Citations in South Carolina
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in South Carolina.
Statistics for South Carolina (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in South Carolina
A resident with acute respiratory failure and hypoxia did not receive oxygen therapy as ordered, with observations showing oxygen administered at a higher flow rate than prescribed and tubing not changed according to the physician's schedule. Documentation by nursing staff did not match actual practice, and both an LPN and the DON confirmed the discrepancies in oxygen administration and tubing change frequency.
A resident with ESRD who required hemodialysis did not receive scheduled morning medications on multiple dialysis days, despite physician orders allowing for adjusted administration times. An LPN withheld all medications except pain medication and did not clarify the order, while the DON was unaware of the specific instructions, resulting in missed doses.
Staff did not adhere to Enhanced Barrier Precautions (EBP) when providing indwelling urinary catheter care for two residents with urinary retention, using only gloves instead of the required gowns and face shields. Despite facility policy and staff training on EBP, staff demonstrated inconsistent understanding and failed to implement the necessary PPE during catheter care, as confirmed by interviews and observations. The DON stated that staff were expected to follow EBP protocols and report PPE shortages, but this did not occur.
A CNA did not wear a gown while bathing a resident with a feeding tube, despite facility policy and CDC/CMS guidelines requiring both gloves and a gown for high-contact care activities involving indwelling medical devices. The resident, who was fully dependent on staff due to cerebral palsy and contractures, had a care plan directing staff to use enhanced barrier precautions. Facility leadership confirmed the expectation for proper PPE use during such care, and acknowledged the lapse in protocol.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, as required.
A resident with dementia and dysphagia was involved in an altercation with another resident, but the resident's representative was not notified as required by facility policy. Review of records and interviews with staff and the representative confirmed that no notification or documentation occurred regarding the incident, despite expectations for immediate family notification and documentation by nursing staff.
Staff failed to perform hand hygiene before handling clean dishes in multiple kitchens, and kitchenware was stored while still wet, contrary to facility policy. These deficiencies had the potential to affect nearly all residents receiving dietary services.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident and their representative were not given a written bed hold notice that included the required current per diem rate when the resident was transferred to a hospital. Although the bed hold policy and rate changes were reviewed at admission and mailed to representatives, the specific rate was not included on the notice at the time of transfer, leaving the resident without all necessary information.
Surveyors found that an insulin pen in use was missing required labeling, including the open and expiration dates, and an expired nasal allergy spray was stored with current medications. Both issues were confirmed by LPNs and involved two of eight medication carts reviewed, in violation of facility policy for medication storage and labeling.
Failure to Administer Oxygen Therapy per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of acute respiratory failure with hypoxia did not receive oxygen therapy according to physician orders. The physician's order specified oxygen at 2 liters per minute (LPM) via nasal cannula continuously and required the oxygen tubing to be changed weekly on Wednesdays. However, observations revealed that the resident was receiving oxygen at 3 LPM, and the oxygen tubing in use was dated nearly two weeks prior, indicating it had not been changed as ordered. Documentation in the Treatment Administration Record confirmed that nursing staff recorded the resident as being on 2 LPM, but direct observation contradicted this, showing the oxygen set at 3 LPM. During interviews, an LPN acknowledged the discrepancy in both the oxygen flow rate and the tubing change schedule, stating tubing was changed every three days rather than weekly. The DON confirmed that staff were expected to check oxygen settings every shift and change tubing weekly, but these practices were not followed for this resident.
Failure to Administer Scheduled Medications for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) who required hemodialysis received their scheduled morning medications either before or after returning from dialysis. Review of the resident's care plan and physician orders indicated that medication administration times on dialysis days could be adjusted to ensure proper absorption, but the September Medication Administration Record showed that several medications, including amlodipine, Aricept, and duloxetine, were not administered on multiple dialysis days. The facility's policy required staff to be trained in the timing and administration of medications for residents receiving dialysis, but this was not followed in practice. Interviews revealed that the LPN responsible for the resident's care withheld all medications except pain medication on dialysis days and did not administer them when the resident returned. The LPN also stated that she did not seek clarification regarding medication administration for the resident on dialysis days. Additionally, the DON was unaware of the specific order allowing for medication time adjustments and believed all medications were to be held on dialysis days. This lack of communication and adherence to physician orders resulted in the resident missing scheduled doses of essential medications.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to follow infection prevention and control guidelines regarding Enhanced Barrier Precautions (EBP) during the provision of indwelling urinary catheter care for two residents with urinary retention and indwelling catheters. Facility policy required the use of EBP, including wearing gowns, gloves, and face shields during device care for residents with indwelling catheters. However, during multiple observations, staff members performed catheter care using only gloves and did not wear gowns or face shields as required. Interviews with certified nurse aides revealed inconsistent understanding and application of EBP protocols, with some staff believing gowns were only necessary for residents with wounds, and others acknowledging they should have worn additional PPE but did not obtain it prior to providing care. The residents involved had documented orders and care plans specifying the need for catheter care and EBP due to their indwelling urinary catheters. Despite receiving training on EBP, staff did not consistently implement the required precautions. The Director of Nursing confirmed that staff were expected to follow EBP protocols and to notify management if PPE was unavailable, but this expectation was not met during the observed care events.
Failure to Follow Enhanced Barrier Precautions During Resident Bathing
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow the facility's Enhanced Barrier Precautions (EBP) policy while providing direct care to a resident with a feeding tube. During an observed bathing and dressing activity, the CNA wore a surgical mask and gloves but did not don a gown, despite the resident being on EBP due to the presence of a percutaneous endoscopic gastrostomy (PEG) feeding tube. The facility's policy, consistent with CDC and CMS guidelines, requires staff to wear both gloves and a gown during high-contact care activities, such as bathing, for residents with indwelling medical devices, regardless of their multi-drug resistant organism status. The resident involved had a medical history of cerebral palsy, contractures in all limbs, and was dependent on staff for all activities of daily living, including bathing. The care plan specifically directed staff to follow enhanced barrier precautions related to the resident's PEG tube. Both the Director of Nursing and the Administrator confirmed that the expectation was for staff to don appropriate PPE, including a gown, during such care activities, and acknowledged that the CNA did not comply with these protocols during the observed incident.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Resident Representative of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to notify a resident's representative of the resident's involvement in a resident-to-resident altercation, as required by facility policy. The incident involved a resident with Alzheimer's, vascular dementia, and dysphagia, who was pushed in the back by another resident while attempting to access a food cart. No injuries were noted. Review of the resident's records, including progress notes and the electronic health record, revealed no documentation that the resident's representative was informed of the incident. There was also no SBAR documentation related to the event. Interviews with the resident's representative confirmed that neither he nor his wife had been notified of the altercation. Facility staff, including an LPN, acknowledged the absence of documentation and notification, and the DON and Administrator stated that it was their expectation for staff to notify the resident's representative and document such incidents. The nurse responsible for the resident at the time did not follow this protocol, resulting in the deficiency.
Failure to Ensure Hand Hygiene and Proper Drying of Kitchenware
Penalty
Summary
Staff in four out of five facility kitchens failed to perform adequate hand hygiene while washing dishes, as observed during multiple instances. Dietary aides were seen moving from handling dirty dishes to removing clean dishes from the dishwasher without washing their hands. This was confirmed by both direct observation and staff interviews, where dietary aides acknowledged not performing hand hygiene before touching clean dishes. Facility policy required staff to wash hands before handling clean dishes, a requirement confirmed by both the Dietary Manager and Dietary Manager Assistant. Additionally, in the main kitchen, metal pans and plastic lids were observed to be stored while still wet, with water standing on them, indicating they were not thoroughly air-dried prior to storage. Both the Dietary Manager and Dietary Manager Assistant confirmed that all dishes were expected to be dry before being placed on storage shelves, and that there should be a designated area for items needing additional air-drying. These failures had the potential to affect 74 of 77 residents receiving dietary services.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide Complete Bed Hold Notice Including Current Per Diem Rate
Penalty
Summary
The facility failed to provide a resident or their representative with a written notice specifying the duration of the bed hold policy and the current rate for the reserve bed payment at the time of the resident's transfer to a hospital. Record review showed that the "Bed Hold Notice" given to the resident did not include the basic per diem rate, which is necessary information for decision-making regarding bed hold during a hospital stay. The facility's policy requires that written information about bed hold practices, including reserve bed payment, be provided to all residents and/or their representatives both in advance and at the time of transfer. Interviews with facility staff confirmed that the Social Services Director was responsible for completing the "Bed Hold Notice" forms and acknowledged that the basic per diem rate was omitted from the notice provided to the resident. Although the bed hold rates were reviewed with residents and representatives at admission and rate increases were mailed to representatives, this information was not included on the "Bed Hold Notice" at the time of the resident's transfer. The omission left the resident without all necessary information regarding the bed hold policy and associated costs.
Failure to Properly Label and Remove Expired Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and storage of drugs and biologicals in accordance with professional standards and facility policy. Specifically, during an observation of Medication Cart 1, a Humalog insulin pen was found in use without an open date, expiration date, or use-by date. This was confirmed by an LPN, and the insulin pen was subsequently removed from storage. The facility's policy requires that multi-dose vials, including insulin, be dated and initialed upon first use and used within 28 days unless otherwise specified by the manufacturer. Additionally, during an observation of Medication Cart 2, a bottle of nasal allergy spray was found to be expired and still stored with medications currently in use. This expired medication was also confirmed by an LPN and removed from the cart. The facility's policy mandates that outdated medications be immediately removed from stock and disposed of according to procedures. These findings were noted in 2 of 8 medication carts reviewed.
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