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.
Some of the Latest Corrective Actions taken by Facilities in South Carolina
- Implemented 1:1 supervision for the exit-seeking resident with ongoing compliance monitoring by department heads (J - F0689 - SC)
- Installed double lock/window stop systems on all resident room windows and established twice-daily and quarterly functionality checks (J - F0689 - SC)
- Reeducated all staff quarterly on the facility’s Emergency Procedure for a Missing Resident (J - F0689 - SC)
- Initiated a QAPI project to maintain appropriate supervision and assistive devices for residents exhibiting exit-seeking behaviors (J - F0689 - SC)
Failure to Prevent Elopement of Resident with Known Risk
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement and moderate cognitive impairment was not provided with adequate supervision to prevent elopement. The resident, who had diagnoses including urinary tract infection, difficulty walking, dependence on supplemental oxygen, anxiety disorder, and a PICC line, was assessed as being at risk for elopement upon admission and was equipped with an electronic monitoring device. However, documentation showed inconsistent checks of the device, and staff were not fully aware of the resident's exit-seeking behaviors. On the night of the incident, the resident was last seen at the nurse's station for supervision due to attempts to stand without assistance, but was later assisted to bed and left unsupervised in his room. The resident managed to open his window, remove the screen, and exit the building without being detected by staff. His roommate witnessed the elopement and attempted to alert staff, but there was a delay before staff responded. The resident was missing for several hours before being found by law enforcement in a wooded area on facility property, approximately 75 feet from the building. The resident sustained minor injuries, including scratches and abrasions, but was able to ambulate with limited assistance when found. Interviews with staff revealed gaps in communication and awareness regarding the resident's elopement risk and the proper monitoring of the electronic monitoring device. The DON and Administrator were not fully informed of the resident's prior history of elopement, and staff training on elopement risk identification and response was incomplete at the time of the incident. The facility's policy for missing residents was not fully effective in preventing the resident's elopement or ensuring immediate detection and response.
Removal Plan
- Implemented 1:1 supervision for this resident when he is not in group settings and will remain for this resident for the duration of his stay at the facility. Compliance will be monitored by Department Heads along with the Administrator and Director of Nursing.
- Installed a double lock/window stop system on his patient room window to increase safety. Window lock/stops will be checked for proper operation twice daily for the duration of R2's stay at the facility. The lock/stop system has been installed on all patient room windows and will be monitored quarterly. Compliance will be monitored by the Director of Plant Maintenance.
- Reeducated the staff on the facility's Emergency Procedure for a Missing Resident. Education will continue for all employees quarterly on each shift. Compliance will be monitored by the Department Heads along with the Administrator and Director of Nursing.
- A Quality Assurance Performance Improvement (QAPI) was initiated to ensure that R2 and other facility residents have appropriate supervision and assistive devices in place to prevent accidents, especially those with exit seeking behaviors. Compliance will be monitored by Department Heads along with Administrator and Director of Nursing.
Failure to Implement Therapeutic Diet Results in Resident Death
Penalty
Summary
A facility failed to ensure that a resident with dysphagia and documented swallowing difficulties received a therapeutic diet consistent with the recommendations of the Speech Language Pathologist (SLP). The resident, who had diagnoses including dementia, dysphagia, and aphasia, was admitted on a regular diet with nectar thick liquids. Multiple SLP evaluations and weekly treatment plans recommended a mechanical soft diet and nectar thick liquids due to poor swallow safety, moderate confusion, and observed difficulties such as holding food in the mouth, coughing or choking during meals, and spitting or spilling food. Despite these recommendations, the resident continued to receive regular textured food. The resident's care plan did not include interventions related to a therapeutic diet, and the diet order in the electronic medical record did not reflect the SLP's recommendations for a mechanical soft diet. Staff interviews revealed a lack of awareness regarding any changes to the resident's diet, with nursing and dietary staff indicating that they were not informed of the SLP's recommendations. The SLP stated that diet communication slips were provided to both dietary and nursing departments, but the new diet recommendation was not effectively communicated or implemented. On the day of the incident, the resident was served a meal that included a hot dog, which is specifically listed as a food to avoid for individuals on a mechanical soft diet. The resident was later found unresponsive and without a pulse after eating, with staff and EMS removing pieces of hot dog from her airway. The resident suffered asphyxiation and expired in the facility. The deficiency was cited under 42 CFR 483.25 for failure to provide adequate nutrition and hydration consistent with the resident's clinical needs.
Removal Plan
- Resident is no longer in the facility.
- Resident was picked up on speech caseload with a goal of consuming regular diet and thin liquids. Resident was discharged from speech with recommendations for mechanically altered diet and thin liquids.
- New diet recommendation not communicated effectively by speech therapist to dietary or nursing departments. Investigation initiated and contracted therapy provider was notified. SLP will be suspended pending investigation. Regional therapist in house for an additional audit of residents on current speech caseload.
- An audit of current resident's diet as well as most current speech recommendations will be completed by Interdisciplinary Team to identify any discrepancies. Discrepancies identified were corrected with recommended speech diets, provider notified, and care plans updated.
- Meal Tracker will also be audited to ensure ordered diets match the tray ticket. Discrepancies identified were corrected.
- Licensed nurses and therapy department were re-educated regarding the expectation that any changes to diet are communicated within the IDT team via diet communication slip. SLP to complete diet communication slip, keep a copy, and give a copy to DOR, CDM, and Nurse Manager.
- Dietary Communication Slips will be reviewed in clinical morning meeting Monday-Friday.
- Administrator/designee will review 3 residents per week, according to MDS assessment per calendar, to validate ordered diet matches most current speech recommendation.
- Facility Administrator/designee will be responsible for the overall implementation and validation of this plan.
- Results of these reviews will be presented to the Quality Assurance Performance Improvement committee for review and recommendations. Any concerns will be addressed at time.
- An Ad Hoc QAPI will be held.
- Medical Director was notified of the incident and plan for improvement.
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