Pruitthealth- Moncks Corner

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 obtain a physician order for advance directives for one resident who was reviewed for advance directives. The resident was admitted with diagnoses including acquired absence of the right leg below the knee, type 2 diabetes mellitus with diabetic chronic kidney disease, and muscle weakness. The resident's EMR contained a physician order dated as open-ended indicating Full Code status, while the hospice communication binder contained a Resident Request Do Not Resuscitate (DNR) form signed by the resident representative and a DNR form signed by the attending physician and concurring physician with an effective date and no expiration date. The resident's care plan showed hospice services for terminal care due to severe protein-calorie malnutrition and other related diagnoses, COPD, and a short-term goal of death with dignity, but it did not include a care plan focused on advance directives. The quarterly MDS assessed the resident with moderate cognitive impairment, a life expectancy of less than 6 months, and hospice services. During interviews, staff stated that residents are admitted as Full Code by default, that social services updates code status and banners, and that nurses make the order changes, but the resident's orders and banner did not match at the time of review.

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 protect a resident from the misappropriation of a narcotic medication, specifically Ativan, which was intended for a resident with cognitive communication deficit, anxiety disorder, and unspecified intellectual disabilities. The resident was moderately cognitively impaired, as indicated by a BIMS score of 9 out of 15. The issue arose when a card containing 15 tablets of Ativan went missing, and the facility could not account for it. The Controlled Drug Record and the corresponding narcotic sheet were also missing, leading to the resident missing two doses of the medication. The deficiency was identified when the facility's Physician Assistant (PA) was alerted by the pharmacy that it was too soon to reorder the Ativan. The PA gave a verbal order to administer 0.5 mg Ativan from the Cubex until the pharmacy could deliver a new card. However, this order was not documented in the system, and the Medication Administration Record (MAR) did not reflect the administration of the 0.5 mg doses. The Director of Nursing (DON) confirmed that the missing card and sheet led to the resident missing doses, and the discrepancy was discovered during preparations for an upcoming storm. The facility's failure to properly track and document the administration of the narcotic medication resulted in the misappropriation of the resident's medication.

Penalty

Inspection fine: $10,845

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 a resident diagnosed with dementia was free from neglect, resulting in the resident eloping from the facility. The resident, who had a history of vascular dementia, cognitive communication deficit, altered mental status, and a history of falling, was found in the parking lot near a major highway after being unaccounted for during bedtime. The resident had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment and was known to exhibit exit-seeking behavior, particularly during the evening when sundowning behaviors were more pronounced. On the day of the incident, the resident was noted to be continuously attempting to leave the facility and was redirected multiple times by staff. Despite these efforts, the resident managed to exit the facility through the front door, which was not properly aligned and failed to lock, allowing the resident to elope. The resident was found outside by a CNA, who heard the alarm going off by the front door but could not hear it from the resident's unit due to its location at the back of the facility. The CNA found the resident in the parking lot with another resident's family member and managed to convince the resident to return inside. Interviews with staff revealed that the resident's exit-seeking behavior was known, and an Electronic Monitoring Device (EMD) had been placed on the resident's ankle to prevent elopement. However, the door's malfunction allowed the resident to exit despite the EMD. The facility's Administrator and Director of Nursing were informed of the incident, and it was noted that the door had ongoing issues that had not been resolved, contributing to the resident's ability to elope.

Removal Plan

• R1 was brought back into the facility immediately and safely by the Certified Nursing Assistant (CNA) and the Nurse.
• A body audit was completed which revealed no injuries.
• R1 was assisted to bed where he fell asleep and remained for the remainder of the night.
• R1 responsible party was notified, and a 100% resident head count was completed for all residents with all residents being accounted for, Medical Director/provider made aware.
• Facility Administrator was on-site within an hour of the reporting of the incident.
• The Maintenance Director was contacted and arrived at the facility minutes later to repair the front door.
• All other doors checked and verified for proper egress/ingress functioning to include alarming the electronic medical device system.
• The front door was monitoring continuously until the repairs were completed and appropriate functionality of the door was confirmed.
• The front door continued to be monitored for 24 hours after the event with no recurrence.
• All staff are to receive education on Code Pink/ Missing Residents which include neglect of a resident; how to handle malfunctioning doors by the Administrator, Clinical Competency Coordinator (CCC), Director of Health Services (DHS), and/or licensed designated charge nurse initiated.
• All new hires will receive education in orientation.
• Any partner that is on leave will receive education prior to their next scheduled shift.
• Replacement of the front door has been approved and the work order has been requested by the vendor, awaiting date/time of replacement to be scheduled.
• All doors not limited to the front door is in working order to secure the facility properly and functioning properly.
• The Maintenance Director or designee will verify the proper functioning of all doors twice daily times one month or until replacement of the door is complete.
• Results will be reviewed in the Quality Assurance and Performance Improvement (QAPI) monthly for three months and/or until substantial compliance is achieved.

Penalty

Inspection fine: $10,845

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 adequate supervision to prevent a resident from eloping, which resulted in the resident being found in the parking lot near a major highway. The resident, who had severe cognitive impairment and a history of exit-seeking behavior, was admitted with diagnoses including vascular dementia and altered mental status. Despite having an electronic monitoring device (EMD) on their ankle, the resident was able to exit the facility through the front door, which was not properly aligned and failed to lock. On the evening of the incident, the resident was last seen at the nurse's station in their wheelchair, expressing that they were not ready for bed. A CNA, after attending to another resident, noticed the resident was missing and eventually found them outside in the parking lot. The CNA heard the alarm from the front door, which was not audible from the resident's unit, and found the resident with another resident's family member. The resident was outside for approximately 10 to 15 minutes before being brought back inside by the CNA. Interviews with staff revealed that the EMD alarms were functioning, but the door's misalignment allowed the resident to exit. The Director of Nursing and the Administrator were informed of the elopement, and it was discovered that the door had ongoing issues and needed replacement. The facility's policy on occurrences emphasized the need for appropriate interventions based on residents' risk assessments, which were not effectively implemented in this case, leading to the resident's elopement.

Removal Plan

• R1 was brought back into the facility immediately and safely by the Certified Nursing Assistant (CNA) and the Nurse.
• A body audit was completed which revealed no injuries.
• R1 was assisted to bed where he fell asleep and remained for the remainder of the night.
• R1 responsible party was notified, and a 100% resident head count was completed for all residents with all residents being accounted for.
• Medical Director/provider made aware.
• Facility Administrator was on-site within an hour of the reporting of the incident.
• The Maintenance Director was conducted and arrived at the facility minutes later to repair the front door.
• All other doors checked and verified for proper egress/ingress functioning to include alarming the electronic medical device system.
• The front door was monitoring continuously until the repairs were completed and appropriate functionality of the door was confirmed.
• The front door continued to be monitored for 24 hours after the event with no recurrence.
• All staff are to receive education on Code Pink/ Missing Residents which include neglect of a resident; how to handle malfunctioning doors by the Administrator, Clinical Competency Coordinator (CCC), Director of Health Services (DHS), and/or licensed designated charge nurse initiated.
• All new hires will receive education in orientation.
• Any partner that is on leave will receive education prior to their next scheduled shift.
• Replacement of the front door has been approved and the work order has been requested by the vendor, awaiting date/time of replacement to be scheduled.
• All doors not limited to the front door is in working order to secure the facility properly and functioning properly.
• The Maintenance Director or designee will verify the proper functioning of all doors twice daily times one month or until replacement of the door is complete.
• Results will be reviewed in the Quality Assurance and Performance Improvement (QAPI) monthly for three months and/or until substantial compliance is achieved.

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 11 residents received their physician-ordered medications, leading to significant medication errors. The issue was identified during a review of the facility's policy, observations, record reviews, and interviews. The facility's policy required medications to be administered as prescribed and within a specific time frame. However, the Electronic Medication Administration Record (EMAR) revealed that several residents did not receive their medications as scheduled, with some medications documented as not administered or administered late. Interviews with residents and staff highlighted the circumstances leading to the deficiency. One resident reported not receiving their medication on a particular day, while another resident mentioned that the nurse was late in passing medications. The Interim Director of Nurses (IDON) and the Administrator were informed of the issue when the Infection Preventionist (IP) Nurse discovered medications that were documented as given but were still in their original packaging. The Licensed Practical Nurse Unit Manager (LPNUM) responsible for the medication pass on the day in question was unable to complete the task due to being overwhelmed and not in a mental state to continue, leading to missed and late medication administrations. The LPNUM admitted to being behind in the medication pass and failing to notify the Director of Nursing (DON) or the physician about the situation. The LPNUM was eventually relieved by the night Registered Nurse (RN), who discovered the unopened medications. The facility's failure to administer medications as prescribed and the lack of timely communication and reporting contributed to the significant medication errors observed during the survey.

Penalty

Inspection fine: $11,125

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 system to ensure that every employed nurse aide received a performance review every 12 months and the required 12 hours of inservice training based on these reviews. A review of the Annual Skills Fair, dated 08/18/23, revealed that it did not include the necessary content or total hours to meet the 12-hour inservice requirement for Certified Nursing Assistants (CNAs). The Skills Fair was attended by all staff, including nurses, CNAs, maintenance, and housekeeping, but lacked documentation of performance reviews and specific inservice training hours for CNAs. Further examination of a document titled 'Course Completion History' showed that 13 out of 20 CNAs had not completed the required 12 hours of inservice training. Additionally, those CNAs who did complete at least 12 hours of training did not have documentation of receiving a performance review. During an interview, the Administrator confirmed that while all employees attended the annual skills fair, there was no documentation to support that CNAs had received the necessary performance reviews and inservice training based on those reviews.

Penalty

Inspection fine: $11,125

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 proper storage of medications for one resident, one medication room, and two treatment carts. During an initial tour, an opened bottle of esomeprazole magnesium was found on a bedside table belonging to a resident who was not present in the room. The resident later denied having the medication in their possession. Additionally, opened tubes of MediHoney labeled for single use were found on treatment carts, with one tube missing a cap, exposing its contents. Furthermore, the medication room refrigerator was found to be operating at temperatures below the recommended range for storing medications, with readings around 32 degrees Fahrenheit. This was verified by multiple thermometers, despite the facility's temperature log indicating a higher temperature earlier that day. The refrigerator contained various medications, including insulins and other injectables, which require storage between 36-46 degrees Fahrenheit. The Director of Nursing was informed of these findings.

Penalty

Inspection fine: $11,125

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 maintain the dignity of a resident, identified as R40, by not addressing his personal grooming needs, specifically the trimming of nose hairs. R40, who was admitted with diagnoses including unspecified dementia and altered mental status, was severely cognitively impaired and dependent on staff for personal hygiene. Observations noted that R40 had nose hairs extending beyond his nostrils, which was not addressed by the staff. The facility's policy and CNA job description require CNAs to assist with personal grooming, but there was a lack of clarity and action regarding nose hair care. Interviews with staff revealed a gap in understanding and execution of grooming responsibilities. A CNA expressed uncertainty about addressing nose hair care, stating that her duties were limited to shaving the beard and mustache. The Director of Nursing indicated that CNAs are expected to groom residents daily, including shaving as needed. However, the documentation of R40's personal hygiene care showed inconsistencies, with some shifts not recording any activity. This lack of consistent grooming care and documentation contributed to the deficiency in maintaining the resident's dignity.

Penalty

Inspection fine: $11,125

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 a resident with diagnoses of post-traumatic stress disorder (PTSD) and bipolar disorder was referred and screened for possible needed services using the PASARR Level II screening and evaluation tool. The resident was admitted on 06/14/18 with diagnoses including cerebral vascular accident, anxiety, pain disorder, morbid obesity, and panic disorder. The PASARR Level I screening completed on 06/28/17 did not include the diagnoses of bipolar disorder, PTSD, panic disorder, or anxiety disorder, and stated that no further evaluation was recommended despite indicators being present. No reasons were provided for this recommendation. A review of the resident's medical record revealed diagnoses of PTSD dated 01/28/20 and 05/03/23, bipolar disorder, anxiety disorder, and panic disorder, but no documentation of a PASARR Level II screening or evaluation was found after these diagnoses were made. During an interview, the Social Services Director acknowledged that the resident was screened on admission without the diagnoses of PTSD and bipolar disorder and mentioned that the facility is in the process of auditing to submit the paperwork for PASARR Level II screening.

Penalty

Inspection fine: $11,125

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 update the care plan for a resident, identified as R677, regarding their oxygen use and pain management. Despite the resident's documented use of oxygen therapy and complaints of severe pain, the care plan did not include goals or approaches for managing these issues. Observations and interviews revealed that the resident experienced significant pain, which was not adequately addressed in the care plan. The facility's policy requires that care plans be updated to reflect changes in a resident's condition, but this was not done for R677, as confirmed by the facility's administrator. Additionally, the facility did not accurately reflect another resident's, identified as R31, advance directives in their care plan. Although the resident was documented as Do Not Resuscitate (DNR) and on hospice, the care plan incorrectly indicated a full code status. Interviews with staff, including an LPN and the DON, revealed that the care plan was not updated to reflect the resident's current advance directives, which is a requirement according to the facility's policy. This oversight highlights a failure in the facility's process to ensure that residents' wishes and medical needs are accurately documented and followed.

Penalty

Inspection fine: $11,125

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 proper hand hygiene and resident privacy during wound care for Resident 13. The facility's policy on wound care outlines specific steps for hand hygiene and maintaining resident privacy, which were not followed during the observed procedure. The policy requires hand washing or the use of an alcohol cleanser after removing soiled dressings and before applying new gloves, as well as ensuring resident privacy by closing doors, pulling curtains, and closing blinds. During the wound care observation, RN1 did not wash or clean her hands between glove changes multiple times throughout the procedure. RN1 only cleaned her hands once during the entire wound care process, despite changing gloves several times. Additionally, RN1 did not ensure resident privacy, as she did not close the room door, pull the privacy curtain, or close the blinds, leaving Resident 13 exposed to the view from the outside window facing the parking lot. Resident 13, who is non-verbal and on Enhanced Barrier Precautions due to multiple wounds and other medical conditions, was not provided with the necessary privacy and infection control measures during wound care. The failure to adhere to the facility's policy on hand hygiene and privacy during wound care was confirmed by RN1 during an interview, acknowledging the lack of proper hand cleaning and privacy measures.

Penalty

Inspection fine: $11,125

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 follow proper catheter care procedures for a resident, identified as R13, who was reviewed for catheter care. The facility's policy for catheter care includes specific steps for cleaning the perineal area and catheter tubing to prevent infections. However, during an observation, a Certified Nursing Assistant (CNA) did not adhere to these procedures. The CNA performed catheter care without using soap or any type of cleaner, which is contrary to the facility's policy that requires washing with soap or perineal cleanser. The CNA only cleaned the catheter tubing and did not follow the steps outlined for cleaning the perineal area, which is essential for preventing infections. R13, a resident with a history of urinary tract infections and other medical conditions such as anoxic brain damage and osteomyelitis, was observed during the catheter care procedure. The CNA, who was wearing appropriate personal protective equipment due to the resident being on enhanced precautions, stated that they were taught in school to only clean the tubing and that nurses were responsible for the rest of the catheter care. This indicates a gap in the CNA's understanding of the facility's catheter care policy, leading to incomplete care for R13.

Penalty

Inspection fine: $11,125

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 establish a physician order for oxygen use for Resident 677, who was admitted with diagnoses including shortness of breath and paroxysmal atrial fibrillation. The facility's policy on oxygen administration, revised on 08/02/23, requires that oxygen be administered only when ordered by a physician, PA, or NP. However, a review of Resident 677's records revealed no physician order for oxygen therapy, despite the resident receiving oxygen via nasal cannula on multiple occasions, as noted in a physician progress note and during observations on 06/18/24, 06/19/24, and 06/20/24. The Director of Nursing confirmed that there should be a physician order for oxygen use unless it is an emergency situation, which was not the case for Resident 677.

Penalty

Inspection fine: $11,125

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 a medication prescribed to a resident for fecal impaction was administered according to physician orders. The resident, who was admitted with a diagnosis including constipation, was hospitalized due to projectile vomiting and diagnosed with a small bowel obstruction. Upon discharge back to the facility, the resident had a physician order for Senokot Plus to be administered twice daily. However, a review of the Medication Administration Record revealed that the 9:00 PM doses were not administered on multiple occasions after the resident's return from the hospital. The Interim Director of Nursing acknowledged that multiple doses of the medication were not administered as ordered on the evening shift.

Penalty

Inspection fine: $11,125

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 adhere to proper infection control practices concerning the cleaning of glucometers, as observed during a medication pass. The facility's policy, revised on June 27, 2023, mandates that glucometers used for multiple residents must be cleaned and disinfected after each use according to the manufacturer's instructions. The manufacturer's guide specifies that the EvenCare G3 glucometer should be cleaned and disinfected between each patient using approved disinfectant wipes. However, during an observation, an LPN was seen using an alcohol prep pad to clean the glucometer before and after testing a resident's blood sugar, which is not in line with the manufacturer's recommendations. The LPN confirmed during an interview that the glucometer was used for other residents and admitted to using an alcohol prep pad for cleaning, questioning if this was acceptable. Although the LPN later located a container of MicroKill Bleach, which is an approved disinfectant, it was not used to clean the glucometer. The following day, the LPN acknowledged the mistake after discussing it with the Director of Nursing and mentioned having received in-service training. The deficiency was identified for one of the three residents observed for finger stick blood sugar testing.

Penalty

Inspection fine: $11,125

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 designate a licensed nurse to serve as a charge nurse on each tour of duty. A review of the daily staffing sheets from January 1, 2024, through June 16, 2024, revealed that there was no designated licensed nurse assigned as a charge nurse for each shift. The staffing sheets included a line for a Shift Supervisor, but this section was left blank. During an interview, the Director of Nursing (DON) stated that each nurse working on each unit should act as the charge nurse, but confirmed that no specific nurse was designated to be in charge for each shift. When questioned about the protocol for staff to follow if an issue arises and no one is available, the DON did not provide a response.