Achieve Rehab Center: Immediate Jeopardy Violations - SC
ANDERSON, SC - Federal inspectors cited Achieve Rehabilitation and Nursing Center for immediate jeopardy violations after discovering a dangerous mix-up in advance directives that could have denied life-saving treatment to a resident who specifically requested resuscitation.
Critical Mix-Up in Life-Saving Directives
The most serious violation involved a resident whose medical records contained conflicting information about his end-of-life wishes. While the facility's electronic medical record system showed the resident as "Do Not Resuscitate" (DNR), the resident had actually signed a form specifically requesting "Full Code" status, meaning he wanted all emergency medical measures used to restore vital functions if needed.
The resident clearly communicated his wishes during the inspection, stating he wanted to be resuscitated and wanted to be Full Code. He also confirmed he would want to be sent to the hospital if needed for emergency care.
However, facility staff consistently checked the electronic system and confirmed they would not start cardiopulmonary resuscitation (CPR) based on the incorrect DNR status in the computer. This discrepancy had been in place since the resident's admission, creating a potentially life-threatening situation where staff would deny requested emergency treatment.
System Failures in Documentation
The documentation error highlighted significant gaps in the facility's advance directive protocols. The resident's actual advance directive form, which he had signed, clearly indicated his choice for "Full Code" status with emergency medical measures. This form included his specific request that "if [resident's name] has sudden failure of a vital function that emergency medical measures be used to restore the function."
Despite having this signed documentation, the facility's care planning system incorrectly listed the resident as DNR with a revision date that did not align with his actual wishes. The administrator confirmed during the inspection that this resident had the order in place since [admission date] and confirmed it had been incorrect since [admission date].
Medical Significance of Advance Directives
Advance directives serve as critical legal documents that communicate a person's healthcare preferences when they cannot advocate for themselves. The distinction between "Full Code" and "DNR" status represents fundamentally different approaches to emergency medical care.
Full Code status means healthcare providers should use all available medical interventions during a cardiac or respiratory emergency, including CPR, electric shock treatments, medications, and mechanical ventilation. DNR status specifically prohibits these interventions, allowing natural death to occur.
When healthcare facilities fail to accurately implement these directives, residents face serious risks. In this case, a resident who wanted all life-saving measures could have been denied emergency treatment during a medical crisis, potentially resulting in preventable death.
Widespread Care Quality Concerns
Beyond the immediate jeopardy violation, inspectors documented numerous other deficiencies affecting resident care and facility operations:
Personal Hygiene and Activities of Daily Living
The facility failed to maintain adequate personal hygiene standards for residents. One resident received only two documented showers in over a month, despite facility policy requiring three showers per week. The resident complained she had "gone 13 days without a shower, then received a shower only to go another 11 days without a shower."
Another resident with diabetes showed signs of neglected nail care, including long fingernails with black material underneath and an offensive odor from a contracted hand. Staff acknowledged that understaffing sometimes prevented adequate nail care, and licensed nurses responsible for diabetic residents' nail trimming had not provided this essential care.
Medical Equipment and Treatment Failures
Residents requiring oxygen therapy experienced significant care gaps. Two residents received incorrect oxygen flow rates - one receiving 6 liters per minute instead of the prescribed 8 liters, and another receiving 3 liters instead of the prescribed 2 liters. These discrepancies can lead to serious medical complications, including tissue damage from too much oxygen or inadequate oxygenation of vital organs.
One resident had been using oxygen for years without any physician orders for the treatment. Inspectors found no physician order for oxygen, care plan, or information for the resident's oxygen use in the clinical record, representing a fundamental failure in medical oversight.
Nutritional Monitoring Deficiencies
A resident with Alzheimer's disease experienced dangerous weight loss that went unaddressed by facility staff. The resident lost over 20 pounds in three months - from 115 pounds to 92.5 pounds - representing a 21.3 percent weight loss.
Despite facility policies requiring weekly weight monitoring for residents experiencing significant weight loss, staff failed to implement these protocols. The registered dietitian did not evaluate the resident until three weeks after the weight loss was documented, and nursing staff were unaware of the severity of the situation.
Infection Control and Food Safety Violations
Kitchen operations revealed multiple food safety hazards that could lead to foodborne illness. Inspectors found sanitizing solutions at zero parts per million effectiveness, expired spices from 2023 still in use, and improperly stored opened food products that should have been refrigerated.
Food service staff failed to follow posted menus, serving incorrect portion sizes and omitting required items like bread and hushpuppies. These menu deviations affect nutritional planning and can impact residents with specific dietary needs.
Infrastructure and Environmental Concerns
The facility struggled with basic maintenance issues affecting resident comfort and safety. Multiple rooms experienced non-functioning electrical outlets for over a month, preventing residents from using televisions, charging devices, or operating personal refrigerators.
One resident reported that "the outlets in her room have not functioned for the past three to four weeks" and she liked to watch television but couldn't do so in her room due to the electrical problems.
Housekeeping standards fell short across multiple units, with inspectors noting heavy dirt buildup along baseboards, water-stained ceiling tiles, and soiled walls throughout common areas and resident rooms.
Industry Standards and Best Practices
Federal regulations require nursing homes to honor residents' advance directives and provide care according to their documented wishes. The Centers for Medicare & Medicaid Services mandate that facilities have systems in place to ensure advance directives are accurately documented, communicated to all relevant staff, and regularly reviewed.
Proper advance directive management includes verification processes to confirm electronic records match signed documents, staff education on accessing and interpreting these directives, and regular audits to identify discrepancies. The facility's failure to implement these basic safeguards created the immediate jeopardy situation.
Facility Response and Corrections
Following the identification of violations, Achieve Rehabilitation and Nursing Center implemented immediate corrective measures. The facility updated the resident's code status in medical records and provided staff education on advance directive protocols.
The facility's corrective action plan includes daily audits of advance directives for four weeks, followed by weekly audits for another four weeks, then monthly monitoring. All licensed nursing staff received re-education on residents' rights regarding treatment decisions and the importance of accurate documentation.
For other violations, the facility committed to addressing staffing levels for activities programming, improving oxygen equipment maintenance, implementing proper weight monitoring protocols, and correcting food service and environmental issues identified during the inspection.
The immediate jeopardy violation was removed after the facility demonstrated compliance with corrective measures, but the incident highlights the critical importance of accurate medical record keeping in nursing home care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Condor Health Anderson from 2025-01-11 including all violations, facility responses, and corrective action plans.
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