Citations in South Carolina n

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a documented history of wandering, psychosis, anxiety disorder, paranoid schizophrenia, schizoaffective disorder, and epilepsy was not adequately supervised to prevent elopement. The resident was identified as being at risk for elopement and wandering, with an active care plan in place that included interventions such as a wander guard device, comfort measures, and environmental modifications. Despite these interventions, the resident was last seen by staff at approximately 5:30 PM and was later found outside the facility by first responders at 6:06 PM, indicating a lapse in supervision and monitoring. The resident's care plan and medical records indicated daily wandering behaviors and cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 9. On the day of the incident, the resident was observed ambulating in the hallway and did not exhibit exit-seeking behaviors at that time. However, the door alarm was activated at approximately 5:15 PM, and a CNA responded but assumed another resident with a wander guard had triggered the alarm. The CNA looked outside but did not see anyone and did not further investigate, resulting in the resident leaving the facility undetected. Staff did not become aware of the resident's absence until contacted by police, at which point a Code White/elopement was initiated. The resident was located approximately 700 feet from the facility and was transported to the hospital for evaluation. Interviews with staff confirmed that the wander guard was functioning, but no alarms were heard by the assigned nurse during the relevant time period. The incident revealed a failure to ensure adequate supervision and response to alarm systems for a resident at high risk of elopement.

Removal Plan

• Resident transported to hospital ER per EMS. Upon reentry, assigned nurse verified resident wander guard bracelet was in place, intact and functioning on right wrist.
• Assigned nurse performed body audit with no injury noted and documented body audit results in resident's medical record.
• Elopement Risk Observation repeated.
• Intervention: Wander guard bracelet to wrist and checked weekly.
• Maintenance Director/Designee performed an audit to ensure facility exits alarms were functioning.
• Wander guard audits completed.
• Residents at risk of elopement identified; placement and function of wander guards verified by DON for each.
• Elopement Risk Observations done in the past 90 days on current residents reviewed by nursing managers for accuracy; residents identified at risk will be reviewed for appropriate interventions.
• Educate facility staff regarding Wander guard System with emphasis on determining cause of alarm if sounding.
• New admissions will be reviewed in morning meeting daily as part of the clinical morning meeting process.
• Elopement Risk Observations will be reviewed for accuracy and interventions validated if indicated.
• Quarterly assessments will be reviewed as part of the MDS/Care planning process.
• The Director of Nursing will randomly audit a minimum of 5 Elopement Risk Observations weekly for 4 weeks then monthly for 2 additional months to validate accuracy.
• The Maintenance Director/designee will inspect facility doors with wander guard system 3 times weekly for 4 weeks then weekly for 2 additional months.
• The Facility Administrator will make rounds weekly for 4 weeks then monthly for 2 additional months with maintenance director to validate that doors are functioning properly.
• Ad hoc QAPI held to discuss the resident elopement and plan for improvement.
• This process will be reviewed in QAPI for a minimum of 3 months.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to ensure that call lights were within reach for five residents in rooms reviewed for call light placement. Observations revealed that call lights were found on the floor at the foot or head of the bed, or otherwise unreachable, for multiple residents. One resident, who had severe cognitive impairment and diagnoses including muscle weakness, sequelae of cerebral infarction, dementia, and hypertension, was observed lying in bed with the call light on the floor and reported being left wet after urinating on herself, stating that staff took the call light away and were slow to respond to her needs. Other residents' call lights were similarly found out of reach during the same observation period. Interviews with staff indicated that some were aware of the call lights being on the floor but did not take action to make them accessible to the residents. A CNA in training acknowledged the issue but did not correct it, and another CNA stated that the cognitively impaired resident often pulled her call light out of the wall. The facility's policy requires that call lights be within reach and accessible in resident rooms, bathrooms, and bathing areas, but this was not followed for the residents observed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that appropriate post-fall interventions were developed and implemented through care plan revision for one resident following a fall that resulted in a fracture. According to the facility's policy, care plans must be updated when a resident experiences a significant change in condition, such as a fall. Review of the resident's electronic medical record and care plan revealed that after the resident experienced a fall with a fracture, there were no updates or revisions made to the care plan to address new or revised interventions, identification of causative or contributing factors, enhanced supervision, environmental modifications, or individualized fall-prevention strategies. The resident involved had multiple diagnoses, including a fracture of the neck of the right femur, encephalopathy, bone density disorders, rhabdomyolysis, dysphagia, and cognitive communication deficit, and was assessed as having severe cognitive impairment. Despite the resident's return from the hospital and a significant change assessment being completed, the care plan was not updated to reflect the fall and subsequent fracture. Interviews with facility staff confirmed that the care plan was not revised as required following the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary care and services to a resident who was admitted with multiple diagnoses, including hypertensive crisis, likely acute intracranial hemorrhage, left PCA occlusion, dementia with word-finding difficulties, and ambulatory dysfunction. Upon admission, the resident's blood pressure was recorded at 192/103, which exceeded the threshold for intervention as outlined in the facility's policy and the physician's order for as-needed antihypertensive medication. Despite this, documentation did not show that the ordered medication was administered following the elevated blood pressure reading. The resident's care plan indicated the need for antihypertensive medication and required staff to observe for side effects and promptly notify the physician if any were observed. However, there was a lack of communication and follow-through among staff regarding the resident's abnormal vital signs. The CNA who took the vital signs did not report the elevated blood pressure to the LPN, and the LPN was unaware of the abnormal reading. The resident was not entered into the electronic medical record system, which contributed to the lack of documentation and follow-up. The resident was later found unresponsive and pronounced deceased. Interviews with staff revealed confusion about reporting protocols and a lack of clarity regarding responsibilities for monitoring and responding to abnormal vital signs. The facility's failure to monitor and provide medications as ordered by the physician resulted in neglect of the resident's care needs, as evidenced by the lack of timely intervention for the hypertensive crisis.

Removal Plan

• Administrator notified the Medical Director of the Immediate Jeopardy.
• Director of Nursing and/or designee initiated education for all staff on Abuse/Neglect policies and procedures.
• All staff (including any agency assigned staff) that have not completed education will not be permitted to work until education is completed.
• Director of Nursing and/or designee initiated education to all nursing staff on procedure for follow up on abnormal vital signs.
• Director of Nursing and/or designee initiated education to all CNAs related to reporting abnormal vital signs.
• Director of Nursing and/or designee initiated an audit on all residents' Medication Administration Records (MARs) with anti-hypertensive and/or cardiovascular medications to ensure medications were given as ordered.
• 10 residents receiving cardiac medications will be audited weekly for 4 weeks and monthly for 2 months to ensure medications are given as ordered.
• Director of Nursing and/or designee initiated education with CNAs on facility policy and procedure for following checklist for taking resident vital signs.
• Director of Nursing and/or designee initiated education with all licensed nurses on what medications are available in Omnicell and how to pull medications from the Omnicell.
• Director of Nursing and/or designee initiated education for all licensed nurses on entering residents into PCC (PointClickCare) timely upon admission.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to initiate cardiopulmonary resuscitation (CPR) for a resident in accordance with physician orders and the resident’s code status. The resident was admitted with multiple diagnoses, including hypertensive crisis, likely acute intracranial hemorrhage, left PCA occlusion, dementia with word-finding difficulties, and ambulatory dysfunction. Documentation revealed that the resident’s Medication Administration Record (MAR) indicated a full code status, but this was not reflected on the face sheet or care plan. When the resident was found unresponsive, staff did not initiate CPR, and the nurse documented that a Do Not Resuscitate (DNR) order was confirmed, despite the absence of such documentation in the medical record. Interviews with facility staff revealed confusion and inconsistency regarding the resident’s code status. The Director of Nursing (DON) and other staff members indicated reliance on information from the hospital and verbal statements from the resident’s daughter, but there was no documented discussion or signed DNR in the facility’s records. The nurse practitioner and other staff described challenges with entering code status into the electronic medical record and uncertainty about the process for confirming and documenting code status upon admission. The social services director also confirmed that there was no opportunity to speak with the resident or family about advance directives prior to the incident. The lack of clear documentation and communication regarding the resident’s code status led to the failure to provide basic life support as required by physician orders. The facility’s policies required that advance directives be respected and documented, but these procedures were not followed, resulting in the omission of CPR for a resident who was, according to available orders, a full code. This deficiency was determined by the survey team to constitute substandard quality of care and was cited under 42 CFR 483.24 – Quality of Life.

Removal Plan

• Administrator notified the Medical Director of Immediate Jeopardy.
• Social Service Director initiated an audit on Code Status for all new admissions.
• All code binders in all cottages audited to ensure they match orders in PCC.
• Social Service Director initiated an audit on Code Status for all other residents and audited code binders in all cottages to ensure they match orders in PCC.
• New admission's code status and code books will be audited.
• Social Service Director initiated an audit on Advanced Directive to determine if conversations with resident and/or responsible representative held at time of admissions for all new admissions.
• New admissions will be audited to ensure education offered on Advance Directives and code status honored.
• Education provided by the Assistant Regional Director of Clinical Services and Regional President of Operations to Administrator, Director of Nursing, Assistant Director of Nursing, and Social Service Director on conversations with resident and/or responsible representative for Advanced Directives upon admission.
• Education conducted as a review of facility policy and procedure in regard to Advanced Directives with resident and/or responsible representative upon admission.
• Education initiated by Director of Nursing and/or designee to all licensed nurses related to education resident and/or responsible representative on Advanced Directive and code status upon admission.
• All staff (including any agency-assigned staff) that have not completed education will not be permitted to work until education is completed.
• Director of Nursing and/or designee-initiated education for all nursing staff on Code Blue policy and procedures.
• Director of Nursing initiated an audit on Code Status accuracy and Advanced Directives on all resident Care Plans.
• Care plans will be audited to ensure code status is accurate.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely report an allegation of sexual abuse involving a resident with intact cognition and multiple medical diagnoses, including chronic obstructive pulmonary disease, muscle weakness, anxiety disorder, depression, and adult failure to thrive. According to the facility's policy, all alleged violations involving abuse or resulting in serious bodily injury must be reported to the state agency and other required authorities immediately, but not later than two hours after the allegation is made. On the date of the incident, the resident informed the Medical Records Clerk that a staff member had raped them. The MR Clerk immediately notified the Administrator, and an LPN also reported the allegation to the Abuse Coordinator and Administrator shortly thereafter. Despite being promptly informed of the allegation, the Administrator did not submit a reportable incident to the state survey agency on the same day. Instead, the facility notified the state survey agency of the allegation the following day, exceeding the required reporting timeframe outlined in facility policy. The Administrator acknowledged during an interview that the report should have been made immediately but was delayed until the next day.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Certified nurse aides (CNAs) failed to notify a nurse before assisting a resident who had fallen back into bed, contrary to facility policy. On the date of the incident, two CNAs found a resident on the floor in a kneeling position by their bed and, at the resident's insistence, helped them back into bed without first alerting the nurse on duty. The nurse was only informed after the resident was already back in bed, and the reason for the check was not disclosed at that time. The facility's Fall Prevention Program policy requires that when a resident experiences a fall, staff must assess the resident, including a full body audit, before moving them. The resident involved had a history of muscle weakness, required assistance with personal care, and was dependent on staff for transfers. The resident also had moderate cognitive impairment and was at risk for falls due to multiple medical conditions, including confusion, deconditioning, gait and balance problems, and chronic illnesses. Interviews with the CNAs confirmed that they were aware of the policy to notify a nurse before moving a resident after a fall but did not follow it in this instance. The nurse on duty was not made aware of the fall until the following day, after the resident self-reported the incident. There was no documentation of the fall in the resident's medical record at the time of the incident, and the required assessment was not performed immediately after the fall.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement a comprehensive, person-centered care plan to address the fall risk for one resident with severe cognitive impairment and multiple medical conditions, including senile degeneration of the brain, atrial fibrillation, and hypertension. The resident required partial to moderate assistance with bed mobility and transfers and was identified as being at risk for falls due to factors such as altered balance, mental status, medication use, cardiovascular disease, decreased coordination, history of falls, unsteady gait, and visual impairment. Following an unwitnessed fall, the care plan was updated to include hourly rounding as an intervention to prevent further incidents. Despite this intervention being added to the care plan, there was no documentation in the resident's medical record to indicate that hourly rounding was being conducted as directed. Interviews with facility leadership confirmed the absence of evidence that staff were following the care plan's specified intervention. This lack of implementation and documentation of the care plan intervention constituted a failure to meet the resident's needs as outlined in facility policy and regulatory requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nursing assistant (CNA) physically abused a resident by pinching the resident's nose, resulting in visible injuries including bruising and discoloration to the nose, forehead, and above the right eyebrow. The incident took place during morning activities of daily living (ADL) care, after the resident verbally abused the CNA with racial slurs. The CNA admitted to pinching the resident's nose and also reported that the resident hit his head on the bed rail during care. The resident, who had a history of hemiplegia, hemiparesis, dysphagia, restlessness, agitation, and vascular dementia, was rarely or never understood and had not exhibited physical or verbal behaviors during the look-back period according to the Minimum Data Set (MDS). The licensed practical nurse (LPN) was present outside the resident's room during the incident and was informed by the CNA about the verbal abuse. The LPN offered the CNA the option to switch assignments, but the CNA declined and stated she had something for the situation. After the incident, the CNA told the LPN in a joking tone that she had pinched the resident's nose. The LPN initially responded that she was not doing any incident reports that day, but later, upon noticing the resident's facial injuries during wound care, decided to report the incident to the supervisor. The CNA attempted to provide a cream to cover up the injury, but the LPN refused to apply it. The incident was not reported to administration until several hours later, after the RN supervisor was notified. The CNA was then removed from the unit and admitted to pinching the resident's nose, stating she was triggered by the resident's language. The resident was assessed and found to have multiple bruises on the face but denied knowing what happened and did not verbalize pain. The facility's policy required staff to be trained in abuse prevention and to report and remediate abuse immediately, but in this case, there was a delay in reporting and a failure to protect the resident from physical abuse.

Removal Plan

• The staff member who reported pinching the resident's nose was removed from care, a statement was obtained, and she was immediately put on administrative leave.
• A report was completed and provided to the authorities including Certification, Veterans Association, Ombudsman, VA contract monitor, Medical Director, and local authorities.
• The resident had a psychosocial visit completed by the Social Services Director.
• The resident was provided safety and interviewed for any feelings of fear or anxiety.
• The resident had pain monitored and was re-evaluated for side rail need; 1/4 rails were removed.
• The care plan was updated to reflect that staff should discontinue care and report to the nurse when a resident's physical or verbal behaviors escalate.
• Other residents cared for by the accused staff member were interviewed or had body checks completed by a licensed nurse; no concerns or skin issues were noted.
• Interviews were completed with other staff members providing care on that unit; no unusual findings or discoloration on the resident's nose were identified.
• The resident's responsible party was notified and the occurrence explained in full.
• A review of risk reports, grievance process, and resident council minutes was completed; no concerns related to potential abuse were identified.
• A root cause analysis was conducted, determining that the involved staff member did not follow protocol regarding residents who are combative or abusive.
• The QAPI committee determined that re-education was warranted on the abuse policy, which was started.
• All staff were re-educated on the abuse policy, including types of abuse, what and when to report abuse, and what to do when a resident is abusive verbally/physically.
• Policy and procedure were reviewed and updated with emphasis on removing self from a resident with escalating behaviors and notifying the nurse for assistance/guidance.
• Hiring practices were reviewed to include background and reference checks and orientation that includes abuse prevention.
• The accused staff member's file was reviewed and found complete as per practice.
• The accused staff member was immediately placed on administrative leave and, following investigation, employment was terminated.
• Questionnaires (audits) testing staff knowledge of abuse prevention and handling escalating behaviors will be completed randomly, with results reviewed in the QAPI process until compliance is attained and maintained.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents were free from unnecessary psychotropic medications and did not follow established protocols for medication monitoring and documentation. For one resident with a history of dementia, psychotic disturbance, and schizoaffective disorder, an antipsychotic medication (aripiprazole) was administered without documented evidence of behaviors or symptoms justifying its continued use. Multiple staff interviews confirmed the absence of hallucinations, delusions, or paranoia, and the resident herself denied current symptoms. Despite this, the medication remained active, and the interdisciplinary team had not documented a recent evaluation supporting its necessity. Another resident with Alzheimer's disease and agitation, who was on hospice care, had an active PRN order for lorazepam (an antianxiety medication) without a required stop date. The DON was unaware of the need for stop dates on hospice-prescribed medications. Additionally, a third resident with PTSD, major depressive disorder, and ADHD had two PRN orders for Adderall (a CNS stimulant) without end dates, and the medication had not been administered since being ordered. The DON did not recognize Adderall as a psychotropic medication and believed that unused orders would be discontinued after 30 days, but the orders remained active. Review of facility policy indicated that psychotropic medications should not be used unless clinically indicated and that PRN orders for such medications must have a documented rationale and duration, especially if extended beyond 14 days. The facility's failure to ensure adequate monitoring, documentation, and adherence to stop-date requirements for psychotropic and CNS stimulant medications resulted in deficiencies for three residents reviewed.