Pruitthealth- Dillon
PruittHealth- Dillon in Dillon, SC — inspection on June 21, 2024.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
something else. MD1 concluded, Educate me on what I should use.
jeopardy to resident health or On 06/21/24, the facility provided an acceptable IJ Removal Plan, which included the following: safety Implementation of the removal plan for F-F605 include: R369 was admitted to the facility on [DATE]
disorder, anxiety disorder, and adjustment disorder. R369 displayed exit seeking behaviors upon admission and throughout her stay within the facility.
Interventions of 1:1 supervision and placement of an Electronic Monitoring Device (EMD) were put into place to ensure resident safety and security.
While R369 was in the facility, partners/staff attempted to redirect the resident when she displayed exit seeking behaviors and she stated, I am going home with family . He knows not to leave me here.
Medical Director (MD)1 witnessed R369 displaying exit seeking behaviors and that the partners/staff were having difficulty redirecting the resident due to the resident's agitation. MD1 placed a one-time order of Haloperidol 5 mg oral tablet for the resident's agitation.
Methods to identify any other resident who might be affected include: all ambulatory residents with exit seeking behaviors and increased agitation.
Systemic Changes include: the facility regional Area [NAME] President (AVP) and or Senior Nurse Consultant (SNC) has scheduled an in-service on 06/20/24 to be instructed by our Chief Medical Officer to the facility MD (MD1).
This in-service will include recommendations of interventions for residents with increased agitation while displaying exit seeking behaviors that are following the manufacturer's recommendations of the medication while meeting the Center's of Medicare and Medicaid (CMS) regulations/guidelines for not chemically sedating.
New orders for psychotropic will be reviewed with the MD and Quality Assurance and Performance Improvement (QAPI) committee monthly to ensure/confirm rational and appropriate usage.
The date of substantial compliance is set at 06/21/24.
Monitoring includes: the Administrator will present results of reviews to the QAPI Committee monthly for three months and or until substantial compliance is achieved.
425113 06/21/2024
Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536
agencies such as Adult Protective Services (APS),the Ombudsman, and/or local law enforcement
jeopardy to resident health or QAPI Committee monthly for three months and or until substantial compliance is achieved. safety
425113 06/21/2024
Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536
Review of the facility policy titled Care Plans last revised on 07/21/21, revealed, It is policy of the health care center for each patient/residents to have a person centered baseline care plan followed by a comprehensive care plan developed following the completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice.
Comprehensive care plans should be reviewed not less than quarterly according to the MDS schedule, following the completion of the assessment.
Care plans updates/reviews will be performed within seven days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay.
Care plans will be updated by Nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment.
Review of R55's Face Sheet revealed R55 was admitted to the facility on [DATE], with diagnoses including but not limited to: respiratory syncytial pneumonia, sleep apnea, type 2 diabetes, and muscle weakness.
Review of R55's Quarterly MDS with an Assessment Reference Date (ARD) of 06/05/24, revealed R55 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates that R55 is cognitively intact.
Further review of the Quarterly MDS revealed that R55 utilizes oxygen as a special treatment.
Review of R55's Physician Order Report dated 05/21/24 - 06/21/24, revealed R55 had an order for oxygen with a start date of 05/16/24, at 2 liters/minute via nasal cannula as needed.
Review of R55's Care Plan revealed R55 no care plan or interventions related to oxygen or oxygen usage.
During an interview on 06/18/24 at 11:30 AM, R55 revealed they were unsure of the last time the facility spoke with her about her plan of care/care plan meetings.
During an interview on 06/21/24 at 10:36 AM, Licensed Practical Nurse (LPN)4 verified that R55 had not been care planned and has no intervention for oxygen use in her Electronic Medical Record (EMR) at this time. LPN4 stated that according to the EMR, R55's last care plan conference occurred on 03/04/24 and a quarterly care plan should have taken place on 06/02/24, but was unable to verify that it occurred.
During an interview on 06/21/24 at 11:24 AM, the Director of Nursing (DON) revealed R55 should have a care plan and interventions related to her oxygen use and they were also not able to verify if a care plan meeting took place on 06/02/24 for R55 and their resident representative.
425113 06/21/2024
Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536
Review of the facility policy titled, Charting Activities of Daily Living (ADLs) with a date of 2014, revealed, Definitions: Activities of Daily Living (ADLS's): The task of everyday life.
The ability or inability to perform ADL's is a measurement of the functional status of a person.
Review of R2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/19/24, indicated R2 was admitted to the facility from the hospital on [DATE], with diagnoses including but not limited to: chronic obstructive pulmonary disease with (acute) exacerbation, chronic diastolic (congestive) heart failure, malignant neoplasm of upper lobe, left bronchus or lung, syndrome of inappropriate secretion of antidiuretic hormone, and dementia.
Further review of the MDS revealed R2 had a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which revealed the resident was moderately cognitively impaired.
During an observation on 06/18/24 at 2:04 PM, R2 was lying in bed, hair disheveled, nails dirty, face and clothing had dried on food.
During an observation on 06/19/24 at 11:20 AM, R2's hair was unkept, she was wearing a black shirt with a bright pink emblem. R2's nails were dirty. R2's face, clothing, and sheets contained dried food.
During an observation on 06/20/24 at 11:03 AM, R2 was lying in bed with the same black and pink shirt that she wore on the previous day. R2's nails were dirty, hair unkept, and dried food was on her clothes, face, and sheets.
During an observation on 06/20/24 at 4:34 PM, R2 was lying in bed with the same black and pink shirt that she wore previously. R2's nails were dirty, hair unkept, and dried food was on her clothes, face, and sheets.
During an interview on 06/20/24 at approximately 7:03 PM, Certified Nursing Assistant (CNA)4 revealed she was not assigned to R2. CNA4 stated, It is never acceptable for residents not to get assistance daily with ADL care.
During an interview on 06/20/24 at approximately 7:18 PM, CNA1 revealed she was assigned to R2 and is familiar with the resident. CNA1 stated R2 requires extensive care and follows R2's shower schedules that are in the system. R2 gets bed baths on the days that she does not get showers. CNA1 further stated nail care and hair care is included when she provides ADL care.
425113 06/21/2024
Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536
Review of the facility policy title Labeling, Dating, and Storage dated 2014, revealed, Policy Statement: It is the policy of PruittHealth for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating, and storage to ensure proper food safety.
During an observation on 06/18/24 at 10:47 AM, with the Dietary Manager (DM), revealed the cooler contained the following: 2 rotten heads of cabbage, dated 05/08/24, 3 cucumbers undated in a box that contained potatoes, 1 jar of reliance Italian dressing, opened 06/03/21 with an expiration date of 04/30/24, 1 large container of Apple Sauce dated 06/10/24, no expiration date.
During an interview on 06/19/24 at 12:48 PM, the Kitchen Manager-Dietary Manager (DM) revealed labeling, storing, discarding of expired items are done by all staff and all staff received training.
The items are always first in first out in all storage areas. It is the DM's expectation that staff always label, date, and discard of expired items.
425113 06/21/2024
Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536
document in the MAR when a resident is on oxygen even if the order is as needed/prn.
The DON also
425113 06/21/2024
Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536
Review of the facility policy titled Infection Prevention - Hand Hygiene dated 2014, revealed, D.
Indication Requiring Hand Wash or Hand Rub: 9.
Passing meal trays to residents.
During an observation on 06/19/24 at 8:18 AM, revealed on the Northside, staff not sanitizing their hands while passing out breakfast trays to residents.
During an observation on 06/19/24 at approximately 12:37 PM, Certified Nursing Assistant (CNA)3 was not sanitizing her hands while passing out lunch meal trays.
During an observation on 06/20/24 at 5:37 PM, CNA4 was not sanitizing her hands while passing out dinner meal trays.
During an interview on 06/19/24 at approximately 2:37 PM, CNA3 revealed the policy and procedure for sanitizing hands while passing out meal trays is to always sanitize hand before going in the room and coming out of the residents' room, no exceptions.
During an interview on 06/20/24 at approximately 7:03 PM, CNA4 stated, You always wash hands before passing out the trays and after wash them passing out the meal trays.
During an interview on 06/21/24 at 8:43 AM, the Director of Nursing (DON) revealed all staff are required to sanitize their hands before passing out meal trays and after passing out meal trays, any time the staff hands become soiled.
Review of R55's Face Sheet revealed R55 was admitted to the facility on [DATE], with diagnoses including but not limited to: respiratory syncytial pneumonia, sleep apnea, type 2 diabetes, and muscle weakness.
Review of R55's Quarterly MDS with an Assessment Reference Date (ARD) of 06/05/24, revealed R55 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicates that R55 is cognitively intact.
Further review of the Quarterly MDS revealed that R55 utilizes oxygen as a special treatment.
Review of R55's Physician Order Report dated 05/21/24 - 06/21/24, revealed R55 had an order for oxygen with a start date of 05/16/24, at 2 liters/minute via nasal cannula as needed.
Review of R55's Care Plan revealed R55 no care plan or interventions related to oxygen or oxygen usage.
During an interview on 06/18/24 at 11:30 AM, R55 revealed they were unsure of the last time the facility spoke with her about her plan of care/care plan meetings.
During an interview on 06/21/24 at 10:36 AM, Licensed Practical Nurse (LPN)4 verified that R55 had not been care planned and has no intervention for oxygen use in her Electronic Medical Record (EMR) at this time. LPN4 stated that according to the EMR, R55's last care plan conference occurred on 03/04/24 and a quarterly care plan should have taken place on 06/02/24, but was unable to verify that it occurred.
425113
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 425113 B.
Wing 06/21/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Pruitthealth- Dillon 413 Lakeside Court Dillon, SC 29536
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.