Autumn Care of Saluda

In the surveyor’s words

From the most serious findings on record at Autumn Care of Saluda, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580May 16, 2024

  Based on record review, staff, Nurse Practitioner (NP), and Medical Doctor (MD) interviews, the facility failed to notify the physician of a fall when they reported a change in condition to the physician for a severely cognitively impaired resident on blood thinner. In addition, the physician was not notified when there was a delay in a STAT (immediately without delay) x-ray order of the left hip for a resident with a decrease in range of motion in her left hip and pain. The STAT x-ray order was ordered on [DATE] at 12:48 PM and not obtained until [DATE] that showed an acute fracture of the left hip at the intertrochanteric region (the area near the hip joint). On [DATE] Resident #1 underwent surgery to repair the left hip fracture. […]

• Immediate jeopardy, isolatedF600May 16, 2024

  Based on observation, record review, and staff, Nurse Practitioner, and Medical Doctor interviews, the facility failed to protect a resident's right to be free from neglect when staff disregarded Resident #1's plan of care and transferred the resident without the use of a total mechanical lift and two-person assistance. During the first transfer Resident #1 was assisted to the floor. The following day ([DATE]) the Nurse Practitioner was asked to assess Resident #1 due to her left foot dragging on the floor and x-ray results revealed an acute fracture of the left hip. On [DATE] Resident #1 underwent surgery to repair the left hip fracture. […]

• Immediate jeopardy, isolatedF684May 16, 2024

  Based on record review and Medical Doctor (MD), Nurse Practitioner (NP) and staff interviews, the facility failed to assess Resident #1 by a nurse after a fall and prior to getting her off the floor. Additionally, the facility failed to ensure a STAT (immediate) order for x-ray was executed resulting in delayed care. On 4/24/24 Nurse Aide (NA) #1 transferred Resident #1 from her bed to the sit to stand lift and transported Resident #1 to the shower room. During a transfer in the shower room from the toilet to the sit-to-stand lift Resident #1's foot slipped and NA #1 had to lower Resident #1 to the floor. NA #1 called for assistance from NA #2. NA #1 and NA #2 did not notify the Nurse that Resident #1 had fallen. […]

• Immediate jeopardy, isolatedF689May 16, 2024

  Based on observation, record review, and staff, Nurse Practitioner, and Medical Doctor interviews, the facility failed to safely transfer a resident from the toilet to the shower chair when one staff member used the sit to stand mechanical lift instead of the total mechanical lift resulting in the resident falling to the floor for 1 of 3 sampled residents reviewed for accidents (Resident #1). On [DATE] Nurse Aide (NA) #1 transferred Resident #1 independently using a sit to stand mechanical lift. Resident #1's care plan indicated the resident required use of a total mechanical lift with 2-person assistance. During the transfer from the toilet to the sit to stand mechanical lift, Resident #1's foot slipped, and NA #1 had to lower Resident #1 to the floor. […]

• Immediate jeopardy, isolatedF726May 16, 2024

  Based on record review and staff interviews the facility failed to ensure all nursing staff, including agency staff, received orientation to include the location of resident care guides or the Kardex (nurse aide guide that contains individualized care information) and verify competencies including resident transfers and total and sit to stand lifts prior to providing care for the residents in the facility. On [DATE] Nurse Aide (NA) #1 transferred Resident #1 independently using a sit to stand mechanical lift. Resident #1's care plan indicated the resident required use of a total mechanical lift with 2-person assistance. During the transfer from the toilet to the sit to stand mechanical lift, Resident #1's foot slipped, and NA #1 had to lower Resident #1 to the floor. […]