Sumter East Health & Rehabilitation Center

Penalty

Inspection fine: $25,505

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, identified as R1, from physical abuse by a Certified Nursing Assistant (CNA1). The incident involved CNA1 slapping R1's bilateral stumps to ensure they were flat on the bed. R1, who was admitted with diagnoses including respiratory failure, end-stage renal disease, and bilateral below-knee amputations, was cognitively intact with a BIMS score of 15 out of 15. The abuse was reported by R1 to the Social Services Director, who stated that R1 felt distressed and upset by the CNA's actions. During the incident, R1 had called for assistance, and CNA1, who was not assigned to R1, responded. According to R1, CNA1 slapped his stumps and restrained him by holding his hands against his upper chest and neck area. R1 expressed fear that his dialysis catheter might be pulled out during the altercation. The Director of Nursing confirmed that CNA1 admitted to restraining R1, claiming it was necessary to prevent being hit by the resident. The incident was reported to the facility's administration, and an investigation was initiated. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury or punishment resulting in physical harm or mental anguish. The actions of CNA1 were found to be in violation of this policy, leading to the determination of Immediate Jeopardy at F600, related to the resident's freedom from abuse, neglect, and exploitation.

Removal Plan

• LPN1 informed the Unit Manager and the Director of Nursing of the allegation.
• The DON contacted CNA1 via phone and suspended him. The DON requested that CNA1 provide a written statement regarding his interactions with R1. The DON interviewed CNA1 in which he admitted that he restrained the resident.
• The DON provided notification to the South Carolina Department of Public Health of the allegation of abuse.
• The DON interviewed resident R1 as a part of the investigation. She completed a body audit that was negative for marks or bruises. Resident R1 disclosed that CNA1 hit his legs and told him to put them down if he wanted to be changed. The resident demonstrated how CNA1 crossed the resident's arms on his upper chest and held his arms.
• The DON notified the local police authorities. Officers responded and statements were taken and a report was filed.
• The DON contacted the family and left a message. The family returned the call and spoke with LPN1 regarding the allegations.
• LPN1 notified the Attending Physician of the allegation of abuse.
• The DON began providing education to staff regarding Abuse Neglect and Restraints. The SDC took over the training after arriving at the facility.
• The Social Service Director began to monitor the resident R1 for residual and latent effects. She reports no latent effects and that the resident R1 is glad that CNA1 no longer works here.
• The Social Services Director interviewed other residents able to be interviewed and no pattern was noted. No residents reported abuse or being restrained.
• The Staff Development Coordinator began education on Abuse, Neglect and Exploitation for staff. Education will be provided upon hire, annually and as needed.
• All education will be completed by Staff. Staff will not be allowed to work without completing the training.
• The Abuse, Neglect and Exploitation Policy was reviewed by the DON, the Administrator and the Corporate Nurse Consultant. No Policy Revision needed at this time.
• The SDC will audit new hire Orientation Packets Monthly x 6 months and then quarterly to ensure that employees were provided training on restraints. The SDC will track and trend and report the results of the audits monthly x 6 months and then quarterly.
• Annually, the SDC, DON, or Designee will provide education to staff regarding Restraints. Annually, the SDC will audit all employee training records to ensure that all staff have received annual training. The SDC will track and trend her annual education audit and report to QAPI at least annually.
• An Ad Hoc QAPI Committee meeting was held with the Medical Director attending via phone. The plan of actions taken were reviewed and it was determined that the appropriate preventative actions had been taken. The Committee approved the addition of restraints as a focus to the new hire process and annual education.
• The Committee will monitor the results of the new hire and the annual training audits and make recommendations and modifications as needed to ensure continued compliance.

Penalty

Inspection fine: $25,505

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 being physically restrained by a Certified Nursing Assistant (CNA). During incontinence care, the CNA grabbed both of the resident's hands and held them crossed against the resident's upper chest. This incident was reported by the Social Services Director, who stated that the resident felt distressed and abused by the CNA's actions. The Director of Nursing confirmed that the CNA admitted to restraining the resident, claiming it was necessary to prevent being hit. The resident involved in the incident was admitted with multiple medical conditions, including respiratory failure, end-stage renal disease, and bilateral below-knee amputations. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. The resident's care plan noted a self-care deficit related to activities of daily living and impaired mobility, which required assistance from staff. Interviews with the resident and staff revealed that the CNA entered the resident's room to provide care when the assigned CNA was unavailable. The resident reported that the CNA was rough and aggressive, causing fear of potential harm to the dialysis catheter. The CNA's actions were not in line with the facility's policy on maintaining a restraint-free environment, which prohibits the use of physical restraints unless medically necessary.

Removal Plan

• LPN1 informed the Unit Manager and the Director of Nursing of the allegation.
• LPN1 remained with the resident pending the arrival of the DON to start the investigation.
• The DON contacted CNA1 via phone and suspended him. The DON requested that CNA1 provide a written statement regarding his interactions with R1. The DON interviewed CNA1 in which he admitted that he restrained the resident.
• The DON provided notification to the South Carolina Department of Public Health of the allegation of abuse.
• The DON interviewed resident (R1) as a part of the investigation. She completed a body audit that was negative for marks or bruises. Resident (R1) disclosed that he was lying on his back with his legs bent. He demonstrated and it was observed that due to amputations his legs point up into the air. Resident #1 states that when CNA1 entered the room, CNA1 hit his legs and told him to put them down if he wanted to be changed. The resident did not disclose pain or injury from the open-handed contact but it made him mad and then he took a swing at CNA1. The resident then demonstrated how CNA1 crossed the resident's arms on his upper chest and held his arms.
• The DON notified the local police authorities. Officers responded and statements were taken and a report was filed.
• The DON contacted the family and left a message. The family returned the call and spoke with LPN1 regarding the allegations.
• LPN1 notified the Attending Physician of the allegation of abuse.
• The Social Service Director began to monitor the resident (R1) for residual and latent effects. She reports no latent effects and that the resident (R1) is glad that CNA1 no longer works there.
• The Social Services Director interviewed other residents able to be interviewed and no pattern was noted. No residents reported abuse or being restrained.
• The Staff Development Coordinator, DON and or Unit Manager/Coordinator began providing education to staff regarding restraints to include holding a resident's hands down. Education will be provided upon hire, annually and as needed.
• All education will be completed by Staff. Staff will not be allowed to work without completing the training.
• The Restraint Policy was reviewed by the DON, the Administrator and the Corporate Nurse Consultant. No Policy Revision needed at this time.
• The SDC will audit new hire Orientation Packets Monthly x 6 months and then quarterly to ensure that employees were provided training on restraints. The SDC will track and trend and report the results of the audits monthly x 6 months and then quarterly.
• Annually, the SDC, DON, or Designee will provide education to staff regarding Restraints. Annually, the SDC will audit all employee training records to ensure that all staff have received annual training. The SDC will track and trend her annual education audit and report to QAPI at least annually.
• An Ad Hoc QAPI Committee meeting was held with the Medical Director attending via phone. The plan of actions taken were reviewed and it was determined that the appropriate preventative actions had been taken. The Committee approved the addition of restraints as a focus to the new hire process and annual education.
• The Committee will monitor the results of the new hire and the annual training audits and make recommendations and modifications as needed to ensure continued compliance.

Penalty

Inspection fine: $16,801

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

Summary

The facility failed to provide appropriate supervision for a resident, identified as R78, which resulted in the resident successfully eloping from the facility. R78 was admitted with diagnoses including dementia, cognitive communication deficit, and abnormalities of gait and mobility. The resident's Quarterly Minimum Data Set (MDS) indicated moderate impairment in cognitive skills for daily decision-making, but no behaviors of rejection of care or wandering were noted. On the day of the incident, R78 was found outside the facility by a dietary staff member, wet from the rain, and lying on the ground near a tree. Interviews with facility staff revealed that the door alarm had sounded, but the receptionist was unable to respond immediately due to assisting a family member. The alarm stopped after about 15 seconds, and a CNA later noticed R78 was missing from her room. The CNA and other staff searched the building but could not find R78 inside. The Director of Nursing (DON) and the Administrator both stated that R78 was not considered an elopement risk prior to the incident, and an updated assessment had not been conducted until after the elopement occurred. The facility's policy on elopements and wandering residents emphasized that alarms are not a replacement for necessary supervision and that residents should be assessed for elopement risk upon admission and throughout their stay. However, the facility did not conduct an updated assessment for R78, who was found to be walking the halls but had not previously attempted to elope. The lack of timely response to the door alarm and the absence of an updated risk assessment contributed to the resident's ability to leave the facility unsupervised.

Removal Plan

• Resident #78 was returned to the facility and experienced no injury while outside of the facility. The Director of Nursing completed the initial report to South Carolina Department of Public Health for the elopement of Resident #78.
• When Resident #78 returned to the facility an Elopement Assessment, Head to Toe Skin Assessment and an Incident Report were completed by the charge nurse including notification to the Physician and Responsible Party/Family of the incident and safe return.
• Facility nursing staff initiated q 15-minute checks x 72 hours on Resident #78. Checks were completed without any negative occurrences.
• Based upon the elopement assessment, a wander guard bracelet was placed on Resident #78 by the charge nurse with the Attending Physician and Family notified by the charge nurse. Resident #78's CP has been updated with intervention for wander guard by MDS.
• Resident #78's Care Plan was updated to reflect this incident and her increased exit seeking behavior by the MDS Director.
• The Administrator completed a post incident Brief interview Mental Status on Resident #78.
• Nursing Supervisor accounted for all residents listed on 24-hour census. All residents were accounted.
• Nursing Supervisor checked all residents with wander guard bracelet. All doors with wander guard alarms were audited by Maintenance Director or designee determined to be in good working order.
• Wander guard door in the EAST building will be monitored by staff to ensure residents at risk do not elope from the buildings.
• Administrator provided education to the Central Supply Clerk, DON and Unit Managers on a Par System for Wander guard Bracelets.
• Administrator provided education to the Central Supply Clerk regarding the maintaining adequate supply of Wanderguard bracelets. PAR level was established of at least 5 and she was educated and verbalized understanding. She placed an order for 20 wander guards to meet current needs and exceed PAR Level.
• The DON completed an Audit of residents identified as an elopement risk and needing a WanderGuard Bracelet. The DON created log to track which resident was issued a wander guard bracelet and the expiration of date of the Bracelet. The DON will update the log as wander guard bracelets are issued or as they expire. New wandering and elopement assessments will be completed by the DON, IDT Team and charge nurse on all residents and care plans will be updated as needed.
• The Elopement Policy has been reviewed by the DON, Administrator and Corporate Nurse Consultant to include supervision for residents with increased behaviors/exit seeking behaviors.
• Door Vendor assessed wander guard doors and in the assessment process the vendor caused disruption of normal working and was not able to restore normal operations. Doors were already being watched by staff post elopement.
• A second vendor was able to assist Maintenance Director in replacing equipment that had been damaged and doors returned to normal operations. Door watch continues pending abatement of IJ.
• Wander guard bracelets were received by Central Supply Clerk and nurses place bracelets on newly identified residents determined to be at risk and the bracelet removed by the resident and the bracelet found not to be operating by nursing staff.
• Staff will be educated on the elopement policy to include management of exit seeking behaviors. Any staff member who has not completed training will not be allowed to work until training is complete.
• The training is conducted by the DON, Staff Development Coordinator and the Administrator.
• Staff will be educated on the elopement policy and how to manage exit seeking behaviors upon hire, annually and as needed by the Staff Development Coordinator, Administrator, Director of Nursing or Designee ongoing.
• Elopement drills will be conducted weekly for 4 weeks on each shift by the Maintenance Director or Designee.
• Monthly elopement drills will be done for two months and then at least quarterly by the Maintenance Director or Designee.
• The corporate regulatory consultant will do monthly random audits of behavior care plans and assessments for 90 days.
• The DON/Designee will audit binder monthly and alert the central supply clerk of the number of bracelets to expire in order to ensure PAR is maintained.
• An Ad Hoc QAPI Committee Meeting was held with the DON, Administrator and Medical Director. The plan of actions taken were reviewed and it was determined that all necessary actions had been taken.
• The results of the audits, drills and wander guard documentation will be reported to the QAPI Committee for review and assessment to assure continued compliance.

Penalty

Inspection fine: $16,801

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 three clothes dryers in the East Building were free from an excessive amount of lint, which was observed on top of the lint baskets and around the wiring. This deficiency was identified during an observation conducted on October 10, 2024, at 7:40 AM, and was confirmed by both a laundry worker and the Maintenance Director. The facility's policy on the care of equipment requires that lint screens be cleaned every two or three loads, and the area around the dryers, including the control panel and wiring, be kept free of lint at all times. However, the observation revealed that these procedures were not adequately followed. The Work History Report indicated that the dryer vent cleaning in the East Building was completed on October 1, 2024, with previous cleanings scheduled and completed on August 31, 2024, and September 18, 2024. Despite these records, the excessive lint accumulation suggests a failure in maintaining the equipment as per the facility's policy. During an interview, the Maintenance Director acknowledged the presence of lint and stated that the area above the lint baskets and on the wiring is typically cleaned monthly, indicating a lapse in the regular maintenance schedule.

Penalty

Inspection fine: $16,801

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

Summary

The facility failed to provide adequate nutritional interventions for three residents, leading to significant weight loss. Resident 78 experienced a notable weight decline from 145 pounds to 115 pounds over several months. Despite the Registered Dietitian (RD) identifying the weight loss and suggesting interventions such as Med pass, these were not ordered or implemented. The RD admitted to not following up on the interventions, and the facility's system for entering non-medication orders was not utilized effectively. Resident 3 also suffered from unplanned weight loss, dropping from 154.2 pounds to 120 pounds before slightly recovering to 133.8 pounds. The RD noted a 13.75% weight loss and expressed concerns about the accuracy of the scales used for weighing residents. The RD was only present at the facility once a week and sometimes requested reweighs, but there was no consistent follow-up. The attending physician expressed a preference for not being too aggressive with elderly patients and indicated a lack of trust in the scales, which may have contributed to the oversight in addressing the weight loss. Resident 19, who was cognitively intact, reported having to purchase his own nondairy supplements due to lactose intolerance, as the facility did not provide them. Despite being followed by the RD and wound MD, the resident's dietary preferences and needs were not adequately met, leading to weight loss. Interviews with staff and family members highlighted the resident's picky eating habits and the facility's failure to provide suitable dietary options. The Medical Director was aware of the situation but relied on visual assessments and resident feedback rather than consistent weight monitoring.

Penalty

Inspection fine: $16,801

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

Summary

The facility failed to provide the required documents to notify two residents regarding their Medicare eligibility and coverage. According to the facility's policy, Medicare beneficiaries should be informed of their potential liability for payment through specific forms. However, the facility did not issue the correct forms to the residents. Resident 63, who was admitted for rehabilitation services, did not receive the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055, after the last covered day of Part A Medicare services, despite having benefit days remaining. Instead, Resident 63 received the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, and Form CMS-R-131 for Medicare Part B services. Similarly, Resident 125, also admitted for rehabilitation services, did not receive Form CMS-10055 after the last covered day of Part A Medicare services, even though benefit days remained. Instead, Resident 125 received two notices of non-coverage. During an interview, the Social Services Assistant admitted to being unaware that incorrect forms were being used and stated that the facility only had and used the CMS-10123 and CMS-R-131 forms.

Penalty

Inspection fine: $16,801

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

Summary

The facility failed to provide appropriate respiratory care for a resident, identified as R18, who required oxygen therapy. R18 was admitted with diagnoses including chronic respiratory failure, congestive heart failure, and chronic obstructive pulmonary disease. Despite the care plan indicating the need for oxygen use, there were no physician orders for oxygen therapy documented in R18's records. Observations revealed R18 receiving oxygen at 2 liters per minute via nasal cannula, yet the necessary physician orders were missing. Interviews with staff, including an LPN and the Director of Nursing, confirmed the absence of documented orders for R18's oxygen therapy. The LPN acknowledged the lack of orders and the DON explained that orders from the hospital are typically populated into the system for review and sign-off by the medical director. However, the DON was unaware of the frequency of physician reviews of these orders, indicating a lapse in ensuring that R18's oxygen therapy was consistent with professional standards of practice.

Penalty

Inspection fine: $16,801

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 all drugs and biologicals were labeled according to professional standards, including expiration dates, across multiple medication storage areas. Observations revealed expired items in three medication storage rooms, one medication cart, and one treatment cart. Specific expired items included CareFusion MaxPlus Clear needleless connectors, EZ Huber Safety Infusion Sets, and dressing change kits. Additionally, refrigerator logs for a storage room were incomplete for several days in August 2024, indicating a lapse in temperature monitoring. Interviews with staff, including LPNs and the Director of Nursing (DON), highlighted a lack of consistent oversight and responsibility for checking and discarding expired medications. LPNs expressed confusion and acknowledged the presence of expired items despite multiple checks. The facility was in a transitional phase, with some staff roles, such as the manager responsible for refrigerator checks, unfilled. The DON confirmed that expired medications should be discarded and mentioned that the Staff Development Coordinator provides education on treatment supplies.

Penalty

Inspection fine: $16,801

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 properly clean a glucometer machine, as observed during a survey. The facility's policy on blood glucose monitoring, dated 2023, requires that nurses perform blood glucose tests using the facility's glucometer according to the manufacturer's instructions and the facility's disinfection policy. Specifically, the policy mandates cleaning and disinfecting the glucometer as per the manufacturer's instructions. However, during an observation, an LPN was seen cleaning a glucometer with an alcohol wipe, which was not in accordance with the facility's stated practice of using bleach wipes for disinfection. During an interview, the Director of Nursing confirmed that glucometer machines are supposed to be cleaned with bleach wipes, indicating a deviation from the established infection control practices.