurse deals with the physician to change. The hospice nurse should have relayed to facility nurse. Then the facility nurse would have referred to restorative to look at him." The Restorative Nurse was interviewed on 4/11/12 at 12: 15 PM. She stated there was no referral for resident #2 regarding the decline of his ADL's or development of contractures. On 4/11/12 at 1:45 PM Resident #2's Physician was interviewed regarding the decline in the resident. The Physician stated the resident was ambulating on admission, "with assistance". He was in danger of falling. The resident was admitted on hospice. The Physician stated, "No one let me know about the contractures. There are some things that can be done." The Physician confirmed restorative could look at the resident. "The problem with therapy is everything is paid for by Hospice and they won't cover therapy. . | 2015-08-01 |
| 9333 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2011-06-02 | 253 | E | 0 | 1 | UJW911 | On the days of the survey, based on observations and interviews, the facility failed to provide effective housekeeping and maintenance services for the bathrooms on one of two resident care units. Multiple rooms/bathrooms on the 200 Hall had soiled walls and baseboards, as well as stained floors, toilet bowls, and sinks. In addition, the 100 Hall Spa #2 had excessive soiled build-up on the baseboards. The findings included: During the Initial Tour on 200 Hall with Licensed Practical Nurse #4 on 5-31-11 beginning at approximately 11:30 AM, and during the environmental tour with the Maintenance Supervisor and Administrator on 6-2-11 at 9 AM, the following housekeeping/maintenance concerns were identified and confirmed: -Room 202 bathroom had pink-orange build-up on the baseboards. -Toilets had rust-colored stains inside the bowls in the bathrooms for Rooms 203, 205, 206, 207, 208, 209, 211, and 215. -Bathroom floor covering was stained (rust-colored) behind toilets and/or in corners around the toilet and sink areas in Rooms 205, 206, 207, 208, 209, 211, 212, 213, 214, and 215. -Bathroom baseboards had heavy pink-orange build-up in Rooms 202, 206, 208, 209, 210, 214, and 215. -Rooms 207 and 209 bathrooms had cracked toilet bowls and the grout at the bases was soiled dark brown/black. -Bathroom sinks were in poor repair in Rooms 208, 209,211, 213, 214, and 215. They appeared as if unsuccessful attempts had been made with either porcelain repair or some type of paint, resulting in a chalky appearing porous-type substance on the surfaces. -Dried spills were noted on the walls in the bathrooms in Rooms 205 and 207. During the initial tour of the facility on 05/31/11 at approximately 12 noon, an observation was made of the Spa Room on the 100 unit. The shower in the Spa Room was observed to be soiled with a filmy build-up around the bottom of the shower walls. Multiple observations were made during the survey and the condition of the shower stall remained unchanged. | 2015-05-01 |
| 9334 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2011-06-02 | 425 | D | 0 | 1 | UJW911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observation, interview and review of the facility policy entitled "MEDICATION STORAGE IN THE HEALTHCARE CENTERS (11/07), " the facility failed to follow a procedure to ensure proper storage and disposal of single use medication. The findings included: During the Initial Tour on 06/01/2011 at 10:30 AM, in room [ROOM NUMBER], one open 100 ml (milliliter) single use bottle of Normal Saline with a date of 04/26 on the lid was noted on the bedside table. Also, in a zip-lock bag, there was an open/ undated bottle of the same solution. In room [ROOM NUMBER], two 100 ml single use bottles of Normal Saline were noted on the bedside table. During observation and interview on 06/01/2011 at 1:20 PM, Registered Nurse (RN) #2 verified the above observations and stated that, once open, the bottles of Normal Saline were only good for 24 hours. Upon request, a copy of the facility's policy entitled "MEDICATION STORAGE IN THE HEALTHCARE CENTERS (11/07)" was obtained from the Director of Nursing on 06/01/2011. However, the policy failed to address the use and storage of this product. | 2015-05-01 |
| 9335 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2011-06-02 | 314 | D | 0 | 1 | UJW911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, record review, and interview, the facility failed to provide care and services to promote the prevention of pressure ulcer development for two of ten sampled residents reviewed for care and services. The facility failed to turn and position Residents #4 and #6 as ordered by the physician. Both resident's had a history of [REDACTED]. The findings included: The facility admitted Resident #4 on 10/16/2006 with [DIAGNOSES REDACTED]. limited to Altered Mental Status, Spinal Cord Disease, Spondylosis, Multiple Joint Contractures, Failure to Thrive, Diabetes Mellitus, and History of Pressure Ulcer. During multiple observations (on 06/01/2011 at 10:40 AM, 11:10 AM, 12:08 PM, and 6:00 PM), Resident #4 was noted laying on her back in bed. On 06/01/2011 at 2:40 PM and 3:40 PM the resident was observed in the geri- chair. Record Review on 06/01/2011 at 10:45 AM revealed a physician's orders [REDACTED]. "TURN Q2HR (every two hours)." Review of the "ADL (activities of daily living) CARE PLAN RECORD" revealed that staff was to turn and position " the resident every two hours". Further review revealed that the resident was care planned for "Potential for pressure ulcer/skin breakdown due to impaired mobility and incontinence of bowel and bladder". Approaches included "Turn and position frequently". Record review also revealed a 11/23/2010 "BRADEN SCALE-FOR PREDICTING PRESSURE SORE RISK" score of 11. (A score of 12 or less represented high risk.) During an interview on 06/01/2011 at 3:30 PM, the physician's orders [REDACTED]. and positioning every two hours was confirmed by Licensed Practical Nurse (LPN) #2. The facility admitted Resident #6 on 4/7/10 with [DIAGNOSES REDACTED]. Record review on 5/31/11 at 4:30 PM revealed current physician's orders [REDACTED]. Avoid direct pressure over wound site while limiting side lying position to 30 degree tilt and/or HOB (Head of Bed) elevation to 30 degrees in bed." Review of the Care Plan revealed the Problem: "Actual pressure ulcer/Skin breakdown due to impaired mobility." Under the Approaches was listed: "Assist and encourage frequent position changes." It was observed on 5/31/11 at 4:10 PM, and 6:20 PM that Resident #6 was flat on her back with the head of the bed at a 30 degree angle of elevation. No position change was noted during these times. It was observed on 6/1/11 at 8:30 AM, 10:15 AM, 12:15 PM, and 1:10 PM, that Resident #6 was flat on her back with the head of the bed at a 30 degree angle. No change of position was noted during these times. During an interview on 6/1/11 at 4:20 PM, Certified Nursing Assistant (CNA) #1 admitted that Resident #6 had only been turned at 3:00 PM that day and she could not remember turning her the day before. Record review revealed that CNA #1 was the assigned care giver for Resident #6 on 5/31/11 and 6/1/11. During an interview on 6/1/11 at 5:25 PM, the Director of Nursing stated that her expectations for care of a resident that was at risk for skin break down or that had a pressure ulcer was to "Turn every two hours." | 2015-05-01 |
| 9336 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2011-06-02 | 281 | D | 0 | 1 | UJW911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, interview and review of the Advisory Board Opinion "Nursing Management Of Invasive Devices (Catheter, Lines and Tubes)", the facility failed to provide services that met professional standards for one of one sampled residents reviewed with a suprapubic catheter. A suprapubic catheter change was performed on Resident #7 by a Licensed Practical Nurse (LPN) who had not received training or education to perform this task. The findings included: The facility admitted Resident #7 on 3-14-07 with [DIAGNOSES REDACTED]. Record review on 6-1-11 at approximately 12:30 PM revealed a physician's orders [REDACTED]." Review of the Nurses Notes revealed Licensed Practical Nurse (LPN) #1 performed a suprapubic catheter change on 5-26-11 at 4:45 PM. Review of the facility's policy and procedure on suprapubic catheter change on 6-2-11 at approximately 1:00 PM revealed that it did not stipulate what qualified or licensed staff should perform this task or what the professional qualifications were. Review of the "Nursing Management of Invasive Devices (Catheter, Lines and Tubes)" from the South Carolina Board of Nursing confirmed that an LPN could perform a suprapubic catheter change with specialized education and training, which the facility failed to provide for LPN #1. . During an interview with the Director of Nursing (DON) on 6-2-11 at approximately 10:45 am, she confirmed the identity of LPN #1 by verifying her signature on the facility's "Bamberg County Nursing Center Licensed Staff Signature Sheet", and that LPN #1 was an LPN. The DON confirmed there was no inservice or specialized training provided to nursing staff regarding suprapubic catheter change, and she verified that after speaking with LPN #1, she had not received any prior training or competency. | 2015-05-01 |
| 9337 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2011-06-02 | 164 | D | 0 | 1 | UJW911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the South Carolina Nurse Aide Candidate Handbook the facility failed to provide full visual privacy for two of eight residents observed for treatments. During observation of wound care, Resident # 1 was overly exposed, the privacy curtain was not pulled entirely, and a Certified Nursing Assistant (CNA) entered the room several times to attend to the roommate. Resident #6 was overly exposed during Foley catheter care. The findings included: The facility admitted Resident #1 on 8-10-07 with [DIAGNOSES REDACTED]. During observation by two surveyors of sacral wound care to Resident #1 on 6-1-11 at 12:35 PM, Registered Nurse (RN) #2 failed to close the privacy curtain entirely. It was pulled from the wall to the end of the bed on both sides, leaving the entire end of the bed exposed. Resident #1 was in a semi-private room in the bed nearest the door. Certified Nursing Assistant (CNA) #2 knocked and, without waiting for someone to give permission, entered and walked past Resident #1's bed to deliver a lunch tray to the roommate. The CNA then walked past the bed again to exit the room. Several minutes later CNA #2 knocked and entered the room, even though RN #2 stated she was "doing a dressing." She walked past the foot of the bed to deliver an overbed tray table, and then walked past the bed again to enter the bathroom to wash her hands. She returned to the roommate to set up the lunch tray, and then walked past to exit the room. During this time, Resident #1 was lying on her right side with her entire back side of her body exposed. During an interview on 6-1-11 at approximately 1:00 PM with RN #2 and CNA #1, when asked if they had observed CNA #2 enter the room without knocking on her third entrance, they both said they "were not paying attention." The facility admitted Resident #6 on 4-7-10 with [DIAGNOSES REDACTED]. During observation of Foley catheter care to Resident # 6 on 6-1-11 at 11:15 am, CNA # 3 removed the sheet off Resident # 6 and pulled her gown up to her chest and began the procedure. The Resident remained exposed from the chest to the toes during the entire procedure. The CNA failed to cover the areas of the body that were not necessary to be exposed. The South Carolina Nurse Aide Candidate Handbook under Catheter Care page 28, state: ..."Provides for client's privacy during procedure with curtain, screen or door....Exposes only area surrounding catheter." | 2015-05-01 |
| 9338 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2011-06-02 | 323 | E | 0 | 1 | UJW911 | On the days of the survey, based on observations, interviews, and record reviews, the facility failed to provide residents with safe water temperatures on one of two nursing care units. Water temperatures above 120 degrees Fahrenheit were recorded in residents' bathrooms and the shower room on the 200 Hall. The findings included: During the Initial Tour beginning at 12:05 PM on 5/31/11, the water in Room 205 bathroom felt exceedingly warm. The water temperature was taken with the surveyor's digital thermometer which recorded a temperature of 131.3 degrees Fahrenheit (F). In Room 208 bathroom, a reading of 134.6 degrees was noted. At 12:15 PM, in the residents' shower room (north 200 wing), the water temperature was 134.5 degrees. During an interview on 5/31/11 at 2:10 PM, the Maintenance Supervisor stated that the water temperatures were "monitored everyday with a thermometer." At 2:10 PM in Room 223, the Maintenance Supervisor and Environmental Consultant recorded a water temperature reading of 128.3 F. Across the hall, in Room 224, a water temperature of 129.6 degrees was noted. The residents' shower room near Room 209, on the other end of the 200 Hall, registered 133.9 degrees. The Maintenance Supervisor stated, "The water temperatures were too high. They should not be over 120 degrees." The Maintenance Supervisor then stated that he had had "problems with the water heater" in the past, but "had not been contacted by the (Maintenance) Assistant in a couple of weeks for high temperatures." During an interview on 6/1/11 at 2:00 PM, the Administrator stated that the water temperatures were to be monitored every day and that he was kept informed of trends. He stated, "I review water temperatures every month", and was "aware of the possibilities" of potential outcome to the residents. Following the Initial Tour, surveyors checked and recorded water temperatures in resident rooms throughout the facility. The 100 Hall had temperatures within the acceptable range. Water temperatures were recorded on the 200 Hall as follows: Room 223 = 125 F, Room 224 = 126.5, Room 222 = 127.9, Room 225 = 128, Room 221 = 128.5, Room 226 = 128.3, Room 227 = 128.8, Room 220 = 130.3, Room 228 = 132.1, Room 218 = 133.5, Room 219 = 132.7. During an interview on 5-31-11 at approximately 2:20 PM, the Maintenance Supervisor stated that the Maintenance Assistant was responsible for taking water temperatures and did so with a laser-type (point and shoot) thermometer. When asked about the operation of the device as he stood back from the sink to determine the water temperature, he stated that the temperature was measured when the laser "comes in contact with water". The Environmental Consultant stated that the thermometer had to be within 2 feet of the water source and retook the temperatures using a digital device. The digital device measured the temperatures 2.3 to 3.6 degrees higher than the laser. During an interview on 5-31 11 at 4 PM, the Maintenance Supervisor stated that his assistant usually let him know about temperature concerns but had not done so recently. He stated that water temperatures were rechecked and water heaters adjusted when outliers were brought to his attention. However, he estimated that no concerns had been brought to his attention since "prior to April". When asked if an outside contractor serviced the boilers/hot water heaters, he stated that this was not done routinely. The contractor had come in approximately three months previously to service a unit because of "no hot water". Review of the Water Temperature Daily Logs on 5-31-11 revealed that during the month of 5-2011 to the date of the survey, water temperatures for the 200 Hall were recorded at greater than 120 and up to 130 degrees on 12 days. Water temperatures for the 200 Hall were recorded at greater than 120 and up to 140 degrees for 21 of 30 days in 4-2011. Water temperatures for the 200 Hall were recorded at greater than 120 and up to 135 degrees for 29 of 31 days in 3-2011. During an interview (with the Administrator present) at 4:40 PM on 5-31-11, the Maintenance Assistant stated that he reported to work at 7 AM and "CNA's come at me" because the water "is not hot enough". He stated that if the water was too hot, he would report it to the supervisor who would then adjust the water heater. He stated that he had had no recent problems with the water being too hot. When asked at what water temperature he would let his supervisor know, he stated, "If over 125-127." Later in the interview, the Assistant stated, "Water temps shouldn't go over 120. 125 to 130 is too hot." During an interview on 6-1-11 at 11:30 AM, the contractor who did repair service for the facility stated that he had not been aware of any concerns about water temperatures being too hot in the resident care areas until notified on 5-31-11. Receipts for service calls were reviewed and he confirmed that in 2-2011, he had been contacted for "no hot water". In 3-2011, he had serviced the water heater supplying the kitchen and laundry areas. The contractor noted that the mixing valve had been replaced several years ago. He reviewed the logs and stated he had not been advised that the water temperatures were running high or that the facility was unable to maintain consistent temperatures within the acceptable range. On 6-1-11 at 2 PM, when asked if he checked the water temperature log, the Administrator stated he "usually checked them once a month and should have caught it". He stated he expected the water temperatures to be monitored daily and would expect immediate notification and intervention if results were outside acceptable parameters. The Administrator stated that he would also expect the temperatures to be rechecked and the results of any intervention documented. Review of the facility policy provided by the Administrator on 6-1-11 noted: "Plumbing fixtures that require hot water and that are accessible to residents shall be supplied with water that is thermostatically controlled to a temperature.....not to exceed one-hundred and twenty (120) degrees Fahrenheit at the fixture." During group interview, two of five residents complained that the water was too cold; and three of five resident's stated the water fluctuated between hot and cold. There were no documented negative resident incidents related to elevated water temperatures | 2015-05-01 |
| 9339 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2011-06-02 | 407 | D | 0 | 1 | UJW911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record reviews and interviews, the facility failed to provide Physical and/or Occupational Therapy services as ordered in a timely manner for 2 of 4 sampled residents reviewed for rehabilitation services. A Physical Therapy consultation ordered on 4-13-11 for Resident #6 was not done until 4/20/11. Resident #7 had a 4-14-11 order for Occupational Therapy and Physical Therapy consultations which were not done until 4-27-11 and 4-28-11. The findings included: The facility admitted Resident #6 on 4/7/10 with [DIAGNOSES REDACTED]. Record review on 6/2/11 at 8:30 AM revealed Nurses Notes written on 4/13/11 at 11:00 PM which indicated that a new order had been received from the Physician for a "PT (Physical Therapy) Consult." Review of Physician's Interim Orders on 4/13/11 at 11:00 PM revealed "Consult PT for ROM (Range of Motion) exercises." Further documentation revealed that Resident #6 was not seen until 4/20/11 for loss of ROM. During an interview on 6/2/11 at 10:20 AM, the Rehabilitation Director stated, "We are notified within 24 hours of the order written.'' At 10:40 AM she stated, "We were short of staff that week and PT came in on the twentieth for evaluations." She indicated that the Registered Therapist only came to the facility on a weekly basis to conduct the therapy evaluations. The Rehabilitation Director then provided a note that stated, "PT came in on 4/20 for evals (evaluations)/sups (supervision)." The Facility admitted Resident #7 on 3-14-07 with [DIAGNOSES REDACTED]. Record Review on 6-1-11 at 12:30 pm revealed a physician's orders [REDACTED]." A xeroxed copy of this order was attached to the original with a note to the physician of the facility dated 4-20-11 stating "Need u (you) to write an order if you want him to have PT/OT." One week later on 4-27-11 a physician's orders [REDACTED].-28-11 a physician's orders [REDACTED]." Further review of the Physical Therapy record on 6-1-11 at 12:30 pm revealed Resident #7 did not receive a Physical Therapy consultation until fourteen days later on 4-28-11. During an interview with the Director of Nursing on 6-2-11 at approximately 10:05 am, she confirmed that Resident #7 did have a PT/OT order written on 4-14-11 and after she spoke with the physical therapy department, she "does not know why" the order was not implemented until 4-28-11. She said that she remembers discussing that the resident had an order for [REDACTED]. | 2015-05-01 |
| 9340 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2011-06-02 | 441 | E | 0 | 1 | UJW911 | On the days of the survey, based on observation, interviews, review of laundry temperature logs, and review of the facility policy entitled "Temperature Control", the facility failed to implement procedures to ensure that personal laundry was being hygienically cleansed. The findings included: During observation of the laundry process on 6-1-11 at 9:30 AM, the Housekeeping/Laundry Supervisor and Laundry Aide stated that the personal laundry was being sanitized by maintenance of the hot water temperatures over 160 degrees. The bleach dispenser had a red light flashing on it, which the Aide indicated meant "It's empty." Both staff noted that bleach was not used. The Supervisor stated that she thought there was bleach in the detergent, (Solid Super Star) but review of the manufacturer's information did not support this. The Supervisor stated that water temperatures were taken every morning and were recorded consistently at greater than 160. She provided logs which corroborated this. However, upon direct observation, both washers were in use and set on "warm" instead of "hot". The surveyor asked the Laundry Aide to check the water temperature entering one of the washers with the facility's routinely-used digital thermometer. The temperature of the water was 80.2 degrees. During an interview on 6-1-11 at approximately 10 AM, after the Administrator was advised of the washer settings, he confirmed that the water temperatures in the washers should have been maintained at over 160 degrees. He provided for review the facility policy which stated: "Hot water provided for washing linen and clothing shall not be less than one-hundred and sixty (160) degrees Fahrenheit..." | 2015-05-01 |
| 9341 | PRUITTHEALTH BAMBERG | 425104 | 439 NORTH STREET | BAMBERG | SC | 29003 | 2011-06-02 | 463 | E | 0 | 1 | UJW911 | On the days of the survey, based on observation and interviews, the facility failed to ensure that all portions of the call systems were fully functional. Random observations revealed that the call system in the 200 Hall Shower Room did not have a visual signal outside the door. Also, the 100 Hall audible system was observed to be turned off at the nursing station on 6-2-11. The findings included: During the Initial Tour on 200 Hall with Licensed Practical Nurse (LPN) #4 on 5-31-11 beginning at approximately 11:30 AM, and during the environmental tour with the Maintenance Supervisor and Administrator on 6-2-11 at 9 AM, the facility staff verified that the three call lights in the Shower Room did not have a visual signal outside the door. LPN #4 stated that the call lights had not worked properly for "some time" (unspecified). The Maintenance Supervisor stated that he was unaware of the needed repair. The surveyor requested preventive maintenance records for the call system, but none were provided for review. Prior to a treatment observation on the 100 Hall on 6-2-11 at 11:20 AM, and immediately after completion of the treatment, a call light was "on" in the corridor outside of Room 127. No audible signal was heard at the nursing station. There were four staff members in the immediate area. When the surveyor brought this to the staff's attention in the presence of the Unit Manager, one of the staff reached over the counter of the nursing station and turned the audible portion of the call system panel "on". | 2015-05-01 |
| 2396 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 159 | E | 0 | 1 | EUVJ11 | Based on record review and interviews, the facility failed to assure that 4 of 5 residents sampled for personal funds had written authorizations to manage their funds and/or authorizations for specific deductions. The facility also failed to provide evidence that quarterly statements were sent to residents whose personal funds were managed by the facility. The findings included: During interviews on 10-3-16 and 10-4-16, Residents #11, #41, #90, #119 and #128 stated they had personal funds accounts with the facility but that they had not been advised of account balances at least quarterly. During an interview at 1:10 PM on 10-6-16, the Business Office Manager (BOM) reviewed the resident trust account and stated that Resident #119 had not placed money in the account prior to 7-16 when s/he had last sent quarterly statements. (This was verified by review of the resident's account.) The BOM stated that s/he kept a copy of quarterly statements in the residents' files. When asked, the BOM and Business Office Assistant (BOA) were unable to locate the statement copies to verify they had been sent. Upon investigation, they stated that Resident #128's statement was noted in the computer to be sent to her/his son, instead of to the resident. Review of the accounting for the above-listed residents with the BOM and BOA on 10-6-16 at 1:38 PM revealed that 4 of the 5 had no authorizations to manage personal funds and/or authorization for specific deductions from their funds: (1) Resident #119 had monies in the Personal Funds account managed by the facility but had no written authorization on file. Review of the admission agreement signed 4-29-16 revealed a checkmark in front of the statement: The resident chooses not to maintain a Personal Fund with the Facility. Review of the accounting period from 7-1-16 through 9-30-16 revealed deductions from the account for room and board and beauty shop charges without specific authorization to do so. (2) Resident #11 had monies in the Personal Funds account managed by the facility but had no written authorization on file. Review of the admission agreement signed on 2-23-15 by the Power of Attorney revealed no checkmark in front of the statement: The resident authorizes the Business Office of the Facility to maintain a Personal Fund Account for the resident . Review of the accounting period from 7-1-16 through 9-30-16 revealed deductions from the account for room and board, beauty shop charges, and monthly deductions of $129.00 from the account for dental insurance without specific authorization to do so. (3) Resident #128 had monies in the Resident Trust account managed by the facility for which a family member gave written authorization. Review of computerized financial records revealed that the quarterly statements were being sent to the family member instead of the resident. Review of the Brief Interview for Mental Status (BIMS) revealed that the resident scored 15, indicating s/he was cognitively intact. Further record review revealed the resident to be alert, oriented, and capable of making her/his own decisions. There was no evidence in the record that the resident had authorized an alternate decision maker. (4) The facility had a written authorization to manage a Personal Funds Account for Resident #41 which stated: I understand and agree that this gives the facility, through its designated personnel, approval to transfer monies from the account to cover any patient liability charges, or any personal care items not covered under the Medicaid program which appears on my receivable account while a resident or upon discharge. Review of the accounting period from 7-1-16 through 9-30-16 revealed monthly deductions of $129.00 from the account for dental insurance with authorization signed by a family member, instead of the resident. The Business Office Manager stated s/he was not sure of the resident's ability to authorize withdrawals. Review of the BIMS revealed that the resident scored 15, indicating s/he was cognitively intact. | 2020-09-01 |
| 2397 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 253 | E | 0 | 1 | EUVJ11 | Based on observations and interviews, the facility failed to provide effective housekeeping and maintenance services on two of two units. Concerns included damaged walls, floors, and odors in bathrooms. The findings included: On all days of the survey (10-3-16 through 10-6-16), the following housekeeping and maintenance concerns were identified and confirmed by the Maintenance Supervisor during the Environmental Tour at 11:00 AM on 10-6-16. Unit 1 Room 113 - The room and bathroom had a stale urine odor. Room 114 - The bathroom had a strong musty urine odor. Room 125 - Drywall damaged at the head of bed, next to the closet below the sharps receptacle/hand sanitizer, and between the bed and room door at the baseboard. B-bed had dried spills on the siderail and overbed table. Room 112 - The room door had a deeply gouged area near the door handle. The Maintenance Director stated this had already been repaired but was caused by the bathroom door being left open. Unit 2 Room 211- The bathroom had a stale urine odor, brown stains around the base of the toilet, and yellow stains around the baseboard. Room 205 -The bathroom had a stale urine odor, brown yellow stains on baseboard, brown stains around the base of the toilet. Room 204 - The bathroom doors were deeply scratched. There was brown substance around the bottom of the commode on the floor and discolored tile in the toilet area. Room 229 - The floor had discolored tile. Floor tile was in disrepair: four tiles were deeply scuffed; six tiles were cracked; three tiles had half-moon-shaped gouges; two tiles had missing pieces. | 2020-09-01 |
| 2398 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 258 | E | 0 | 1 | EUVJ11 | Based on observations and interviews, the facility failed to maintain comfortable sound levels for 6 of 26 census sampled residents interviewed on 2 of 2 units. Residents #3, #11, #41, #94, and #128 complained of not being able to rest/sleep due to noise levels on the evening/night shifts. The findings included: During an interview on 10/03/2016 at 3:43 PM, when asked Do you have any problems with the temperature, lighting, noise or anything else in the building that affects your comfort? Resident #119 stated s/he had problems with the noise level at night. On 10-6-16 at 2:52 PM, s/he stated, It disturbs my rest. During an interview on 10/03/2016 at 1:17 PM, when asked Do you have any problems with the temperature, lighting, noise or anything else in the building that affects your comfort? Resident #41 stated s/he had problems with the noise level at night. When asked about the noise at 2:47 PM on 10-6-16, the resident stated, Staff and residents are going up and down the hall at night. Staff are calling to each other. They keep you awake at night. It's really loud just before 7 AM. During an interview on 10/03/2016 at 12:50 PM, when asked Do you have any problems with the temperature, lighting, noise or anything else in the building that affects your comfort? Resident #128 stated s/he had problems with the noise all the time. When asked about the noise on 10-6-16 at 2:40 PM, the resident stated, That's just the way it is here at night. When asked if the noise keep her/him from sleeping, s/he stated, You might say that. It comes from CNA's (Certified Nursing Assistants) talking real loud and knocking things around. During an interview on 10/03/2016 at 2:19 PM, when asked Do you have any problems with the temperature, lighting, noise or anything else in the building that affects your comfort? Resident #94 stated,There is a lot of talking and laughing going on at night. I don't know who it is. On 10/4/16 at 11:00 AM, when asked if the noise awakened or kept her/him awake, Resident #94 stated, I just hear it when I am already awake. When asked about the noise on 10-6-16 at 1:53 PM, the resident stated, It's the workers on the night shift. I can't get rest. During an interview on 10/04/2016 at 10:22 AM, when asked Do you have any problems with the temperature, lighting, noise or anything else in the building that affects your comfort? Resident #11 stated, It's loud in the evenings. During an interview on 10/03/2016 at 3:49 PM, when asked Do you have any problems with the temperature, lighting, noise or anything else in the building that affects your comfort? Resident #3 stated, I can hear them going on all night. It keeps me awake all night. The young people working sound like they are about to fight. I'm used to it being quiet. During the Environmental Tour on Unit 2 beginning at 11:00 AM on 10-6-16, the Maintenance Supervisor was unable to hear the surveyor because of noise the ice machine was making. S/he further stated, It can get pretty loud at the nurses station. | 2020-09-01 |
| 2399 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 278 | D | 0 | 1 | EUVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to assure that 2 of 5 sampled residents reviewed for unnecessary medications received accurate assessments. Resident #141 had a Minimum Data Set (MDS) assessment completed with inaccurate data related to Race/Ethnicity and hospice services. Resident #94 had a MDS assessment completed with inaccurate data related to medication received. The findings included: The facility admitted Resident #141 with [DIAGNOSES REDACTED]. Record review on 10/4/16 at 3:36 PM revealed that a Physician Telephone Order was received on 7/18/2016, that read d/c (discharge) from hospice 7/18/16. Further record review revealed a Significant Change in Status (SCSA) MDS an with ARD of 7/25/16, where Section O-Special Treatments, Procedures, and Programs (O0100k.) Hospice care was not checked as a service received wtihin last 14 days. During an interview on 10/6/16 at 11:01 am MDS Coordinator #2 verified that on the SCSA MDS Hospice Care while a resident was not checked under Section O and that resident had been receiving hospice services during the 14 day assessment window. Further review of Section A-Identification Information (A1000F) Race/Ethnicity-revealed white was checked. Resident #141 was not Caucasian. During an interview with Director of Nursing and Administrator on 10/6/16 at approximately 4:00 pm, both verified that Resident #141 was not Caucasian. The facility admitted Resident #94 with [DIAGNOSES REDACTED]. Record review on 10/6/2016 at 12:04 pm revealed that Resident #94 had a Physician order [REDACTED]. Review of Facts and Comparisons and Drugs.com revealed that [MEDICATION NAME] is a sedative/hypnotic. Review of the 8/14/16 MDS revealed that Section N-Medications-item N0410D Hypnotic was coded as 0 (zero) days for the 7 day assessment window of (MONTH) 8-14, (YEAR). | 2020-09-01 |
| 2400 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 280 | D | 0 | 1 | EUVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of the facility policy titled, Resident Family Participation, the facility failed to ensure Resident #104 was invited to attend and encouraged to participate in the development of the Comprehensive Care Plan for 1 of 1 resident reviewed for Participation in Care Planning. The findings included: The facility admitted Resident #104 with [DIAGNOSES REDACTED]. An interview on 10/3/2016 at 4:56 PM with Resident #104 revealed that he/she had not been invited to or encouraged to participate in the care planning process. Review on 10/4/2016 at approximately 3:43 PM of the Care Plan Review sheets revealed that Resident #104 had not been invited to participate in the care planning process. The form has a box to check which reads, Resident received invitation to care plan meeting, and the box had not been checked. Review on 10/4/2016 at approximately 4:51 PM of the policy titled, Resident/Family Participation, states under, Policy Statement: Each resident and his/her family members and or/legal representative shall be permitted to participate in the development of the resident's comprehensive care plan. The Policy Interpretation and Implementation states, 1. Residents, their families, and/or their legal representatives, are invited to attend and participate in the resident's care planning conferences. Number 2 states, Advance notice of the care planning conference is provided to the resident and the interested family members. Such notice is made by mail, in person, and/or telephone. During an interview on 10/4/2016 at approximately 4:53 PM with the MDS (Minimum Data Set) assessment/ Care Plan Coordinator, he/she confirmed that Resident #104 had not been invited or encouraged to attend and participate in the care planning process. | 2020-09-01 |
| 2401 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 287 | D | 0 | 1 | EUVJ11 | Based on record reviews, interviews and review of the facility policy titled, Resident Assessment, the facility failed to ensure resident's assessments were completed and electronically transmitted to the Centers for Medicare and Medicaid Services System (CMS) in a timely manner for 10 of 10 assessments reviewed on the Casper Report for (YEAR). The findings included: Review of the Casper Report for McCoy Memorial Nursing Center on 10/3/2016 at approximately 10:00 AM revealed 10 missing OBRA assessments for (YEAR). An interview on 10/6/2016 at approximately 12:18 PM with the MDS (Minimum Data Set )assessments, Care Plan Coordinator verified the findings. During an interview on 10/6/2016 at approximately 2:00 PM with the Administrator, he/she stated, the assessments were batched and sent but we cannot find a confirmation that they were transmitted to CMS. Review on 10/6/2016 at approximately 2:00 PM of the facility policy titled, Resident Assessment, states under Transmittal requirements, states, Within 14 days after the facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: a. Admission assessment. b. Annual assessment. c. Significant change in status assessment. d. Significant correction of prior full assessment. e. Significant correction of a prior quarterly assessment. f. Quarterly review. g. A subset of items upon a resident's transfer, reentry, discharge, and death. h. Background (face-sheet) information, for an initial transmission of MDS data on a resident that does not have an admission assessment. | 2020-09-01 |
| 2402 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 323 | D | 0 | 1 | EUVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that fall prevention measures were operational for one of one sampled resident reviewed for accidents. Resident #97, who had a history of [REDACTED]. The findings included: The facility admitted Resident #97 with [DIAGNOSES REDACTED]. Review of the 08/19/16 Minimum Data Set (MDS) assessment revealed that the resident's Brief Interview for Mental Status (BIMS) score was 3 indicating severe cognitive impairment. The 05/31/2016 MDS noted the resident had sustained a fall. Review of Nurses Notes at 10:05 AM on 10-5-16 revealed the resident sustained [REDACTED]. An alarm was placed at that time. Review of the 8-30-16 fall risk assessment revealed that Resident #97 was at high risk for falls. Record review on 10/04/2016 at 4:38 PM revealed a physician's orders [REDACTED]. On 10-4-16 from 11:30 AM to 11:52 AM, Resident #97 was observed propelling her/himself in the wheelchair in the corridor. A magnetic alarm unit was attached to the chair but the cord was not clipped to the resident's clothing and the magnet was detached from the unit. No alarm was sounding. On 10-5-16 at 8:48 AM, the resident was observed up in the wheelchair in her/his room with a chair alarm in place. Certified Nursing Assistant (CNA) #1 was assisting the roommate with feeding. When asked to demonstrate how the alarm worked, s/he found that when the magnet was detached, the alarm did not sound. The CNA stated,Night shift got her (him) up. They're supposed to check (the alarm) when they get her (him) up. Review of the Treatment Administration Records (TAR) at 9:45 AM on 10-5-16 revealed that the tab alarm to bed and wheelchair was being initialed as checked every shift for placement. There was no record of function tests in the resident's record. During an interview at 10:28 AM on 10-5-16, the Director of Nurses (DON) stated,They are supposed to change out batteries the 5th of each month. S/he verified placement but no function checks documented on the TAR. When asked how staff ensured the alarms were operational, the DON stated that the nurse on the unit checked them once daily. | 2020-09-01 |
| 2403 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 332 | D | 0 | 1 | EUVJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record keeping and interviews the facility failed to assure that it was free of a medication error rate of 5% (percent) or more. The medication error rate was 8.0% based on 2 errors occurring during 25 medication pass observations. The findings include: Error # 1: During medication pass observation on 10/3/16 at approximately 10:44 AM, LPN (Licensed Practical Nurse) # 1 administered one inhalation of Breo Ellipta 100-25 to Resident # 10 and failed to have the resident rinse and spit with water after administration. The Breo Ellipta package insert states Rinse your mouth with water after you have used the inhaler and spit water out. Do not swallow the water. Error # 2: During medication pass reconciliation on 10/3/16 at approximately 12:18 PM a review of the October, (YEAR) physician orders [REDACTED].# 1 failed to administer this medication during the medication pass observation. On 10/3/16 at approximately 12:25 PM, LPN # 1 verified that the resident had not rinsed his/her mouth with water after the Breo Ellipta inhalation and that the [MEDICATION NAME] sulfate had not been administered. | 2020-09-01 |
| 2404 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 363 | E | 0 | 1 | EUVJ11 | Based on review of facility menu and Spreadsheet of Diets, observation, and interview, the facility failed to follow the planned menu for puree diet and did not have sufficient quantity of vegetables for regular diet for 1 of 1 meal observed which had the potential to affect all residents who were served puree diets and some residents who received regular diets for lunch meal on 10/5/16. The findings included: Review of the planned menu listed on the Spreadsheet of Diets provided by Certified Dietary Manager (CDM) on 10/5/16 at 12:02 PM revealed both the regular and puree diets were to be served as beets and potato salad. Observations in the kitchen during the lunch meal on 10/5/16 revealed that pureed corn and mashed potatoes were prepared for residents on pureed diets. Pureed bread, pureed potato salad and pureed pie were not prepared until surveyor asked for them, although the tray line and dietary aides were ready for lunch service. During interview on 10/5/16 at approximately 11:55 AM, the cook reported that puree corn was substituted for puree beets because there were only 6 cans of beets available for meal. Further observation of the storeroom on 10/5/16 at approximately 12:00 PM revealed that there were no additional cans of beets available. Observation in the main dining room during lunch meal on 10/5/16 at 1:43 PM revealed that 13 out of 26 residents with regular diets received green beans instead of the planned menu item of beets. Further observation revealed that on tray cards reviewed in the dining room did not have beets listed as a dislike. Further observation revealed that 3 of 5 residents observed with puree diets in the 100 hall dining room were not served puree bread for the lunch meal. During an interview on 10/5/16 at approximately 4:00 PM, the CDM verified that green beans were not on the planned menu for the regular diets and puree corn was not on the menu for puree diets. S/he stated We talked about running low on the beets- for regular diets, we substituted green beans for the vegetable. When the surveyor questioned the substitution, the CDM replied, We had enough for usual, but we had a number of staff that ate as well and we ran out of beets This resulted in the menu not followed for the residents. | 2020-09-01 |
| 2405 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 371 | F | 0 | 1 | EUVJ11 | Based on observations during both initial tour and meal preparation/service, and interviews, the facility failed to store and serve food under sanitary conditions in one of one main kitchen. Food was improperly stored in the walk-in freezer and cold food was served at greater than 41 degrees Fahrenheit (F), placing all residents fed from the main kitchen at risk. The findings included: During the initial tour with the Certified Dietary Manager (CDM) on 10/3/16 at 10:28 AM, two opened, unlabeled, undated bags of food items were noted in the walk-in freezer. The CDM verified that one bag of french fries and one bag of hashbrowns were opened, unlabelled and undated. S/he removed them from the freezer. During the review of food temperatures prior to the lunch meal service on 10/5/16 at 12:02 PM, the temperature of the potato salad when tested was 41 degrees F. Review of the extended menu revealed that not all pureed diet items had been prepared, although the tray line and dietary aides were ready for meal service. The potato salad was placed in the walk-in refrigerator at 12:12 pm, while pureed diet items were being prepared. At 12:33 PM, when all of the pureed diet items had been prepared and were ready to be served, the potato salad was removed from walk-in refrigerator and returned to the service line. Recheck of the potato salad temperature at 12:34 PM revealed a temperature of 50 degrees F. At 12:40 PM, the dietary aide and CDM placed the bowls with individual servings of potato salad in an ice bath. Between 12:42 PM and 12:44 PM, a total of four meal trays were prepared and placed on the delivery cart without potato salad. At 12:44 PM, when the 5th meal tray was prepared, the dietary aide placed the potato salad on the tray without checking the temperature. At 12:45 PM, the surveyor requested that the temperature of the potato salad be checked before service. The dietary aide calibrated the thermometer and confirmed the temperature of 43-44 degrees F. The dietary aide then continued serving the potato salad with temperature of 43-44 degrees F. When the CDM was made aware of the potato salad temperature, s/he responded, It's coming down. S/he did not stop the tray line. On 12/5/16 at 12:48 PM, the surveyor alerted the CDM that the tray line had to be stopped because the potato salad could not be served. The CDM announced to the kitchen staff that the potato salad would not be served, and that mashed potatoes would be served as a substitute. | 2020-09-01 |
| 2406 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 456 | E | 0 | 1 | EUVJ11 | Based on observation, interview and review of the facility policy titled, Description of Dryers, the facility failed to ensure resident care equipment was in safe operating condition. An extremely heavy build up of lint was observed behind 3 of 3 gas clothes dryers. The findings included: An observation on 10/6/2016 at approximately 8:30 AM revealed an extremely heavy build up of lint on the backs of 3 of 3 clothes dryers in close proximity of the flame. An interview on 10/6/2016 at approximately 8:35 AM with the Maintenance Director confirmed the heavy build up of lint. The Maintenance Director went on to say that the backs of the clothes dryers are cleaned of lint every 2 months. Review on 10/6/2016 at approximately 9:00 AM of the facility policy titled, Description of Dryers, states, Lint also may build up on the top compartment of the dryer. This is dangerous because the heat source is here. The top panel must be opened and the area cleaned daily. | 2020-09-01 |
| 2407 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2016-10-06 | 469 | E | 0 | 1 | EUVJ11 | Based on observations and interviews, the facility failed to maintain an effective pest control program on 2 of 2 units and one of one kitchen. Flies were observed in multiple locations in the facility and the bug light was in disrepair in the kitchen. The findings included: Multiple (at least 6) flies were observed in the kitchen during the Initial Tour of the facility on 10-3-16. The bug light/trap in the kitchen did not appear to be functioning as the light was plugged in but was not on. Multiple flies were observed in the 100 Hall dining/day room during meal service at 12:30 PM on 10-4-16. Resident #19 was observed with flies in his/her room and on the bed on 10-3-16 at 11:52 AM and 2:47 PM and on 10-4-16 at 9:07 AM, 2:34 PM, and 4:10 PM. On 10-3-16, a resident in a wheelchair in the hallway near Room 204 was observed swatting at flies with his/her hand. On 10/03/2016 at 1:55 PM, flies in the resident's room landed on Resident #96 repeatedly. The resident waved them off. On 10-4-16 at approximately 11 AM, the same observation was made. On 10-6-16, flies were observed on the resident while s/he was sleeping. During the Environmental Tour beginning at 11:00 AM on 10-6-16, the Maintenance Supervisor verified the flies in Resident #94's room. When asked what was being done about the flies in the resident rooms, dining areas, and kitchen. S/he noted lighted bug traps near each nursing station, but when one of the two was checked, s/he stated the trap was full and needed to be changed. The Maintenance Supervisor also noted fly curtains at the ancillary hall entrance and a bug light/trap in the kitchen. At 11:45 AM on 10-6-16, s/he verified that the bug light/trap in the kitchen was out of order. S/he stated s/he had not been notified and was unaware of how long it had not been operational. There were multiple flies observed in the kitchen during the initial tour on 10/3/16 between 10:28 AM and 11:00 AM, During observation on 10/5/16 at 1:31 PM, while trays were being served in the 100 hall dining room, a staff member was observed fanning the air around a resident . When asked, Are you fanning the flies away? Certified Nursing Assistant #2 stated, Yes. On 10/5/16 at 4:06 PM, flies were observed landing on a resident in the 100 hallway. On 10/5/16 at 12:01 PM, 9 flies were observed in the kitchen. | 2020-09-01 |
| 2408 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2017-10-11 | 281 | E | 0 | 1 | YIRJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide services that met professional standards. Resident #133, 1 of 3 residents reviewed for accuracy of medication administration, had a medication discontinued but it continued to be signed off as given by three different nurses for 9 days after it was discontinued. The findings included: Resident #133 was admitted with [DIAGNOSES REDACTED]. Record review of the (MONTH) physician's orders [REDACTED]. Further review of the Physician's Telephone Orders revealed an order on 9/25/17 that stated, D/C (discontinue) [MEDICATION NAME]). Record review of the Consultant Pharmacist Drug Regimen Review on 10/10/17 at 12:45pm revealed an entry on 10/4/17 that stated, [MEDICATION NAME] d/cd (discontinue). Further review of the 9/25/17 physician progress notes [REDACTED]. Review of the Care Plan contained a hand written entry that stated, D/cd (Discontinue) 9/25/17). Record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview on 10/10/17 at 2:45pm, LPN #1 verified the [MEDICATION NAME] was discontinued on 9/25/17 but was on the current MAR. At 2:58pm, LPN #1 stated s/he spoke with the pharmacy, and the medication has not been sent since it was discontinued. S/he stated it was initialed as administered but the resident did not receive the medication because the medication was not sent by the pharmacy. During an interview on 10/10/17, at 4:27pm, the Director of Nursing verified that three different nurses documented the medication as given, and s/he will provide education and counsel the nurses. S/he provided documentation from the pharmacy that the medication had not been sent for the nurses to administer. | 2020-09-01 |
| 5331 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 157 | D | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interview and review of the facility policy titled, Notification of Families/Responsible Parties, the facility failed to notify Resident #12's responsible party of a change in condition and need for evaluation at the hospital emergency room for 1 of 2 residents reviewed for hospitalization . The findings included: The facility admitted Resident #12 with a [DIAGNOSES REDACTED]. Record review on 6/11/2015 at approximately 4:00 PM revealed a nurse's note dated 1/9/2015 written at 9:15 AM which states, reported by nurse manager, resident needs to be sent to ER (emergency room ), in to assess, informed resident having [MEDICAL CONDITION] activity, not responding to verbal stimuli. HOB (Head of Bed) elevated 45 degrees. VS (Vital Signs) 100/70, 68, 99.6, 18, B/S (blood sugar) 98. Respirations even, unlabored, pupils nonreactive, head slumped at this time. EMS (Emergency Medical Service) notified. Further review on 6/11/2015 at approximately 4:00 PM revealed the next nurse's note dated 1/9//2015 written at 9:30 AM which states,transported X 2 attendants to Mcleod ER. No mention in the notes that the family/responsible party was notified. The next documented nurse's note was dated 1/16/15 and written at 4:00 PM which states, Resident readmitted to the facility from Mcleod, arrived via ambulance Review of the physicians telephone orders on 6/11/2015 at approximately 4:00 PM revealed an order dated 1/9/2015 at 10:45 AM which states, Send to ER for eval. No mention on the order that the family nor the responsible party was notified of the change in condition or the need to be hospitalized . During an interview on 6/11/2015 at approximately 4:05 PM with LPN (Licensed Practical Nurse) #2 confirmed that the family/responsible party had not been notified of resident #12's change in condition nor the need to go to the ER. Review on 6/11/2015 at approximately 4:15 PM of the facility policy titled, Notification of Families/Responsible Parties, states, It is the policy of the Nursing Center to ensure that the resident, the resident's legal representative(s), and/or the resident's responsible party (ies) will be made aware of:: # 2. reads, Significant changes in the resident's physical, mental or psychosocial status. # 5: reads, Any time that you need to call a physician. #7. reads, Need to transfer or discharge a resident. The policy went on to read, Immediately to within 24 hours (depending on the circumstances), the facility will promptly notify the resident, the resident's legal representative (s), and /or the resident's responsible party (ies) of any of the above changes. This will be documented in the nurses' notes or on the telephone order form if applicable. | 2019-01-01 |
| 5332 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 164 | D | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy titled Dressing Change the facility failed to provide privacy during pressure ulcer treatment for 1 of 2 pressure ulcer treatments observed.(Resident #50) The findings included: The facility admitted Resident #50 with [DIAGNOSES REDACTED]. Observation of pressure ulcer treatment on 6/10/15 at 10:25 AM revealed Licensed Practical Nurse(LPN) #2, prior to starting the procedure, did not close the blind or pull the privacy curtain around the resident. During an interview with LPN #2 on 6/10/15 at 10:50 AM, he/she confirmed the privacy curtain had not been pulled and the blinds had not been closed. Review of the facility policy titled Dressing Change revealed under the Policy Interpretation and Implementation #5 the following: Provide privacy by closing the room door and bathroom door(if the bathroom is shared by two rooms), pulling the cubicle curtain around the bed, and closing the blinds. | 2019-01-01 |
| 5333 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 241 | E | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide an environment to promote the dignity of residents during the dining experience. Residents had milk cartons on their trays in 2 of 3 dining rooms and were not offered cups for their milk. The findings included: Dining room observation on 6/8/15 at 12:51pm revealed 11 residents who received lunch trays were not offered cups to drink their milk. Observation on 6/10/15 at 8:55 am revealed 2 residents in room [ROOM NUMBER] were not offered or provided cups to drink their milk. During an interview with the Certified Dietary Manager (CDM) on 6/11/15 at 7:30 pm, the CMD admitted the State conducted a survey a while back and only 4 residents wanted a cup for their milk while the other residents who could not respond were served cartons. Main dining room observation on 6/10/15 at 9:10 am revealed 17 residents in the dining area with no cups to drink their milk. A total of 21 trays were observed without glasses for drinking milk. During an interview with the Certified Dietary Manager on 6/11/15, s/he stated that previously residents were care planned for their preference related to having milk served in cartons or glasses. S/he continued by stating residents newly admitted probably had not had their preference documented. During the survey, no facility policy was provided related to the dining experience and resident preferences. | 2019-01-01 |
| 5334 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 253 | E | 0 | 1 | 6INV11 | Based on record review and interview, the facility failed to ensure housekeeping and maintenance maintained a clean interior and in good repair for 3 of 4 halls. Halls 2, 3, and 4 were observed with damaged walls, scuffed furniture and wax build-up on floors. The findings included: During initial room reviews on 6/8/15 and random observations, the following was observed: Room 203-bedside tables worn, bathroom wall and door scuffed, bathroom floor with dark substance observed Room 207-scuffed, chipped room wall, worn bedside tables Room 210-bathroom door scuffed, wall damage noted near commode Room 213-baseboards dirty Room 216-damaged wall behind bed, scuffed bathroom door Room 221-scuffed bedside table Room 225-wardrobe scuffed Room 301-bathroom door scuffed Room 302-wax build-up noted on floor, scuffed bathroom door and bedside table Room 303-damaged wall behind bed Room 403-damaged wall behind bed Room 406-room chair torn Room 410-scuffed wall. Environmental rounds were made with the Administrator on 6/11/15 at approximately 3:30 PM. No cleaning schedules were provided during the survey. The Administrator presented a renovation memo which stated a number of resident rooms had been renovated which included new paint, baseboards, replacement of stained tiles and bathroom fixture repair/replacement. This will be an ongoing program whereas each resident room will receive this same upgrade. In addition, walls behind the beds are in the process of being replaced and currently this was being identified through priority. | 2019-01-01 |
| 5335 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 274 | D | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a significant change assessment was completed in a timely manner for 1 of 1 resident reviewed for a significant change. Resident #117 had a decline in 2 areas of Activities of Daily Living. The findings included: The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Review of the medical record on 6/10/2015 at approximately 1:41 PM revealed a MDS (Minimum Data Set) assessment dated [DATE] Section G Functional Status under H. reads, Eating - how resident eats and drinks regardless of skill, is coded as (1) for supervision and oversight and a (1) for setup help only. Further review of the MDS on 6/10/2015 at approximately 1:41 PM dated 2/15/2015 revealed section H, Bowel and Bladder. Section H0300 for Urinary Continence and section H0400 is coded (1) as Occasionally incontinent of bowel Review of the MDS assessment dated [DATE] on 6/10/2015 at approximately 1:45 PM revealed Section H. Bowel and Bladder coded H0300 a (2) for Urinary Incontinence which reads, Frequently incontinent of bladder and H0400 a (1) for Occasionally incontinent of bowel. Further review of the MDS assessment revealed under section H - Functional Status revealed section H. Eating coded as (4) for total dependence - full staff performance every time during entire 7 day period. Resident #117 had a significant decline in bowel and bladder continence and eating. No significant change assessment was completed for resident #117's decline in a timely manner. During an interview on 6/11/2015 at approximately 6:40 PM with the MDS/Care Plan Coordinator, he/she confirmed that a significant change assessment had not been completed. | 2019-01-01 |
| 5336 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 280 | D | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to revise Care Plan interventions for 2 of 18 sampled residents reviewed for review and revision of Care Plan. Resident #50's Care Plan was not updated to reflect a change in use of a pressure ulcer prevention device. Resident #10's Care Plan was not updated to reflect inappropriate sexual behaviors, impotence, and consultation with the mental health clinic. The findings included: The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Review of Resident #10's Admission Minimum Data Set (MDS) assessment dated [DATE] confirmed that the resident's speech was coded as clear. Further observation of Resident #10 revealed s/he does have slurred speech which indicated the MDS as inaccurate. Record review on 6/11/15 at 12:35 PM revealed behaviors listed for Resident #10 on the Behavior Psychoactive Flow Record as depression and anxiety, that are not known behaviors. Social Services Notes reviewed on 6/11/15 at 2:53 PM revealed inappropriate sexual comments towards staff and impotency. Record review of Resident # 10's care plan on 6/11/15 did not reveal any mental health appointments or notes. During an interview with the Minimum Data Set (MDS) Coordinator and the Director of Nursing (DON) on 6/11/15 @ 3:38 PM, they confirmed that Social Service's Notes revealed inappropriate sexual behavior towards staff and that Resident #10 was seen at the Mental Health Clinic. During an interview on 6/11/15 at 5:50 PM with the DON and the MDS Coordinator, it was confirmed that Resident #10's record revealed the resident had a mental health appointment on 3/2/15 with no notes documented. The MDS Coordinator verified that there were no mental health reports in the resident's chart and was unaware the resident was seen at mental health. The MDS Coordinator confirmed that notes should be under consultation. The facility admitted Resident #50 with [DIAGNOSES REDACTED]. Record review of the care plan on 6/10/15 revealed the resident was care planned for a roho cushion to the wheelchair. Observation of the resident with the Director of Nursing(DON) on 6/11/15 at 4:45 PM revealed Resident #50 did not have a roho cushion. The DON at the time of the observation stated the roho cushion did not work very well for the resident so a thick gel cushion had been placed in the resident's wheelchair. During an interview with the Care Plan Coordinator on 6/11/15, he/she stated a change would be made on the care plan to reflect the cushion the resident was currently using. | 2019-01-01 |
| 5337 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 282 | D | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure services were provided in accordance with the written Comprehensive Plan of Care for 2 of 15 residents reviewed for care plans. Resident #117's written plan of care not followed related to a toileting program and Resident #50's written plan of care not followed related to an alternating pressure mattress. The findings included: The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Review on 6/10/2015 at approximately 3:00 PM of Resident #117's comprehensive plan of care revealed an intervention dated 3/26/2015 for staff to toilet resident every 2 hours and as needed with the assistance of one. No documentation could be found in resident #117's medical record where this resident was toileted by staff. Resident #117's plan of care had not been followed. An interview on 6/10/2015 at approximately 3:00 PM with Licensed Practical Nurse (LPN) #3 revealed Resident #117 had not been toileted. LPN #3 went on to say that this resident was not on a toileting program and had not been on a toileting program. An interview on 6/10/2015 at approximately 3:05 PM with CNA (Certified Nursing Assistant ) #1 stated resident #117 will let you know when he/she needs to use the restroom but could not produce any documentation that resident #117 had been assisted to the restroom. The facility admitted Resident #50 with [DIAGNOSES REDACTED]. Review of the care plan on 6/10/15 revealed the resident was care planned to have an air mattress which was to be checked every shift with the setting on the alternating mode. Observation of the resident's air mattress on 6/10/15 at 10:25 AM and 4:00 PM and on 6/11/15 at 9:56 AM and 12:05 PM revealed the air mattress was on the static pressure mode. On 6/11/15 at 4:45 PM, the resident's mattress was observed with the Director of Nursing (DON). At the time of the observation, the DON confirmed the mattress was on static mode. | 2019-01-01 |
| 5338 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 309 | E | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and the facility agreement with [MEDICAL TREATMENT] titled, Long-Term Care Facility Outpatient [MEDICAL TREATMENT] Services Agreement, the facility failed to ensure coordination of care for 1 of 1 resident reviewed for [MEDICAL TREATMENT] care and services. Resident #128. The facility further failed to ensure Trazadone was given as ordered by the physician for 1 of 6 residents reviewed for unnecessary medications. Resident #160. The findings included: The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Review of Resident #128's medical record on 6/10/2015 at approximately 10:59 AM revealed no communication sheets with the facility and the [MEDICAL TREATMENT] center. Registered Nurse (RN) #1 produced a communication sheet dated 6/9/2015 from the [MEDICAL TREATMENT] center that the [MEDICAL TREATMENT] center had filled out and returned to the facility. The facility had not filled out any of their portion of the form to communicate with the [MEDICAL TREATMENT] center. During an interview on 6/10/2015 at approximately 10:59 AM with RN #1, he/she verified that the communication sheet dated 6/9/2015 was the only one the facility had. RN #1 went on to say that the facility would send one with the resident to [MEDICAL TREATMENT] but the [MEDICAL TREATMENT] center would not send one back to them to let the facility know of any labs, new orders or basically how the resident tolerated the [MEDICAL TREATMENT] treatment. Review on 6/10/2015 at approximately 11:15 AM of the facility's agreement with [MEDICAL TREATMENT] center titled, Long-Term Care Facility Outpatient [MEDICAL TREATMENT] Services Agreement, under Section A. #2 states, Interchange of Information. The nursing facility shall provide for the interchange of information useful or necessary for the care of the [MEDICAL CONDITION] residents, including a Registered Nurse as a contact person at the Nursing Facility whose responsibilities include oversight of provision of Services to the [MEDICAL CONDITION] Residents. Review of Section B. Obligations of the [MEDICAL CONDITION] [MEDICAL TREATMENT] Unit and/or Company, #1 D. states, To provide the Nursing Facility information on all aspects of the management of [MEDICAL CONDITION] Resident's care related to the provision of Services, including directions on management of medical and non-medical emergencies, including, but not limited to, bleeding, infection, and care of [MEDICAL TREATMENT]. The facility admitted Resident #160 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Resident #160 received Trazadone only 1 time from 6/1/15 through 6/8/15. During an interview on 6/9/15 at 5:35 PM, the Minimum Data Set (MDS) Coordinator verified that the medication Trazadone had not been given to Resident #160 as ordered. | 2019-01-01 |
| 5339 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 314 | D | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and review of the facility policy titled Dressing Change and Wound Irrigation, the facility failed to prevent pressure ulcer development and failed to follow infection control techniques for 1 of 2 pressure ulcer treatments observed.(Resident #50) In addition, the facility failed to follow ordered interventions or care planned interventions for 2 of 4 residents reviewed for pressure ulcers. Resident #50's bed was on static pressure and a roho cushion was not in use and Resident #160 an air mattress and heel protectors were not in place as ordered. The findings included: The facility admitted Resident #50 with [DIAGNOSES REDACTED]. Record review on 6/10/15 revealed Resident #50 developed a pressure wound to the left hip which was documented as a Stage III. Further review of the incident report revealed on 3/21/15 two open areas were noted on the upper left thigh area caused by rivets in the resident's wheelchair. Further review revealed the cushion for the wheelchair was very worn and thin and did not function properly which caused the wounds. Review of the approaches on the resident's care plan dated 4/24/15 revealed the resident had been care planned for a roho cushion in the wheelchair and the resident's bed was to be in the alternating mode. Further review of the Treatment Record for (MONTH) (YEAR) revealed an Air Mattress -check function every shift alternating function. Staff initials were noted each shift related to the air mattress on the alternating function. Current physician orders revealed an order for [REDACTED]. Observation of the pressure ulcer treatment on 6/10/15 at 10:25 AM revealed the Unit Manager in preparing the items for the procedure obtained a bottle of Normal Saline from the treatment cart which had an open date of 6/9/15 at 9:40 AM. At the time of the observation, the Unit Manager was asked how long the Normal Saline was good for once opened. S/he stated s/he did not know and would have to find out. The Unit Manager left the treatment cart and returned with a new bottle of Normal Saline. S/he stated the Normal Saline was only good for 24 hours once opened. Upon entering the resident's room, multiple packages of 4 x 4's and a box of gloves were taken into the room and placed on the over the bed table. The over the bed table was not cleaned and no barrier was placed. Upon finishing the treatment, 4x4 packages and the box of gloves were removed from the room and placed on the treatment cart. The resident had been on contact isolation. Observation of the resident's air mattress on 6/10/15 at 10:25 AM and 4:00 PM and on 6/11/15 at 9:56 AM and 12:05 PM revealed the air mattress was on the static pressure mode. Observation of the resident with the Director of Nursing(DON) on 6/11/15 at 4:45 PM revealed Resident #50 did not have a roho cushion. The DON at the time of the observation stated the roho cushion did not work very well for the resident so a thick gel cushion had been placed in the resident's wheelchair. The DON after observing the resident's bed on 6/11/15 at approximately 4:45 PM confirmed the bed was in static mode. At that time, s/he stated the roho cushion was not effective and a thick gel cushion had been implemented. During an interview with the Wound Care Nurse on 6/10/15 at 10:50 AM, s/he confirmed the over the bed table had not been cleaned nor had a barrier been placed on the table. S/he also confirmed that extra supplies had been taken into the resident's room and removed from the room which had previously been in isolation. Review of information provided by the facility titled Wound Irrigation indicated the following: It is important to note the date of opening a saline container, as bacterial growth in saline may be present within 24 hours of opening the container. Review of the facility policy titled Dressing Change listed the following: 2.Set up materials on over bed table-a. Clean table then place clean towel on table-set up supplies. and under section 6g-Remove gloves-throw away any materials you did not use The facility admitted Resident #160 with [DIAGNOSES REDACTED]. Review of Nursing Progress Notes on 6-9-15 at 4:20 PM revealed the resident had an 11X7 stage 1 pressure ulcer. Record review on 06/09/2015 at 3:53 PM revealed the resident was at high risk for development of pressure ulcers and had Physician Orders for Air mattress to bed .should always be on alternating and Moonboots to bilat(eral) feet WIB (when in bed) as tolerated. These interventions were reflected on the Resident Admission Care Plan. Observation on 6-10-15 at 8:55 AM revealed Resident #160 in bed on his/her back with the head of the bed elevated. The power button on the air mattress unit on the foot of the bed was not lit to indicate that the unit was on. During an interview on 6-10-15 at 9:30 AM, Licensed Practical Nurse (LPN) #4 observed the resident and verified that the air mattress was plugged in but would not turn on. S/he stated that the mattress should be on alternating pressure. When asked to check the resident for moon boots, LPN #4 also verified that Resident #160 had no heel protectors in place as ordered. During an interview at 9:50 AM on 6-10-15, a 200 Hall Certified Nursing Assistant (CNA) was asked how they were made aware of care required for individual residents. S/he stated that the information was placed on the back of the closet door. CNA #2, assigned to Resident #160, reviewed the Nursing Assistant Care Information form on the closet door and verified that there were no instructions for application of moon boots or the air mattress. | 2019-01-01 |
| 5340 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 315 | D | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide care and services to improve and or to prevent decline in normal bladder function for 1 of 3 residents reviewed for urinary incontinence. Resident #117 The findings included: The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Review of Resident #117's medical record on 6/10/2015 at approximately 2:24 PM revealed an Admission Nursing assessment dated [DATE]. The assessment included bowel and bladder and was checked as continent of bowel and bladder. Review on 6/10/2015 at approximately 2:24 PM of a form titled, Bowel and Bladder Incontinence Management dated 3/26/2015 included a total score of 7. A scale of 6 to 9 points states,resident is likely to benefit from a retraining program or consideration program or adult briefs. Candidate was checked as yes with an intervention for staff to toilet resident every 2 hours and as needed with the assistance of one. A form titled, Candidate for Adult Briefs states, wears briefs for incontinent episodes. A progress note on the form, Candidate for Adult Briefs read, Resident is frequently incontinent of bladder and occasionally incontinent of bowel. Resident is usually continent on days with the assistance of one with toileting. Staff to toilet resident every 2 hours and as needed. Staff to offer incontinent care as needed. Review on 6/10/2015 at approximately 3:00 PM of Resident #117's comprehensive plan of care revealed an intervention dated 3/26/2015 for staff to toilet resident every 2 hours and as needed with the assistance of one. No documentation could be found in resident #117's medical record where this resident was toileted by staff. An interview on 6/10/2015 at approximately 3:05 PM with CNA (Certified Nursing Assistant ) #1 stated resident #117 will let you know when he/she needs to use the restroom but could not produce any documentation that resident #117 had been assisted to the restroom. An interview on 6/10/2015 at approximately 3:05 PM with Licensed Practical Nurse (LPN) #3 revealed Resident #117 had not been toileted. LPN #3 went on to say that this resident was not on a toileting program and had not been on a toileting program. | 2019-01-01 |
| 5341 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 329 | E | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that medications were adequately monitored for effectiveness and had specific indications for use for 2 of 6 sampled reviewed residents for unnecessary medications. Resident #146's blood pressure (bp) was not monitored prior to administering [MEDICATION NAME] as required. Resident # 10's behavior monitoring addressed anxiety and depression as behaviors with Social Service notes referencing inappropriate sexual comments to staff, but no documentation in the clinical record of the activity or interventions implemented prior to the use of medication. The findings included: The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Record review of the Behavior Monitoring Psychoactive Flow Record on 6/11/15 at 12:35 PM revealed anxiety and depression as behaviors. Record review of the Social Services Notes on 6/11/15 at 2:53 PM revealed inappropriate sexual comments to staff and impotency concerns by Resident #10. Review of Resident #10's Care Plan on 6/11/15 at 3 PM did not reveal any documentation regarding inappropriate behaviors towards staff or interventions. Record review of Nurses Notes on 6/11/15 at 2:50 PM revealed mental health appointment on 3/2/15 with prescribed medications: [REDACTED] [MEDICATION NAME] E.R. 500 milligrams (mg) 4 tabs daily at bedtime for [MEDICAL CONDITION], [MEDICATION NAME] 20 milligrams (mg) 1 tab at bedtime for [MEDICAL CONDITION], and Klonopin 1mg 1 twice daily for Anxiety. During an interview with the Director of Nursing (DON) on 6/11/15 at 6:35 PM, s/he confirmed mental health appointments on 1/26/15, 3/2/15, 4/21/15,and 5/15/15. The DON reviewed the Nursing Progress Notes and confirmed no documented interventions had been provided to the resident prior to administering of the medications. The facility admitted Resident #146 with [DIAGNOSES REDACTED]. On 6-10-15 at approximately 9:00AM, record review of (MONTH) through (MONTH) (YEAR) Medication Administration Records revealed that resident #146 was receiving [MEDICATION NAME] 50mg. one tablet by mouth twice daily for hypertension (HTN). (Hold if systolic less than 120 mm/hg) millimeters of mercury . The times of medication administration were at 10AM/ pulse and 8PM /pulse. The pulse was taken twice a day instead of the blood pressure (B/P) for the months of (MONTH) through (MONTH) (YEAR). On 6-10-15 at approximately 9:15AM, record review of the Physician's Telephone Order revealed that on 3-25-15 to Hold all BP meds if the systolic is less than 120. Physician order [REDACTED]. Take 1 tablet by mouth twice daily *Hold if systolic ( On 6-10-15 at approximately 10:30AM, record review of the ResidentVital Signs Record revealed from 3-29-15 until 5-24-15 blood pressures were taken on different dates and times. There were 5 blood pressure readings taken that were under the blood pressure reading of a systolic 120mm/hg to hold b/p medication: 4-4-15--3:00PM---B/P 118/68 4-5-15--12:30PM- B/P 100/60 5-3-15--12:15PM--B/P 118/64 5-9-15--1:00PM--- B/P 110/70 5-17-15-1:14PM---B/P 100/70 On 6-10-15 at approximately 11:00 AM, interview with LPN#5 verified that on the [MEDICATION NAME] 50mg. one tablet po twice daily should have a blood pressure taken instead of the pulse. S/he verified that the medication should be held if the systolic blood pressure was 120 mm/hg and below. LPN#5 also verified that the physician order [REDACTED]. [MEDICATION NAME] 50mg. one tablet po twice a day from (MONTH) 1 to (MONTH) 11, (YEAR) provided 103 days -twice a day for 206 dosages for the blood pressure to be taken and held if the systolic was below 120mm. /hg. at the appointed times of 10:00AM and 8:00PM. On 6-10-15 at approximately 3:45PM, record review of the nursing notes from 3-1-15 through 6-11-15 revealed that the blood pressure was frequently taken by staff and documented there. There were 136 times that the blood pressure was over 120mm/hg. taken at different times. There were approximately 40 times that the systolic blood pressure was below 120 mm/hg. at different times documented in the nursing notes. The Blood pressure was taken 176 times during 3-6-15 through 6-11-15 documented in the nursing notes. | 2019-01-01 |
| 5342 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 431 | D | 0 | 1 | 6INV11 | Based on observation, interview, review of the Controlled Drug Accountability Record, and review of the facility's Pharmacy Services Policy, the facility failed to follow procedures to ensure proper labeling of external medications on 1 of 2 treatment carts to ensure that controlled drugs were handled appropriately. The Controlled Drug Accountability Record did not match the actual drug count on 1 of 2 med carts on the 100-400 hall. The findings included: Observation on 6/11/15 @ 9:18 AM revealed the treatment cart on 200-300 hall contained 3 opened tubes of external medications that did not have appropriate labeling with residents names. Medication included: Preparation H 1 oz (ounce), SAF Gel Wound Dressing 3 oz., and Hemorrhoidal Ointment 2 oz. During an interview on 6/11/15 at 9:18 AM, Licensed Practical Nurse (LPN) #2 verified that the external medications should have been labeled. Observation on 6/11/15 at 4:56 PM revealed that the controlled drug count on medication cart 1 on the 100-400 hall for Resident # 32's Clorazepate 3.75 (milligrams) mg did not match the Controlled Drug Accountability Record and the Medication Administration Record [REDACTED] During an interview with Licensed Practical Nurse (LPN) # 1 on 6/11/15 at 5:15 PM, s/he admitted that the Medication Administration Record [REDACTED]. | 2019-01-01 |
| 5343 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 441 | D | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy titled, Hand Washing, and the facility policy titled, Perineal Care, the facility failed to ensure proper handwashing technique was followed prior to urinary incontinent care for 1 of 1 resident observed for incontinent care. (Resident #117) The findings included: The facility admitted Resident #117 with [DIAGNOSES REDACTED]. Observation on 6/10/2015 at approximately 2:40 PM of urinary incontinence care for Resident #117 revealed CNA (Certified Nursing Assistant) #1 donning gloves and proceeding with incontinent care. CNA #1 did not wash his/her hands prior to starting incontinent care for Resident #117. During an interview on 6/10/2015 at approximately 2:58 PM, CNA #1 confirmed that he/she had not washed his/her hands prior to starting incontinent care. Review on 6/10/2015 at approximately 3:00 PM of the facility policy titled, Hand Washing, states, Staff shall wash their hands or use hand sanitizer to help prevent the transmission of infection. Review on 6/10/2015 at approximately 3:00 PM of the facility policy titled, Perineal Care, states, Perineal care shall be performed to assist in the prevention or elimination of infection and odor, promote healing, remove secretions, and provide comfort. Review on 6/10/2015 at approximately 3:15 PM of the facility inservices dated 3/2/2015 included, Proper Handwashing and the attendance sheet included CNA #1. Review of another inservice dated 4/15/2015 included, Handwashing. The inservice dated 4/15/2015 states, Each employee was inserviced during check offs on the importance of handwashing and times when hands should be washed. CNA #1 was in attendance for the inservice. | 2019-01-01 |
| 5344 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 467 | E | 0 | 1 | 6INV11 | Based on observation and interview, the facility failed to maintain an adequate outside ventilation system for 2 of 4 halls. The findings included: During room reviews on 6/8/15, odors were noted in several resident restrooms. Upon further observation, the exhaust fan in the restrooms could not be heard. On 6/11/15 at approximately 4:39 PM, the Maintenance Director tested a restroom shared by Rooms 201 and 203 and confirmed the exhaust was not working. He/she continued by stating the 100 and 200 halls only had an open ventilation with no exhaust. On 6/11/15 at 5:45 PM, after testing resident restrooms, the Maintenance Director provided information which stated the 100 and 200 Halls only had an open ventilation system. In addition, the exhaust fans for shared restrooms for rooms 301/303, 403/405, 402/404, and a private restroom for room 410 were not functioning. | 2019-01-01 |
| 5345 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2015-06-11 | 514 | E | 0 | 1 | 6INV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized for 4 of 19 residents reviewed for accuracy of clinical records. Resident #10 had 4 mental health appointments and no evidence of the appointments or results listed in the chart, Resident #126 with an incorrect time for tube feeding listed on the physician orders and Medication Administration Record [REDACTED]. In addition, Resident #146 was given [MEDICATION NAME] not signed out on the MAR. The findings included: The facility admitted Resident #126 with [DIAGNOSES REDACTED]. On 6-10-15 at approximately 11:00AM, record review of the Physician's Orders revealed [MEDICATION NAME] 1.5 cal (calories) liquid at 80ml/hr (milliliter/hour) via percutaneous enteral gastrostomy( peg) x 12 hours from 8AM to 8 PM and flush peg with 60 ml. water x 12 hours from 8AM to 8PM. Under the section listed Medications the hour listed was 8PM ON and 8AM OFF for (MONTH) 1 through (MONTH) 30, (YEAR). Flush peg with 60 ml water times 12 hours from 8PM to 8AM. On the (MONTH) 1-31, (YEAR) Physician's Orders record review revealed the following physician order, [MEDICATION NAME] 1.5 at 80ml/hr via peg x 12 hrs from 8AM to 8PM. Flush peg with 60 ml. water x 12 hrs. from 8AM to 8PM. On the Physician's Orders for (MONTH) 1 through (MONTH) 30 revealed the following order [MEDICATION NAME] 1.5 cal bolus-one can at hs with 100 ml water flush at 10PM. [MEDICATION NAME] 1.5 cal-one can if po intake is During an interview on 6-10-15 at approximately 11:15AM with LPN#5 verified that the times were not correct on the physician orders from 8AM to 8PM but the resident was getting the tube feeding correctly from 8PM to 8AM as noted on the Medication Administration Record [REDACTED]. The facility admitted Resident #146 with [DIAGNOSES REDACTED]. On 6-10-15 at approximately 3:00pm, record review revealed that [MEDICATION NAME] 5-325 tablet, [MEDICATION NAME]-APAP 5/325 take 1 tablet by mouth every 6 hours as needed for pain was signed out on the Controlled Drug Accountability Record on 6-9-15 at 2:15PM but not on the medication administration record. On 6-10-15 at approximately 3:10PM LPN#1 verified that the [MEDICATION NAME]/[MEDICATION NAME] was not signed out on the Medication Administration Record [REDACTED] Also on 6-10-15 at approximately 2:35 PM, the Medication Administration Record [REDACTED]. take 1 tablet by mouth once a day (Depression) On 6-10-15 at approximately 2:38PM, revealed the Behavioral Monitoring/ Psychoactive Flow Record had correct medications for (MONTH) and (MONTH) (YEAR) [MEDICATION NAME] and [MEDICATION NAME]. On (MONTH) and (MONTH) (YEAR), the resident Behavioral Monitoring/Psychoactive Flow Record had [MEDICATION NAME] and Trazadone listed on the Antipsychotic/Psychoactive drugs, which the resident was not taking and was not ordered by the physician. On 6-10-15 at approximately 2:45 PM, LPN#5 verified that [MEDICATION NAME] and Trazadone were incorrect on the Behavioral Monitoring/Psychoactive Flow Record and that the resident was not on these two drugs at anytime. Resident #146 was on [MEDICATION NAME] for anxiety and [MEDICATION NAME] for depression for behavioral monitoring. The facility admitted Resident #128 with [DIAGNOSES REDACTED]. Review of Resident #128's medical record on 6/10/2015 at approximately 11:00 AM revealed monthly signed physician orders dated 5/1/2015 through 5/31/2015 for [MEDICAL TREATMENT] days on Monday, Wednesday and Friday. Further review on 6/10/2015 at approximately 11:10 AM revealed monthly signed physician orders dated 6/1/2015 through 6/30/2015 for [MEDICAL TREATMENT] on Monday, Wednesday and Friday. Review of the physician telephone orders on 6/10/2015 at approximately 11:15 AM revealed a telephone order dated 4/24/2015, a late entry for 4/22/2015 which stated, HD ([MEDICAL TREATMENT]) schedule changed to Tuesday, Thursday and Saturday per medical doctor requests. During an interview on 6/10/2015 at approximately 11:15 AM with the MDS (Minimum Data Set)/Care plan coordinator he/she confirmed that the (MONTH) and (MONTH) monthly physician orders did not have the correct days for which Resident #128 was attending [MEDICAL TREATMENT] as ordered on [DATE]. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Record review on 6-11-15 at 10:03 AM revealed that the resident had been seen for mental health services on 3-2-15, but no consultant report could be located. During an interview on 6-11-15 at 3:38 PM, the Minimum Data Set (MDS) Coordinator stated s/he was unaware the resident had been seen by mental health. The Director of Nursing stated the resident had been seen several times for services. On 6-1-15 at 5:50 PM, the MDS Coordinator stated that the resident had gone for mental health appointments on 1-26-15, 3-2-15, 4-21-15, and 5-15-15. S/he stated that the reports should have been in the consult section of the medical record, but verified they were not in the chart. At 6:35 PM, the Unit Manager verified that they had not received reports from the clinic. | 2019-01-01 |
| 6596 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2014-02-25 | 241 | D | 0 | 1 | NBGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on observations, interviews, and review of the facility's guidelines for Nursing Assistant Duties for the 7 AM-3 PM shift, the facility failed to ensure that 1 of 3 residents reviewed for dignity, received care in a manner that enhanced their dignity. Resident #95 was observed with excessive facial hair. The findings included: The facility admitted Resident #95 with [DIAGNOSES REDACTED]. During an observation on 2/18/14 at 4:50 PM, Resident #95 was observed to have excessive white facial hair on her chin. On 2/21/14 at 4:05 PM, during an interview with Resident #95, when asked if s/he had chin hair would s/he prefer to have it removed, the resident stated s/he would want it off. At that time, Resident #95 asked Registered Nurse (RN) #1 if s/he would do her a favor and pointed to the unwanted hair on his/her face (indicating s/he wished for the hair to be removed). RN #1 confirmed Resident #95 had facial hair s/he wished removed. During an interview with RN #1, s/he stated that Resident #95 was care planned for behaviors related to refusing care. However, there was no notation in the nurse's notes to reflect the resident had recently refused care. RN # 1 continued stating that during baths/showers, the CNA's should have offered/removed the facial hair. Review of the daily assignment for the Azalea Unit revealed a bath/shower schedule of Monday/Wednesday/Friday for Resident #95. Review of the Nursing Assistant Duties for day shift nursing assistants, directed the staff to shave females weekly as needed on Sundays. | 2017-12-01 |
| 6597 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2014-02-25 | 248 | E | 0 | 1 | NBGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the Recertification Survey based on observations, staff interview, record review and review of facility policies, the facility failed to provide an ongoing program of activities for 3 of 4 residents reviewed for activities during the days of the survey. The facility also failed to assess individual residents with regards for activity preferences and personal interest. The facility failed to implement the plan of care related to the Activity program for Resident # 118. Resident # 21 and Resident # 123 were not assessed and there was no documented evidence of the resident's participating in Activities. The findings included: The facility admitted Resident # 118 with the [DIAGNOSES REDACTED]. Review of Resident #118 ' s Plan of Care for Activities on 2/20/14 at approximately 3:14 PM, it stated Resident needs to participate in out of room activities for socialization to prevent depression . According to the resident's Plan of Care, the interventions stated - include resident in group activities, provide variety in activities based on residents preferences, monitor and record attendance and assist to and from activities as needed. Review of Resident #118 ' s Admission Minimum Data Set Assessment. Section F. (Preferences for Customary and Routine activities) noted that the resident thought it was important to listen to the music he/she likes and somewhat important to do things with groups of people and to participate in his/her favorite activity. Further review of the resident ' s medical record on 2/20/14 at approximately 5:15 PM did not reveal a facility activity assessment for the resident to assess the resident ' s preferences for activities since his/her admission of 12/12/13 to the facility. Review of the facility provided policy titled Activity Assessment stated Within 72 hours a resident's admission to the facillity, an Activities Assessment will be conducted to assist in developing an activity plan that reflects the choices and interest of the resident. Observations were made of Resident #118 on the days of the survey; not participating in activities. On 2/19/14 at 11:14 AM, the resident was observed sitting in his/her room watching television while a group activity was in progress. On 2/20/14 at 2:39 PM, the resident was observed in his/her room facing the wall. Checkers for guys was in progress in the Activity room. On 2/21/14 at 9:41 AM, the resident was observed sitting in the hallway across from the nurse ' s station with head down and no staff interaction. On 2/21/14 at 10:10 AM, the resident was observed sitting in the hall across from the nurses station. Activities were in progress at time but the resident had not been included. Review of the facility's Activity Attendance Log dated 2/17/14-2/21/14 did not document Resident #118 had participated in any group activity held by the facility. During an interview on 2/20/14 at 5:00 PM with the Activity Assistant s/he stated, Resident #118 does not like coming out of the room. I go by the room daily to speak with the resident. The resident rarely participates in activities. The Certified Nursing Assistants usually do not get (him/her) up out of the bed during the evenings when religious activities are held. The Activity Assistant confirmed that no activity assessment was completed for Resident #118. During a random interview with a resident in the Dining area on 2/21/14 at 6:11 PM, he/she stated that there were limited activities especially on the evening and weekends. The resident stated the activities they do have during the week are not interesting. The facility admitted Resident #21 with [DIAGNOSES REDACTED]. Record review on 2/20/14 revealed the resident's Brief Interview for Mental Status(BIMS) was coded as having short and long term memory problems and Moderately Impaired Cognitive Skills for daily decision making. Further review of the current (1/30/14) MDS(MInimum Data Set) revealed there was no resident response to questions related to activity preferences. Per the Care Area Assessment(CAA) resident is not able to actively participate in activities at this time. The CAA also revealed the resident was up in a geri-chair daily as tolerated and from prior assessments likes to attend church services. The care plan reviewed had an onset date of 2/5/14, goal date of 5/6/14 and included approaches as follows: 1) Provide variety in activities based on residents preferences; 2) Include resident in group activities; 3) Maintain positive manner when inviting resident to activities; 4) Introduce to other residents; 5) Encourage to talk about family members and past life; 6) Monitor and record attendance and interactions during activities; 7) Place activity calendar in room; 8) Assist to and from activities. Review of the Activity Section in the medical record revealed there was no Activity Assessment or activity notes. On 2/20/14, activity assessments, notes, and any one to one activities were requested. During multiple observations of the resident on 2/20/14 at 9:35 AM, 11:25 AM, and 4:08 PM, the resident was observed lying in bed with no activities noted. On 2/21/14 at 11:11 AM and 3:30 PM the resident was observed at the nurse's station and/or in the bed with no activities noted. Review of the Activity Attendance Log from 2/17/14-2/21/14 revealed the resident was not in attendance during any of the activities offered. The facility admitted Resident #123 with [DIAGNOSES REDACTED]. Record review on 2/20/14 of the MDS dated [DATE] revealed the resident had short and long term memory problems and severe cognitive skills for daily decision making. Further review of the MDS revealed there was no resident response to the interview for daily preferences. Review of the Care Area Assessment for activities revealed the resident was invited to out of room activities and assisted by staff. The CAA reflected Resident #123 enjoyed listening to music and would often sit in the hallway near the nurses desk. Review of the Activities care plan with an onset date of 11/21/13 included approaches that included the following: 1) Provide variety in activities based on residents preferences. Invite resident to listen to music, bands and church activities; 2) Include resident in group activities; 3)Maintain positive manner when inviting resident to activities; 4) Introduce to other residents; 5) Encourage to talk about family members and past life; 6) Monitor and record attendance and interactions during activities; 7) Place activity calendar in room; 8) Assist resident to and from activities. It was noted that the plan of care for Resident # 21 and Resident # 123 were identical and not individualized to the resident's needs and or preferences. Further record review of the Activity section of the medical record revealed there was no activity assessment or activity notes. The activity assessment and notes were requested on 2/20/14. Multiple observations of Resident #123 on 2/18/14 at 4:33 PM, 2/19/14 at 9:44 AM and 4:12 PM, and on 2/21/14 at 11:08 AM revealed the resident was in the bed and no activities in progress during the times of observation. Review of the Activity Attendance Log for 2/17/14-2/21/14 revealed the resident did not attend any activities during this timeframe. On 2/20/14, activity assessments and notes were requested. On 2/20/14 at 4:40 PM, the Activity Assistant was asked if the activity assessments and notes had been located. At that time, the Social Service Director informed the surveyor several different people had been in the Activity position since July. He/she confirmed Resident #21 and #123 did not have an activity assessment or activity notes. One to one activities was requested on Resident #21 and #123 and the Social Service Director stated he/she would look for the documentation. During the interview, the Social Service Director was asked since the facility was aware of the turnover in the area of staffing for the Activity area, what did the facility do to ensure that the residents were assessed appropriately and were provided activities? He/she stated it appeared an audit would have to be done. No evidence of one to one visits were presented for Resident #21 during the survey. On 2/21/14 one to one activities documentation was provided for Resident #123. On 2/21/14 at 3:20 PM, the Activity Assistant verified no documentation of one to one activities had been available on 2/20/14. An audit for activity assessments was performed by the facility on 2/20/14. The audit revealed 16 residents did not have an initial activity assessment and 12 other residents had no documentation of whether an assessment had or had not been done per the audit appearing to result in an incomplete audit. Review of correspondence from the Administrator to the previous Activity Director dated 12/16/13 revealed that during the stand up meeting concerns related to Ambassador reports were discussed. Activities was discussed due to residents indicating they have little desire to participate(so they do not); the activities offered did not interest them and no one from activities visits with them. During an interview with the Administrator on 2/21/14 at 9:30 AM, he stated that the previous person in the Activity Director position was qualified based on the regulations. H/she continued by stating the Activity Director left the faciity on [DATE] without working out a full notice and the person who was in the activity assistant position did not have any experience. Upon further explanation, advertisements had been placed in the paper and resumes had been received, but the facility had been hindered by the weather in filling the position. H/she confirmed an audit had been done on 2/20/14 and sixteen residents did not have an activity assessment and/or notes. H/she stated that a quality assurance on charts had been implemented prior to the survey, but activities was not at the forefront. The Administrator stated during the interview that the assessments and one to one activities had fallen through the crack. | 2017-12-01 |
| 6598 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2014-02-25 | 253 | E | 0 | 1 | NBGB11 | Based on observations and interview the facility failed to provide maintenance services necessary to maintain a comfortable interior in good repair. Two of two units were observed with concerns related to damaged chairs, walls, bed tables, baseboards, loose toilet commode in a resident bathroom, dust build up on vents in the shower rooms, cracked tile in the shower room, and a broken light cover in 1 of 3 shower rooms. The findings include: During initial tour of the facility on 2/10/14 at approximately 10:54 AM, observations revealed a cracked/broken light cover and broken wall tile in the shower room on the Bradford unit. In room 101, the surveyor observed multiple scuffs and scrapes on the wall and the bathroom contained a loose toilet commode that moved with a gentle touch. Loose baseboards, scrapes and scuffs were observed in room 127. Further observations during the initial tour revealed a loose grab bar in the shower room on the Azalea unit. Observation on 2/20/14 at 1:20 PM, revealed the shower room on the Bradford unit with a heavy build up of dust on the vent, the 300 unit dining/day room had 2 upright chairs with damaged seats (brown and green), tears and slits in the cushion of the love seat, and scuff marks on the wall. Room 201 had damage to the wall with scrapes and scratches, room 210 had damage to the wall behind the bed and room 211 was observed with a rust colored build up in front of the commode. Observations of room 212 revealed a rust color chair with a split in the seat. During a tour of the facility on 2/21/14 at approximately 9:00 AM, the Maintenance Director confirmed these findings. Additionally, observations during the tour revealed there were loose baseboard on the 200 unit hallway and peeling paint on walls. These observations were also confirmed by the Maintenance Director during tour. S/he stated that there were no logs for routine inspection to keep track of maintenance services. Random observations revealed the following on the Bradford Unit: 1. Room #101 B: paint scraped off of the wall near the left side of the Television. 2. Room #102 B: White colored patched areas noted on the wall near the left side of the bathroom door. 3. Room #105 A: Left side of the bathroom door noted with black scrape marks, wheelchair noted with both armpads cracked. 4. Room #105 B: Scrape marks noted on the wall to the left side of the bed. 5. Room #106 B: Scrape marks noted on the wall above the head of the bed and on the wall near the left side of the bed, scrape marks noted on the bathroom door, wheelchair seat cracked. During initial tour on 2/10/14 the following was observed on the 300 Hall: 1) Damaged areas noted along the wall behind the medication carts; 2) (1) brown upright chair with a damaged seat in the 300 Hall Dining Room; 3) Slits noted in the seat of a love seat noted in the 300 Hall Dining Room: 4) (1) over the bed table with a damaged corner located in the 300 Hall Dining Room; 5) Built up of dust noted on the vent in the private shower. On 2/18/14, observation of Room 210 revealed chipped areas on the wall beside both resident beds and chipping of paint around the bathroom sink. On 2/19/14 observations of resident rooms revealed the following: 1) Room 212A-scuffed areas noted beside the entry to the bathroom; 2) Room 216A-chipped areas noted behind resident's bed; 3) Room 217A-scuffed areas noted along wall in resident's room; 4) Room 223A-scuffed areas noted along wall in resident's room, damaged wall noted behind the resident's bed and in the resident's bathroom; 5) Room 225B-damaged wall noted in resident's room and scuffed areas on wall noted in bathroom; 6) Room 231-small tear on wall noted behind head of bed. 7) Room 301B-damaged wall noted behind bed A and B. During a tour of the facility on 2/21/14 at approximately 9:00 AM, the Maintenance Director confirmed these findings. Additionally, observations during the tour revealed there were loose baseboard on the 200 unit hallway and peeling paint on walls. These observations were also confirmed by the Maintenance Director during tour. S/he stated that there were no logs for routine inspection to keep track of maintenance services. | 2017-12-01 |
| 6599 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2014-02-25 | 272 | E | 0 | 1 | NBGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on interviews and record reviews, the facility failed to complete and maintain an ongoing and accurate assessment for 3 of 4 residents related to activity assessments.(Resident #21, 118, and 123) Cross refer to F-248 related to the failure of the facility to assess activity preferences. The findings included: The facility admitted Resident #21 on 1/23/14 with [DIAGNOSES REDACTED]. On 2/20/14, review of the activity section in the medical record revealed there was no activity assessment or activity notes. The facility admitted Resident #123 on 11/11/13 with [DIAGNOSES REDACTED]. On 2/20/14, review of the activity section in the medical record revealed there was no activity assessment or activity notes. On 2/20/14, activity assessments, notes, and any one to one activities were requested. On 2/20/14 at 4:40 PM, the Social Service Director confirmed there were no activity assessments for Resident #21 and #123. The facility admitted Resident # 118 on 12/10/13 with the [DIAGNOSES REDACTED]. Review of Resident #118 ' s Plan of Care for Activities on 2/20/14 at approximately 3:14 PM, it stated Resident needs to participate in out of room activities for socialization to prevent depression . According to the resident's Plan of Care, the interventions stated - include resident in group activities, provide variety in activities based on residents preferences, monitor and record attendance and assist to and from activities as needed. Review of Resident #118's Admission Minimum Data Set Assessment. Section F. (Preferences for Customary and Routine activities) noted that the resident thought it was important to listen to the music he/she likes and somewhat important to do things with groups of people and to participate in his/her favorite activity. Further review of the resident ' s medical record on 2/20/14 at approximately 5:15 PM did not reveal a facility activity assessment for the resident to assess the resident ' s preferences for activities since his/her admission of 12/12/13 to the facility. Review of the facility provided policy titled Activity Assessment stated Within 72 hours a resident's admission to the facillity, an Activities Assessment will be conducted to assist in developing an activity plan that reflects the choices and interest of the resident | 2017-12-01 |
| 6600 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2014-02-25 | 309 | D | 0 | 1 | NBGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide necessary care and services related to following physician orders [REDACTED]. There was no evidence Insulin was administered per a physician's orders [REDACTED]. The findings included: The facility admitted Resident #38 with a [DIAGNOSES REDACTED]. Record review on 2/20/2014 at approximately 2:40 PM revealed a Medication Administration Record [REDACTED]. For a Finger Stick Blood Sugar of 151-200 give 2 Units, 201-250 give 4 Units, 251-300 give 6 Units, 301-350 give 8 Units, 351-400 give 10 Units, 401-450 give 12 Units and greater than 451 give 15 Units and recheck the Finger Stick Blood Sugar in 2 hours. If still greater than 451 call the Physician. Record review on 2/20/2014 at approximately 2:40 PM also revealed a form entitled Glucose Monitoring Form. The following concerns were identified during review of the documentation: On 11/3/2013 at 4:30 PM, the resident's blood sugar was recorded as 225. There was no documentation Insulin coverage was administered as ordered by the Physician. On 1/6/2014 at 7:30 PM the blood sugar was recorded as 174 with no documentation Insulin was administered as ordered by the Physician. On 1/13/2014 at 11:30 the blood sugar result was 256 with no documentation Insulin coverage was administered as ordered by the Physician. On 1/15/2014 at 2:30 AM the blood sugar result was 304 with no documentation Insulin was administered as ordered by the Physician. On 2/18/2014 at 8:30 PM the blood sugar result was 372 with no documentation Insulin was administered as ordered by the Physician. An interview on 2/20/2014 at approximately 4:48 PM with the Registered Nurse Supervisor for(NAME)Halls 1 and 2 confirmed there was no evidence the sliding scale Insulin coverage had been administered per the physician's orders [REDACTED].> | 2017-12-01 |
| 6601 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2014-02-25 | 314 | D | 0 | 1 | NBGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review, observation and interview, the facility failed to provide necessary treatment and services to promote healing and prevent new sores from developing for 1 of 2 residents reviewed with pressure sores. Resident #123 was observed without a dressing to his/her wound. The findings included: The facility admitted Resident #123 with [DIAGNOSES REDACTED]. Record review on 2/18/14 revealed Resident #123 developed a Stage II pressure area on 2/10/14 with measurements of 3 cm(centimeters) x 2 cm. Further record review revealed a physician's orders [REDACTED]. Further review of the medical record revealed the resident was incontinent of bowel and bladder. Observation of pressure sore on 2/20/14 at 12:06 PM revealed the resident did not have a pressure ulcer dressing on at that time and the resident had been incontinent. LPN (Licensed Practical Nurse) #3 stated the dressing must have come off with the bath this morning and they did not tell me. Incontinent care was provided, the area cleansed and the dressing placed. On 2/20/14 at 1:00 PM, CNA (Certified Nursing Assistant) #3 stated when providing AM care to Resident #123 that morning, the resident did not have a pressure ulcer dressing on the sacrum. On 2/21/14 at 4:20 PM, LPN #3 stated when a dressing comes off of a pressure ulcer wound, he/she would expect the CNA to notify the nurse so it could be reapplied. | 2017-12-01 |
| 6602 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2014-02-25 | 323 | E | 0 | 1 | NBGB11 | Based on observations, record reviews and staff interviews, it was determined that the facility did not ensure the environment remained as free of accident hazards as possible related to elevated hot water temperatures in resident areas. Elevated water temperatures were noted on 2 of 2 units. The findings included: During initial tour of the facility on 2/10/14 at approximately 10:50 AM, observations revealed the water temperature at the bathroom sink of the Bradford shower room was 124.2 degrees Fahrenheit when tested using a digital thermometer. The surveyor conducted further testing revealing the following: Room 105: 126 degrees Fahrenheit Room 108: 126 degrees Fahrenheit Room 110: 127 degrees Fahrenheit Room 111: 126.5 degrees Fahrenheit Room 114: 126 degrees Fahrenheit Azalea Shower Room: 124 degrees Fahrenheit Room 202: 122 degrees Fahrenheit Room 207: 133 degrees Fahrenheit Room 210: 130 degrees Fahrenheit On 2/10/14 at approximately 12 PM, during an interview with the Nurse on the unit, s/he stated the residents in the rooms were not able to access the bathrooms independently and the residents were accompanied to the shower rooms by the Certified Nursing Assistants. In both areas the CNA's would test the water temperature prior to use. On 2/10/14 at 12:05 PM, re- testing of the water temperatures in the resident's bathroom sink revealed the following: Room 101-132.9 degrees Fahrenheit Room 102-131.5 degrees Fahrenheit Room 105-133.3 degrees Fahrenheit Room 108-133 degrees Fahrenheit Room 111-131.3 degrees Fahrenheit Room 110-130.4 degrees Fahrenheit. On 2/10/14 at 12:30 PM, the temperatures were rechecked by the Maintenance Director and revealed the following: Room 101-124 degrees Fahrenheit Room 102-121 degrees Fahrenheit Room 105-126 degrees Fahrenheit Room 108-126.5 degrees Fahrenheit Room 110-127 degrees Fahrenheit Room 111-126.5 degrees Fahrenheit Room 114-126 degrees Fahrenheit Room 127-111.5 degrees Fahrenheit Room 216-119.5 degrees Fahrenheit Room 210-119.5 degrees Fahrenheit Room 207-120.5 degrees Fahrenheit Room 301-117.5 degrees Fahrenheit Room 306 120 degrees Fahrenheit. On 2/10/14, the shower room water temperatures were measured and rechecked by the Maintenance Director as follows: Hall 100-125 degrees Fahrenheit Hall 200- 129 degrees Fahrenheit with a recheck of 118 degrees Fahrenheit Hall 300- 125 degrees Fahrenheit with a recheck of 118.5 degrees Fahrenheit. During an interview with the Maintenance Director on 2/10/14 at 12:32 PM, s/he reviewed the hot water temperatures and stated that it would be adjusted. The Maintenance Director stated that lines were replaced due to leaks approximately one year ago. The current system in place was natural gas and there was no electric or computerized monitoring system. The Maintenance Director provided the surveyor with water temperature checks logs that were performed monthly from August 2013 to January 2014. There was no evidence of elevated water temperatures during this time. On 2/10/14 at 5:27 PM, the Administrator stated the water would be shut off for a short time to empty the tanks and then refilled starting at a lower temperature. Interview with staff on 2/10/14 revealed only residents in rooms 207, 210, and 306 were independent in using the restroom. An interview with Unit Manager #1 on 2/10/14 stated there was no thermometer for staff to check the water on the units. However, s/he stated if the water felt too hot, Maintenance would be notified. On 2/10/14, CNA (Certified Nursing Assistant) #2 stated he/she tested the water and would also ask an alert resident to put their hand under the water to see if the temperature needed to be adjusted per the resident's choice. He/she continued by stating if the resident was not alert and oriented, would adjust the temperature to warm and if the water ever felt too hot, he/she would notify the supervisor so that Maintenance would be aware. On 2/10/14, the incident/accident log was reviewed for a six month time frame which revealed no burns, scalding or resident injury related to water temperatures. On 2/11/14, the staff was instructed by a memo to review the hot water temperature policy and call maintenance if the water is suspected to be outside the acceptable range of 100-120 degrees. If Maintenance was not available, the staff was to test the water and if greater than 120 degrees to turn off the water supply at the access point. On 2/14/14, the staff was instructed prior to giving baths/showers to test the water temperature and document the finding on the shower log. Shower water temperature logs were provided for the dates of 2/14/14-2/21/14 which revealed temperatures ranging from 88-117.5. On 2/21/14 at approximately 4:00 PM, the Maintenance Director stated that when the facility used an analog thermometer, the thermometer was calibrated two times per month. S/he continued by stating the facility now uses a digital thermometer and if it needed to be calibrated would place the thermometer into ice water to get a reading of 32 degrees Fahrenheit. Temperatures in resident room/areas were taken at varied times such as first thing in the morning and/or late in the afternoon. Temperatures were taken only once a month but now that would be changing. When the maintenance department measures temperatures in rooms, the first two or three rooms are tested and the next month the rooms at the end of the hall are tested . The Maintenance Director stated that when the elevated temperatures were found, the staff on the halls had been instructed on taking the temperatures in the shower rooms. | 2017-12-01 |
| 6603 | MCCOY MEMORIAL NURSING CENTER | 425174 | 207 CHAPPELL DRIVE | BISHOPVILLE | SC | 29010 | 2014-02-25 | 329 | D | 0 | 1 | NBGB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On the days of the survey, based on record review and interview, the facility failed to provide adequate monitoring and documentation for 1 of 5 residents reviewed for unnecessary medications. [MEDICATION NAME] was administered to Resident # 38 without documentation to support the need for the medication. The findings included: The facility admitted on Resident #38 on 8/1/13 with a [DIAGNOSES REDACTED]. Record review on 2/20/2014 at approximately 2:24 PM revealed a physician's orders [REDACTED]. Review of a form entitled Behavior Monitoring Sheet for February 2014 revealed a hand written [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. The reverse side of the MAR indicated [REDACTED]. There was no evidence documented of an attempt to use non-medicinal intervention(s) prior to the use of the medication. Review of the Nurse's Notes contained no documentation of anxious episodes for the mentioned dates. An interview on 2/20/2014 at approximately 4:48 PM with the Registered Nurse Supervisor for(NAME)Halls 1 and 2 confirmed [MEDICATION NAME] was administered without attempting a non-medicinal intervention first and without documentation of the need for the medication. | 2017-12-01 |