Francis Marion Manor Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Francis Marion Manor Health & Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Aug 14, 2024

  Based on staff interview and facility document review, the facility staff failed to ensure information provided on the payroll-based journal (PBJ) was accurate. The findings include: The facility staff were including Hospice staff not employed by the facility on the PBJ report. This facility had triggered for one star staff rating and No Registered Nurse (RN) coverage for quarter 3 of 2023 (April, May, June). When reviewing these reports, the surveyor noted the facility staff had included Hospice staff on the report. On 08/14/24 at 9:15 a.m., the surveyor interviewed the staff the facility identified as being responsible for these reports RN #3. This staff stated Hospice personnel were contracted and they were patient care givers. […]

• No harm, potential for more than minimal, isolatedF607Aug 14, 2024

  Based on staff interview, employee record review, and facility document review, the facility staff failed to follow their policy regarding screening of new hires for 2 of 15 employees. New hire #1 and #14. The findings include: The facility staff failed to follow their policy for screening of new employees. The facility staff failed to obtain criminal background checks through the Virginia State Police (VSP) criminal records exchange. The facility administrative staff provided the surveyor with a copy of their policy titled, Background Checks-Human Resources. […]

• No harm, potential for more than minimal, isolatedF727Aug 14, 2024

  Based on staff interview and facility document review, the facility staff failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day 7 days a week for quarter 3 of 2023. The findings include: The facility staff failed to ensure they had RN coverage for 8 consecutive hours a day 7 days a week for quarter 3 of 2023 (April, May, June). There was no facility employed RN on staff on 04/30/23, 05/14/23, 05/27/23, 05/28/23, 06/11/23, and 06/25/23. The facility census was as follows 04/30/23 (40), 05/14/23, 05/27/23, 05/28/23 (39), 06/11/23 (38), and for 06/25/23 (35). Three surveyors entered the facility on 08/12/24 at 6:10 p.m., staffing was as follows 1 RN, 2 Licensed Practical Nurses (LPN's), and 3 Certified Nursing Assistants (C.N.A.'s). The census was 25. […]

• No harm, potential for more than minimal, isolatedF842Aug 14, 2024

  Based on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for 2 of 14 residents, Resident #19 and #23. The findings include: 1. For Resident #19, the facility staff failed to ensure the residents' order for Digoxin was accurate regarding administering the medication with food. Resident #19's diagnoses included atrial fibrillation and chronic heart failure. Section C (cognitive patterns) of Resident #19's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/08/24 included a brief interview for mental status (BIMS) summary score of 15. Per the MDS manual a score of 15=cognitively intact. […]

• No harm, potential for more than minimal, isolatedF578Nov 4, 2021

  Based on observations, staff interviews, and facility document review, it was determined the facility staff failed to accurately implement facility policies, procedures, and/or processes relating to DNR (do not resuscitate) status for two (2) of 21 facility residents (Resident #15 and Resident #49). The following information was found in a facility policy titled DO NOT RESUSCIATE ORDERS (DNR) AND DURABLE DO NOT RESUSCITATE (DDNR) ORDERS - VIRGINIA - (medical corporation name omitted) (with an effective date of 10/1/21): To issue a DDNR order, an Authorized Practitioner must: a. Explain to the patient or Legally Authorized Representative the DDNR Order and alternatives available for response in the event of Cardiac or Respiratory Arrest. b. […]