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)
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.
Latest Citations in South Carolina
A resident with a history of elopement and moderate cognitive impairment was able to exit the facility through a window without detection, despite being assessed as an elopement risk and equipped with an electronic monitoring device. Staff were not fully aware of the resident's exit-seeking behaviors, and there were lapses in supervision and monitoring. The resident was missing for several hours before being found by law enforcement on facility property with minor injuries.
A resident with significant mobility impairments and a history of osteoporosis was transferred by an LPN without the required sit-to-stand lift, contrary to the resident's care plan and physical therapy recommendations. During the manual transfer, the resident's legs buckled, resulting in a fall into a recliner and a fractured arm that required surgery. Staff interviews confirmed the LPN was aware of the transfer requirements but did not follow them at the time.
Medications, including expired influenza vaccine syringes, were found improperly stored in medication room refrigerators, with temperatures outside the required 36-46°F range and incomplete temperature logs. Staff and pharmacy personnel confirmed the deficiencies, and temperature monitoring was not performed as required by facility policy.
The facility did not inform residents of their right to access contact information for state regulatory agencies, advocacy groups, or details on filing complaints or reporting abuse. Resident council minutes lacked documentation of this information, and all residents interviewed were unaware of their rights or where to find such details. Staff interviews confirmed that specific information about the Ombudsman and complaint procedures was not communicated.
A resident was discharged to the hospital, but the facility failed to complete and submit the required discharge MDS assessment. The MDS Coordinator acknowledged the assessment was missed, and the DON confirmed that all necessary MDS assessments were expected to be completed.
A resident was provided with side rails for movement and repositioning without documented evidence that alternative measures were attempted or that an assessment for entrapment risk was completed. Staff interviews revealed that bedrails were routinely installed upon admission without exploring alternatives, and there was no formal process or equipment in place to assess for entrapment risk. The DON and LPN were unaware of the requirement to consider alternatives prior to bedrail use.
A resident with dysphagia and swallowing difficulties did not receive a mechanical soft diet as recommended by the SLP, resulting in continued provision of regular textured food. The care plan and diet orders were not updated to reflect the SLP's recommendations, and staff were unaware of any changes. The resident was served a meal including a hot dog, subsequently suffered asphyxiation, and died after choking on the food.
Two residents with urinary catheters had discrepancies between their physician orders and care plans regarding catheter balloon size. One resident with severe cognitive impairment had a care plan listing a different balloon size than ordered, while another resident with a history of cancer and chronic self-catheterization also had mismatched documentation. Facility policy requires care plans to reflect physician orders, and this inconsistency was confirmed by the Director of Clinical Excellence.
The facility failed to consistently monitor and document the use of a wander guard device for a resident with cognitive impairment and wandering behaviors, with inconsistent records and lack of required daily checks. Additionally, two residents with pain were administered PRN opioid and non-opioid medications without clear physician order parameters or documentation of non-pharmacological interventions, and the care plan did not address opioid use. The Director of Clinical Excellence confirmed these deficiencies in monitoring, documentation, and adherence to policy.
A resident with significant respiratory conditions was observed receiving oxygen at a lower flow rate than prescribed by the physician. Despite orders and care plan interventions specifying 4 L/min during ambulation and 2 L/min at rest, the oxygen concentrator was repeatedly set at only 1 L/min. This discrepancy was confirmed by the DCE during the survey.
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 Follow Individualized Transfer Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to follow a resident's individualized transfer plan as recommended by Physical Therapy. The resident, who had a history of osteoporosis, muscle weakness, reduced mobility, abnormal posture, dementia, and functional quadriplegia, was assessed as requiring a sit-to-stand lift for all transfers. The care plan and physical therapy discharge summary both specified the use of this assistive device, and the resident's transfer status was posted on the outside of the room door. On the day of the incident, the LPN encountered the resident in the hallway, addressed a complaint of leg pain, and later assisted the resident in transferring from a wheelchair to a recliner. Instead of using the required sit-to-stand lift, the LPN attempted a manual transfer by grabbing the resident's pants and hips. During the transfer, the resident's legs buckled, and the resident fell into the recliner, landing on their right arm. A certified nurse aide (CNA) responded to calls for help and assisted in completing the transfer, at which point both staff members noticed the resident's arm appeared injured. Subsequent evaluation by a nurse practitioner and hospital staff revealed that the resident had sustained a dislocation and an acute fracture of the right arm, requiring surgical intervention. Interviews with staff confirmed that the LPN was aware of the resident's need for a sit-to-stand lift but failed to use it, stating that she forgot in the moment. The director of nursing and therapy director both confirmed that the resident's care plan required the use of a mechanical lift for transfers, and that the LPN did not adhere to this protocol at the time of the incident.
Failure to Properly Store and Monitor Medications in Medication Rooms
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in all three medication rooms, as required by facility policy and professional standards. During inspection, expired influenza vaccine syringes were found in active storage in one medication room refrigerator, despite being intended for return to the manufacturer. This was confirmed by both a nurse and the consultant pharmacist. Additionally, refrigerator temperature logs and thermometer readings revealed that medication refrigerators were not consistently maintained within the required temperature range of 36-46 degrees Fahrenheit. One refrigerator was found at 32 degrees Fahrenheit, while another was at 17 degrees Fahrenheit, with missing temperature log entries for the day shift. Staff confirmed the out-of-range temperatures and acknowledged that temperature monitoring and documentation were not performed as required. The maintenance director was notified but did not immediately verify the temperatures with available thermometers. The surveyor's calibrated thermometer readings further confirmed the temperature discrepancies. These findings demonstrate a failure to follow facility policy regarding medication storage, temperature monitoring, and removal of outdated medications.
Failure to Inform Residents of Rights and Access to Regulatory Contact Information
Penalty
Summary
The facility failed to ensure that residents were informed of their right to access the names, addresses, and telephone numbers of all pertinent state regulatory and informational agencies, resident advocacy groups, and information on filing a complaint or reporting alleged abuse violations. Review of Resident Council Minutes over several months showed no documentation that residents were informed of these rights or the location of such information within the facility. During a resident council meeting, all residents in attendance confirmed they were not aware of their right to access this information or where it was located. Interviews with facility staff, including the Activity Director and the Administrator, revealed a lack of knowledge regarding the location and communication of contact information for the Ombudsman and the state complaint line. The Activity Director stated that while resident rights were discussed in general terms, specific information about how to contact the Ombudsman or file a complaint was not reviewed. The Administrator acknowledged the need to improve communication of this information, particularly for new residents.
Failure to Complete and Submit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to complete and submit a discharge Minimum Data Set (MDS) assessment in a timely manner for one resident who was discharged to the hospital. Record review showed that the resident was admitted to the facility and later discharged, but no discharge MDS assessment was found in the electronic medical record. The MDS Coordinator acknowledged during interview that the discharge assessment was missed, despite daily census activity reports and morning meetings intended to track discharges. The Director of Nursing confirmed the expectation that all necessary MDS assessments should be completed.
Failure to Assess Alternatives and Entrapment Risk Prior to Bedrail Use
Penalty
Summary
The facility failed to ensure that alternative measures were attempted prior to the installation of side rails and did not complete proper assessments for the risk of entrapment for a resident reviewed for side rail use. Review of the resident's care plan and order summary indicated that side rails were implemented for enabling increased movement and for turning and repositioning, but there was no documented evidence in the electronic medical record that alternatives to side rails were considered or attempted before their use. Additionally, there was no documentation of an assessment for the risk of entrapment related to the use of side rails. Interviews with facility staff revealed that bedrails were routinely provided to residents upon admission without exploring alternatives, and staff were not aware of the requirement to consider alternatives prior to bedrail use. The LPN stated that nearly all residents received bedrails on the day of admission and that alternatives were not explored. The Maintenance Director confirmed that while monthly audits of bedrails were conducted for functionality and mattress fit, there was no formal assessment for entrapment risk, nor was there a device available to check for such risk. The DON also indicated a lack of awareness regarding the need to explore alternatives before bedrail use and stated that assessments were expected but not consistently performed.
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.
Failure to Individualize and Accurately Document Catheter Balloon Size in Care Plans
Penalty
Summary
The facility failed to individualize and accurately document comprehensive care plans for urinary catheter bulb size for two residents who required catheter care. For one resident with severe cognitive impairment and urinary retention, the physician order specified an 18 French catheter with a 5 cc balloon, but the care plan incorrectly listed a 10 cc balloon. For another resident with a history of prostate and bladder cancer, chronic self-catheterization, and intact cognition, the physician order specified a 16 French catheter with a 10 cc balloon, while the care plan referenced a 14 French catheter with a 10 ml balloon. These discrepancies were identified through clinical record review, policy review, and staff interview. Facility policy requires that all physician orders, including specific instructions such as catheter and balloon size, be accurately documented and reflected in the resident's care plan. The care plans are to be developed by an interdisciplinary team and must include measurable goals and timetables based on the comprehensive assessment. The Director of Clinical Excellence confirmed that the care plan should match the physician order for catheter balloon size, as this is a standard of care. The failure to ensure consistency between physician orders and care plans for catheter care was observed for both residents reviewed.
Failure to Monitor Wander Guard and Inadequate Pain Management Documentation
Penalty
Summary
The facility failed to monitor and document the use of a wander guard device according to professional standards for a resident assessed at risk for wandering. The resident, who had diagnoses including traumatic subarachnoid hemorrhage, dementia, and depression, was identified as severely cognitively impaired and exhibited wandering behaviors. Although the care plan and facility policy required daily checks for the placement and function of the wander guard, as well as skin checks for irritation, documentation was inconsistent. Clinical records showed alternating documentation of the device being present or absent on various days, and there was no evidence of daily checks or skin assessments as required. The Director of Clinical Excellence confirmed that the physician's order for the wander guard was not obtained in a timely manner and that documentation was inaccurate, with no evidence of adherence to policy or care plan interventions. The facility also failed to provide care and services consistent with professional standards for pain management for another resident with a history of fractures and malignancy, who was cognitively intact and reported frequent pain. The care plan included interventions for pain assessment and medication administration, but physician orders for both opioid (Tramadol) and non-opioid (Tylenol) pain medications lacked specific parameters for use. Nursing staff administered PRN Tramadol on most days, sometimes multiple times per day, and also administered Tylenol for similar pain scores, without clear guidance on which medication to use for specific pain levels. Documentation did not include non-pharmacological interventions prior to opioid administration, and the care plan did not address the use of opioid medication. Interviews with the Director of Clinical Excellence confirmed that the facility did not clarify physician orders for pain medications, did not document non-pharmacological interventions prior to opioid use, and did not follow facility policy or accepted standards of practice for pain management. The lack of clear parameters for medication administration and incomplete documentation contributed to the deficiencies identified in the management of both the wander guard device and pain control.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
A deficiency was identified when staff failed to follow physician orders for oxygen therapy for a resident with multiple respiratory diagnoses, including acute and chronic respiratory failure with hypoxia, COPD, acute pulmonary manifestations due to radiation, pneumonia, and influenza. The resident's care plan and physician orders specified oxygen administration via nasal cannula at 4 liters per minute during ambulation and 2 liters per minute at rest. However, during multiple observations, the resident was found sitting in a wheelchair in their room with the oxygen concentrator set at only 1 liter per minute, which was not consistent with the prescribed orders. These observations were confirmed on three separate occasions, including one in the presence of the Director of Clinical Excellence, who acknowledged that the physician's order for supplemental oxygen was not being followed. The clinical record and care plan documentation supported the need for specific oxygen settings, but staff did not adhere to these requirements during the survey period.
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