rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2016-07-18,225,D,0,1,Z68211,"Based on record review, interview and review of the other facility documents, it was determined that the facility failed to ensure that an allegation that had the potential for emotional abuse for one (R8) out of 30 Stage 2 sampled residents, was reported immediately to the State Agency. Additionally, the facility failed to have documented evidence that this allegation was thoroughly investigated. Findings include: The facility's Administrative Policy entitled Investigation Protocol, effective date (MONTH) (YEAR), stated, .to attempt to determine if abuse .to provide appropriate follow-up including intervention to prevent further incidents. Procedure .1 .The investigator will maintain neutrality and conduct an impartial investigation. 2 .The investigation will be thorough, prompt, and include data collection and analysis. Investigator Responsibilities 1. Log the alleged event on an incident report via computer/manual tracking form (Resident Incident Monitoring Log) .Documentation must provide evidence that alleged violations are thoroughly investigated (i.e., summary report, copies of record, summary witness statements, etc.) .Complete and submit summary of findings of investigation to State within five (5) working days of incident. Include summary of any corrective action . Review of R8's clinical record revealed: R8's 6/25/16 quarterly MDS assessment stated that R8 was cognitively intact. 7/11/16 at 11:48 PM, a nurse's note stated At about 1900 (7:00 PM) staff (unknown) reported to this writer (E10 RN) that Resident slapped her (unknown staff) on her face. This writer went to Resident's room, Resident appeared to be angry, Resident states 'am going to report that girl to the State tomorrow she was laughing at me'. Resident calm and relaxed at this time. During an interview with E2 (DON) on 7/15/16 at 10:20 AM, she stated that there was no incident report for this occurrence. 7/15/16 at approximately 3:30 PM, E10 (RN) and E2 were interviewed. E10 stated that she investigated the situation, however, she did not write an incident and an investigation report. E10 and E2 stated that the allegation of staff laughing at her was part of R8's behavior problems. There was no documented evidence in the clinical record of R8's behavior of previous allegations of staff laughing at her. The facility failed to recognize that R8's statement was an allegation that had the potential for emotional abuse. The facility failed to ensure that the alleged incident was recorded on an incident report and was thoroughly investigated with documented evidence of such. This finding was discussed with E2 on 7/18/16 at 4:30 PM.",2020-09-01
2,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2016-07-18,280,D,0,1,Z68211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, it was determined that for 2 (R8 and R62) out of 30 Stage 2 sampled residents, the facility failed to ensure that their care plans were reviewed and/or revised after each assessment. Findings include: 1. Review of R8's clinical record revealed: For R8, the facility developed a care plan entitled UTI-Altered urinary elimination related to (+) bacteriuria, effective 5/6/16. Review of R8's record revealed that this resident had a supra-pubic catheter. The care plan interventions included: - monitor for signs and symptoms of UTI such as painful urination, frequency and urgency, etc.; - encourage frequent voiding to promote bladder emptying. These interventions were not appropriate since R8 had a supra-pubic catheter. Additionally, on 7/18/16 at approximately 12:20 PM, E2 (DON) stated that R8 changes her own supra-pubic drainage bag. The care plan interventions failed to include that R8 was changing her own drainage bag and that education and staff monitoring was occurring periodically. The facility failed to ensure that R8's care plan was revised to reflect appropriate interventions for supra-pubic catheter care. Findings were reviewed with E2 and confirmed on 7/18/16 at approximately 4:30 PM. 2. Cross refer to F315 Review of R62's clinical record revealed: R62 has resided at the facility for multiple years and has [DIAGNOSES REDACTED]. 1/10/14 - A care plan for occasional urinary incontinence r/t altered mobility and inability to always voice need to urinate was developed. Interventions included: Observe for s/sx of UTI, toilet resident on toilet/commode to promote complete emptying of bladder, toilet per toileting schedule and as needed, incontinence care after each incontinent episode. 4/9/16 - The quarterly MDS assessment stated that during the seven (7) day review period R62 was frequently incontinent of bladder. This was a decline from the previous 1/8/16 annual MDS assessment, when R62 was occasionally incontinent. The facility failed to revise R62's incontinence care plan when a decline in continence status occurred. Findings were confirmed by E2 (DON) during an interview on 7/14/16 at approximately 2:00 PM.",2020-09-01
3,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2016-07-18,312,E,0,1,Z68211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews and review of facility documentation, it was determined that for 2 (R66 and R46) out of 30 Stage 2 sampled residents, the facility failed to ensure those residents, who were unable to carry out activities of daily living (ADLs), received the necessary services to maintain good grooming. For R66, the facility failed to ensure he maintained good grooming as evidenced by multiple observations of being unshaven and having jagged fingernails. In addition, the facility failed to ensure that R66 was bathed twice a week according to his plan of care. For R46, the facility failed to ensure fingernail cleanliness was maintained. Findings include: The facility policy entitled Bathing and Grooming, dated (MONTH) (YEAR), stated, To ensure that all residents are bathed, shaved, and receive fingernail care, as appropriate, to maintain cleanliness and a sense of well-being .Tub baths or showers are given by all nursing staff twice a week, or as necessary .Follow bathing schedule posted on each unit .Males and females, as appropriate, will have facial hair removed/shaved every other day .Finger nail care will be completed as scheduled, on the CNA assignment sheet . 1. Review of R66's clinical record revealed: R66 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/8/15, R66 was care planned for ADLs that included total assistance for bathing due to impaired cognition with an approach to provide a tub/shower two times a week and nail care. Review of R66's CNA documentation record regarding bathing revealed the following: May (YEAR) - bathed 4 out of 9 scheduled times; June (YEAR) - bathed 1 out of 9 scheduled times; and July 1 - 17, (YEAR) - bathed 0 out of 4 scheduled times. Review of R66's progress notes from (MONTH) 1, (YEAR) through (MONTH) 17, (YEAR) lacked evidence of R66 refusing bathing and/or grooming services. Observations of R66 included the following: - on 7/11/16 at 2:52 PM, observed unshaven with jagged fingernails. - on 7/13/16 at 4:34 PM, observed unshaven. - on 7/14/16 at 11:53 AM, observed unshaven with jagged fingernails. - on 7/15/16 at 11:43 AM, observed with jagged fingernails. This surveyor asked E5 (LPN, UM) to look at R66's fingernails. E5 immediately obtained nail clippers to trim R66's fingernails. - on 7/15/16 at 3:26 PM, observed unshaven. - on 7/18/16 at 9:19 AM, observed clean shaven. In an interview on 7/18/16 at 9:37 AM, E6 (CNA) stated that R66 was to be bathed on Mondays and Thursdays on the 11 PM to 7 AM shift. E6 stated that R66 requires total assist of one staff person for bathing, shaving and nail care. In an interview on 7/18/16 at 10 AM, findings were reviewed with E5 regarding multiple observations over 5 days of R66 being unshaven until today. E5 confirmed the finding after reviewing R66's clinical record and stated he was not aware of R66 not receiving scheduled showers since (MONTH) (YEAR). The facility failed to ensure that R66, a resident who is unable to carry out ADLs, received the necessary services to maintain good grooming, personal hygiene and bathing. Findings were reviewed with E2 (DON) on 7/18/16 at 10:08 AM. 2. Review of R46's clinical record revealed: R46's care plan for ADLs, effective 12/14/13, stated the resident was dependent for personal hygiene. An intervention included for staff to provide assistance for a daily sponge bath and twice weekly tub/shower and nail care. The 6/17/16 annual MDS assessment stated R46's cognitive skills for daily decision making were moderately impaired (decisions poor; cues/supervision required) and that R46 was totally dependent on one staff person for hygiene and bathing. Observations on 7/12/16 at 10:04 AM and 7/14/16 at 11:06 AM revealed R46 with dark colored debris under the fingernails of the left hand. In an interview on 7/14/16 at 11:07 AM, E7 (LPN) confirmed R46's left hand fingernails were dirty. E7 proceeded to clean R46's fingernails. The facility failed to provide R46, who was unable to carry out activities of daily living, the necessary services to maintain good grooming and personal hygiene. Findings were reviewed with E1 (NHA) and E2 on 7/18/16 at approximately 5:50 PM during the exit conference.",2020-09-01
4,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2016-07-18,315,D,0,1,Z68211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews and review of other facility documents as indicated, it was determined that for one (R62) out of 30 Stage 2 sampled residents, the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. The facility failed to re-assess R62 when a decline in bladder continence occurred, and failed to develop an individualized toileting plan. Findings include: The facility nursing policy titled Incontinence (treatment), dated 6/30/06, stated, .PR[NAME]EDURE: Incontinence is assessed on admission. 1. Section H of the MDS in (sic) completed on admission, on re-admission, quarterly and with significant change. Identify those residents who are incontinent, or have experienced a decline in continence. 2. On admission, all residents .should have a voiding diary completed. The diary need only be completed with new incontinence or changes in incontinence patterns (decline) .3. Complete the diary for two days (48) hours, evaluating the resident every 2 hours .4. After 48 hours, review the Voiding Diary to determine if there is a voiding pattern .Complete the Incontinence Assessment .5. If a toileting plan is developed, monitor the planned toileting times and its results for one month. Modify the schedule as needed . A revised nursing policy titled Incontinence Assessment and Management, effective (MONTH) (YEAR), stated, .PR[NAME]EDURE: 1. Upon admission, all residents will be assessed for incontinence using the Bowel and Bladder Diary. 2. Complete the diary for three days (72 hours). 3. After 72 hours, review the Voiding Diary to determine if there is a pattern of incontinence .Complete the Bowel and Bladder Assessment and develop an appropriate plan of care .6. On a quarterly basis and with a decline in continence status, the facility will complete a bowel and bladder assessment. Based on the assessment, a voiding diary will be initiated and the plan of care will be revised if necessary. Review of R62's clinical record revealed the following: R62 had resided at the facility for multiple years and had [DIAGNOSES REDACTED]. 1/10/14 - A care plan, target date 7/18/16, for occasional urinary incontinence r/t altered mobility and inability to always voice need to urinate was developed. Interventions included: Observe for s/sx of UTI, toilet resident on toilet/commode to promote complete emptying of bladder, toilet per toileting schedule and as needed, incontinence care after each incontinent episode. 2/1/15 through 2/28/15 - Review revealed that this was the last time R62 was on a toileting program. 1/1/16 through 1/31/16 - Review of the electronic CNA Documentation History Detail report for bladder continence revealed R62 had 14 episodes of urinary incontinence. 1/6/16 - A quarterly Bowel and Bladder Assessment was completed. This assessment stated: - there were no changes in factors affecting bowel and bladder function; - there was no change in management of bladder function; - R62 was continent of bladder. This assessment was inaccurate, as the electronic CNA Documentation History Detail report revealed R62 was having episodes of urinary incontinence. 1/8/16 - R62's annual MDS assessment stated that during the seven (7) day review period: - daily decision making skills were moderately impaired (decisions poor; cues/supervision required); - required extensive assist of two (2) staff for transfers and toilet use; - had not walked in the room or corridor; - was occasionally incontinent of bladder (four (4) episodes of urinary incontinence during the review time period); - received a diuretic daily during the seven (7) day review period. The CAA portion of the 1/8/16 annual MDS assessment triggered incontinence as a potential problem area and was checked off to proceed with care planning. 2/1/16 through 2/29/16 - Review of the electronic CNA Documentation History Detail report for bladder continence revealed R62 had seven (7) episodes of urinary incontinence. 2/9/16 - A quarterly Bowel and Bladder Assessment was completed after R62 was readmitted to the facility post hospitalization and again erroneously stated R62 was continent of bladder. 3/1/16 through 3/31/16 - Review of the electronic CNA Documentation History Detail report for bladder continence revealed R62 had 16 episodes of urinary incontinence. 4/1/16 through 4/30/16 - Review of the electronic CNA Documentation History Detail report for bladder continence revealed R62 had 24 episodes of urinary incontinence. 4/5/16 - A quarterly Bowel and Bladder Assessment was completed and again erroneously stated R62 was continent of bladder. 4/9/16 - A quarterly MDS assessment stated that during the seven (7) day review period R62: - daily decision making skills were moderately impaired (decisions poor; cues/supervision required); - required extensive assist of two (2) staff for transfers and toilet use; - had not walked in the room or corridor; - was frequently incontinent of bladder (nine episodes of urinary incontinence during the review time period); - received a diuretic daily during the seven (7) day review period. After completion of the 4/9/16 MDS assessment, the facility failed to identify R62's decline in urinary continence, they failed to re-assess R62, and failed to develop an individualized toileting plan based on established voiding patterns (voiding diary). Additionally, the facility failed to revise R62's plan of care to address the decline in urinary continence. 5/1/16 through 5/31/16 - Review of the electronic CNA Documentation History Detail report for bladder continence revealed R62 had 13 episodes of urinary incontinence. 6/1/16 through 6/31/16 - Review of the electronic CNA Documentation History Detail report for bladder continence revealed R62 had 19 episodes of urinary incontinence. 7/1/16 through 7/14/16 - Review of the electronic CNA Documentation History Detail report for bladder continence revealed R62 had 13 episodes of urinary incontinence. 7/4/16 - A quarterly Bowel and Bladder Assessment was completed and once again erroneously stated R62 was continent of bladder. 7/13/16 at approximately 2:30 PM - The electronic CNA Assignments Summary, which lists the care CNAs are to provide for R62, was printed. It stated R62 was continent of bladder, used the toilet, wore an incontinence brief, and to SEE TOILETING SCHEDULE. As already stated, the last documented evidence of R62 being on a scheduled toileting plan was back in February, (YEAR). 7/14/16 at 11:19 AM - In an interview with E9 (CNA), R62's assigned aide that day, she stated that when she got the resident up and into the bathroom that despite a slightly wet brief, R62 did also urinate into the toilet. E9 stated that as far as she was aware, R62 does ask to be taken to the bathroom when she needs to go. E9 stated that she was not aware of R62 being on any scheduled toileting plan. This surveyor and E9 then checked the binder on the unit where CNAs document if a resident is on a scheduled toileting plan. There was no scheduled toileting plan found for R62. 7/14/16 at 11:41 AM - During an interview, E8 (RNAC) confirmed that according to the MDS assessments, R62 had a decline from occasionally incontinent (1/8/16 MDS) to frequently incontinent (4/8/16 MDS). E8 stated that when there is a decline the resident should be re-assessed and have a new voiding diary completed. E8 stated that when a decline is noted, she goes to speak with the UM and then the team will decide if a toileting plan would help or not. E8 was not able to state whether this had occurred after completion of R62's 4/8/16 MDS assessment. Additionally, E8 confirmed that the last voiding diary completed for R62 was dated 6/24/14. 7/14/16 at 2:10 PM - During an interview with E2 (DON) the findings were confirmed. E2 stated that the facility felt they had an issue/concern with their incontinence management program and had revised the policy, which went into effect in (MONTH) (YEAR). E2 stated that she personally went through all the resident's bowel and bladder assessments, and those who were incontinent had a new voiding diary completed. E8 stated she reviewed R62's Bowel and Bladder Assessment, but because it stated the resident was continent no further action was taken. 7/14/15 at approximately 4:00 PM - E4 (RN/UM), who completed R62's Bowel and Bladder Assessments from 1/16 through 7/16, was interviewed. When asked how she determined R62's continence status, E4 stated that she calculated percentages and if the resident had a higher percentage of being continent then that was what she documented as the resident's status (e.g. if 92% of the time R62 was continent then she marked continent.). The facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. Per the 4/9/16 quarterly MDS assessment, R62 had a decline from occasionally incontinent to frequently incontinent. There was no evidence the resident was re-assessed, no voiding diary completed, no evidence of an individualized toileting plan, and no revision to the resident's plan of care. Although the incontinence care plan stated R62 was on a toileting plan, the last documented evidence of scheduled toileting was back in (MONTH) of (YEAR). 7/18/16 at approximately 5:30 PM - findings were reviewed with E1 (NHA) and E2 during the exit conference.",2020-09-01
5,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2016-07-18,329,D,0,1,Z68211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, it was determined that the facility failed to have two (R126 and R112) out of 30 Stage 2 sampled resident's drug regimen free from unnecessary medications. The facility failed to monitor the resident's lipid profile periodically as indicated for [MEDICATION NAME], a medication for [MEDICAL CONDITION]. Findings include: The product information for [MEDICATION NAME], last revised 7/2016, stated, . Adult Patients .Since maximal effect of a given dose is seen within 4 weeks, periodic lipid determinations should be performed at this time and dosage adjusted according to the patient's response to therapy and established treatment guidelines . 1. Review of R126's clinical record revealed: R126 was admitted to the facility on [DATE] with [MEDICATION NAME] medication included in her daily medication therapy. Review of R126's clinical record from (MONTH) (YEAR) to (MONTH) 13, (YEAR) lacked evidence of the facility monitoring the resident's response to the [MEDICATION NAME] therapy. In an interview on 7/14/16 at 11:15 AM, E5 (LPN, UM) confirmed the finding. On 7/14/16 at 12:55 PM, a physician's orders [REDACTED]. The facility failed to ensure that R112 was being periodically monitored for the response to the [MEDICATION NAME] medication. Findings were reviewed with E2 (DON) on 7/18/16 at 10:10 AM. 2. Review of R112's clinical record revealed: R112 was admitted to the facility on [DATE] with [MEDICATION NAME] medication included in her daily medication therapy. Review of R112's clinical record from (MONTH) (YEAR) to (MONTH) 13, (YEAR) lacked evidence of the facility monitoring the resident's response to the [MEDICATION NAME] therapy. In an interview on 7/15/16 at 3:32 PM, E5 confirmed the finding that a lipid profile was not performed since (MONTH) (YEAR). The facility failed to ensure that R112 was being periodically monitored for the response to the [MEDICATION NAME] medication. Findings were reviewed with E2 on 7/18/16 at 10:10 AM.",2020-09-01
6,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2016-07-18,428,D,0,1,Z68211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, it was determined that the monthly MRR, completed by the consultant pharmacist, failed to identify the lack of monitoring of efficacy of Pravastatin for two (R126 and R112) out of 30 Stage 2 sampled residents. Findings include: The product information for Pravastatin, last revised 7/2016, stated, . Adult Patients . Since maximal effect of a given dose is seen within 4 weeks, periodic lipid determinations should be performed at this time and dosage adjusted according to the patient's response to therapy and established treatment guidelines . Cross refer to F329, example 1 1. Review of R126's clinical record revealed: R126 had a physician's orders [REDACTED]. Review of R126's pharmacy reviews from (MONTH) (YEAR) to (MONTH) (YEAR) revealed the consultant pharmacist's failure to identify that R126 was not getting lipid determinations performed periodically as indicated while taking Pravastatin. In an interview on 7/14/16 at 11:15 AM, E5 (LPN, UM) confirmed the finding. Findings were reviewed with E2 (DON) on 7/18/16 at 10:10 AM. Cross refer to F329, example 2 2. Review of R112's clinical record revealed: R112 had a physician's orders [REDACTED]. Review of R112's pharmacy reviews from (MONTH) (YEAR) to (MONTH) (YEAR) revealed the consultant pharmacist's failure to identify that R112 was not getting lipid determinations performed periodically as indicated while taking Pravastatin. In an interview on 7/15/16 at 3:32 PM, E5 confirmed the finding. Findings were reviewed with E2 (DON) on 7/18/16 at 10:10 AM.",2020-09-01
7,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2017-09-07,224,D,0,1,H3FV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of facility documents, it was determined that the facility failed to ensure abuse training was provided for one out of 8 employees interviewed. E5 (beautician), was not able to identify potential abuse and did not know how to handle reports of resident abuse, including whom to report to. Findings include: Review of the facility policy, dated (MONTH) (YEAR), and entitled Abuse, Neglect, Mistreatment, Misappropriation and Exploitation stated, All employees, contracted providers, and volunteers upon hire, and annually thereafter, will receive mandatory training on issues related to abuse, neglect, mistreatment, misappropriation of resident property and exploitation, consistent with their expected roles, pursuant to the Training Policy. On 9/7/17 at 11:14 AM, E5 (contracted beautician) was interviewed regarding reporting observed or suspected abuse or mistreatment. E5 stated that she had worked at the facility for about one year. E5 stated that she had never observed any mistreatment of [REDACTED]. On 9/7/17 at approximately 3:30 PM, findings were discussed with E2 (DON) and E4 (ADON). On 9/7/17 at 3:57 PM E2 reported that E5 was not trained on issues related to abuse, neglect, mistreatment, misappropriation of resident property and exploitation. Findings were reviewed with E2 (DON) and E4 (ADON) on 9/7/17 at approximately 3: 30 PM.",2020-09-01
8,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2017-09-07,225,D,1,1,H3FV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews and review of facility documentation, it was determined that the facility failed to report a fall with injury that required hospital treatment to the DLTCRP (Division of Long Term Care Residents Protection) State agency within 24 hours and they failed to submit a 5 day follow up for one (R8) out of 25 Stage 2 sampled residents. R8 fell on [DATE], was sent to the ER (emergency room ) and received stitches for a cut in her eyebrow. Findings include: 1. Review of R8's clinical record revealed the following: R8 resides in the locked dementia unit of the facility. She has both short and long term memory problems according to a 7/2/17 annual MDS. R8 fell on [DATE] and was sent to the ER where she received 3 stitches to her right eyebrow. While reviewing the facility's investigation of the fall, there was no documentation that the facility reported the fall to the DLTCRP State agency within 24 hours and no documentation of a 5 day follow up being sent to the DLTCRP. During an interview with E2 (DON) on 9/7/17 at 11:20 AM, E2 confirmed that R8's 1/3/17 fall with injury that required the resident to be sent to the hospital and treated was not reported to the DLTCRP. Findings were reviewed with E2 (DON) and E4 (ADON) on 9/7/17 at approximately 3: 30 PM.",2020-09-01
9,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2017-09-07,309,D,1,1,H3FV11,"> Based on observation and record review, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (R15) out of 25 Stage 2 sampled residents. For R15, the facility failed to implement interventions listed on R15's care plans to address her confusion, crying and distress on 8/31/17 when R15 thought she was lost. Findings include: Review of R15's clinical record revealed: R15's most recent MDS assessment, dated 6/7/17, coded R15's cognitive patterns as severely impaired (never/rarely made decisions). R15's care plan for Dementia/Cognitive Deficits, effective 9/7/16, listed interventions to: Allow resident ample time to absorb and respond to information . Understand that people with dementia do not have access to logic. R15's care plan for Social Services-Mood/Verbalizing Negative Statements, effective 9/7/16, listed an intervention to: Calmly reassure resident. R15's care plan for Social Services - False Beliefs/Accusations, Resident presents with false beliefs/accusations crying, getting upset ., effective 12/20/16, had interventions to: Listen to resident's thoughts . Calmly explain .; and Redirect her On 8/31/17 at 3:10 PM, the surveyor was on the 2nd floor in the doorway between the dining room and the common area. At 3:11 PM on 8/31/17, R15 approached the surveyor using a walker. R15 was crying and stated, Will you help me? I'm lost. Surveyor responded, The nurses will help you, let's go get the nurse. R15 continued crying and stated, they won't help me, I'm lost. The surveyor walked R15 toward the nurse's station where 8 staff members were standing/sitting during the change of shift. Some of the staff turned to watch the surveyor and R15 approach. R15 was crying and stated again, they won't help me, I'm lost. The surveyor replied, the nurses will help you. No staff responded to R15. The resident stated they don't help me. Surveyor asked E3 (LPN) the resident's room number. E3 responded with R15's room number. The surveyor walked R15 down the hallway to her room. R15 continued crying and stating, I'm lost. The surveyor and R15 entered resident's room where the surveyor remained with R15 for approximately 15 minutes until R15 stopped crying and was calm. No staff came to the room to check on R15 while the surveyor was there. When the surveyor walked back past the nurse's station, no staff approached the surveyor and inquired about R15. The facility failed to follow R15's care plan to provide the highest practicable mental and psychosocial well-being, when R15 was upset, crying and repeatedly stating she was lost, and staff did nothing to assist the resident. Findings were reviewed with E2 (DON) and E4 (ADON) on 9/7/17 at approximately 3:30 pm.",2020-09-01
10,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2017-09-07,329,E,1,1,H3FV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and staff interview, it was determined that the facility failed to monitor the effectiveness of [MEDICATION NAME] for one (R45) out of 25 Stage 2 sampled residents. Findings include: Review of R45's clinical record revealed the following: 5/11/17 - R45 was admitted to the facility with [DIAGNOSES REDACTED]. 5/11/17 - A physician's orders [REDACTED]. 5/24/17 - A care plan was developed for [MEDICAL CONDITION] drug use related to depression and [MEDICAL CONDITION]. Interventions included to assess need for psychotherapeutic medication and assess effectiveness of the medication. Review of MARs from 5/11/17 through 8/30/17 revealed that R45 received [MEDICATION NAME] on the following dates: 5/12/17, 5/17/17, 5/20/17, 6/16/17, 7/2/17, 7/16/17, 7/23/17, and 8/6/17. Review of behavior monitoring sheets, MARs and progress notes revealed the lack of monitoring of effectiveness of the [MEDICATION NAME] on the above listed dates. 8/31/17 at 10:25 AM - Findings were reviewed with E2 (DON). E2 confirmed the facility failed to monitor the effectiveness of the [MEDICATION NAME].",2020-09-01
11,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2017-09-07,385,D,1,1,H3FV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and interviews, it was determined that for one (R177) out of 25 Stage 2 sampled residents, the facility failed to ensure that a physician was supervising the medical care of R177, specifically from 7/22/16 through 8/11/16, when R177 was identified with a [MEDICAL CONDITION]/growth on her coccyx/sacrum which later became an open wound. Findings include: Review of R177's clinical record revealed the following: 7/21/16 at 3:38 PM - A progress note stated that R177 had a [MEDICAL CONDITION]/growth on her coccyx and the facility's physician was notified. 7/22/16 at 12:16 PM - A progress note by E4 (ADON/Wound Care Nurse) stated that she was asked to assess R177's coccyx/sacrum regarding a [MEDICAL CONDITION]/growth. E4 stated that R177 had a raised 1.0 cm x 1.0 cm red to black area with no drainage, the skin around the area was blanchable, there was hair present throughout the [MEDICAL CONDITION]/growth and R177 had pain when the area was touched. E4 stated that the MD (physician) to evaluate on this day. Review of the clinical record revealed lack of evidence that a physician evaluated R177 on 7/22/16. 7/29/16 at 2:49 PM - A progress note by E4 stated that she was asked to re-assess R177's coccyx/sacrum regarding the [MEDICAL CONDITION]/growth which was now an open wound. E4 stated that R177's raised area was now open measuring 1.0 x 1.0 x 0.1 cm with a tan wound bed, scant amount serous drainage and fleshtone peri-wound. E4 stated that the MD to assess area .MD to evaluate. Review of R177's clinical record from 7/22/16 through 8/11/17 revealed lack of evidence that R177 was seen and evaluated by a physician regarding her open wound. 9/5/17 at 4:16 PM - During a combined interview, E4 (ADON) and E9 (RNAC) stated that they both were in R177's room on 7/22/16. E4 stated that she assessed the [MEDICAL CONDITION]/growth while E9 was translating as the R177's primary language was Spanish. E9 stated that she observed R177's [MEDICAL CONDITION]/growth on 7/22/16 and described the area as a bump or mole. 9/5/16 at 5:01 PM - During an interview, E10 (LPN) stated that she was the nurse who first identified the [MEDICAL CONDITION]/growth on R177's coccyx on 7/21/16. E10 stated that the area was not a blister or a mole. E10 stated that she was very familiar with R177 as she toileted her often and had never seen the [MEDICAL CONDITION]/growth before. E10 stated that she notified the physician and referred it to the wound care nurse, E4, to be assessed further. 9/6/17 at 4:36 PM - During a combined interview, E2 (DON) and E4 confirmed the findings. The facility failed to ensure that R177 was evaluated by a physician from 7/22/16 through 8/11/16 when a [MEDICAL CONDITION]/growth was identified on her coccyx/sacrum which later became an open wound.",2020-09-01
12,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2017-09-07,406,E,1,1,H3FV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and interviews, it was determined that for one (R142) out of 25 Stage 2 sampled residents, the facility failed to obtain and coordinate specialized rehabilitative services from an outside rehabilitation center per a 4/10/17 facility physician's orders [REDACTED]. Findings include: Review of R142's clinical record revealed the following: 12/12/16 - R142 was admitted to the facility for rehabilitation after a stroke resulting in right sided weakness. 12/13/17 through 2/2/17 - R142 received rehabilitative services from the facility's inhouse physical therapy (PT) department. 2/3/17 at 12:48 PM - The facility's inhouse PT discharge summary stated that R142 achieved his highest practical level and restorative nursing care was not appropriate at the time due to inconsistent abilities and tone changes on the right side of his body. 2/28/17 - R142 was seen by C1 (neurologist) who recommended a physiatry evaluation to discuss resuming therapy. 3/8/17 at 2:43 PM - The facility's inhouse PT assessed R142 at the request of C1. The facility's PT evaluation stated that R142's functional mobility skills remained unchanged since his inhouse therapy discharge on 2/3/17 and treatment was not recommended at this time. 3/28/17 at 10:14 AM - A progress note stated that R142's POA (unidentified #1 or #2) insisted on scheduling an appointment with C2 (physiatrist), which was arranged for 4/7/17 at 1 PM. 4/7/17 - R142 was seen by C2 and received a referral for physical therapy two times a week for six weeks. In addition, a follow-up appointment with C2 was scheduled on 6/6/17 at 12:30 PM, approximately eight weeks later. 4/10/17 at 3:23 PM - The facility's physician order [REDACTED]. 5/1/17 at 9:37 AM - The facility's physician order [REDACTED]. 5/31/17 - The facility's physician order [REDACTED]. 6/1/17 at 12:29 PM - A facility's progress note stated that R142 returned from the outside rehabilitation center with no new orders. 6/6/17 at 10:20 AM - The facility's physician order [REDACTED]. 6/6/17 at 5:23 PM - The facility's inhouse PT evaluation stated that another family member of R142 asked that he be re-evaluated for transfer and gait training in addition to educating the family on how to transfer him so they could take him to family functions. The evaluation stated that R142 continued to lack sufficient motor control needed to advance his functional mobility skills and treatment was not recommended. 6/6/17 at 5:34 PM - The facility's physician order [REDACTED]. 7/14/17 - The facility's Rehab Screening Form stated E8 (Rehab Director) spoke with F2 (POA #2) regarding R142's cognitive status and the need for 24 hour care because of safety concerns and his lack of insight regarding his abilities. E8 stated that R142 does not appear at the current time to have further potential to reach a greater independence of mobility . E8 stated that the family wishes to pursue a second opinion from outside therapy . 7/26/17 at 6:13 PM - The facility's physician order [REDACTED]. It was unclear why it took the facility approximately 4 months to obtain and coordinate outside therapy services for R142 when the facility's physician ordered the specialized services on 4/10/17. 8/30/17 at 10:57 AM - During an interview, F1 (POA #1) stated that the facility delayed in obtaining therapy services for R142 eventhough C2 referred him for additional therapy. F1 stated that it had been a very difficult situation trying to obtain outside therapy services. F1 stated that R142 was finally receiving therapy services now at an outside rehabilitation center. 9/6/17 at 3:14 PM - During an interview, E8 stated the following: - on 3/8/17, the facility's inhouse PT evaluated R142 per a neurologist consult and determined that R142 was at his baseline; - on 3/23/17, the facility's inhouse OT evaluated R142's right hand and ordered a splint; - on 6/6/17, R142's family member asked the facility's inhouse PT if they could help them with taking R142 home for family functions (transfers, toileting). The facility's inhouse PT evaluated R142 on 6/6/17 and then called F1 (POA #1) to discuss options. F1 declined the facility's inhouse PT services and told them he was looking at other outside rehabilitation options for R142; and - on 7/14/17, E8 attempted to contact F1 without success and then called F2 (POA #2). F2 stated that he was looking at other rehabilitation options. 9/6/17 at 4:39 PM - During an interview, E4 (ADON) stated that there were delays due to billing issues regarding therapy services between the facility's inhouse PT and the outside rehabilitation center in addition to delays in arranging for medical transportation to the outside rehabilitation center. E4 stated that the facility's former social worker was directly involved but was no longer employed there. It was unclear exactly how the facility's former social worker was involved as R177's clinical record lacked evidence of social services documentation. 9/6/17 at 4:45 PM - Findings were reviewed and confirmed with E2 (DON) and E4 (ADON). The facility failed to obtain and coordinate specialized rehabilitative services from an outside resource per a 4/10/17 facility physician's orders [REDACTED]. On 8/4/17, approximately 4 months later, R142 received specialized PT services at an outside rehabilitation center.",2020-09-01
13,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2017-09-07,463,D,1,1,H3FV11,"> Based on observations, the facility failed to maintain a properly functioning communication system used by residents to contact staff in 3 out of 35 rooms. Findings include: 1. During a review of the environment on 8/30/17 from 2 PM to 4 PM with E6 (Maintenance Director) and E7 (Housekeeping Director), the hallway light outside of room 104 did not turn on when activated by pulling the call bell cords in the bedroom and bathroom. 2 On 8/30/17 between 2 PM and 4 PM, the call bell cord in the bathroom of room 232 was observed to be tightly wrapped around the handrail, preventing their activation. 3. On 8/30/17 between 2 PM and 4 PM, the call bell cord in the bathroom of room 318 was observed to be tightly wrapped around the handrail, preventing their activation. Findings were confirmed with E6 on 8/30/17 from 2-4 PM during the environmental tour.",2020-09-01
14,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,558,D,1,1,H65F11,"> Based on observation and interview, it was determined that the facility failed to provide reasonable accommodation of an individual needs for one (R9) out of 54 sampled residents, by not having the call bell within reach. Findings include: Observation on 11/27/18 at 3:28 PM, revealed R9 seated in a wheelchair in her room near her bed. R9's call bell was observed clipped on the opposite side of her bed up against the wall where she was unable to reach it. E5 (LPN) was called into R9's room and confirmed that the resident was capable of using the call bell when requiring assistance. E5 confirmed that the call bell was out of reach and proceeded to place it within R9's reach. Findings were reviewed with E2 (DON) on 12/5/18 at 1:50 PM. On 12/6/18 at approximately 7:45 PM, findings were reviewed with E1 (NHA), E2, E3 (ADON), and E14 (QA) during the exit conference.",2020-09-01
15,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,580,D,1,1,H65F11,"> Based on interviews and review of the clinical record and facility documentation, it was determined that for one (R45) out of 54 sampled residents, the facility failed to immediately notify the resident's representative and immediately consult with the resident's physician when there was an incident that had the potential for requiring physician intervention and a change in treatment. For R45, the facility failed to immediately consult with F4 (Physician/Medical Director) and failed to immediately notify F6 (R45's POA) after an allegation of sexual abuse was made on 11/7/18 at 6:30 AM. Findings include: Cross refer to F607, F608, F609 and F610 The facility's policy entitled Provider Notification of Resident Change in Medical Condition, effective (MONTH) (YEAR), stated, It is the policy .that staff communicates changes in a resident's medical condition to providers in a timely and accurate manner .Any incident requiring notification of the Division of Long Term Care Resident Protection . Review of R45's clinical record revealed: 11/7/18 at 6:30 AM - The facility's Incident/Accident Report, completed by E2 (DON), stated the following: - Description of what happened: CNA alleged staff was inappropriately touching resident; - Physician notified at 6:30 AM; - POA notified on 11/8/18 at 9:45 AM. 12/6/18 at 8:46 AM - During an interview, this surveyor showed E4 (Medical Director) a copy of the facility's incident report for the 11/7/18 allegation of sexual abuse, which stated that E4 was notified at 6:30 AM and asked her if she remembered being notified. E4 stated that she was unable to remember exactly when she was notified. E4 stated that she remembered being told by E9 (RN, Supervisor) about the incident by hey did you hear ., but does not remember being officially notified about the incident involving R45. E4 stated that she would have immediately sent R45 to be examined at the hospital, as they are the experts, upon being told that there was an allegation of sexual assault. This surveyor said that E4 ordered R45 to be sent to the hospital's Emergency Department to be examined on Friday, 11/9/18, two days after the alleged incident. E4 stated that it was her practice that if she was notified of an allegation of a sexual assault, she would immediately send the resident to the hospital to be examined by the Forensic Team. The facility failed to immediately notify E4 of the 11/7/18 allegation of sexual abuse. 12/6/18 at 9:09 AM - During an interview, this surveyor asked who notified E4 (Medical Director) on 11/7/18 at 6:30 AM, as recorded on the facility's Incident Report. E2 (DON) and E3 (ADON) said neither one notified E4. 12/12/18 at 10:48 AM - During an interview, F6 (POA) stated that she was notified on 11/8/18 at 9:45 AM about the 11/7/18 allegation of sexual abuse involving R45. The facility failed to immediately notify F6 until approximately 27 hours later.",2020-09-01
16,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,600,G,1,1,H65F11,"> Based on record review, observations, and review of other facility documentation as indicated, it was determined that for 2 (R31 and R52) out of 54 sampled residents, the facility failed to ensure that residents were free from abuse. For R31, the facility failed to ensure R31 was free from potential physical, emotional and verbal abuse and for R52, the facility failed to ensure R52 was free from actual physical, emotional and verbal abuse from resident to resident altercations. For R31, another resident in the same hallway (R15), has wandered into R31's room during the night which has the potential for abuse. R52, who resides in the same hall as R31 and R15, has been emotionally, verbally and physically abused by R15 as evidenced by cursing, yelling, hurtful remarks, hitting, and being accused of things. As a result of this abuse, R52 has experienced feeling fearful, upset, sad, anxious, and at times, R52 isolates herself in her room to avoid R15. This is a harm level deficiency for R52. Findings include: Review of the facility policy entitled Abuse, Neglect, Mistreatment, Misappropriation, and Exploitation, effective (MONTH) (YEAR), stated, . Purpose: To ensure that all patients and residents will be free from abuse, neglect, mistreatment, misappropriation and exploitation of funds and resources . a. Physical abuse by unnecessarily inflicting pain or injury to a patient or resident. This includes but is not limited to, hitting, kicking, punching, slapping, pulling hair, or corporal punishment of any kind . c. Emotional Abuse which includes, but is not limited to, ridiculing, demeaning, humiliating, or cursing at a patient or resident , or threatening a patient or resident with physical harm Staff Responsibilities . b. If an act of abuse, neglect, mistreatment or property misappropriation is witnessed, the witness must act to first remove the source of the act, whether it is a staff member or a visitor, and then take steps to protect the resident . 1. Review of R52's clinical record revealed the following: R52 was admitted to the facility in (YEAR). A quarterly MDS assessment, dated 10/4/18, coded R52 on a scale of 0-15, with 0 being never/rarely made decisions and 15 being the highest level of cognition (decisions consistent/reasonable), as a 15. Review of an incident report for R52, dated 11/25/18 and timed 3:30 PM, stated, Resident involved in incident with another Resident (R15) in which she was slapped on right arm . Resident (R15) noted verbally aggressive/physically aggressive towards another Resident (R52). The incident occurred in the lounge near the nurses station. Review of a CNA statement on 11/25/18 and timed 3:30 PM, stated, I witnessed (R15) come out of her room yelling at (R52). I walked over as she (R15) was hitting (R52) (she (R15) smacked her (R52) on her arm once). A progress note, dated 11/25/18 and timed 5:05 PM, was written for R15 (the resident involved in the incident) and it was included in the incident report. The progress note, written by a nurse, stated, At approx. (approximately) 1530 (3:30 PM), resident (R15) noted standing in lounge area, agitated while shouting 'you stole my money' headed towards another resident (R52). CNA approached (R15) and (sic) a very calm therapeutic manner, however resident continued to be verbally aggressive (towards other resident) and quickly slapped the resident's left (sic) arm. Attempts to redirect made, resident (R15) escorted to her room . remains A&OX1 (alert to person only, not to place or time); to self, per established baseline. Nursing staff to monitor . A progress note, dated 11/25/18 and timed 5:05 PM, stated, At approximately 1530 (3:30 PM) (R52) was involved in an incident with another resident (R15). Another resident became verbally aggressive towards (R52), and quickly slapped her on the right arm. (R52) was removed from scene immediately, and assessed by Nurse . Resident stated, 'I don't know why she did that', when asked if she knew anything that could have contributed to the incident . There was no obvious injury to R52's arm. R52 was interviewed by the state surveyor on 11/28/18 at 9:15 AM. R52 expressed that R15, who resides down the hall a few doors from her room curses and hits her. When asked how long this has been going on, R52 stated since she (R52) has been in the facility for 3+ years. R52 stated that R15 slapped her in the face previously, but has not caused her bodily injury. R52 further stated that R15 has accused her (R52) of stealing R15's money and buying clothes. R52 stated that she was not the only person R15 abuses and stated when R15 walks down the hall, she'll use her walker to hit anyone in her way. R52 stated that if she see's R15 in the hall where they reside, she'll go into her room, close the door and turn down the television sound so she (R15) won't know I'm there. R52 stated that staff have observed these behaviors from R15 and advised her not to hit R15 back, however, she stated, I'd really like to hit her back. When asked if she's talked to staff about her concerns regarding R15, R52 stated that she talked to E1 (NHA) a few days ago and was told that they'd try to remove sitting chairs in the hall so if R15 sits, it will be in the area by the nurses station. E52 became tearful several times when discussing R15 and stated I don't even look in her (R15's) room when I walk by and the CNA's are afraid of her. When asked how all this makes her feel, R52 stated, I can't take it anymore. I feel terrible, it upsets me. Sometimes I feel like pulling my hair out by it's roots. R52 also stated that she didn't want to have a nervous breakdown . I don't want to have . one because of her (R15). R52 denied any further incidents with R15 throughout the survey from 11/28/18- 12/6/18. Record review revealed that R52 has received counseling from a psychologist (E15) on an ongoing basis since at least (MONTH) (YEAR). On 11/28/18 at 11:43 AM, R52 was seen by E15. R52's mood was described as depressed and anxious. The progress notes stated, . Pt (patient) discussed how she had an altercation with another resident and how the situation is being handled . Psychologist provided supportive and empathetic listening and feedback to pt(patient) . A progress note, dated 11/28/18 and timed 4:32 PM, was written by E2 (DON). The note stated, . Spoke with resident after interaction on 11/25/18. Resident states she feels much better today and that she slept 'like a baby' last night. Resident states she has felt comfortable on the unit and continues to sit and converse with peers . AAO x 3 (alert and oriented to person, place and time). Verbally able to make needs known. Continues to attend the dinning (sic) room for meals with good appetite . right arm . no marks or bruises . denies pain . Continues to self propel w/c (wheel chair) on and off unit without difficulty . Continues to participate in activities. A progress note, dated 11/28/18 and timed 5:51 PM, written by E2, stated, Spoke to resident daughter regarding resident status. Daughter pleased to hear resident doing well. Will continue to monitor. The 5 day follow up, written by E2 (DON), was submitted to the state agency on 11/30/18 for the 11/25/18 incident. The follow up stated, . Spoke with (R52) on 11/26 and 11/28 following interaction on 11/25. (R52) remains AAOx 3. Verbally able to make needs known . Seen by psychologist with no further interventions necessary. Resident (R15) with no further episodes of physical aggression towards other residents. Has dx (diagnosis) depression, pseudobulbar affect (neurological condition characterized with uncontrollable laughing and crying) and dementia. Has known behaviors related to physical aggression and receives counseling. Continues to ambulate (walk) on unit with RW (rolling walker) . ADON spoke with resident regarding programing on the dementia unit and potential benefits. Family in agreement to trail (sic- trial) unit during day before making a decision. R52 stated that R15 had not bothered her during the survey period of 11/28/18 through 12/6/18. On 12/5/18 at 2:35 PM, findings were discussed with E2 (DON) and she was advised that this was a harm level deficiency. The facility failed protect R52 from emotional, verbal and physical abuse from R15. R15 has a history of physical aggression towards staff and other residents, verbal aggression including yelling and cursing at staff and other residents, and false beliefs/accusations, including that someone stole her money and other belongings. R52, who is cognitively intact, stated that R15 curses at her, says hurtful things to her, and hits her, even going out of her way to do so, at times. R52 was most recently hit by R15 on 11/25/18. As a result of R15's behaviors towards R52, R52 stated that she secludes herself in her room when she see's R15 in the hall (both reside in same hall) by shutting her bedroom door and turning down the volume on her tv so R15 won't know R52's in her room. R52 also reported that she feels sad, upset and afraid due to R15's abuse. R52 stated that she doesn't want to have a nervous breakdown because of R15. 2. Review of R31's clinical record revealed the following: R31 was admitted to the facility in 2014. Review of a quarterly MDS assessment, dated 9/13/18, coded R31 on a scale of 0-15, with 0 being never/rarely made decisions and 15 being the highest level of cognition (decisions consistent/reasonable), as a 15. R31 was interviewed by the state surveyor on 11/28/18 at 9:58 AM. R31 stated that R15 wandered into his room last night about 2:00 AM and she was asking where someone was. R31 further stated, I feel like she doesn't belong on this floor, but family doesn't want her to go to 3rd floor. R31 further stated this was not the first time R15 had done this, but it's the first time in awhile. R31 stated that his roommate likes the door open, so R15 see's it open and wanders in. Findings were reviewed with E2 (DON) on 12/5/18 at 2:35 PM and advised this has the potential for harm. The facility failed to ensure R31 was free from potential abuse when R15 wandered into R31's room due to lack of adequate monitoring and supervision on 11/28/18 at approximately 2:00 AM. R15 has a history of distressed behaviors, including verbal and physical abuse of staff and other residents. R31 stated that R15 had wandered into his room previously, too. Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), and E14 (RN/QA) on 12/6/18 at approximately 7:45 PM during the exit conference.",2020-09-01
17,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,607,D,1,1,H65F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of the clinical record, hospital record, facility and other documentation as indicated, it was determined that for one (R45) out of 54 sampled residents, the facility failed to develop and implement an abuse policy and procedure that addressed the requirements of the Federal Regulation 483.12(b). Specifically under the Protection requirement, the facility failed to have written procedures that ensured that all residents are protected from physical and psychosocial harm during and after the investigation. This must include: Responding immediately to protect the alleged victim and integrity of the investigation . The facility failed to protect R45 (alleged victim) and all residents when: - The allegation of sexual abuse was made on 11/7/18 and the facility began an investigation by obtaining written statements of those staff involved. However, the facility failed to immediately protect R45 as E7 (accused nurse) returned to R45's floor before leaving the facility on 11/7/18; and - The facility failed to protect all residents, including R45, when an investigation by law enforcement started on 11/21/18 and was ongoing as of 12/6/18 regarding the 11/7/18 allegation of sexual abuse against E7, a facility nurse. E7 remained on duty during the ongoing investigation, which allowed the accused nurse to have access to all residents, including R45. An immediate jeopardy situation was identified on 12/6/18 at 1:32 PM. Findings include: Cross refer to F580, F608, F609 and F610 The facility's policy entitled, Abuse, Neglect, Mistreatment, Misappropriation and Exploitation, effective (MONTH) (YEAR), stated, .Procedures: .5. Staff Responsibilities .b. If an act of abuse .is witnessed, the witness must act to first remove the source of the act, whether it is a staff member or a visitor, and then take steps to protect the resident . The facility failed to have written procedures as per the Federal Regulation requirement to ensure protection of all residents/alleged victim during and after the investigation. Review of R45's clinical record revealed: 10/2/18 - Review of a quarterly MDS assessment stated that R45 was severely cognitively impaired and had active [DIAGNOSES REDACTED]. 11/7/18 at 6:45 AM - An allegation of sexual abuse involving E7 (accused nurse) and a resident, R45, was reported by E10 (CNA) to E9 (RN, House Supervisor). E9 reported the allegation to E2 (DON), then E9 and E2 reported the allegation to E1 (NHA). E7 was requested to leave the floor to meet with E1 (NHA) and E2 (DON) on the ground floor where the facility management offices are located. E7 was then requested to write a statement. Once the allegation was made and facility's investigation started by obtaining written statements of those staff involved, the facility failed to protect R45 as E7 was allowed to return to R45's floor before leaving the facility on 11/7/18. The following events occurred after facility management was made aware and started their investigation: - At 8:07 AM, E7 documented a nurse's note in R45's electronic clinical record; - At 8:21 AM, E7 exited R45's floor according to E7's electronic swipe Card Activity History Report; - At 8:22 AM, E7 exited the facility. 11/8/18 at 10:04 AM - According to the facility's Incident Report submitted to the Delaware's Office of Long Term Care Resident Protection, the facility stated, .An internal investigation was conducted and completed and the allegation was found unsubstantiated. 11/8/18 between 9:45 AM-10:04 AM - F6 (R45's POA) stated, during a follow-up interview on 12/12/18 at 11:24 AM, that she asked if the facility called the local law enforcement agency to report the allegation of sexual abuse. It was not until after F1 (R45's family member) arrived at the facility at approx. 11:30 AM, met with E1 (NHA) and E2 (DON), F1 called F6 with an update, and it was at this point when R45's family (F1 and F6) insisted on a police report. 11/8/18 at 1:49 PM - According to the local law enforcement agency's dispatch records, the police were called at 1:49 PM. A police officer, F3, responded to the facility and met with E1 (NHA) and E2 (DON), whom informed F3 about the allegation and the facility's internal investigation findings, which were unsubstantiated. F3 left the facility without writing a report at 2:04 PM. 11/9/18 at 1 PM - A late entry nurse's note documented on 11/12/18 at 11:19 AM by E2 (DON) stated, After discussion with IDT, decided to send resident (R45) to ED for comprehensive exam .(F2, family member) called and in agreement with decision . 11/9/18 at 5:48 PM - According to the hospital record, R45 was seen and examined by the Emergency Department's Forensic Team. F4 (hospital Forensic Nurse) notified the local law enforcement agency and the State Survey Agency (at 5:53 PM) that R45 was seen and examined for an alleged sexual assault of adult. 11/21/18 at approx. 1 PM - According to email correspondence between F5 (Detective with the local law enforcement agency's Criminal Investigations Division) and E1 (NHA) and E2 (DON), F5 met with E1 and E2 at the facility about the 11/7/18 allegation of sexual abuse of R45. The facility provided F5 with requested facility documents, names and contact information for facility staff involved. The facility became aware that the 11/7/18 allegation of sexual abuse involving R45 and E7 (accused nurse) was being investigated by the local law enforcement agency's Criminal Investigations Division. 11/21/18 through 12/6/18 - The facility moved E7 (accused nurse) to a different floor from R45 after the 11/7/18 incident. Review of E7's Time Card Report revealed the accused nurse worked the following 11 PM to 7 AM shifts: - Friday, 11/23/18, into Saturday, 11/24/18; - Saturday, 11/24/18, into Sunday, 11/25/18; - Sunday, 11/25/18, into Monday, 11/26/18; - Monday, 11/26/18, into Tuesday, 11/27/18; - Friday, 11/30/18, into Saturday, 12/1/18; - Saturday, 12/1/18, into Sunday, 12/2/18; - Sunday, 12/2/18, into Monday, 12/3/18; and - Monday, 12/3/18, into Tuesday, 12/4/18. 11/21/18 through 12/6/18 - Review of the facility's staff posting revealed that E7 (accused nurse) worked as a floor nurse in addition to being the facility's House Supervisor on the following 11 PM to 7 AM shifts: - Saturday, 11/24/18, into Sunday, 11/25/18; - Friday, 11/30/18, into Saturday, 12/1/18; and - Saturday, 12/1/18, into Sunday, 12/2/18. Review of the facility's Nurse Supervisor policy, effective 5/16, stated, .Policy: To outline the duties and responsibilities of the Nurse Supervisor in compliance with State regulatory procedures .1. In compliance with State regulation, 2 hours of Registered Nurse (RN) time each shift (7-3, 3-11, 11-7), will be dedicated to administrative functions which include: - Rounds on units - Assisting with coverage/scheduling issues - Family concerns - Problem solving . 11/21/18 through 12/6/18 - Review of the facility's electronic swipe Card Activity History Report, which captured E7's assigned card access/exit to the floor where R45 was located, revealed the following dates and times: - 12/2/18 at 1:36 AM; - 12/2/18 at 2:20 AM; - 12/2/18 at 2:23 AM; - 12/2/18 at 6:44 AM; - 12/2/18 at 7:18 AM; - 12/3/18 at 6:52 AM. The facility became aware on 11/21/18 that the local law enforcement agency's Criminal Investigations Unit was investigating the 11/7/18 allegation of sexual abuse of R45 by E7. The facility failed to protect all the residents, including R45, during the investigation by allowing E7 to remain on duty, including assigning E7 as House Supervisor for 3 out of 8 shifts, giving E7 access to all residents, including R45, from 11/21/18 to 12/6/18. 12/5/18 at 2:10 PM - During an interview, E1 (NHA) stated that during the facility's investigation, the staffing schedule was checked to see if E7 (accused nurse) was off and E7 was. E1 stated otherwise, we would have had to suspend E7 or asked E7 not to come in until the facility finished their investigation. E7 was not scheduled to work until Saturday night, 11/10/18, on 11PM to 7AM shift. E1 stated that F5 (Detective from Criminal Investigations Unit) met with her and E2 (DON) and that F5 would notify her of the outcome of their investigation. E1 stated that she spoke with F6 (R45's POA) about not having E7 care for R45 and F6 agreed. E1 stated that E7 was assigned to a different floor from R45. E1 was asked by this surveyor if E7 had been House Supervisor on the 11PM-7AM shifts since the 11/7/18 incident, E1 said yes. 12/6/18 at 1:23 PM - E1 (NHA) and E2 (DON) was informed of an Immediate Jeopardy. 12/6/18 at 8:15 PM - The Immediate Jeopardy was abated. E1 (NHA) stated that R7 was placed on Administrative Leave until the conclusion of the criminal investigation.",2020-09-01
18,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,608,D,1,1,H65F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of the clinical record, facility documentation and other documentation as indicated, it was determined that for one (R45) out of 54 sampled residents, the facility: - failed to develop and implement written policies and procedures for covered individuals (included employees) that ensured reporting of crimes occurring in a federally-funded long-term care facility in accordance with section 1150B of the Social Security Act; - failed to report to the law enforcement entity for the political subdivision in which the facility was located any reasonable suspicion of a crime against any individual who was a resident of, or was receiving care from, the facility; and - failed to report not later than 24 hours if the event that caused the suspicion did not result in serious bodily injury. After the 11/7/18 allegation of sexual abuse of R45 (alleged victim) by E7 (accused nurse) was made by E10 (CNA), the facility failed to recognize its responsibility to report a suspected crime to the local law enforcement entity; failed to report a suspected crime not later than 24 hours later; failed to maintain the integrity of any evidence; and failed to transfer R45 to the hospital emergency department for a forensic examination until 2 days later. Findings include: Cross refer to F580, F607, F609 and F610 Review of the facility's Abuse, Neglect, Mistreatment, Misappropriation and Exploitation policy and procedure, effective (MONTH) (YEAR), stated under Procedure: .2 .b. Such training, if consistent with the individual's expected role, shall include: .iii. Reporting of crimes occurring in the facility .4. Investigation and Reporting. a. All alleged incidents involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property shall be reported to the administrator of the facility immediately. b. Thereafter, the administrator and other appropriate persons at facility shall investigate allegations pursuant to the Incident Investigation Guideline and make reports to appropriate officials as directed by federal and state law . The facility's policy and procedure failed to specify the following components under 42 CFR 483.12(b)(5): - Identification of who in the facility is considered a covered individual; - Identification of crimes that must be reported; - Identification of what constitutes 'serious bodily injury'; - The timeframe for which the reports must be made; and - Which entities must be contacted for example, the State Survey Agency and local law enforcement. Review of the R45's clinical record revealed: 10/2/18 - Review of a quarterly MDS assessment revealed that R45 was severely cognitively impaired and had active [DIAGNOSES REDACTED]. 11/7/18 at 6:30 AM - The facility's Incident/Accident Report stated the following: - R45, resident, was confused and disoriented before the incident; - Description of what happened: CNA alleged staff was inappropriately touching resident; - Physician notified at 6:30 AM; - POA notified on 11/8/18 at 9:45 AM. The facility's internal incident report failed to identify the accused staff member and failed to document the internal investigation and findings. 11/7/18 (untimed) - The facility conducted an internal investigation and obtained statements from the following staff: - E8 (CNA) stated, Today on 11-7-18 on shift 11-7 about 6:30 AM I headed toward the end of the hall to search for the nurse (E7). I stop in front of room (number). I see the resident (R45) lying on her side facing the window and the nurse bent down to her level. The resident was covered from the waist down. I see movement under the covers moving fast. I stepped back out of the room and stepped back into the doorway and called the nurses (sic) name. The nurse immediately pulled his hands from underneath the covers and covers the resident up with the blanket. He jumps back and then exits the room with me. - E9 (RN, House Supervisor) stated, On 11/7/18 at 6:45 AM E8 (CNA name) came to me to report that she had witnessed E7 (nurse name) doing something on (sic) Resident (R45's name). She witnessed that E7's hand is under R45's blanket and the blanket was moving very fast. Staff sent back to floor immediately to ensure resident's safety. - E7 (RN) stated, Toward the end of the 11-7 shift on 11/7/18 this nurse noted a skin check was due on the TAR. I performed the skin check on resident (R45) in rm (room number) while resident was lying in bed. Resident was awake & (and) @ (at) baseline level of orientation. I informed resident that I needed to check her skin and resident smiled, giggled and stated ok. I proceeded to assess her upper back, buttocks & groin area after lowering her hipsters then groin area proceeding to assess back of thighs & legs to heels & feet soles, ankles, dorsal aspect then toes, shins upper legs to groin & abdomen, upper chest arms neck, shoulders, neck & head. Resident appeared in no distress occasionally giggling & reaching out. Readjusted incontinence product & hipsters & covered resident c (with) bed linen & then proceeded to respond to request from CN[NAME] 11/8/18 at 9:45 AM - On the following day, the facility notified F6 (R45's POA) of the 11/7/18 allegation of sexual abuse involving R45. The facility failed to immediately notify F6 of the 11/7/18 allegation of sexual abuse until 27 hours later. 11/8/18 at 10:04 AM - The facility's reporting person, E2 (DON), notified the State Survey Agency of the 11/7/18 allegation of sexual abuse involving R45 (resident) and E7 (accused nurse). The facility reported: .CNA alleged that she saw a .nurse touch a resident inappropriately. CNA stated that resident was lying in bed and that the nurse was bent down to the resident level. The resident was covered with a blanket from waist down and the CNA stated she saw fast movement under the covers. The CNA stated she called the nurses name he pulled his hand out from under the covers. The nurse was interviewed and stated that the resident was lying on her left side and he was attempting to pull down her hipsters to assess her skin when the CNA called his name. A thorough assessment of the resident was completed and no signs of trauma was noted to the peri area. An internal (facility) investigation was conducted and completed and the allegation was found unsubstantiated. 11/8/18 at 1:49 PM - According to the local law enforcement's dispatch records, E1 (NHA) called the local law enforcement agency to report the 11/7/18 allegation of sexual abuse. A police officer, F3, was dispatched to the facility. The facility failed to identify its responsibility to report an allegation of sexual abuse involving a resident until approximately 33 hours after the incident occurred and at the insistence of R45's POA/family. 11/8/18 at 2:04 PM - According to the local law enforcement dispatch records, F3 left the facility. F3 did not write a report after meeting with E1 (NHA) and E2 (DON). 11/9/18 at 5:48 PM - According to the hospital record, R45 was seen and examined by the Emergency Department's Forensic Team two days after the alleged incident. F4 (hospital Forensic Nurse) notified the local law enforcement agency and the State Survey Agency (at 5:53 PM) that R45 was seen and examined for an alleged sexual assault of adult. 11/21/18 after 1 PM - According to email correspondence between F5 (Detective with the local Criminal Investigations Unit) and E1 (NHA) and E2 (DON), F5 met with E1 (NHA) and E2 (DON) regarding the 11/7/18 allegation of sexual abuse of R45. F5 requested documents and facility staff names and contact information. 12/5/18 at 9:43 AM - During an interview, E2 (DON) stated that on 11/8/18, F1 (family member) talked to F6 (POA) and F6 wanted the police to be called. E1 (NHA) stated we can do that. F1 stated that she will inform F6 that you are going to call the police. E1 called the police and an officer came out. We (E1 and E2) met with F3, the officer. F3 asked what happened and E1 explained from the CNA standing at the door what she said she saw, the statements that were written, order for the skin check, nurse did indicate that resident had hipsters on and he was shimmering them up. E1 had to explain what hipsters are to the officer. Officer said I can't take a report on a crime that wasn't committed. So E1 said that the family wanted us to call so can you give some kind of proof that you were here. Officer said they can call and make a complaint if they want and he said they have record of any calls that come in and who is dispatched out. E1 said can you give us something, do you have a card at least. Officer pulled out a blue generic card and wrote his last name on the card. E1 called F2 (R45's family member) and did let him know the police officer did come out, that he didn't take a report but did say they could call for a complaint and E1 gave F2 the number on the blue card and the officer's last name. F2 said fair enough and I will definitely pass this information along. 12/5/18 at 12:51 PM - During a telephone interview, F7 (hospital Forensic Nurse supervisor) stated it was their standard practice that if a dependent resident was evaluated for sexual assault to notify the police detective division and the State Survey Agency, if the resident was in a long-term-care facility. 12/5/18 at 2:10 PM - During an interview, E1 (NHA) stated that there were multiple calls going on with R45's family and they were not documented. E1 stated that she was keeping F2 (R45's family member) informed. E1 stated that F1 (R45's family member) came in and was upset. E1 stated the family asked for the police to be notified and she was unsure of the exact time. E1 stated that F3 (officer) arrived and we (E1 and E2, DON) told him what happened and what we found in our investigation. E1 stated that F3 didn't think there was a reason to take a report. E1 stated that she asked F3 for some kind of documentation from him and received a blue card with his name on it. E1 stated that F5 (Detective) came to the facility and he would notify me of the outcome of the investigation. E1 stated that E7 (accused nurse) was assigned to a different floor from R45. 12/6/18 at 8:45 AM - During an interview, this surveyor showed E4 (Medical Director) a copy of the facility's incident report for the 11/7/18 allegation of sexual abuse, which stated that E4 was notified at 6:30 AM and asked her if she remembered being notified. E4 stated that she was unable to remember exactly when she was notified. E4 stated that she remembered being told by E9 (RN, Supervisor) about the incident by hey did you hear ., but does not remember being officially notified about the incident involving R45. E4 stated that she would have immediately sent R45 to be examined at the hospital, as they are the experts, upon being told that there was an allegation of sexual assault. This surveyor said that E4 ordered R45 to be sent to the hospital's Emergency Department to be examined on Friday, 11/9/18, two days after the incident occurred. E4 stated that it was her practice that if she was notified of an allegation of a sexual assault, she would immediately send the resident to the hospital to be examined by the Forensic Team. 12/6/18 at 9:09 AM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON). This surveyor asked who notified E4 (Medical Director) on 11/7/18 at 6:30 AM, E2 and E3 both said neither one notified E4. 12/12/18 at 10:48 AM - During an interview, F6 (POA) stated that she told F1, a family member, that she wanted a police report. F6 stated that F1 went to the local police station to file a report of the 11/7/18 allegation of sexual abuse and the police told her that she could not file a report, the facility had to file a report. F6 stated that F1 went back to the facility and met with E1 (NHA). 12/14/18 at 11:24 AM - During a follow-up interview, F6 (POA) stated that after she was notified about the allegation on 11/8/18 at 9:45 AM and given the phone number of the State Survey Agency, F6 asked E1 (NHA) if law enforcement was called. F6 stated that E1 told her it would be up to the family. F6 stated she was unable to give an exact time of when this discussion occurred on 11/8/18, but stated it occurred before the facility reported the allegation to the State Survey Agency (on 11/8/18 at 10:04 AM). F6 stated that she was on the phone to the State Survey Agency immediately after being notified of the allegation. F6 stated that she asked a representative of the State Survey Agency if they call the police, and F6 was told no that the facility had to call the police. 12/14/18 at 12:30 PM - During an interview, F1 (R45's family member) stated that she arrived at the facility on 11/8/18 between 11:30 AM and 12 Noon to check on R45 after talking to F6 (POA), who was out of state. F1 stated she went immediately to R45's room. F1 stated that she was greeted by E18 (LPN) and asked if F1 was here about R45's bruise. F1 stated no and she told E18 about the 11/7/18 incident involving R45. F1 stated that E18 was not aware of the allegation of sexual abuse. F1 stated that E1 (NHA), E2 (DON) and E16 (former DON) met her on R45's floor and spoke to her in R45's room. F1 stated that she asked E1, was the police involved? F1 stated that E1 said no, she was going to call the authorities but she didn't after she spoke to everyone and the accused nurse was doing what he was supposed to, a skin check. F1 stated that E1 said that E7 (accused nurse) was nice, worked here for (number) of years and had no incidents with the nurse. F1 stated that she called F6 (POA) and F6 said she wanted a police report. F1 stated it was around lunchtime and no one was around. F1 stated that she drove to the local police station to make a report. F1 was informed by a staff person at the police station that she could not make a report and that the facility would have to make a report. F1 stated that she returned to the facility and met with E1 (NHA). F1 stated that they (F1 and E1) tried calling the phone number given to her at the police station and there was no answer. F1 stated that she had to leave the facility. F1 stated that E1 (NHA) offered to call the police and make the report. F1 stated that E1 told her she would call F1 once she got through to the police. F1 stated that E1 called her after she got through to the police. The facility failed to develop and implement written policies and procedures for covered individuals (included employees) that ensured reporting of suspected crimes occurring in a federally-funded long-term care facility in accordance with section 1150B of the Social Security Act. The facility failed to identify its responsibility to report a suspected crime to the local law enforcement entity after the 11/7/18 allegation of sexual abuse of R45; failed to report a suspected crime not later than 24 hours later; failed to maintain the integrity of any evidence, failed to transfer R45 to the hospital emergency department for a forensic examination, which occurred 2 days after the 11/7/18 allegation of sexual abuse.",2020-09-01
19,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,609,D,1,1,H65F11,"> Based on interview and review of facility and other documentation as indicated, it was determined that for one (R45) out of 54 sampled residents, the facility failed to ensure that an alleged violation involving abuse was reported immediately, but not later than 2 hours after the allegation was made, if the event that caused the allegation involved abuse to the State Survey Agency. For R45, the facility failed to report to the State Survey Agency an allegation of sexual abuse involving R45 and E7, a facility nurse, until 27 hours after the allegation was made. Findings include: Cross refer to F580, F607, F608 and F610 The facility's Abuse policy, effective (MONTH) (YEAR), stated under Procedures .4. Investigation and Reporting .b. Thereafter, the administrator and other appropriate persons at facility shall investigate allegations pursuant to the Incident Investigation Guideline and make reports to appropriate officials as directed by federal and state law .5. Staff Responsibilities .e. Facilities will fully report allegations of abuse .to the Division of Long Term Care Resident Protection/licensing. 11/8/18 - Review of the facility's Incident/Accident Report completed by E2 (DON) stated, but not limited to, the following: - Date of Incident/accident: 11/7/18; - Time of Incident/accident: 6:30 AM. - Description: CNA alleged staff was inappropriately touching resident. 11/8/18 at 10:04 AM - According to the facility's Incident Report submitted to the Delaware Office of Long Term Care Resident Protection, E2 (DON) reported that an allegation of sexual abuse involving R45 and a facility nurse, E7, with an incident date/time as 11/7/18 at 6:30 AM. 12/6/18 at 9:09 AM - Finding was reviewed with E1 (NHA) and E2 (DON). The facility failed to report to the State Survey Agency an allegation of sexual abuse involving R45 and E7, a facility nurse, not later than 2 hours after the allegation of abuse was made. The facility reported the allegation of sexual abuse 27 hours after the allegation was made to the State Survey Agency.",2020-09-01
20,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,610,D,1,1,H65F11,"> Based on interviews and review of facility and other documentation as indicated, it was determined that for one (R45) out of 54 sampled residents, the facility failed to have evidence that an alleged violation was thoroughly investigated. In response to the 11/7/18 allegation of sexual abuse of R45, the facility failed to thoroughly investigate and failed to document the investigation/findings involving R45 and E7 (facility nurse). Findings include: Cross refer to F580, F607, F608 and F609 The facility's Incident/Accident Report of the 11/7/18 allegation of sexual abuse involving R45 and E7(facility nurse)stated: - incident date/time: 11/7/18 at 6:30 AM; - location of incident: R45's room number; - resident's condition before the incident: confused and disoriented; - height of bed: adjustable=yes, down=yes; - describe exactly what happened, why it happened, causes: CNA alleged staff was inappropriately touching resident; - type of injury: none; - name/time of physician notified: E4 (Medical Director) at 6:30 AM; - name/time of resident representative notified: F6 (POA) on 11/8/18 at 9:45 AM; - person seen by physician: no; - person taken to hospital: no; - name/title/contact information of witness: E8 (CNA); - additional comments and/or steps to prevent recurrence: blank; - signature of person preparing report/date: E2 (DON), 11/8/18; - signature of Director of Nursing: E2, 11/8/18; - signature of Medical Director: E4, 11/17/18; - signature of Administrator: E1, 11/8/18 Handwritten statements of E7 (accused nurse), E8 (CNA) and E9 (RN, House Supervisor), all dated 11/7/18, were attached to the Incident/Accident Report. The facility's incident report failed to identify the accused nurse and failed to document the internal investigation and findings. 11/8/18 at 10:04 AM - According to the facility's Incident Report submitted to Delaware's Office of Long Term Care Resident Protection (OLTCRP), the facility stated, Initial and 5 day combined. CNA alleged that she saw a .nurse touch a resident inappropriately. CNA stated that resident was lying in bed and that the nurse was bent down to the resident level. The resident was covered with a blanket from waist down and the CNA stated she saw fast movement under the covers. The CNA stated she called the nurses name he pulled his hand out from under the covers. The nurse was interviewed and stated that the resident was lying on her left side and he was attempting to pull down her hipsters to assess her skin when the CNA called his name. A thorough assessment of the resident was completed and no signs of trauma was noted to the peri area. An internal investigation was conducted and completed and the allegation was found unsubstantiated. The facility's investigation lacked evidence of: - the immediate consultation with E4 (Medical Director) of the allegation of sexual abuse to determine the potential need of physician intervention; - any interviews conducted with facility staff directly involved and other facility staff on duty during and following the 11/7/18 allegation; - assessment of R45's room, the area involved in the allegation, and securing any possible evidence associated with the allegation; - ongoing monitoring of R45 by staff after the 11/7/18 allegation; - reviewing of video surveillance on the floor around the time of the incident; - addressing further questions (why was the bed at the lowest level? were gloves worn during the skin assessment? why was R45's door open to the hallway? what was the lighting in R45's bedroom during the skin assessment?); and - documentation of multiple communications that occurred between facility staff and R45's POA/family. 11/8/18 at 10:04 AM - After the facility completed and unsubstantiated their internal investigation as per the statement submitted to the OLTCRP, the facility did the following: - notified the local law enforcement agency at the POA's insistence of a police report during the afternoon of 11/8/18, approx. 33 hours after the allegation; and - sent R45 to be examined by the hospital's Forensic Team for sexual assault of adult according to hospital records during the afternoon of 11/9/18, two days after the allegation. 12/3/18 at 6:57 PM - During an interview, E26 (CNA) stated that she was assigned to R45 on 11/7/18 during the 7AM - 3PM shift following the incident. E26 stated that she was not told about the incident involving R45 before providing morning care, which included peri-care. There was no evidence that E26 was interviewed at any time regarding any changes in R45's behavior or physical appearance. 12/4/18 at 12:25 PM - During an interview, E18 (LPN) stated that he worked the 7-3PM shift on 11/7/18 following the incident. E18 stated that he was not told about the incident until approached by F1 (R45's family member) on 11/8/18, one day later. There was no evidence that E18 was interviewed at any time regarding any changes in R45's behavior. 12/5/18 at 2:10 PM - During an interview, E1 (NHA) stated that E7 (accused nurse), E8 (CNA) and E9 (RN, House Supervisor) were interviewed and provided handwritten statements. E2 (DON) checked if R45 was scheduled for a skin check and she was. There were multiple calls going on with the family. E1 stated it was not documented. E1 was asked by this surveyor if staff were observing for any changes with R45 after the incident and E1 replied, I can't say 100% sure. 12/5/18 at 4:46 PM - During an interview, this surveyor asked E1 (NHA) about the video surveillance on the floor and if the video on 11/7/18 was available to be viewed. E1 stated that she would ask IT (Information Technology). The facility failed to consider that the video was a potential source for information. 12/6/18 at 8:46 AM - During an interview, this surveyor showed E4 (Medical Director) a copy of the facility's incident report for the 11/7/18 allegation of sexual abuse, which stated that E4 was notified at 6:30 AM and asked her if she remembered being notified. E4 stated that she was unable to remember exactly when she was notified. E4 stated that she remembered being told by E9 (RN, Supervisor) about the incident by hey did you hear ., but does not remember being officially notified about the incident involving R45. E4 stated that she would have immediately sent R45 to be examined at the hospital, as they are the experts, upon being told that there was an allegation of sexual assault. This surveyor said that E4 ordered R45 to be sent to the hospital's Emergency Department to be examined on Friday, 11/9/18, two days after the alleged incident. E4 stated that it was her practice that if she was notified of an allegation of a sexual assault, she would immediately send the resident to the hospital to be examined by the Forensic Team. The facility failed to immediately notify E4 of the 11/7/18 allegation of sexual abuse. 12/6/18 at 8:56 AM - During an interview, E1 (NHA) provided this surveyor with a copy of the surveillance video that was available, however, it did not capture the incident date of 11/7/18. 12/6/18 at 9:09 AM - Findings were discussed with E1 (NHA), E2 (DON) and E3 (ADON). In response to the 11/7/18 allegation of sexual abuse of R45, the facility failed to thoroughly investigate and failed to document the investigation/findings involving R45 and E7 (facility nurse).",2020-09-01
21,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,678,K,1,1,H65F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews and review of other facility documentation as indicated, the facility failed to ensure that the residents' code status (advanced directives) listed on the individually printed Resident Face Sheets, kept in binders in the ground floor reception area and the second floor nurses station, matched the electronic medical record (physician orders [REDACTED]. For 6 (R7, R20, R54, R73, R83, and R96) out of 97 sampled residents, the Resident Face Sheets were inconsistent with the electronic medical records (EMR). For 2 residents (R54 and R96), their electronic medical documents failed to match the Emergency Face Sheets binder located in the ground floor reception area. For 4 residents (R7, R20, R73, and R83), their EMR's failed to match the 2nd Floor Face Sheets binder located in the second floor nurses station. The facility no longer uses charts. Furthermore, interviews with multiple staff revealed inconsistencies regarding where to find the backup information on each resident's code status in the event of an EMR system failure. The facility failed to have a system in place for staff to obtain the residents' accurate code status in the event of an EMR system failure which placed these residents in an immediate jeopardy situation. The IJ was identified on [DATE] at 10:55 AM and was abated on [DATE] at 3:30 PM. Findings include: The facility's Advance Directives policy (undated) stated, Every resident has the right to accept or refuse medical care. Advance Directives communicate your choices of care in the event that you become physically or mentally unable to communicate yourself . specific types of Advance Directives include: 1. Do Not Resuscitate (DNR) which means that if a resident is found not breathing or non-responsive, measures would not be taken to try to start the heart pumping again. 2. Cardio-Pulmonary resuscitation (CPR) is the act of applying force to the chest with the hand, compressing the heart, and breathing into the resident's mouth, filling the lungs with air in an attempt to restart the heart beating again. The facility's Consent Form Code Status policy (undated) stated, At some point . a catastrophic event may occur (for example, the resident's heart or breathing may stop). At that point, the question of whether to begin extraordinary measures to attempt resuscitation arises (for example, cardiopulmonary resuscitation (CPR) attempts, electric shock potentially leading to chest surgery, artificial breathing machines .) Without written instructions to the contrary, these invasive procedures must be attempted . some residents decide either independently or through their substitute Decision maker that they do not wish for resuscitation measures in cases of heart or breathing failure. In those cases the doctor will write a DO NOT RESUSCITATE or 'DNR' order. Once that order is written, no measures will be taken to restart the heart or respirations (no CPR or mechanical ventilation . 1. Review of R7's clinical record revealed: During the initial pool record review, a code status form (scanned into the EMR), dated [DATE], stated that R7 was a no code or DNR and there was a current physician order [REDACTED]. The emergency book in the reception area listed R7's code status as DNR. R7 resided on the 2nd floor. In contrast to the code status form, physician order [REDACTED]. 2. Review of R20's clinical record revealed: During the initial pool record review, a code status form, dated [DATE], stated that R20 was a DNR and there was a current physician order [REDACTED]. The emergency book in the reception area listed R20's code status as DNR. R20 resided on the 2nd floor. In contrast to the code status form, the physician order [REDACTED]. The remainder of resident's were identified when code status' were checked for all residents that did not have record reviews during the initial pool. 3. Review of R73's clinical record revealed: Review of R73's code status form, dated [DATE], stated that R73 was a DNR and there was a physician order, dated [DATE], for DNR in the EMR. The emergency book in the reception area listed R73's code status as DNR. R73 resided on the 2nd floor. In contrast to the code status form, the physician order [REDACTED]. 4. Review of R83's clinical record revealed: Review of R83's code status form, dated [DATE], stated that R83 was a full code and there was a current physician order, dated [DATE] for full code in the EMR. The emergency book in the reception area listed R73's code status as full code. R83 resided on the 2nd floor. In contrast to the code status form, the physician order [REDACTED]. 5. Review of R54's clinical record revealed: Review of R54's code status form, dated [DATE], stated that R54 was a no code or DNR. There was a current physician order [REDACTED]. R54 resided on the 3rd floor of the facility. In contrast to the code status form and the physician's orders [REDACTED]. 6. Review of R96's clinical record revealed: Review of R96's code status form, dated [DATE], stated that R96 was a no code or DNR. There was a current physician order [REDACTED]. The 2nd floor face sheet binder listed R96's code status as DNR. R96 resided on the 2nd floor. In contrast to the code status form and the physician's orders [REDACTED]. [DATE] 9:16 AM - E2 (DON) was interviewed on the 2nd floor. E2 stated that resident code status was in the EMR. When asked how staff would obtain a resident's code status if the EMR was down, E2 stated staff would call the ground floor receptionist office where a book was kept with everyone's face sheet and code status. E2 stated there was someone in the reception area 24 hours a day. E2 stated there was not a code book on the 2nd floor. [DATE] 9:50 AM - E20 (reception clerk) was interviewed. E20 stated that someone was at the reception desk from 8 AM to 8 PM, however, the office was not locked when there was no one at the desk. [DATE] 11:45 AM - E13 (LPN on 2nd floor) was interviewed. When E13 was asked how she would obtain a resident's code status if the EMR was down, E13 stated that when the receptionist was there, she'd call the receptionist (on the ground floor) to obtain a resident's code status (have binder of all resident's face sheets listing code status' in the receptionist office). E13 stated on night shift, staff use the 2nd floor Face Sheets binder that's kept in the 2nd floor nurses station. The emergency book in the reception area contained face sheets for each resident. [DATE] 4:47 PM - E19 (LPN) was interviewed on the third floor. When asked how she would obtain a resident's code status if the EMR was down, E19 stated she would ask someone who was familiar with the resident for the code status. E19 stated there was no code status binder on the third floor. [DATE] 10:55 AM - Findings were reviewed with E1 (NHA) and E2 (DON) and they were advised that an IJ was identified when 6 current residents were found to have inconsistent advance directives related to their code status'. [DATE] 3:15 PM - Review of the 2nd floor binder and the Emergency book at the receptionist office verified that the incorrect code status' for the 6 residents were corrected. Additionally, the survey team interviewed 2 nurses from the ,[DATE] shift for each floor and confirmed they were aware of where and how to obtain current code status' for residents. [DATE] 3:30 PM - At this time, we also received an approved plan of correction that included: correction of code status' on identified residents after a whole facility audit of consent forms, orders and face sheets, the facility policy on code status was updated, all new residents and residents with code status changes are to be discussed at High Risk Meetings Monday- Fridays, in-services are to be done including: use of Unit Book/Front office book to verify code status in event of power outage, on hire, a competency verification regarding code status and contingency plan will include nurses, activity, admissions, social service and rehabilitation staff, and annual training will be updated to include review of the policy and process. Additionally, shift report will include communication related to new and/or changes in code status and monitoring will be done on the above measures. The IJ was abated at this time. The facility failed to maintain consistent documentation of residents' code status leading to the possibility that the incorrect code status could be implemented during an emergency event resulting in immediate jeopardy to the residents.",2020-09-01
22,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,684,G,1,1,H65F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews, review of facility documentation and hospital records, it was determined that the facility failed to ensure that treatment and services were provided in accordance with professional standards of practice for two (R85 and R99) out of 54 sampled residents. For R85, the facility failed to ensure that treatment and services were provided in accordance with professional standards of practice. The facility failed to have lab (laboratory) results available for physician review and failed to ensure that the physician was notified of abnormal lab results per facility policy. The facility failed to ensure that an H&H ordered to be drawn on 9/21/18 was completed. Additionally, the facility failed to identify that on 9/27/18, R85's episode of chest pain and shortness of breath could be related to low Hgb and failed to notify the physician when R85 exhibited these symptoms. This resulted in harm to R85 when she had to be emergently sent to the ER and subsequently hospitalized requiring emergency transfusion of 2 Units of PRBCs. For R99, the facility failed to ensure that the physician was notified when R99 refused [MEDICATION NAME] doses resulting in lost opportunities for the physician to adjust medication if he/she desired. The facility failed to notify the physician in a timely manner when R99 experienced a significant change in mental status and was deemed unsafe swallowing medications. Findings include: The facility policy titled, Laboratory and Radiologic Services, dated (MONTH) (YEAR), stated, Abnormal labs and x-rays are called to the charge nurse, who in turn, will notify the physician of the results. Physician notification will be documented in the electronic medical record. The facility policy titled, Physician-Notification of Abnormal Test Results, effective (MONTH) (YEAR), stated, .2. Results of laboratory .tests shall be reported in writing to the resident's attending physician from the testing source. 3. Abnormal results will be called and/or faxed to the physician upon receipt. Normal and abnormal test results provided to the facility will not be filed in the resident's chart before the physician reviews and signs the printed results. The results can be placed in a doctor's box for review and signature. The attending physician will initial and date the results when reviewed .5. The Unit Manager/Charge Nurse/Nurse Supervisor receiving abnormal results shall be responsible for notifying the physician of such test results .The nurse will enter date and time, and sign the report as reported to the physician. 6. Signed and dated reports of all diagnostic tests shall be made a part of the resident's electronic medical record. The facility policy titled, Provider Notification of Resident Change in Medical Condition, effective (MONTH) (YEAR), stated, .staff communicates changes in a resident's medical condition to providers in a timely and accurate manner .Changes in Resident Condition Staff will notify the provider .of: .Significant change in condition in physical, mental, or psychosocial status (i.e., deterioration in mental health, mental, or psychosocial status in either life threatening or clinical components) . 1. Review of R85's clinical record revealed: 8/7/16 - R85 was admitted to the facility with [DIAGNOSES REDACTED]. 7/14/17 - R85 was prescribed the medication Xarelto 20 mg daily, used to prevent blood clots in individuals with [MEDICAL CONDITION]. 8/28/17 - R85's care plan was updated and stated that she had the potential for bleeding due to anticoagulation therapy. Interventions included to monitor lab work as ordered, and to assess for signs of abnormal bleeding. 1/29/18 - A lab report revealed R85's hemoglobin (Hgb) was 12.6 (Normal range: 11.8-14.8). 8/17/18 - There was a physician's orders [REDACTED]. There was no documentation in the EMR signifying whether R85 was having any signs or symptoms of bleeding. 8/19/18 - On the day shift, the TAR documented R85 had a guaiac positive stool. 8/20/18 - On the evening shift, the TAR documented R85 had a guaiac positive stool. 8/20/18 - The lab results for the H&H revealed R85's Hgb was 10.5. This was a decrease of 2.1 points when compared to the 1/29/18 result of 12.6. 8/21/18 at 4:25 PM- A physician's progress note stated R85 was seen for [MEDICAL CONDITION] with 2 out of 3 positive stool guaiac tests. The physician noted that R85 had weight loss, never had a colonoscopy, and had a first relative with a [DIAGNOSES REDACTED]. The plan was to consult a GI physician for EGD and colonoscopy, repeat a CBC, check iron study, vitamin B12, and folic acid in 1 week. 8/21/18 - Review of the EMR revealed that R85 was scheduled for a GI consult on 10/1/18 at 2:00 PM for [MEDICAL CONDITION] with positive guaiac stools and a family history of [MEDICAL CONDITION]. 8/22/18 at 3:42 PM - A nurse's progress note stated that R85 had a third guaiac positive stool, and that the physician would review on the next rounds. R85's clinical record lacked evidence that the physician reviewed her chart following this finding. 8/29/18 - The TAR revealed a signature signifying that R85 had a CBC, iron study, vitamin B12 level and folic acid drawn. Review of the EMR revealed there were no results scanned into the record for these blood tests. Upon surveyor request on 12/4/18, the facility provided the blood test results after obtaining them via fax from the lab. Results of R85's Hgb revealed the level was 9.8, a further decrease from the 10/5/18 Hgb result of 10.5 and the iron level was 24 (normal range 35-165). There was no documented evidence stating that the physician was notified of the results, nor was there any evidence showing that the physician had reviewed the results (no physician dated and initialed copy). 9/13/18 - A physician's orders [REDACTED]. 9/15/18 - Lab results revealed R85's Hgb was 7.9, again signifying a decrease from 8/29/18 when it was 9.8. There was no documentation that the physician was notified of this abnormal result per facility policy. 9/17/18 at 12:18 PM - A physician's progress note stated that R85's labs were reviewed and acknowledged that the Hgb was 7.9. The note stated that R85 was asymptomatic (no symptoms), had a prior history of gastritis, and had no abdominal pain or dark/tarry stools. The note stated the plan was to guaiac stools, check CBC and monitor for any GI bleeding. 9/17/18 - A physician's orders [REDACTED]. 9/19/18 - The CBC result revealed R85's Hgb was 7.4, down from 7.9 on 9/17/18. 9/19/18 11:15 PM - A nurse's progress note stated R85's Hgb level was 7.4 and that the NP was notified. The note stated a new order was received to check an H&H on Friday (9/21/18) and that the order was input. 9/21/18 - Review of the TAR revealed it was initialed by nursing staff signifying that the H&H was completed. Review of the Lab Form revealed that nursing staff had written in that R85 was due for an H&H and that it was signed off and dated as completed by the lab technician on 9/21/18. There were no results found for the 9/21/18 H&H. The was no evidence that the facility followed up with the lab to determine why there were no results sent to the facility. 9/22/18 - During the day shift, the TAR documented R85 had a guaiac positive stool. There was no documented evidence that the physician was notified. 9/25/18 - During the day shift, the TAR documented R85 had a guaiac positive stool. There was no documented evidence that the physician was notified. 9/27/18 2:10 PM - A nurse's progress note stated that during lunch time R85 complained of shortness of breath and chest pain. The note stated sublingual [MEDICATION NAME] was administered along with a nebulizer (medicated breathing treatment) and after 5 minutes the resident stated she felt better. There was no evidence that the nursing staff considered these symptoms could be related to R85's low Hgb and there was no evidence that the episode of chest pain and shortness of breath was reported to the physician. 9/28/18 2:27 PM - A nurse's progress note stated that while out at a cardiology appointment, the facility was notified that R85 had a large bloody bowel movement and was being sent to the ER for further evaluation. Review of hospital records revealed that on arrival to the ER, R85's Hgb was 6.7. R85 required transfusion of 2 units of PRBC, was admitted to the hospital and was found during a colonoscopy to have multiple polyps. 12/4/18 at 1:00 PM - During an interview, E2 (DON) stated that the process was for the facility to receive lab results via fax. The evening shift supervisor reviews the lab results and ensures that the physician is notified of any abnormalities. E2 stated it would have been the responsibility of the evening supervisor to inquire about the missing H&H results on 9/21/18. 12/6/18 approximately 8:10 AM - An interview was conducted with E1 (NHA), E2, E3 (ADON) and E4 (Medical Director). E4 stated that the current standard of practice was to transfuse when the Hgb was below 7 and the patient was symptomatic. E4 stated that previously the standard was to transfuse when the Hgb was below 8. E4 stated the facility was monitoring for symptoms and/or if R85's blood pressure dropped the resident would have been sent out to the ER. It was discussed with E4 that the facility failed to identify that results from the 9/21/18 H&H were never received and that the Hgb level might have decreased further. E4 nodded her head. The facility failed to ensure that treatment and services were provided in accordance with professional standards of practice for R85. The facility failed to document what precipitated R85's 8/17/18 H&H and stool guaiac orders, and failed to have lab results available for physician review. The facility failed to ensure that the physician was notified of abnormal lab results per facility policy, failed to document that the physician was notified of an abnormal lab result per facility policy, and failed to provide evidence that an H&H ordered for R85 on 9/21/18 was completed. Additionally, the facility failed to identify that on 9/27/18, R85's episode of chest pain and shortness of breath might be related to the low Hgb and failed to notify the physician when R85 exhibited these symptoms. This resulted in harm to R85 when she had to be emergently sent to the ER and subsequently hospitalized requiring emergency transfusion of 2 Units of PRBCs. Findings were reviewed with E2 (DON) on 12/4/18 at 1:00 PM. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA). 2. Review of R99's EMR revealed the following: 5/17/18 - R99 was readmitted to the facility post hospitalization with [DIAGNOSES REDACTED]. 6/16/18 - A quarterly MDS assessment stated R99 was alert and able to make decisions independently. 9/5/18 - A physician's orders [REDACTED]. 9/7/18 - The ammonia level results revealed a value of 93 (normal range: 0-60). 9/7/18 - A physician's orders [REDACTED]. The order further stated to administer [MEDICATION NAME] 45 mls three times a day and [MEDICATION NAME] 30 mls once daily (a total of 4 doses per day) x 3 days and to obtain an ammonia level on 9/14/18. 9/8/18 through 9/10/18 - Review of the MAR indicated [REDACTED] - 9/8/18 - all four doses of [MEDICATION NAME] were administered; - 9/9/18 - two doses of [MEDICATION NAME] were refused by R99 and two doses were administered; - 9/10/18 - one dose of [MEDICATION NAME] not administered due to refusal and one dose documented R99 was LOA (Leave of Absence). Review of the EMR lacked evidence that the facility attempted to administer the missed dose when R99 returned from the LO[NAME] Additionally, there was no documented evidence that the facility notified the physician when R99 refused doses. 9/11/18 - Review of the EMR revealed that the previous orders for [MEDICATION NAME] were resumed (30 mls 3 times a day and 45 mls once a day). 9/11/18 through 9/14/18 - Review of the MAR indicated [REDACTED] - 9/11/18 - all four doses administered; - 9/12/18 - all four doses administered; - 9/13/18 - one dose of [MEDICATION NAME] refused and no evidence of physician notification; - 9/14/18 - all doses administered. 9/14/18 - Review of laboratory results revealed that the ammonia level, ordered on [DATE], was not drawn. Review of the 24 Hour Report for 9/8/18 lacked evidence that a 24 hour chart check was completed. 9/14/18 3:59 pm - A nurse's progress note stated the resident was due for an ammonia level, but the draw was not completed because the test was not ordered. The progress note stated the lab was called and rescheduled the ammonia level for 9/15/18. 9/15/18 - Review of the Lab Form revealed that although an ammonia level was entered for R99, it was not signed off by the lab technician as completed. A notation stated Must be called in for Monday 9/17/18. 9/15/18 - Review of the MAR indicated [REDACTED]. There was no evidence the facility attempted to administer the [MEDICATION NAME] upon R99's return from LOA and there was no evidence of physician notification. 9/16/18 - A quarterly MDS assessment stated R99 was alert and able to make decisions independently. 9/16/18 - Review of the MAR indicated [REDACTED]. 9/17/18 - Review of the MAR indicated [REDACTED]. 9/17/18 - An ammonia level was drawn (ordered to be drawn on 9/14/18) with a value of 133. 9/17/18 8:36 pm - A nurse's progress note stated R99's ammonia level was 133, the physician was notified, there were no new orders, and that the physician would review when in the facility. 9/18/18 - Review of the MAR indicated [REDACTED]. 9/19/18 - Review of physician's orders [REDACTED]. However, [MEDICATION NAME] orders were then changed back to the prior doses. Further review revealed that the consultant pharmacist completed a medication review to determine if R99's medications were causing an increase in the ammonia level. There were no irregularities found by the pharmacist. 9/19/18 - Review of the MAR indicated [REDACTED]. The 7 PM dose was not administered and documented in the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Despite this change in R99's mental status, the facility failed to notify the physician. 9/19/18 3 PM to 11 PM shift - Review revealed there were no nurse's progress notes despite the fact that R99 was too lethargic to be given oral medications. 9/20/18 - The MAR indicated [REDACTED]. 9/20/18 3:23 AM - A nurse's progress note stated to send the resident to the emergency room for further evaluation and management. 9/20/18 3:39 AM - A nurse's progress note stated, Resident noted for increase (sic) lethargy .(Nurse Practitioner) made aware at 3:00am with new order to send resident to hospital for further evaluation and management .Call placed to 911. Transferred to the hospital at 3:30am. Review of the Resident CNA Documentation Record from 9/1/18 through 9/19/18 revealed a total of 10 days on which R99 had no bowel movements. Although R99 was administered a [MEDICATION NAME] suppository on 9/19/18 at 3:25 PM, there was no evidence that it was effective. Review of progress notes lacked evidence of the physician having been notified of R99's lack of bowel movements as was desired with the administration of [MEDICATION NAME]. 12/3/18 12:00 PM - During an interview, E2 (DON) provided a 24 Hour Report which staff are to pull/print to verify and check accuracy of any new orders written in the preceding 24 hours (24 hour chart check). The 24 Hour Report revealed that on 9/8/18, staff failed pull the report to complete the 24 hour chart check. Had the 24 hour chart check been completed it would have identified that the ammonia level ordered on [DATE] to be completed on 9/14/18 was not entered for a lab draw. 12/3/18 3:35 PM - In an interview, E10 (RN) confirmed she was assigned to R99 on 9/19/18 on the day shift. E10 stated that she recalled the resident was quieter and more drowsy than usual. E10 also stated she recalls R99 attended a care plan meeting that day. 12/3/18 5:05 PM - During an interview, E11 (RN) confirmed he was R99's assigned nurse on 9/19/18 on the evening shift. E11 stated that it was evident (R99) was declining. E11 stated the resident had been having intermittent confusion and lethargy over the past several weeks. E11 stated R99 was lethargic but arousable, but he did not feel it was a good idea to give anything by mouth. E11 stated he did not feel there was a need to notify the physician and that vital signs (blood pressure, pulse, respirations, temperature) were within normal range. 12/5/18 9:24 AM - In an interview, E12 confirmed she was R99's assigned nurse on 9/20/18 on the night shift. E12 stated that working night shift most residents are asleep and at times it is difficult to determine if there is a change in mental status. E12 stated she started her rounds at approximately 10:45 PM and R99 was asleep. At 12 AM, E12 stated she went in to administer an [MEDICATION NAME] dose and found R99 lethargic, which was not the residents' usual baseline. E12 stated she had been told in change of shift report that R99's ammonia level was elevated and that the resident was lethargic. E12 stated she held the 12 AM [MEDICATION NAME] dose because she felt it was not safe to give it due to the lethargy. E12 stated she went in again around 3 AM and woke R99, who opened her eyes and then promptly closed them. E12 stated this was not R99's norm, as she would usually smile at her. E12 stated she then called the physician and the resident was sent to the hospital. 12/5/18 approximately 8:10 AM - An interview was conducted with E1 (NHA), E2 (DON), E3 (ADON), and E4 (Medical Director). E4 stated that it is difficult to increase a resident's medication ([MEDICATION NAME]) if they are refusing doses. E4 stated that if resident was refusing doses she would not necessarily have increased the dose. E4 was informed that there was no evidence that the physician was notified about the medication refusals, that ordered labs were not completed timely and that when a change in mental status occurred there was a delay in informing the physician, E4 nodded her head. The facility failed to ensure that the physician was notified when R99 refused [MEDICATION NAME] doses resulting in lost opportunities for the physician to adjust medication if he/she desired. The facility failed to notify the physician in a timely manner when R99 experienced a significant change in mental status and was deemed unsafe swallowing medications. At least an 8 hour delay occurred before the physician was notified and R99 was sent to the emergency room for evaluation. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA).",2020-09-01
23,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,689,D,1,1,H65F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, it was determined that for two (R15 and R83) out of 54 sampled residents, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision to prevent accidents. The facility failed to ensure that R83's physician-ordered and care planned interventions were in place to prevent an accident on 11/17/18. For R15, the facility failed to provide adequate supervision to prevent R15, who has a history of non-Alzheimer's dementia with behavior disturbance, pseudobulbar affect, generalized anxiety disorder and major [MEDICAL CONDITION] from emotionally, verbally, and physically abusing R52 and from wandering into other residents rooms (R52 and R31) placing these residents (as well as others) at risk for abuse from R15. Findings include: 1. Review of R83's clinical record and facility documents revealed: R83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R83's care plan revealed that starting on 10/20/17, R83 had a high predictive factor for falls. Interventions included to have fall mats on the sides of R83's bed when he was in bed, and to keep his bed in a low position. physician's orders [REDACTED]. Review of R83's Fall History report revealed that on 11/17/18 at 11:10 PM, R83 fell when attempting to sit on the side of his bed. Interventions that were in use at the time of the fall were listed and did not include fall mats or having R83's bed in a low position. A progress note dated 11/18/18 at 12:05 AM stated, R83 had an unwitnessed fall that evening. The note stated that R83 stated that he was attempting to reposition himself from a lying to a sitting position with his feet resting on the floor, however, the bed was in a raised position. The resident did not realize the bed was raised and fell off the bed and onto the floor. R83 was found on the floor in a prone position on his right side, and presented with a right flank hematoma/abrasion and a right knee abrasion. During an interview on 12/5/18 at 2:32 PM, R83 stated that on 11/17/18 he fell because his bed was usually low to the ground, but that day it was high off the ground, and he was sitting himself up and went to push his feet on the ground and fell off his bed on to the hard floor. R83 stated that his fall mat was not on the floor by his bed and he hit his head and back on the floor and his bedside table. The facility failed to ensure that R83's physician-ordered and care planned interventions were in place to prevent an accident on 11/17/18. Findings were reviewed with E2 on 12/5/18 at 4:30 PM. 2. Cross refer F600, example #1 and #2 Review of R15's clinical record revealed the following: R15 was admitted to the facility in (YEAR). R15 has [DIAGNOSES REDACTED]. R15 resides on the 2nd floor of the facility. 9/7/16 - R15's dementia/cognitive status care plan, stated R15 had increased confusion per baseline with short and long-term memory deficits, decreased communication abilities, moderate impaired cognitive skills for daily decision making due to dementia. Requires cues/supervision. 11/13/17 - R15's behavior management care plan: physical aggression, stated, has become physically aggressive towards staff and other residents due to agitation and/or false beliefs. The goal for this care plan was will demonstrate physical aggression less than 10 times per week over the next 90 days. Interventions included: provide [MEDICAL CONDITION] medications as ordered, psychiatry consult as needed, redirect resident to refrain from physical aggression and consequences for such behavior (i.e., could injure herself or others), identify trigger of increased agitation and ensure resident this will not continue, and attempt to guide resident away from triggering the environment; attempts to distract resident with another activity or discussion. 12/3/17 counseling note by E22 (Psychologist) - . I also suggest a trial period of introducing her (R15) to activities on the 3rd floor (locked dementia unit) to see if she responds well to that environment and, if so, a move to that unit may be considered. 12/11/17 activities note - . During this review period activities has taken (R15) upstairs to 3rd floor for activities, she has really enjoyed being around all the residents on that unit. There are days when she sees us and asks if we are ready to take her upstairs! 1/4/18 10:11 PM nursing progress note - Continues to be confused and needs constant redirection and cueing during this shift. 1/5/18 counseling note by E22 - R15 would redirect briefly, but then persisted in returning to her irritation and desire to go home. Judgement: poor, Insight: poor. Activities report that R15 enjoys going to the 3rd floor and continues to participate in activities there. 2/3/18 counseling note by E22 - R15's confusion and agitation increases as the day goes on. At times, she is lethargic and weepy and at other times she is tearfully agitated and irritated. Redirection is difficult at these times as her confusion is high and persistent. Activities department reported that R15 enjoyed going to the 3rd floor. 2/9/18 counseling note by E22 (Psychologist) - . Staff reports that she does positively respond to visits to the 3rd floor, but has difficulty transitioning back to 2nd floor. I suggest asking a 3rd floor resident to accompany staff and R15 as she returns to her 2nd floor room, thus reducing R15's impression that she is being taken away from the activities and people with whom she's comfortable. 2/17/18 counseling note by E22 - I discussed (R15's) activities on the 3rd floor with (name of former activity director) who explained that (R15) loved participating in activities on the 3rd floor. However, when she returned to her room on the 2nd floor, (R15) became tearful and agitated. Staff are exploring with (R15's) family the possibility of moving her to 3rd floor when a bed is available. 2/27/18 nursing progress note - R15 up until 2:00 AM ambulating on the unit with a rolling walker. Physically and verbally abusive towards staff. Redirected, snack given and toileted without improvement. [MEDICATION NAME] (antianxiety medication) given with positive result. Although there was evidence of attempts to redirect, there was a lack of evidence as to what supervision took place when measures were ineffective and R15 was ambulating in the halls until 2:00 AM. 3/1/18 2:29 AM nursing progress note - R15 has been walking the halls, very confused and disoriented; crying on and off. [MEDICATION NAME] given earlier in shift with no results. Attempted comforting resident. Currently sitting out at nurses station. Will closely monitor. 3/9/18 activity note - R15 enjoys going up to 3rd floor for activities and socialization, getting her to come back down can be challenging as she would prefer to stay upstairs. When she is on the 3rd floor she shines and is very happy and content, when she (sic) bring her back down to 2nd floor she is unhappy and can be very challenging at times. 3/9/18 11:24 PM nursing progress note - R15 followed this writer down the hall during med (medication) pass. (R15) started to enter a partial shut door to one of the other residents room while medication was given. Other resident became upset and said, 'shut the door, don't let that woman in my room'. The door was shut and (R15) started to bang on the door and yell. This writer opened the door which caused the resident that lives in that room to get up and confront (R15) by saying 'this is my room, I don't want you in here.' (R15 became agitated and started to yell at the other resident . Two other resident (sic) came out of there (sic) room and made comments about (R15's) behavior and how disrupting it is to them. 3/10/18 counseling note by E22 - Staff reports that she (R15) can also be irritated and angry at times. When in a calm mood, (R15) is cooperative and pleasant. When not, she can be tearful and anxious. 3/13/18 social services note by E6 - Director of Social Services (DOSS) spoke with (name of daughter- F8) to discuss the possibility of resident moving to memory care unit (3rd floor) when a room becomes available. (F8) to visit the unit with her mom a few times and will get back to DOSS with a decision. There was a lack of evidence in the EMR as to how the facility was providing adequate supervision to R15, whom the facility believed would benefit from residing on the 3rd floor, a locked dementia unit that provides a higher level of supervision than the other floors. 3/19/18 9:47 PM nursing progress note - R15 became anxious and agitated. She walked behind nursing station and approached E23 (physician). R15 was asking E23 about the bus and the train. While E23 was speaking to the resident, R15 started to yell at E23 and raised her arm in a fist to strike E23. It was unclear who was supervising R15 or what measures were in place to deter R15 from approaching E23 in her agitated state. 3/22/18 3:31 PM nursing progress note - R15 noted kicking, hitting and yelling to other resident and staff. She also pore (sic) water to (sic) residents and staff . refused to take [MEDICATION NAME] for anxiety. 3/22/18 3:47 PM nursing progress note - R15 came out of room and began yelling at other residents. Stay away from me you [***] ! Resident attempted to hit 2 other resident's while screaming at them. Staff attempted to redirect R15 and she turned around and hit 3 staff members on the arm. R15 was making false accusations towards staff and began yelling Leave me alone! R15 was unable to be redirected and refused antianxiety medication. Spoke to E4 (Medical Director) who gave verbal order for [MEDICATION NAME] gel topically every 6 hours as needed for anxiety. E4 also gave an order to send R15 to Wilmington Hospital (has psychiatric unit) if R15 is a harm to herself or anyone else. There was no evidence in R15's EMR that she was sent to Wilmington Hospital. 3/23/18 - R15's care plan for social services: verbal aggression stated R15 presents with socially inappropriate behavior aeb yelling, cursing towards staff and other residents related to agitation and/or false beliefs. The care plan goal was will exhibit behaviors no more than 25 x per week . Interventions include: identify triggers of increased agitation and ensure triggering event will not continue to occur, attempt to guide resident away from triggering environment, attempt to distract resident with another activity or discussion, and use therapeutic lies when she starts getting anxious/agitated with her usual worries i.e. The food is already paid for by your daughter or Wait for her to come get you, etc. 3/29/18 11:22 PM nursing progress note - R15 was going up and down halls entering other residents rooms asking for help because of a note she claims someone gave her that she believes is a ransom note. R15 showed staff the piece of paper which had her name and room number on it. R15 was crying and appeared afraid. R15 was taken to her room and started to calm down and become less agitated after [MEDICATION NAME] gel. There was a lack of evidence that R15 was being properly supervised as she was entering other residents rooms. 4/1/18 2:52 PM nursing progress note - R15 was angrily yelling while sitting in nurses station when grandaughter walked in with flowers. R15 began yelling at grandaughter and smacked her in the face. Writer attempted to redirect again and explain that her grandaughter just wanted to give her flowers, but she continued to yell at writer and attempted to hit another resident who was sitting nearby. 4/4/18 11;30 PM nursing progress note - R15 got up from the nurse's station and started heading down the wrong hall towards her room. Attempted to redirect R15 and she got agitated and started yelling at staff and other residents. 4/12/18 9:44 PM nursing progress note - R15 became agitated after dinner. She was pacing the hall saying, I'm lost, I can't find my Mommy. R15 was going in and out of other residents rooms crying for help. Was redirected several times without success. R15 was given [MEDICATION NAME] gel with positive results. There was a lack of evidence that R15 was being properly supervised as she was entering other residents rooms. 4/19/18 progress note by E4 (Medical Director) - Still needs [MEDICATION NAME] gel. Alert and oriented x 1 (to person), calm, able to make short conversation, labile mood, suddenly cried, easily distracted. 5/26/18 counseling note by E22 (psychologist) - R15 was tearful and anxious, reporting that she had no money and no home. I sat with her, reassured her as I redirected her. This often takes some time as (R15) can be persistent in her delusion of poverty and homelessness. 6/5/18 activity note - R15 maintains her established routine on unit and in the facility. Prefers 1:1 time. She requires encouragement to participate in most all activities. 6/20/18 progress note by E23 (physician) - R15 is having aggressive behaviors towards staff. PRN (as needed) [MEDICATION NAME] is no longer effective. Consult psych for need for possible antipsychotics. Will start Trazadone (antidepressant and used as mood stabilizer) low dose twice a day. Discussed with E4 who is in agreement. 6/23/18 counseling note by E22 - E22 met with F8 (R15's daughter) and discussed her concerns about her mother's current condition and the ongoing progression of her disease. F8 is very aware of her mother's confusion and continued decline in mental status. We discussed the possibility of a 3rd floor placement for her mother, but F8 is not ready to agree to that , stating that she is concerned about an increase in R15's confusion in changing her routine and her surroundings. 6/26/18 nursing progress note - R15 required [MEDICATION NAME] gel x 2, due to aggressive behavior and yelling and screaming at staff. R15 was yelling at staff to get her mom, also that staff took her baby. Suggested resident have a snack and a drink as a distraction to aggressive behavior with no help. R15 was also trying to leave floor trying to push the doors open. R15 was up all 11-7, walking up and down hallways. R15 required one to one attention for the whole shift. 7/18/18 nursing progress note - E24 (physician) was in to assess R15 and reviewed prn [MEDICATION NAME] gel usage. R15 frequently has episodes of anxiety and agitation towards staff and other residents. 8/29/18 - Review of R15's annual MDS assessment, coded R15 as a 3 for cognition (severly impaired- never/rarely made decisions). For mood, R15 was coded as feeling down, depressed or hopeless for 12-14 days (out of a 14 day review period). For behaviors, R15 was coded as having physical symptoms (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) directed towards others for 1-3 days (out of a 7 day review period and verbal symptoms (e.g., threatening others, screaming at others and cursing at others) directed towards others for 4-6 days. R15's behaviors were coded as improved compared to the prior MDS assessment. 10/25/18 nursing progress note - Writer noted R15 yelling at another resident and at staff. R15 appeared very angry and agitated. R15 responded well at first while [MEDICATION NAME] gel was applied, but then became angry at the nurse and started to swing at and punch the nurse. 10/28/18 2:08 PM counseling note by E22 (psychologist) - Writer assisted R15 as she was trying to enter another resident's room as the CNA was providing care. R15 was angry and tearful, saying, They don't like me and I don't know why. Writer redirected R15 back to her room and stayed with her. R15 persisted in her anger and her sadness. There was a lack of evidence that facility staff was supervising R15 when she tried to enter another residents room as care was being provided, rather than the psychologist. October (YEAR) - The Behavioral Monitoring Form, completed by CNA's identified the following behaviors: - physical aggression - 98 occurrences; - verbal aggression - 170 occurrences; - false beliefs - 88 occurrences. 11/25/18 5:05 PM nursing progress note - At approximately 1530 (3:30 PM), resident noted standing in lounge area, agitated while shouting 'you stole my money' headed towards another resident. CNA approached (R15) . calm therapeutic manner, however, (R15) continued to be verbally aggressive (towards other resident- R52) and quickly slapped (R52's) left arm. Attempts to redirect made, (R15) escorted to her room . Nursing staff to monitor . There was a lack of evidence that staff were supervising R15 when she was able to strike another resident. 11/28/18 12:05 PM - R15's daughter (F8) was interviewed. F8 stated that her mother has been agitated with other residents and she was called last week by the facility and notified that words were exchanged and R15 thought someone stole her money. F8 stated that facility staff had brought up the idea of R15 going to the 3rd floor, When asked if she had viewed the 3rd floor, F8 stated yes, it's nice, however, she was only willing to let her mother go upstairs to the 3rd floor if her room faced the street where the front entrance of the facility was. F8 confirmed that she was R15's power of attorney (decision-maker). November (YEAR) - Behavioral Monitoring Form, completed by CNA's identified the following behaviors: - physical aggression - 91 occurrences; - verbal aggression - 137 occurrences; - false beliefs - 23 occurrences. Numerous observations of R15 were made on the following dates: 11/29/18, 11/30/18, 12/3/18, 12/4/18, and 12/5/18. Most of the observations took place on the 7-3 shift and R15 was asleep several times. For all of the observations, R15 was not engaged in any activities other than watching tv in her room. The following observations revealed: 12/3/18 10:55 AM - R15 was dressed and sitting in a chair in her room. When the surveyor entered the room, R15 seemed anxious and asked, Where's (females first name? The surveyor stated that she had not seen her yet and that I just came by to say hi. R15 then smiled and seemed fine. 12/3/18 3:45 PM - R15 was sitting in a chair in her room and became tearful when the surveyor entered her room stating that her legs hurt. A few seconds later, R15 stated, I can't walk (untrue) because of my hips. The surveyor asked R15 if she needed pain medication and R15 said no. 12/5/18 4:32 PM - R15 was ambulating with her walker and entered R52's room (in same hall) and a few seconds later she came back out. R52 was not in her room at the time. R15 was anxious with a shaky voice stating that she needed to go to the bathroom, then a second or 2 later saying that she stepped in water with her left foot. There was no staff in the hall, so the surveyor was walking R15 down the hall towards her room when a CNA came down the hall from another residents room. The CNA stated that she was busy, but finally agreed to take R15 to her room after the situation was explained to her. 12/6/18 12:55 PM - Findings were reviewed with E2 (DON) and advised there was a lack of supervision related to abuse of R52 and wandering into R31's and R52's rooms. 12/6/18 2:05 PM - E17 (CNA) was interviewed. E17 was assigned to the rooms on the other side of the hall where R52 and R15 reside. E17 stated she's worked in the facility for 4 years with 3 years being in this hall and she confirmed that she's very familiar with R15. E17 stated she works both day and evening shifts. When asked about R15, E17 stated that her moods are up and down, that she usually sleeps during the day and is agitated in the evenings. E17 stated that staff try to reassure R15 that she's in the right place and is being taken care of, however, she is difficult to redirect at times, and sometimes R15 hits staff and other residents. E17 further stated that R15 gets upset when she comes out of her room naked or without shoes and staff and other residents tell her what to do, she becomes angry. When asked if R15 has hit her, E17 stated no, but stated that R15 has threatened to hit her, has been verbally abusive, including the use of racial slurs. E17 also stated that she has observed R15 wandering into other residents rooms and gave R31's room as an example. Although the facility has provided ongoing psychiatric services to R15 and made efforts since 12/3/17 (there may be other efforts prior to my review period) with R15's family towards placement on the 3rd floor, a locked dementia unit, R15 remained on the 2nd floor as of the exit date of 12/6/18. The facility failed to provide adequate supervision to prevent R15, who has a history of non-Alzheimer's dementia with behavior disturbance, pseudobulbar affect, generalized anxiety disorder and major [MEDICAL CONDITION] from emotionally, verbally, and physically abusing R52 and from wandering into other residents rooms (R52 and R31) placing these residents (as well as others) at risk for abuse from R15.",2020-09-01
24,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,692,D,1,1,H65F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, and interview, it was determined that the facility failed to provide R15 fluids as per facility policy, family request and according to physician orders. A physician ordered to encourage fluids for 3 days on 11/30/18 after R15's BMP laboratory results revealed an elevated BUN. Findings include: The Facility Nursing policy entitled Hydration- Resident, effective (MONTH) (YEAR), stated, . 1. Unless otherwise ordered or contraindicated, residents will routinely be offered fluids during meals . and water will be provided at bedside (as appropriate) . 3. If a resident cannot select the required amount of recommended fluids, extra fluids shall be added to meet their goal. 4. Additional fluids are offered in the following methods: * Styrofoam cups (approx. 480 cc) filled with water every shift and kept at the bedside, or with the resident . * Medication pass . Cross- refer F770, example #3 Review of R15's EMR revealed the following: R15 was admitted to the facility in (YEAR). R15 has [DIAGNOSES REDACTED]. Review of R15's BUN's from 11/22/17 through 5/30/18 ranged from 39-48. 8/29/18- Review of R15's annual MDS assessment, coded R15 as a 3 for cognition (severly impaired- never/rarely made decisions). There were no significant weight gains or losses coded and R15 was able to eat/drink independently after set up help. R15 was coded as receiving diuretics or fluid pills (cause fluid loss daily). 3/2/17- R15's at risk for dehydration related to use of daily diuretic care plan listed interventions including but not limited to: encourage and assist resident as needed to consume 100% of liquids offered at all meals, offer a variety of liquids each shift, even during the night, offer extra fluids when giving medications if medically appropriate, provide an extra 240 cc fluid every shift, offer soup at both lunch and dinner, and evaluate resident for hydration needs. Even residents who are independent may need reminders to drink. 8/30/18- R15 had a physician's orders [REDACTED]. 11/12/18 nutrition risk assessment- estimated fluid needs 1659 ml. R15 's diet order was for a no added salt regular consistency diet with special instructions to receive soup with lunch and dinner. Listed under supplements was encourage po (oral) fluids, extra 240 ml q (every) shift. 11/28/18 12:13 PM- During a family interview with F8 (R15's daughter and POA), she stated that she would like her mother to be offered fresh water 3 times a day. F8 further stated that she's brought it to the facility's attention multiple times, including during care plan meetings. November (YEAR)- Review of R15's MAR included the 8/30/18 order for encourage oral fluids, extra 240 ml every shift. The majority of shifts, nursing documented 240 mls were consumed, however, 120 ml was consumed on 20 out of 90 shifts. 11/30/18- a BMP laboratory (lab) result was reviewed by a physician; R15's BUN was elevated at 47 (normal range 10-26). As a result of this, the physician wrote on the lab result Encourage fluids x (times) 3 days and Repeat BMP 12/3/18. There was no evidence in the (MONTH) or (MONTH) MAR, as of 12/5/18, that the order, dated 11/30/18, was added to the MARs and therefore, implemented. 12/3/18 10:55 AM- R15 had a large styrofoam cup beside the sink in her room. It was undated and felt about 1/2 full. 12/4/18 11:29 AM- R15 was asleep in bed. Unable to see cup in her room from the hallway. 12/5/18 12:35 PM- Findings were reviewed with E3 (ADON). E3 confirmed the orders handwritten onto R15's 11/30/18 BMP lab result for encourage fluids x 3 days was not entered into the EMR as a physician order [REDACTED]. When asked whose responsibility it was to ensure MD or NP orders were input to the EMR, E3 stated after the MD or NP signs the lab results, the unit manager or another nurse on the floor should review the signed lab result and put the order(s) in the EMR. 12/5/18 12:25 PM- R15 was observed sitting in a chair in her room with her lunch tray in front of her. She had eaten all of her soup and very little of what was on her plate. She had a full 8 ounce cup of coffee on her tray and a 4 ounce can of soda; there was still some soda in the can and there was a 4 ounce cup with soda that was 1/2 full. There was no styrofoam cup or any other types of cups in her room with water. 12/5/18 2:35 PM- Findings were reviewed with E2 (DON). 12/6/18 8:45 AM- E2 advised the surveyor that R15 was receiving extra fluids as per the MAR and stated that R15's BUN's had been in the 40's on numerous dates, so the 12/3/18 BUN was in the range of what R15's BUN's have been. Although R15 received extra fluids from the 8/30/18 physician order [REDACTED]. The facility failed to provide R15 fluids as per facility policy, family wishes and according to physician orders. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3, and E14 (QA).",2020-09-01
25,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,758,D,1,1,H65F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, it was determined that the facility failed to ensure medication regimens were free from unnecessary [MEDICAL CONDITION] medications for two (R15 and R83) out of 54 sampled residents. For R15, the facility failed to ensure that non-pharmacological interventions were used prior to her receiving PRN [MEDICATION NAME] and failed to monitor the effectiveness of her PRN [MEDICATION NAME]. For R83, the facility failed to limit PRN [MEDICAL CONDITION] medications to 14 days. Findings include: 1. Review of R15's clinical record revealed: 8/25/16- R15 was admitted to the facility and has [DIAGNOSES REDACTED]. 7/21/18- A recommendation from the pharmacist stated that R15 received [MEDICATION NAME] gel in July, but documentation whether it was effective or ineffective was inconsistent. A physician responded to the recommendation on 7/26/18 and stated, please have nursing document if effective or ineffective after administration. 9/25/18- R15 had a physician's orders [REDACTED]. 10/3/18 and 10/5/18- According to the MAR, R15 received [MEDICATION NAME] Gel on these dates. There was no documentation of non-pharmacological interventions used prior to administering the [MEDICATION NAME] and no documentation of the effectiveness of the medication, including in the progress notes and on behavior monitoring sheets. 10/28/18- R15 had a physician's orders [REDACTED]. 11/1/18, 11/6/18, 11/7/18, 11/11/18, 11/20/18, 11/23/18, 11/25/18, and 11/28/18- According to the MAR, R15 received [MEDICATION NAME] Gel on these dates. There was no documentation of the effectiveness of the [MEDICATION NAME] on all of the dates, including in the progress notes. Additionally, there was no evidence of non-pharmacological interventions being used prior to [MEDICATION NAME] administration on 11/1/18 and 11/28/18, including in the progress notes and behavior monitoring sheets. 12/5/18 2:35 PM- Findings were reviewed with E2 (DON). Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3, and E14 (QA). 2. Review of R83's clinical record revealed: 4/21/17 - R83 was admitted to the facility with [DIAGNOSES REDACTED]. 11/13/18 8:42 AM - A physician progress notes [REDACTED]. The plan was documented that R83 was to receive an order for [REDACTED]. 11/14/18 - An order was entered for R83 to receive [MEDICATION NAME] 0.25 mg PRN every 8 hours PRN for anxiety for 30 days. There was no documented rationale for ordering R83 [MEDICATION NAME] PRN for greater than 30 days. The facility failed to limit R83's PRN [MEDICATION NAME] to 14 days, or provide physician documented rationale. 12/5/18 4:30 PM - Findings were reviewed with E2 (DON).",2020-09-01
26,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,770,D,1,1,H65F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, interviews and review of facility documents as indicated, it was determined that the facility failed to meet the needs of three (R15, R85 and R99) out of 54 sampled residents with regard to the quality and/or timeliness of providing laboratory services. Findings include: 1. Cross refer, F684 example #1 Review of R85's clinical record revealed: 9/19/18 at 11:13 PM - A physician's phone order was entered for an H&H to be drawn on 9/21/18 for R85. Review of R85's clinical record lacked evidence of results for the 9/21/18 H&H. Review of the Lab Form Book on the second floor showed names of residents who needed lab work drawn for 9/21/18. R85 was listed, and it stated she needed an H&H drawn that day. The form was initialed by the laboratory technician and dated 9/21/18, indicating that the lab was drawn. On 12/4/18 at 1:50 PM during an interview, E2 (DON) stated that when the lab results were requested by the surveyor, the facility contacted the lab responsible for doing the lab work for R85 on 9/21/18. E2 stated that the lab had no evidence that the technician had actually drawn blood from R85 for the ordered lab work. The facility failed to obtain laboratory services to meet the needs of R85. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA). 2. Cross refer, F684 example #2 Review of R99's EMR revealed the following: 9/7/18 - A physician's orders [REDACTED]. 9/14/18 - Review of laboratory results revealed that the ammonia level, ordered on [DATE], was not drawn. 9/14/18 3:59 pm - A nurse's progress note stated the resident was due for an ammonia level, but the draw was not completed because the test was not ordered. The progress note stated the lab was called and rescheduled the ammonia level for 9/15/18. 9/15/18 - Review of the Lab Form Book revealed that although an ammonia level was entered to be drawn for R99, it was not signed off by the laboratory technician as completed. A notation stated Must be called in for Monday 9/17/18. 9/17/18 - An ammonia level was drawn 3 days after it was ordered to be drawn. The results revealed the level was 133 (range 0-60). The facility failed to ensure that laboratory services met the needs of R99 and that they were performed timely. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA). 3. Review of R15's EMR revealed the following: Review of R15's laboratory (lab) results for a BMP (set of eight tests that measure blood sugar and calcium levels, kidney function, and chemical and fluid balance), dated 11/30/18, had handwritten notes from the physician that stated, Encourage fluids x 3 days and Repeat BMP 12/3/18. R15's BUN (blood test to measure kidney function) was elevated at 47 (normal range 10-26). Review of R15's EMR revealed there were no BMP results for 12/3/18 and there were no other BMP results for R15 as of 12/5/18. 12/5/18 12:35 PM- findings were reviewed with E3 (ADON). E3 stated that the BMP on 12/3/18 was not entered into the EMR as a physician order, it was not written in the lab book and it wasn't done. When asked whose responsibility it was to ensure MD or NP orders were input to the EMR, E3 stated after the MD or NP signs the lab results, the unit manager or another nurse on the floor should review the signed lab result and put the order(s) in the EMR. The facility failed to obtain laboratory services as per physician order [REDACTED]. Findings were reviewed on 12/6/18 at approximately 7:45 PM during the exit conference with E1 (NHA), E2 (DON), E3, and E14 (QA).",2020-09-01
27,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,790,D,1,1,H65F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to provide routine and/or obtain dental services for one (R83) out of 54 sampled residents. Findings include: Review of R83's clinical record revealed: R83 was admitted to the facility on [DATE]. During an interview on 11/27/18 at 1:48 PM, R83 stated that he was missing some teeth and food would build up in them. He stated that it was aggravating to him, and that the facility had not asked him if he wanted to see a dentist. R85's record lacked evidence that a dentist or dental hygienist had seen R85 for routine dental services since admission. During an interview on 12/5/18 at 1:23 PM, E6 (SW) stated that she was not sure if R85 had been seen for routine dental services while at the facility. She stated that they do not offer the residents routine dental appointments. The residents were only seen by dental services if they requested it or there was an issue. The facility failed to provide and/or obtain routine dental services for R83. Findings were reviewed with E2 on 12/5/18 at 4:30 PM.",2020-09-01
28,KENTMERE REHABILITATION AND HEALTHCARE CENTER,85001,1900 LOVERING AVENUE,WILMINGTON,DE,19806,2018-12-06,842,D,1,1,H65F11,"> Based on record review and interview, it was determined that the facility failed to ensure that medical records were complete and accurately documented for one (R100) out of 54 sampled residents. Findings include: Review of R100's EMR revealed the following: 7/24/18 - R100 was admitted post hospitalization for short term rehabilitation services with the goal of discharge to home. 7/24/18 - A Social Services Initial Psychosocial Evaluation stated that R100's expected length of stay was 10-14 days and the resident wants to be able to function well enough to go home. 7/27/18 1:51 PM - A nurse's progress note stated R100 was alert and oriented to person, place and time and was able to make needs known. 8/8/18 - Care Plan Meeting Notes stated, Discussed discharge with resident and daughter. Resident does forget some things and has loss of balance with walking .She is going to need 24 hours (sic) care. Daughter would like to take her .but at this time is unable to. Decided to keep her at Kentmere until she can locate a facility .and then have transitions there .last covered day for therapy will be 08/10/2018 .Will convert her over to Medicaid at that point for LTC (Long Term Care). 8/8/18 - Physical Therapy Treatment Encounter Note stated, Discharge meeting is attended by the patient, her daughter .and facility staff .It is decided that the patient will remain at this facility if it is a temporary situation . 8/24/18 11:03 AM - A Medical Note stated, .for upcoming discharge .evaluated pt (patient) for upcoming d/c (discharge) - scripts (prescriptions) written . The EMR lacked any notes regarding R100's change from staying as LTC versus her being discharged to home. The facility failed to ensure that medical records were complete and accurate. 8/27/18 - The MDS discharge assessment stated R100 was independent for daily decision making. 12/5/18 approximately 12:10 PM - During an interview, E6 (SW) stated that R100 was passive during meetings and went along with what her daughter said. However, R100 then decided that she was going home to her apartment. E6 confirmed that documentation was lacking regarding R100's desire for discharge. Findings were reviewed on 12/6/18 at approximately 7:45 PM at the exit conference with E1 (NHA), E2 (DON), E3 (ADON), and E14 (QA).",2020-09-01
29,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2017-05-03,225,D,0,1,ZLDY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that 3 incidents involving serious injuries/injuries sustained from unwitnessed falls that required transfers to acute care (hospital), for 1 resident (R27) out of 27 Stage 2 sampled, one (1) incident was not immediately reported to the DLTCRP (Division of Long Term Care Residents Protection),and all three (3) incidents were not thoroughly investigated . Findings include: Review of R27's clinical record revealed the following: 1.a. 1/07/17 at 13:11 (1:11 PM) -Nursing Event Report stated: Description: Un-witnessed fall in hallway. Summary of event: Resident discovered sitting in hallway on buttocks holding bleeding mouth. 1/07/17 at 1:24 PM -Nursing progress note stated that the witness noticed resident sitting on the floor on her buttocks, holding bleeding mouth in the hallway. R27's cognitive status was alert x 2 (person and place) with confusion. R27 sustained a laceration (cut) to her exterior lower lip and internal lower lip. Neuro checks WNL. Resident was given PRN Tylenol for pain with severity of 5 out 10. NP ordered to send R27 to ER for evaluation and treatment. Left the facility at 1:35 PM. 1/7/17 at 17:10 (5:10 PM)-Resident returned to the facility from the hospital with internal and external suture on the bottom lip and swollen with purple bruise noted to left lower shin. CT of the head, neck and face with negative result. Review of records revealed that the facility lacked documentation that this incident was immediately reported to the DLTCRP and was not thoroughly investigated. This finding was reviewed with E1 (Administrator) and E2 (DON) on 5/2/17 at 1:30 PM. 1.b. 4/3/17 at 22:41 (10:41 PM) Nurse's progress note stated that E8 (LPN) heard a thud and saw patient (R27) on the floor. On assessment patient was found to sustain hematoma on her occiput area, and patient verbalized pain on palpation. NP was notified and ordered to send the patient to the ER for further evaluation and treatment. R27 left for the hospital at 10:45 PM. 4/3/17 at 23:35 (11:35 PM) the incident was immediately reported to the DLTCRP. 4/7/17 -The facility's result of the investigation was submitted to the DLTCRP. The facility's follow up/or result of the investigation reported that it was followed up in the facility's fall committee and there was no evidence of abuse or neglect. However, review of the facility's investigation of the incident revealed that it was not investigated thoroughly. For example, there were no evidence that the staff who provided care to R27 prior to these unwitnessed fall were interviewed. On 5/3/17 at 12:30 PM- the facility submitted to the surveyor, copies of interviews/written statements from E8 (LPN), E9 (LPN) and E12 (CNA) conducted by the facility during the survey on/dated 5/2/17 for the 4/3/17 incident of R27's unwitnessed fall with injuries. 1.c. 4/11/17 at 03:30-Nurse's progress note stated that Resident was found on the floor in her room by her dresser at 3:20 AM after her roommate came to the nurse's station. resident sustained [REDACTED]. R27 was unable to tell how she fell or what she was attempting to do. NP ordered to send R27 to the hospital ER for evaluation and treatment. 4/11/17 at 9:59 AM -Incident report was submitted to the DLTCRP. 4/12/17at 22:45 (10:45 PM) Nurse's Progress note stated that R27 returned to the facility with a lacerated wound on her right eyebrow, hematoma to right forehead, right and left Periorbital sides of her nose and right upper lip, hematoma to her right shoulder, left and right forearm, left elbow, right knee and left lower extremity. 4/13/17 follow up/result of investigation was submitted to the DLTCRP. The facility's follow up/or result of the investigation report stated that Resident returned from the hospital with non-displaced nasal bone fracture. P[NAME] updated upon return. No evidence of abuse or neglect. However, review of the facility's investigation of the incident revealed that the facility has no documented evidence that the incident was thoroughly investigated. For example, there was no evidence that the CNA and/or CNAs who provided care to R27 prior to these unwitnessed fall were interviewed and including the roommate who reported the incident. Findings were reviewed with E1 (Administrator) and E2 (DON) on 5/2/17 at 1:30 PM.",2020-09-01
30,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2017-05-03,253,D,0,1,ZLDY11,"Based on observations and interviews, it was determined that the facility failed to provide the necessary housekeeping and maintenance services for 2 rooms (Greenville 116G and Westover 318A) out of 31 rooms surveyed. Findings include: The following was found during the environmental tour on 5/1/17 from 1:30 PM to 2:30 PM as well as during stage 1: Greenville 116G - The fall mat on the left side of the bed was dirty; - The bathroom ceiling tile to the right of the entrance was stained; Westover 318A - The armrest covers of the toilet safety rails were frayed, exposing the metal frame. Findings were reviewed and confirmed with E10 (Facility Maintenance Director) and E11 (Director of Housekeeping) on (MONTH) 1, (YEAR) at approximately 2:30 PM. Findings were reviewed on 5/3/17 at approximately 3:45 PM with E1 (NHA) and E2 (DON).",2020-09-01
31,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2017-05-03,279,D,0,1,ZLDY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R156) out of 27 Stage 2 sampled residents, the facility failed to develop an individualized care plan with measurable goals and interventions to address R156's urinary incontinence. Findings include: Review of R156's clinical record revealed: R156 was admitted to the facility on [DATE]. The admission MDS assessment, dated 9/1/16, stated that R156 was frequently incontinent of urine. The CAA from the 9/1/16 admission MDS assessment triggered urinary incontinence as a potential problem area. The facility stated they would proceed with care planning for urinary incontinence. Review of R156's clinical record revealed the absence of an individualized urinary incontinence care plan. The facility failed to develop an individualized urinary incontinence care plan for R156. During an interview on 5/2/17 at 2:32 PM, findings were reviewed and confirmed by E12 (RNAC).",2020-09-01
32,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2017-05-03,280,D,0,1,ZLDY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that for one (R27) out of 27 Stage 2 sampled residents, the care plan was revised by a team of qualified persons after each of R27's fall assessments. Findings include: The facility's policy entitled, Fall Management dated 3/16/16 included: Develop a plan of care which can include general and specific interventions to reduce falls risk .Implement intervention (immediate) after the fall. As the investigation continues the root cause analysis may trigger additional interventions to resident plan of care .Update the care plan and CNA communication form with new intervention. Review of R27's clinical record revealed the following: R27 was originally admitted to the facility on [DATE] 07/17/15-The facility originally initiated a care plan that stated, Actual/Potential for falls r/t poor safety awareness, cognitive impairment. The initial approaches included: Resident to wear shoes when out of bed, double sided non skid socks while in bed PT/OT eval and assessment PRN Keep call bell within reach as resident allows Have commonly used articles within easy reach Ensure environment is free of clutter 8/28/15 - updated with offer frequent rest period 9/26/16 - updated with Toileting program 12/6/16 - Fall Risk assessment stated that R27 was a high risk for falls. 1/7/17 - Fall Risk assessment identified R27 was a high risk for falls and had a balance problem while walking A review of R27's Nursing Progress notes revealed the following: 1/7/2017 at 13:24 (1:24 PM)-A nursing progress note stated that the resident was found sitting on the floor on her buttocks in the hallway, holding her bleeding mouth. R27 sustained laceration to exterior lower lip and internal lower lip that required hospitalization . R27's bottom lip required sutures when hospitalized . There was no documentation in the care plan that it was updated/revised to reflect immediate intervention implementation after the fall to prevent re-occurrence. 1/9/17- (2 days later), The facility's post fall Verification of Investigation Report for the 1/7/17 fall, identified the following 2 triggered modified interventions to the plan of care: :1) Psychiatrist's review; 2)Therapy referral ( already part of the initial approaches since 7/17/15). The facility failed to update/revise the existing care plan to include a Psychiatrist review. In addition, on 1-9-17- 1/30/17,R27 was under PT's services. PT's evaluation and treatment services summary stated that Nursing was educated to supervise R27 to reduce risk of falls. The facility failed to update/revise the existing care plan to include the type of supervision that was put in place. 1/31/17 - Nursing Progress note stated that R27 at 1:25 AM was out of bed ambulating in the dayroom, lost her balance, fell to the floor hitting her head on the wall. R27 sustained bleeding from the back of her head and was sent to the hospital emergency room for evaluation and treatment. R27 returned to the facility with 3 staples on her posterior scalp laceration. 1/31/17 -The facility's after fall Verification of Investigation identified the following modified interventions to the plan of care: 1) therapy trialed on wheelchair; 2) Anti roll back to wheelchair and dycem initiated; 3) 1 person assist for all transfers and ambulation; 4) every 30 minute safety check; 5) continue offering rest periods. The facility failed to revise/update the care plan to include, the every 30 minute safety check according to the facility's modified interventions identified on 1/31/17 Verification of Investigation. 2/01/17 - R27's Fall care plan was updated/revised and included hip protectors on at all times; 2/3/17-R27's Fall care plan was edited/revised and included the intervention that R27 requires one person assist for safe transfers and ambulation and dycem to wheelchair, wheelchair with anti-roll backs; 2/3/17 -The facility identified that they will request ambulation program. The facility failed to revise the care plan to include this intervention after the 1/31/17 fall. 2/7/17 - The facility identified a nursing intervention to move R27 closer to nursing station. However, the facility failed to revise the care plan to reflect this intervention. 2/16/17- The facility identified a nursing intervention that the Resident was tried with Rolling Walker- not successful. The facility failed to revise the care plan to include this intervention. 2/17/17 -Nursing Progress note stated that R27 was on restorative ambulation program, nursing staff offer hand held assist with ambulation as able. The facility failed to revise/update the care plan for 2/17/17 to include the intervention, Restorative ambulation program. 3/30/17 at 2:57 PM- Nursing Progress note stated that a Rehabilitation staff E7 (OT) was walking towards the linen closet and observed resident ambulating towards main dining room entrance and tripped over fell ow residents wheel of wheelchair and that resident softly hit the back of her head against the corner of entrance of the main dining room and slowly slid to floor. R27 did not sustain injury. 3/31/17-The Verification of Investigation Report for the 3/30/17 fall identified the Modified interventions to the plan of care that stated offered helmet -refused by family. The facility failed to revise the care plan to include the intervention, offered helmet-refused by family. There was no evidence that the facility updated/revised the Fall care plan to address R27's actual falls after the incidents on 1/7/17, 1/31/17, and 3/31/17. 4/3/17- Nurse's note stated that E8 (LPN) heard a thud on the hallway and saw resident on the floor. On assessment R27 sustained hematoma on her occiput area, patient verbalized pain on palpation and was sent to hospital ER for evaluation and treatment. 4/4/17-The intervention Redirect resident to common areas as able was added in response to the 4/3/17 incident of fall. Although the facility periodically reviewed the care plan, it failed to update/revise R27's Fall care plan to include the immediate and specific modified interventions identified in their incident investigations after each fall, including the triggered additional intervention as the investigation continued. 4/11/17-R27 had an unwitnessed fall in her room and sustained Periorbital and facial trauma + lips, hematoma on right shoulder, left and right forearm, left elbow, right knee, left lower extremity and was transported to the hospital for evaluation and treatment. On 4/11/17 and 4/13/17, it was then that the facility revised R27's care plan and put in place the general and specific interventions to reduce falls risk, implemented intervention (immediate) after the fall such as the Bed sensor alarm, Check placement and function every shift, Egress mattress, keep room well lit and clutter free, keep overhead light on while resident in bed, low bed, fall mat at bedside, mobility alarm to rock and go chair and rock and go chair plus restorative ambulation program. This finding was reviewed with E2 (NHA) and E2 (DON) on 5/2/17 at 1:45 PM.",2020-09-01
33,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2017-05-03,332,D,0,1,ZLDY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to ensure that their medication error rate was not 5 percent (%) of greater. The facility medication error rate was 6.9%. Findings include: Medication pass observations on 4/25/17 in the 400's unit, revealed the following: 1a. At 9:15 AM, E4 (RN) incorrectly administered Vitamin D3 1,000u by mouth to R141. The physician's orders [REDACTED]. R141 was to start Vitamin D3 1,000u daily on 6/14/17. The facility failed to administer the correct form and dosage of Vitamin D to R141. Findings were reviewed and confirmed with E4 on 4/25/17 at approximately 2:40 PM. 1b. At 9:25 AM, E4 administered [MEDICATION NAME] (also known as [MEDICATION NAME]) 20 mg by mouth to R24. The physician's orders [REDACTED]. Warnings on the medication label from the pharmacy used by the facility, stated, .Take before food/meal. The Medication Guide for [MEDICATION NAME] (www.fda.gov/downloads/drugs/drugsafety/ucm 9.pdf) stated, .Take [MEDICATION NAME] before a meal . R24 was interviewed on 4/25/17 at 11:32 AM and stated she had breakfast about 8:30 AM. E6 (CNA assigned to R24) was interviewed on 4/25/17 at approximately 11:40 AM and stated that R24 ate around 8:00 to 8:15 AM and was finished eating breakfast about 8:30 AM. R24 was given [MEDICATION NAME] approximately 1 hour after she ate breakfast, not before a meal as per the facility's pharmacy warning and the FDA's (Food and Drug Administration) guidance. Findings were reviewed with E4 and confirmed during an interview on 4/25/17 at 2:40 PM. During the medication pass on 4/25/17 in the 400's unit, 2 medication errors occurred which made the med error rate 6.9% out of 29 opportunities.",2020-09-01
34,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2017-05-03,389,D,0,1,ZLDY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that one (R27) out of 27 Stage 2 sampled residents, received the services of a physician 24 hours a day in case of an emergency. Findings include: Review of R27's clinical record revealed: 1/31/17 at 1:35 AM- Nurse's progress note stated that at 1:25 AM, R27 was ambulating in the dayroom, she lost her balance and fell to the floor hitting her head on the wall. R27 was noted to be bleeding from the back of her head and pressure was applied to the area. Attempted to call on call physician, left message on answering machine, no return call, called 3 additional times with no answer. R27's daughter was notified of the event and gave the OK to send resident to the ER despite R27 had no hospitalization restriction on Palliative care assessment. On call nurse was notified and stated to send resident to the ER. 911 was called at 1:34 AM. R27 was transported to the hospital ER . 1/31/17 at 07:00 AM-R 27 returned to the facility from the hospital with [DIAGNOSES REDACTED]. 5/2/17 at 8:30 AM-During an interview with E13 (LPN), she stated that the NP(E3), who was taking call for the physician, did not return the call. DON (E20) and the physician was made aware. This finding was reviewed with E1 (Administrator) and E2 on 5/2/17 at 1:45 PM.",2020-09-01
35,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2018-08-01,558,D,0,1,LQUY11,"Based on observation and interview, it was determined that the facility failed to provide a reasonable accommodation of individual needs by failing to ensure the call bell was within reach for one (R112) out of 43 sampled residents. Findings include: Observation on 7/24/18 at 10:34 AM, revealed R112 lying in bed and stating that he was having pain. R112 said that he asked staff a while ago for pain medication and had not received it. The surveyor asked if R112 had pushed his call bell, and R112 tried to look for his call bell and could not find it. The call bell was observed to be out of R112's reach on the floor behind his bed. The surveyor then left the room and notified staff that R112 was having pain. Findings were reviewed with E1 (NHA) and E2 (DON) on 8/1/18 at approximately 4:45 PM.",2020-09-01
36,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2018-08-01,689,D,0,1,LQUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, it was determined that for one (R104) out of 43 sampled residents, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible. Findings include: Review of R104's clinical record revealed: R104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R104's care plan revealed that starting on 3/30/18, R104 had the potential for falls related to immobility and dementia. The facility developed a care plan on 3/30/18 for the problem that R104 had the potential for [MEDICAL CONDITION] activity related to a [MEDICAL CONDITION] disorder. Interventions included to protect R104 from injury. Review of R104's 6/28/18 quarterly MDS revealed that R104 was totally dependent for bed mobility and transfers. On 7/24/18 at 8:40 AM, R104 was observed lying in bed with no side rails and no staff in the room. The height of R104's bed was elevated off the ground in a high position. During this observation, E5 (LPN) entered R104's room, provided care to R104's roommate, then quickly left the room without lowering R104's bed. During an observation on 7/30/18 at 2:44 PM, R104 was seen lying in bed with no side rails and he was leaning far over to the right side of his bed. The height of R104's bed was elevated off the ground in a high position, and there were no staff in the room. On 7/30/18 at 4:40 PM, R104 was observed lying in bed with no side rails and no staff in the room. The height of R104's bed was elevated off the ground in a high position. During an interview on 7/30/18 at 4:45 PM, E2 (DON) went with the surveyor to R104's room and observed R104 lying in bed with no side rails and no staff in the room. The height of R104's bed was elevated off the ground in a high position. E2 verified with E4 (RN Unit Manager) that R104 was unable to move his bed up and down by himself. E2 confirmed that for safety, R104's bed should not have been elevated that high when staff were not in the room providing care. The facility failed to ensure that R104's environment remained free of accident hazards, as evidenced by 3 different observations of R104 alone in his room with his bed at an elevated height. Findings were reviewed with E1 (NHA) and E2 on 8/1/18 at approximately 4:45 PM.",2020-09-01
37,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2018-08-01,760,D,0,1,LQUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that for one (R32) out of 43 residents, the facility failed to ensure that the resident was free from any significant medication errors. R32 received three doses of [MEDICATION NAME], an anticoagulant, at the wrong dose. Findings include: Review of R32's clinical record revealed: R32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/22/18 at 5:48 PM, a progress note by E7 (RN) stated that R32 had a lab result of INR-1.41, PT-14.7 that was called to E8 (Medical Director). E8's order stated R32 was to receive [MEDICATION NAME] 11 mg tonight (3/22/18) and starting on 3/23/18, R32 was to receive [MEDICATION NAME] 10.5 mg. A repeat PT/INR was ordered to be drawn on 3/26/18. Review of R32's (MONTH) (YEAR) MAR indicated [REDACTED]. The facility failed to ensure that R32 was free from any significant medication errors as evidenced by R32 receiving three incorrect doses of [MEDICATION NAME]. Findings were reviewed with E2 (DON) and E3 (ADON) on 8/1/18 at 4:30 PM.",2020-09-01
38,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2018-08-01,776,D,0,1,LQUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R32) out of 43 sampled residents, the facility failed to ensure that a STAT x-ray result for R32 was received in a timely manner, in order to facilitate appropriate follow up care. Findings include: Review of R32's clinical record revealed: On 2/2/18, R32 was admitted to the facility with a [DIAGNOSES REDACTED]. 2/9/18, R32's Admission MDS revealed that R32 was able to make consistent and reasonable decisions and he needed limited assistance of one person for transfers. On 2/24/18 at 1:35 PM, a progress note stated that the floor nurse heard R32 calling for help, responded, and found R32 sitting on the floor in the bathroom. R32 told staff that he fell fell while trying to transfer himself from the wheelchair to the toilet, and he landed on his right knee. R32 reported right knee pain of 5 out of 10 (10 being the highest in intensity in a scale of 1 to 10). On 2/24/18 at 5:07 PM, a progress note stated that slight swelling was noted to R32's right knee, and that R32 reported pain of 10 out of 10. Pain medicaton was administered as ordered. The nurse practitioner was notified and gave an order for [REDACTED]. On 2/24/18 at 5:13 PM, an order was placed with the contracted mobile x-ray facility for a STAT x-ray of the right knee. On 2/24/18 at 7:15 PM, a progress note stated the x-ray was done and the results were pending. On 2/24/18 at 7:50 PM, a radiology report, signed by a radiologist, revealed that R32 had an acute fracture involving the right mid patella. The report was not called to or sent to the facility at that time. On 2/24/18 at 10:56 PM, a progress note stated that R32's x-ray of right knee was done and they were awaiting the result. On 2/25/18 at 1:05 AM, a progress note stated that the mobile x-ray facility had been called two times for R32's x-ray results, at 11:30 PM and at 1:00 AM, and they would fax the results immediately. On 2/25/18 at 2:22 AM, a radiology report for R32's STAT right knee x-ray was received at the facility via FAX. On 2/25/18 at 7:10 AM, a progress note stated that results from R32's x-ray were received at 2:30 AM, which showed a fracture involving the right mid patella. The doctor on call was notified and advised the facility to send R32 to the hospital for further management. The ambulance arrived to pick up R32 at 3:00 AM and transported him to the hospital. On 8/1/18 at 2:26 PM, during an interview with a E6 (RN), E6 stated that the expectation for a stat x-ray was that the mobile x-ray facility would call in about an hour once the x-ray was read. The facility failed to obtain timely radiology services to meet the needs of R32, as evidenced by , the results of R32's STAT right knee x-ray were not received for approximately 6.5 hours after it was read and signed by the radiologist. Findings were discussed with E2 (DON) and E3 (ADON) on 8/1/18 at approximately 4:30 PM.",2020-09-01
39,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2019-08-07,550,E,0,1,MCMD11,"Based on observations and interviews, it was determined that for 11 (R24, R33, R41, R89, R130, R1, R73, R36, R58, R107, R129) out of 52 sampled residents, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Findings include: 8/6/19 from 12:40 PM to 12:51 PM - Observations during lunch revealed the following residents were served beverages in disposable plastic cups and/or styrofoam cups: - five (5) residents (R24, R33, R41, R89 and R130) in the DuPont assisted dining room; - two (2) residents (R1 and R73) in their rooms in the Greenville unit; and - four (4) residents (R36, R58, R107 and R129) in the Westover dining room. 8/6/19 at 12:42 PM - During a combined interview with E5 (Acting Food Service Director) and E6 (CNA) in the DuPont assisted dining room, E5 was asked why the residents were served beverages in disposable cups and E5 stated to ask nursing. E6 (CNA) was asked why the residents were served beverages in disposable cups and E6 stated there were no beverage glasses present on the meal trays when they were delivered from the kitchen to the dining room. 8/6/19 at 12:51 PM - During an interview, E4 (Unit Manager) acknowledged that 4 residents in the Westover dining room were served beverages in disposable plastic cups and/or styrofoam cups. 8/7/19 at 2:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).",2020-09-01
40,PARKVIEW NURSING,85002,2801 W. 6TH STREET,WILMINGTON,DE,19805,2019-08-07,609,D,0,1,MCMD11,"Based on record review, interview and review of the State of Delaware Division of Healthcare Quality (DHCQ) Incident Reporting Program, it was determined that for three (R47, R49, R56) out of four sampled residents, the facility failed to notify the state agency within 2 hours of alleged violations of potential abuse involving resident to resident altercations. Findings include: The facility's policy entitled Freedom from Abuse, Neglect, and Exploitation, Version #4 effective date 6/25/17, stated, .Reporting and Response: . 2. The facility will report all alleged violations .to the state agency . 1. Review of R56's clinical record revealed: 2/15/19 at 12:25 PM - A facility event report stated, .Resident to Resident/Aggressive/Combative Behavior .Resident (R56) grabbed onto another resident (R47), resulting on (sic) a physical altercation with (sic) other resident (R47) . Review of the State Survey Agency's report of incidents revealed that the alleged violation of abuse involving a resident to resident altercation between R56 and R47 on 2/15/19 was not reported by the facility. 8/7/19 at 1:47 PM - During an interview, findings were reviewed with E2 (DON). E2 stated that the facility was following a past directive from the State Survey Agency on reporting requirements. 2. Review of R47's clinical record revealed: 2/22/19 at 2:57 PM - A nurse's note stated, Resident (R47) went in another resident's room (R56) and took stuffed animal off resident (sic) table. fell ow resident (R56) attempted to grab item back, . resident (R47) pushed fell ow resident (R56) to the floor in a sitting position . 3/11/19 at 9:36 PM - A nurse's note stated, Resident (R47) became physically aggressive with another resident (R56) tonight; the resident (R47) was found in another resident's room (R56) by a CNA, the CNA reported that the resident (R47) took a cup from the other resident (R56) and pushed that resident (R56) down to the floor; the resident (R47) was kicked by the other resident (R56) . Review of the State Survey Agency's report of incidents revealed that the two alleged violations of abuse involving resident to resident altercations between R47 and R56 on 2/22/19 and 3/11/19 were not reported by the facility. 8/7/19 at 1:47 PM - During an interview, findings were reviewed with E2 (DON). E2 stated that the facility was following a past directive from the State Survey Agency on reporting requirements. 8/7/19 at 2:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON). 3. Review of R49's clinical record revealed: 12/10/18 6:30 PM- An interview done as part of a facility investigation stated that R71 hit R49 on the face two times. R49's face was slightly red. R49 said he/she was in R71's room trying to get his/her chair out when R71 struck him/her. 12/10/18 6:58 PM- An incident statement from an event, stated that R71 punched R49 on the right side of his/her face. R49 was in R71's room getting his/her chair. R49 removed himself/herself from R71's room immediately after the attack. R71 denied attacking R49 12/13/18 A facility care plan evaluation note documented that R71 was involved in a resident to resident altercation. On 8/6/19 at 12:17 PM, review of the State of Delaware DHCQ Incident Reporting Program revealed no evidence that the incident between R71 and R49 was reported to the state agency. 8/7/19 at 2:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA) and E2 (DON).",2020-09-01
41,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-04-15,689,D,1,0,0KN111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, review of facility and other documents as indicated, it was determined that the facility failed to provide 2 person/staff physical assistance for one (R1) out of three (3) sampled residents. R1 was totally dependent for 2 person/staff physical assistance for transfers to and from the bed, chair, wheelchair and into a standing position. R1 was transported to the bathroom via standup lift with one staff member and the standup lift ran into the bathroom door jam. R1 hit his/her left elbow on the door jam and was noted to have a 1.5 x 3.0 cm. bruise (area dark purple) on the elbow. The facility failed to ensure that R1 was provided 2 person/staff physical assistance with transfers when they used a standup lift with one person to transport R1 to the bathroom, which was not in accordance with the resident's assessments and plan of care to prevent accidents. Findings include: The facility's undated Policy and Procedure entitled, Lifting/Transferring/Repositioning Resident Safely stated, .3. Lifting/Tranferring/Repositioning when a mechanical lift device is indicated: .b. Two employees will always be available when using a lift for residents who have no weight bearing ability and cannot provide assistance or balance . Review of R1's clinical record revealed the following: 8/16/17- R1 was admitted to the facility. R1's [DIAGNOSES REDACTED]. 8/17/17 - (last review date 3/21/19) A care plan was initiated entitled, ADL self-care performance deficit r/t Disease process, weakness, impaired balance. Interventions included, Transfer: require extensive assistance by (2) staff to move between surfaces other than toilet; now require the standup lift also as recommended by PT. 12/11/18- R1 was referred to OT for therapy due to complaints of increased pain, decreased range of motion in bilateral shoulder function, and difficulty reaching the grab bar to transfer to the toilet. Per OT's assessment, R1's plan of care was impacted by obesity, difficulty walking, inability to stand upright, and depression. OT's initial assessment indicated maximum assistance of 2 persons for functional transfers from wheelchair to bed. 12/11/18- A care plan entitled, skin tears RLE r/t suspect bumped leg was initiated. The interventions included: Use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. 12/12/18- R1 was referred to PT for decline in functional mobility and increasing generalized weakness. R1 required maximum assistance with transfers from a sitting to a standing position. 12/12/18 - R1's quarterly MDS Assessment stated that this resident's BIMS score for mental status was 15 (decisions consistent/reasonable). Functional Status: bed mobility-extensive assist/2 person physical assist; non-ambulatory (uses motorized wheelchair for mobility), and transfer-extensive assist/2 person physical assist. 1/3/19- An incident report for R1 stated that the resident reported on day shift that a CNA was in a bad mood and roughed her up. R1 clarified that roughed up meant that the CNA had R1 in the standup lift and ran the lift into the door jam (on way to the bathroom) and resident hit his/her arm on the door jam. 1/4/19 9:52 AM- A nursing progress note stated that a 1.5 x 3.0 cm bruise was noted on R1's left elbow and the area was dark purple and the skin was intact. R1 denied pain when the area was touched. 4/11/19 2:30 PM- E3 (ADON) revealed during an interview that on 12/18/18, as per PT's recommendation, R1 needed 1 person assist with transfers, however, on 12/24/18, PT recommended that R1 needed extensive assistance with 2 person physical assist for transfers as coded on 12/12/18 and 3/6/19 MDS quarterly assessments. 4/15/19 1:50 PM- An interview with E5 (CNA) who took care of R1 today (4/15/19), confirmed that R1 currently had 2 staff physical assistance with the standup lift. E5 also stated that 2 person staff assist had been in place for awhile. The facility failed to ensure that R1 received 2 person/ staff assistance during a transfer using the standup lift on 1/3/19, according to the facility's plan of care to ensure the safety of R1 from accidents and injury. This deficient practice resulted in potential for harm when R1 sustained a bruise on his/her left elbow. Findings were reviewed and confirmed with E1 (NHA) and E2 (DON) at 2:15 PM on 4/15/19.",2020-09-01
42,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2017-05-31,241,D,0,1,SQVX11,"Based on observation and interview, it was determined that for one (R22) out of 22 Stage 2 sampled residents, the facility failed to provide care in a manner and in an environment that promotes and maintains R22's dignity and respect in full recognition of his individuality. The facility failed to ensure the resident's privacy of body during a bed bath is maintained . Findings include: On (MONTH) 25, (YEAR) at 10:30AM during a partial bedbath surveyor observation of E5 (CNA) providing care to R22 revealed the following: E5 positioned R22 on his back, removed the adult pad that covered his genital area. E5 exposed and washed, rinsed and dried the genital area. The genital area was very red. E5 attempted to call the treatment nurse via her portable phone to tell the nurse to apply the medicated ointment. While waiting for the treatment nurse, E5 kept R22's genital area exposed instead of placing a towel to cover the area. When the treatment nurse did not come, E5 noticed that her portable phone was not working. E5 went out of the room to get the treatment nurse and left R22 with his genital area exposed and the surveyor in the room. In addition, during R22's upper body wash, E5 removed the resident's top clothing. E5 failed to keep R22's entire chest and back area covered with a towel or bath blanket to prevent chilling. R22 complained of being cold. This finding was reviewed with E2 (NHA) and E5 (CNA) on 5/25/17 at 2:15 PM.",2020-09-01
43,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2017-05-31,280,D,0,1,SQVX11,"Cross-refer to F323 Based on record review and interview, it was determined that the facility failed to ensure that R22's fall risk care plan was periodically revised by a team of qualified persons after each assessment. Findings include: Review of R22's clinical record revealed that he had experienced 7 unwitnessed falls between 9/2016 through 5/2017. R22 sustained minor injuries on three of these unwitnessed falls. After R22 had been assessed and upon investigation, the potential causes for the falls have been identified, the facility failed to revise the care plan to put in place identified corrective actions and appropriate preventative strategies/interventions to reduce his falls. For example, based on the facility's investigation for R22's 7 falls, the facility identified the following problems and corrective actions: 9/16/16 Fall-R22 was non-compliant with the use of the call bell to request for assistance. 10/14/16 fall- Wife and R22 were non-compliant with the use of the call bell to request for assistance 11/18/16 fall- The facility's corrective action per investigation included Monitoring. 4/18/17 fall-The facility's corrective action as a result of the investigation included, Monitoring and continue checks through the night. The fall care plan and approaches were not updated/revised to identify current and appropriate preventative measures and interventions based on the facility's findings to reduce falls. This finding was reviewed with E2 (NHA) on 5/30/17 at 11:40 AM.",2020-09-01
44,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2017-05-31,323,E,0,1,SQVX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to ensure that for 1 (R22) out of 22 Stage 2 sampled residents, the facility failed to ensure that R22 received adequate supervision to prevent accidents. R22 sustained minor injuries during 3 out of 7 unwitnessed falls. Findings include: The Facility's Falls Reduction and Management policy revised 02/16 stated that, 2. After the resident has been assessed and potential causes for falls have been identified, the interdisciplinary care plan team will identify appropriate preventive measures and interventions; 4. Discussion at the weekly meetings includes: a. Investigation regarding the cause (s) of the fall; b. Review appropriate strategies to reduce falls; c. Determination of patterns of falls; d. Development of individual interventions/approaches; e. Recommendation for prevention of future occurrences; 6. The fall care plan and approaches will be updated after each fall and will include current and appropriate preventive measures and interventions; e. Debilitation or weakness .Provide resident frequent observation .use low bed .use a bed alarm use a chair alarm .to assess resident motion; Review of R22's clinical record revealed the following: 08/11/16 -The facility initiated a care plan for R22 entitled, Fall risk related to my gait and balance problems with interventions that included: Anticipate and meet my needs; Be sure my call light is within reach and encourage me to use it for assistance; Keep environment clutter free; Keep my assistive devices (walker and wheelchair) in my room; Keep my bed at an appropriate height; Place a piece of dycem between my chair and the cushion. 9/14/16 - MDS quarterly assessment stated that R22's cognitive skills for daily decision-making were severely impaired (Dementia). R22 was assessed as a high risk for falls related to intermittent confusion, balance problem standing, walking, decreased muscular coordination, changed in gait pattern, unstable making turns, required assistive devices such as walker, wheelchair and was chair bound. a. 9/16/16 at 4:13 AM Nursing Progress note stated that Nursing called to room by CNA, after Resident admitting to falling while attempting to get back to bed after getting up unassisted to turn bathroom light off. Resident was found laying in bed by nurse upon entering room. During assessment, a skin tear noted on his left forearm. The facility failed to provide adequate supervision to R22. b. 10/14/16- Nursing Progress note stated that R22 was found in the bathroom floor on his bottom next to the wheelchair and toilet with wife at side. Wife tried to transfer him into his wheelchair but chair was too far and he slid to his bottom. R22 did not sustain any injury and was assisted off the floor with 2 person. Wife and R22 were non-compliant with use of the call bell. The facility failed to provide adequate supervision to R22. c. 11/18/16 - 4:15 AM - Nursing Progress note stated that R22 was yelling out when the CNA ran to his room to find him sitting on the floor next to his bed. R22 was positioned on his buttocks slightly leaned over to his left resting on his elbow with his back towards the back of his bed, and his face towards the front. R22 stated that he was trying to find his call bell to ring for help. R22 sustained a skin tear to his left elbow, cleansed and treated with dressing and steri-strips applied. The facility failed to provide adequate supervision to R22. d. 1/12/17- Nursing Progress note stated that R22 was observed by nurse on floor in his room at 7:45 AM sitting on the floor on buttocks in front of his wheelchair. R22 was changing hearing aid and slid to floor. R22 did not sustain injury. e. 4/18/17 at 11:50 PM -Nursing Progress note stated that R22 was found by the nurse sitting upright on carpeted floor with pajama shirt, pants and shoes on in front of the closet/door. Resident stated that he was getting up from the recliner to get into the wheelchair and fell . Resident scooted himself from the recliner to the doorway of his room calling for help. R22 sustained abrasion on the right arm and elbow area as per incident investigation. The facility failed to provide adequate supervision to R22. f. 4/19/17-Nursing Progress note- stated this shift (11-7 AM) CNA responded to loud noise heard while attending to a resident's room. Resident noted to be sitting upright on his buttocks on floor near doorway, kicking the door with his feet-calling for help. R22 sustained abrasion on the elbow of his right arm. The facility failed to provide adequate supervision to R22. g. 5/7/17 at 3:00 AM-Nursing Progress note stated that CNA reported to the nurse that resident was heard yelling help. Resident was observed on the floor sitting upright on buttocks next to his bed with back up against the night table. Resident denies striking head; mid/low back area red in color and resident's back was resting on bottom half or small night table with drawers. The facility failed to provide adequate supervision to R22. R22 had 7 unwitnessed falls and 3 of the falls, R22 sustained minor injuries. Based on the facility's investigation for R22's 7 falls, the facility identified that R22 was non-compliant with the use of the call bell and so was the wife. The facility's corrective action following assessments and investigations included monitoring and continue to check through the night. However, the facility failed to have a system in place to supervise/monitor R22 to reduce falls and prevent injuries. On 5/25/17 at 10:00 AM, R22 was observed by the surveyor to have difficulty transferring from his bed to chair while being assisted by E5 (CNA). In an interview on 5/30/17 at 11:40 AM, E2 (NHA) confirmed that R22 was a high risk for falls and repeatedly fell . When asked by the surveyor if the facility staff discussed any type of supervision as an intervention, E2 was not able to provide any established type of supervision that was in place. The facility failed to ensure that R22, who had a history of [REDACTED].",2020-09-01
45,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2017-05-31,431,D,0,1,SQVX11,"Based on observation, the facility failed to ensure that all medications were stored in a locked medication cart when not under the direct observation of authorized personnel for one (1) out of two (2)carts. Findings include: On (MONTH) 25, (YEAR) at 2:24 PM, an unattended medication cart parked against the wall in the[NAME]Gardens hallway was observed to be unlocked. When the top drawer handle was pulled, the compartment with medications came out, confirming the cart was not in the locked position. The cart remained unlocked until 3:10 PM when E4 (Unit Manager) approached the cart and proceeded to insert the key into the lock as if unlocking it, so the cart could be inspected. These findings were reviewed with E2 (NHA) and E3 (Director of Nursing) on 5/25/17 at 3:30 PM.",2020-09-01
46,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,550,D,0,1,N66611,"Based on observations, record review and interview, it was determined that the facility failed to ensure that one (R44) out of two residents reviewed for the care area of urinary catheter/urinary tract infection was treated with respect and dignity. Findings include: Review of R44's clinical record revealed the following: 6/5/19 - A care plan was developed for indwelling Foley catheter use. Interventions included, .position catheter bag and tubing below the level of the bladder and away from entrance room door for my dignity . The following observations were made of R44: 7/2/19 8:58 AM - R44 was observed seated in a recliner in his/her room watching TV. The Foley catheter drainage bag was hanging on the wheel of a wheelchair next to R44 and was visible from the doorway of R44's room. The drainage bag was not covered and the urine was very bloody. 7/2/19 10:16 AM - R44 remained seated in a recliner in his/her room with the urinary drainage bag still hanging on the wheelchair containing bloody urine visible from the doorway. 7/3/19 9:39 AM - R44 was seated in a recliner in his/her room asleep. The urinary drainage bag was hanging on a rollator next to the resident. The drainage bag was currently empty, but not covered and visible from the doorway. 7/8/19 10:40 AM - R44 was seated in a recliner in his/her room with eyes closed. The urinary drainage bag was hanging on a rollator next to him/her, not covered and visible from hallway. The facility failed to ensure that R44 was treated with respect and dignity when his/her catheter drainage bag was left uncovered and visible to anyone in the hallway and/or entering the room. 7/8/19 approximately 5:00 PM - Findings were reviewed with E2 (former DON). 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED).",2020-09-01
47,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,580,D,0,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and review of facility documentation as indicated, it was determined that for 1 out of 1 death record sampled, the facility failed to notify the resident's physician when R48 did not receive 2 doses of Lacosamide medication and R48 had a new [DIAGNOSES REDACTED]. The facility's policy entitled Physician Notification, last revised in 6/2014, stated, . Procedure: 1. The licensed nurse is responsible for notifying the resident's physician at a minimum when there is: . j. The inability to obtain or administer on a prompt and timely basis prescribed medications . 5. Record the following in the resident's health record: a. All attempts to notify the physician or on-call physician, method of attempted contact, time and individuals contacted . b. Reported assessment findings. c. Additional information provided. d. Physician's response. e. physician's orders [REDACTED]. Resident's status and response to the treatment ordered. g. Notification of family or legal representative provided and the family or legal representative response. Review of R48's clinical record revealed: 5/28/19 - The hospital's Medication Orders Upon Discharge stated to administer the next dose of Lacosamide to R48 at 10 PM tonight (5/28/19). 5/28/19 at approximately 12 Noon - R48 was admitted to the facility with a [DIAGNOSES REDACTED]. 5/28/19 - A physician's orders [REDACTED]. 5/28/19 - Review of R48's (MONTH) 2019 eMAR and corresponding Order-Administration Note at 10:33 PM revealed that R48 did not receive Lacosamide at 8 PM because they were waiting for the pharmacy to deliver the medication. Review of R48's clinical record lacked evidence that the physician was notified of the inability to obtain and administer the above medication to R48 on 5/28/19 at 8 PM. 5/29/19 at 1:27 AM - The pharmacy's Proof of Delivery report for R48 revealed that Lacosamide was delivered to the facility at this time. 5/29/19 at 8 AM - Review of R48's eMAR revealed that he/she received the 8 AM dose of Lacosamide. 5/29/19 at 8:45 PM - An Order-Administration Note, written by E24 (RN), for R48's Lacosamide stated, .Not delivered yet from (name) pharmacy. Despite having received the Lacosamide medication from pharmacy on 5/29/19 at 1:27 AM and R48 receiving the 8 AM dose, R48 was not administered the medication at 8 PM. Review of R48's clinical record lacked evidence that R48's physician was notified that R48's anti-[MEDICAL CONDITION] medication was not administered. 7/10/19 at 2:36 PM - During a combined interview with E2 (former DON) and E4 (ADON), E2 stated that when a physician was contacted, nurses should be documenting this information in the progress notes. 7/11/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED). The facility failed to notify the physician when R48's Lacosamide medication was not available and/or administered.",2020-09-01
48,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,622,D,0,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, it was determined that for one (R47) out of one Admission, Transfer, Discharge sampled resident, the facility failed to ensure that appropriate information was communicated to the receiving health care provider to ensure a safe and effective transition of care for R47. Findings include: Review of R47's clinical record revealed: 3/13/19 - R47 was admitted to the facility for skilled nursing and rehabilitation. 4/16/19 - A physician's orders [REDACTED]. Review of R47's clinical record lacked evidence that the facility provided the following information to the receiving health care provider: - lab results dated 4/16/19; - an accurate ADL status of R47 and current vital signs on the interagency nursing communication record; - updated comprehensive care plan; - special instructions/precautions for ongoing care, including adaptive equipment needs; and - a copy of the resident's discharge summary. 7/9/19 at 11:38 AM - During an interview, E17 (SW) stated that he/she did not send R47's care plan to the receiving provider. 7/15/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED). The facility failed to ensure that appropriate information was communicated to the receiving health care provider to ensure a safe and effective transition of care for R47.",2020-09-01
49,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,661,D,0,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview, it was determined that for one (R47) out of one Admission, Transfer, Discharge sampled resident, the facility failed to develop R47's discharge summary that included a recapitulation of R47's stay, a final summary of the resident's status and post-discharge plan of care, including discharge instructions. Findings include: Review of R47's clinical record revealed: 3/13/19 - R47 was admitted to the facility for skilled nursing and rehabilitation. 4/16/19 - A physician's orders [REDACTED]. Review of R47's clinical record lacked evidence of a complete discharge summary that included: - a recapitulation of R47's stay at the facility that included, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology and consultation results; and - a post-discharge plan of care that was developed with the participation of the resident, including any arrangements that have been made for the resident's follow-up care and any post-discharge medical and non-medical services. 7/9/19 at 11:27 AM - During a combined interview, findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E17 (SW) and E4 (ADON). The facility failed to develop a discharge summary that included a recapitulation of R47's stay, a final summary of the resident's status and post-discharge plan of care, including discharge instructions.",2020-09-01
50,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,678,J,1,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of clinical records, interviews and review of facility and other documentation as indicated, it was determined that for 1 (R48) out of 1 death record the facility failed to have an effective system to coordinate, document and implement DNR code status. The facility failed to have a process in place that guaranteed a discussion between a medical practitioner and a resident and/or legal representative concerning DNR code status so that an appropriate and timely DNR order was implemented. For R48, the facility failed to ensure that a physician or nurse practitioner discussed DNR code status with the resident and/or the resident's legal representative upon admission to the facility on [DATE]. R48 had an acute medical emergency at the facility on [DATE] and Emergency Medical Services (EMS) personnel responded. The facility failed to show proper DNR code status paperwork when requested by EMS personnel. The facility's failure to coordinate, document and implement R48's DNR code status in accordance with the facility's DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25, was identified as an Immediate Jeopardy (IJ) on [DATE] at 3:44 PM. IJ was abated on [DATE] at 2:30 PM. Additionally, for two (R1 and R14) current residents with DNR orders, the facility failed to ensure the State DMOST form, also indicating the same DNR status, was signed by the physician in accordance with State law and facility policy. Findings include: The facility's policy and procedure entitled Do Not Resuscitate (DNR), last revised on ,[DATE], stated, Policy. Cardiopulmonary resuscitation (CPR) is administered to any resident suffering a cardiac or respiratory arrest, unless that resident has a 'do not resuscitate (DNR)' order. A DNR order is permitted if the resident or his/her legal representative has discussed the ramifications with their physician or nurse practitioner as allowed per state regulations and the physician or nurse practitioner has placed the appropriate order in the resident's medical record. A DNR order does not permit the facility to refrain from sending the resident to the hospital if, in the professional staff's opinion they cannot provide needed care for the resident. PR[NAME]EDURE: .If a resident does not wish to receive CPR, the resident or staff member must inform his/her attending physician or nurse practitioner. .The resident's legal representative can inform the physician or nurse practitioner if the resident is incapacitated or unable to make his/her wishes known. .The attending physician or nurse practitioner must discuss with the resident and/or family and/or legal representative what a DNR order involves. .Any legal representative deciding on a DNR must base the decision on the resident's wishes, including the resident's religious and moral beliefs; or, if the resident wishes are not known, in the resident's best interest. .The attending physician or nurse practitioner must then write a DNR order and a progress note in the resident's medical record. NOTE: the state designated DNR form will suffice as the progress note. .The progress note must state that the DNR was requested and that the physician or nurse practitioner discussed the DNR order with the resident or the resident's legal representative. Review of Title 16 of the Delaware Code, Chapter 25 Health-Care Decisions, stated, . Section 2501 Definitions . (b) 'Agent' shall mean an individual designated in a power of attorney for health care to make a health-care decision for the individual granting the power . (h) 'Health-care decision' shall mean a decision made by an individual or the individual's agent . regarding the individual's health care, including: . (2) Acceptance or refusal of . orders not to resuscitate; . (4) Execution of a DMOST form pursuant to Chapter 25A of this title . Section 2503 Advance health-care directives . (f) An agent shall make a health-care decision to treat, withdraw or withhold treatment on behalf of the patient after consultation with the attending physician . and in accordance with the principal's individual instructions, if any, and other wishes to the extent known to the agent . Section 2508 Obligations of health-care provider (a) Before implementing a health-care decision made for a patient, a supervising health-care provider, if possible, shall promptly communicate to the patient the decision made and the identity of the person making the decision. The decision of an agent .does not apply if the patient objects to the decision to remove life-sustaining treatment, providing that the objection is (1) by a signed writing or (2) in any manner that communicates in the presence of 2 competent persons, 1 of whom is a physician .Chapter 25A Delaware Medical Orders for Scope of Treatment Act . (c) . (DMOST) means a clinical process to facilitate communication between healthcare professionals and patients . The process encourages shared, informed medical decision-making. The result is a DMOST form, which contains portable medical orders that respect the patient's goals for care in regard to the use of CPR and other medical interventions . (e) .(1) Is used on a voluntary basis . (3) Is not valid unless it meets the requirements for a completed DMOST form as set forth in this chapter . (4) Is intended to provide direction to emergency care personnel regarding the use of emergency care and to health-care providers regarding the use of life-sustaining treatment by indicating the patient's preference concerning the scope of treatment, the use of specified interventions . (7) Must be signed by a health-care practitioner . The Delaware Basic Life Support Protocols, Guidelines and Standing Orders for Prehospital and Interfacility Patients by the Delaware Office of Emergency Medical Services (EMS) and the Delaware Health and Social Services Division of Public Health, effective [DATE], stated, .Current guidelines for do not resuscitate orders .Do Not Resuscitate Order (DNR) .Delaware Medical Orders for Life Sustaining Treatment (DMOST). A DMOST form is a medical order sheet based on the person's current medical condition and wishes .The DMOST form will clearly indicate the patient's wishes concerning life-sustaining treatment and CPR .Section B: . (CPR) . Section E: Review of Orders with Patient. Documents that orders were reviewed with patient or their representative .Section F: Signatures. EMS provider must review this section to ensure it is signed by the patient (or their authorized representative) and healthcare provider . 1. Review of R48's clinical record revealed the following: [DATE] - A copy of R48's advance directive was in the clinical record. The advance directive stated, .I designate the following individual as my Agent to make health care decisions for me: . F2 (Spouse of R48) .I hereby designate additional or successor Agent: . F3 (Family Member of R48) . Qualifying Conditions: Terminally Ill - (selected) Option 3: Do not Prolong Life . Serious Illness or Frailty - (also selected) Option 1: My Agent will make decisions on my behalf: In the event I have a serious Illness or frailty and I am unable to understand, make or communicate my wishes, I direct that my Agent make all medical decisions on my behalf . [DATE] at 10:25 AM - The hospital Discharge Summary stated, .Condition at Discharge stable . [DATE] at 12:45 PM - R48 was admitted to the facility for rehabilitation and intravenous (IV) antibiotic therapy status [REDACTED]. [DATE] at 11:45 AM - A Social Service note, written by E17 (SW), stated, Meeting with resident's spouse, (name) who with resident's permission is signing admission paperwork. Spouse feels resident 'is not herself'. All paperwork completed .He/she has POA (Power of Attorney) with (other family member name) as back up PO[NAME] Code status discussed. Spouse states resident wants DNR status, reported to nursing. D/C (discharge) goal uncertain with current medical conditioning and physical functioning level .Spouse is at bedside most of day. [DATE] at 1:19 PM - A verbal physician's orders [REDACTED]. By entering the verbal physician's orders [REDACTED]. [DATE] at 1:36 PM - A History & Physical (H&P) was completed by E5 (Physician). The H&P did not address R48's code status. [DATE] at 5:31 AM - The EMS Prehospital Care Report revealed that BLS (Basic Life Support) personnel arrived at the patient (R48) on [DATE] at 5:31 AM. The report stated, .Upon arrival of ALS (Advanced Life Support) and BLS crews Pt (patient) was unresponsive pulse less (sic) and apnic (sic) (not breathing) laying supine (on back) on the floor .Pt was found on floor this morning by Facility staff and pt was unresponsive so they called 911 .Facility advised BLS crew that Pt has a DNR however Facility did not have proper DNR paperwork on hand for BLS crew. Pt's (spouse) wished for resuscitation efforts to be initiated by BLS crew. No bystander CPR was being preformed (sic) prior to BLS arrival . [DATE] at 9:11 AM - A late entry nurse's note, written by E19 (RN) stated, Nurse checked on pt at (midnight) .PT WAS SLEEPING soundly, no s/s (signs/symptoms) distress noted . Visual observation on hall way during the night pt sleeping and no s/s distress. Another rounds (sic) done at 3:50 AM and pt was on his/her bed with [MEDICAL CONDITION] on. At 4:56 AM upon entering pt room he/she was found on the floor, pt did not respond to verbal commands but had positive faint carotid (neck) pulse/resp. pt respond (sic) lethargically to sternal rub. immediately contacted .911, md, and spouse. 911 arrived, spouse and .(family member) present. Police officer onsite .Medics MD pronounced pt without signs of life . [DATE] at 10:12 AM - E6 (NP) electronically signed the verbal physician's orders [REDACTED]. [DATE] - The facility's investigation of R48's death on [DATE] failed to identify that R48 had an incomplete DNR code status at the time of the acute medical emergency. The facility failed to identify that R48's incomplete DNR code status was not completed in accordance with the facility's DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25. [DATE] at 7:37 AM - During an interview, E19 (RN) stated that at 4:56 AM, he/she entered R48's room with IV antibiotic medication to administer. E19 stated that R48's right side upper body was leaning against the bed and R48's lower body was on the floor with all the bed linens/blankets underneath him/her. E19 stated that he/she called for help, performed a sternal rub, and checked R48's pulse which was faint. E19 stated R48 was lethargic. E19 stated that he/she lowered R48 to the floor, stepped out of the room and asked E20 (CNA) to stay with R48. E19 stated that he/she called 911, F2 (R48's spouse), E2 (DON) and the on-call physician. E19 stated, And before I even called 911, F2 asked me 'Is somebody coming? Is somebody coming?' E19 stated, Yeah, help is on the way, help is on the way. Because I had to put papers together. I assigned the other nurse and the cna to be there in that room. E19 stated that F2 came immediately and phoned F3 (R48's family member) from R48's room. E19 stated that upon arrival, EMS personnel asked to see the document to make sure R48 was a DNR. E19 stated that he/she told them verbally. E19 stated that he/she printed everything and showed them the eMAR and eTAR, which stated DNR. E19 stated that EMS personnel were given a bunch of documents to show them proof that R48 had the status of a DNR. E19 stated that the documents were: plan of care, face sheet, doctor's H&P, eMAR and eTAR. E19 stated that the EMS personnel asked F2 (R48's spouse) if he/she wanted CPR as F2 was present in the room. E19 stated that F2 said yes. E19 stated that EMS personnel proceeded to give R48 CPR and then a short while later they pronounced him/her. E19 stated that he/she knew R48 was a DNR because he/she reviewed the eMAR/eTAR when the resident was admitted to the facility. E19 stated that was the first thing he/she looked at because you never know, anything could happen. [DATE] at 12:56 PM - During an interview, E6 (NP) confirmed that he/she gave the verbal physician's orders [REDACTED]. When asked if he/she wrote any progress notes in R48's clinical record, E6 stated no after reviewing the electronic clinical record. When asked if he/she had any discussion about code status with R48 and/or R48's family, E6 stated no. [DATE] at 8:38 AM - During an interview, E17 (SW) confirmed that he/she had a code status discussion with F2 (Spouse). E17 stated that F2 (Spouse) wanted a DNR code status for R48. E17 stated he/she could not remember who he/she told, probably the nursing supervisor. E17 stated that nursing passes the information on to the Physician/NP. When asked what the procedure was for DNR code status, E17 stated that the Physician/NP meets with the resident/family and has a conversation and then documents the code status in the clinical record and enters a physician order. [DATE] at 9:26 AM - During an interview, E5 (Physician) stated that R48's spouse (F2) was not present during the History & Physical on [DATE]. E5 stated that he/she did not want to have the code status discussion since the family was not present and he/she left R48's code status section blank on the [DATE] History & Physical. [DATE] at 2:10 PM - During a telephone interview, E22 (RN) stated that between 5 and 5:30 AM he/she went into R48's room to see what was happening. E22 stated that no one else was in the room. E22 stated that he/she did not see R48 on the bed and went further into the room and saw R48 on the floor in between the two beds. E22 stated that he/she observed R48's lips were blue, hands were cold, able to move his/her fingers, and checked R48's brachial (arm) and carotid (neck) pulses. E22 stated there was no pulse. E22 stated he/she went to look for E19 (RN) and found E19 returning to the room (in conflict with E19's (RN) interview on [DATE] when E19 stated that he/she asked E20 (CNA) to stay with R48 prior to leaving the room to make calls). E22 stated that E19 told him/her that he/she called 911 and F2 (R48's spouse). E22 stated the next thing F2 arrived and E22 was trying to console F2, who was crying. E22 stated that F3 (R48's family member) arrived and was on the floor kissing R48 and crying. E22 stated that it took EMS personnel some time to arrive. E22 stated that EMS personnel asked about code status and E19 told them R48 was a DNR. E22 stated that F2 asked EMS Personnel to revive R48. [DATE] from 3:44 PM to 4:22 PM - A meeting was held with E16 (ED), E1 (NHA), E2 (former DON), E3 (acting DON) and the survey team. The survey team informed the facility that an Immediate Jeopardy was identified and involved R48 and the facility's failure to complete R48's code status in accordance with the facility's DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25. The facility MD/NP failed to have a sit down discussion with R48's spouse (POA) to determine his/her code status wishes for R48, what the selected code status entailed and a written progress note of the code status discussion. [DATE] at 6:41 PM - A meeting was held with E1 (NHA), E2 (former DON), E3 (acting DON) and E6 (NP). The survey team identified 2 additional residents (R1 and R14) currently in the facility that had incomplete code status documentation in their clinical records. The facility also conducted an audit of all the current residents and acknowledged that there were incomplete code status issues with some residents. [DATE] at 7:31 PM - The facility submitted a Plan of Correction to the survey team. The facility's NP, E6, was inserviced on the facility's DNR policy and procedure immediately. E6 then started working on the code status for the 2 residents identified by the survey team as having incomplete code status documentation. The facility started inservicing the nursing staff on the DNR policy and procedure. [DATE] from 7:37 PM to 8 PM - E6 (NP) spoke with either the resident/legal representative/POA to discuss each resident's advance directives. E6 wrote progress notes in each resident's clinical record documenting the discussion, the code status and then entered new physician's orders [REDACTED]. [DATE] at 12:35 PM - E5 (Physician) was inserviced on the facility's DNR policy and procedure as he/she signed and dated a copy of the facility's DNR policy and procedure. [DATE] at 2:30 PM - The facility completed the nursing staff inservices on the facility's DNR policy and procedure. The facility's Immediate Jeopardy was abated at this time. The facility failed to have an effective system to coordinate, document and implement DNR code status for R48 in accordance with the DNR policy and procedure and Title 16 of the Delaware Code, Chapter 25. The facility failed to have a process in place that guaranteed a discussion between a medical practitioner and a resident and/or legal representative concerning DNR code status so that an appropriate and timely DNR order was implemented. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED) during the Exit Conference. [DATE] from 4:30 PM to 5:45 PM - A review of all current residents in the facility, totaling 43, revealed incomplete code status documentation in the following residents' (R1 and R14) clinical records: 2. R14's clinical record revealed a DMOST form signed by R14's POA and dated [DATE]. In Section B, R14's POA selected Do not attempt resuscitation. The DMOST form was not signed by a physician in Section F. While R14 had a physician's orders [REDACTED]. record. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED) during the Exit Conference. 3(-. R1's clinical record revealed a DMOST form signed by R1's POA and a Hospice Nurse on [DATE], which was the same day that R1 elected Hospice benefits. In Section B, R1's POA selected Do not attempt resuscitation. The DMOST form was not signed by a physician in Section F. While R1 had a physician's orders [REDACTED]. record. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED) during the Exit Conference.",2020-09-01
51,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,684,D,0,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for two (R42 and R44) out of six (6) residents sampled for medication review, and for one (R48) out of one (1) resident sampled for death review, the facility failed to administer medications as ordered and/or transcribe physician's orders [REDACTED]. 1. Review of R42's clinical record revealed: 6/14/19 - A physician's orders [REDACTED]. 6/28/19 - A physician's orders [REDACTED]. Review of the eMAR revealed R42 received the [MEDICATION NAME] 2.5 mg on 6/28/19, 6/30/19, 7/2/19, and 7/4/19 for a total of four (4) doses. The facility failed to administer the fifth dose of [MEDICATION NAME] on 7/6/19 as per physician's orders [REDACTED]. 7/8/19 approximately 5:00 PM - Findings were reviewed with E2 (former DON). 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED). 2. Review of R44's clinical record revealed the following: 6/5/19 - A physician's orders [REDACTED]. According to the (MONTH) 2019 MAR, the Eliquis was timed to be administered at 9:00 AM and 6:00 PM. 7/2/19 10:35 AM - A physician's orders [REDACTED]. Review of the eMAR revealed that the 7/2/19 9:00 AM Eliquis dose had already been given prior to the order being written. Review of the eMAR revealed that the Eliquis was held on: - 7/2/19 at 6:00 PM; - 7/3/19 at 9:00 AM and 6:00 PM; - 7/4/19 at 9:00 AM and 6:00 PM; - 7/5/19 at 9:00 AM. This was a total of three (3) days or six (6) doses held. According to the physician's orders [REDACTED]. 7/8/19 2:29 PM - During an interview with E6 (NP) regarding the order to hold Eliquis for 2 days, written on 7/2/19, E6 confirmed that he/she would have expected it to be resumed on 7/4/19 with the 6:00 PM dose. 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED). 3. Review of R48's clinical record revealed: A facility policy and procedure entitled Physician order [REDACTED].To strive to ensure that physician orders [REDACTED]. Procedure: 1. The licensed nurse receiving a hand-written physician order [REDACTED]. b. Enter the physician order [REDACTED]. 2. In order to double check that orders were not overlooked and are accurate in the electronic application order entry process, within twenty-four (24) hours, a second licensed nurse shall review the hand-written transcribed and newly entered physician orders [REDACTED]. Notify the physician as to the physician order [REDACTED]. Transcribe the correct order on the electronic health record application. 5/28/19 - R48 was admitted to the facility. 5/30/19 - A handwritten physician's orders [REDACTED]. The facility failed to transcribe the 5/30/19 physician's orders [REDACTED]. 5/31/19 - Review of R48's 24 Hour Chart Check form, performed on the 11 PM to 7 AM shift, revealed a blank space in the Initials column on 5/31/19 where a nurse signs off that it was completed. The facility failed to perform a 24 hour chart check on 5/31/19. 6/1/19 - The handwritten 5/30/19 physician's orders [REDACTED]. Although the 24 Hour Chart Check wasn't completed on 5/31/19, a nurse documented under the written order that he/she reviewed it on 6/1/19, but still did not identify the omission. Review of R48's (MONTH) 2019 and (MONTH) 2019 eMARs and Physician order [REDACTED]. 7/15/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP) and E16 (ED). The facility failed to transcribe the 5/30/19 physician's orders [REDACTED].",2020-09-01
52,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,689,D,0,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews, and review of facility documentation as indicated, it was determined that for two (R26 and R43) out of four (4) residents sampled for accidents, the facility failed to ensure that adequate supervision and assistance was provided to prevent accidents. For R43, the facility failed to complete a Physical Therapy (PT) evaluation post fall on 10/22/18 and failed to ensure that R43 was not left alone while toileting on 4/9/19. R43 fell when left alone in the bathroom and sustained a skin tear to the top of his/her right hand. For R26, despite a care plan for 2 - person transfer assist, an unsafe 1-person stand/pivot transfer was performed when R26 fell from the bed to the wheelchair on 2 occasions. R26 had another fall when R26's bed was not in the lowest position. Additionally, the facility failed to ensure adequate supervision and failed to follow R26's toileting plan when R26 fell while being assisted by his/her spouse off the toilet in the bathroom. R26 had 11 falls in 4 months from (MONTH) through (MONTH) 2019. Findings include: 1. Review of R43's clinical record and facility documents revealed the following: 10/22/18 - The facility's Incident Report stated, .in gym with fitness instructor. While transferring from w/c (wheelchair) .lost his/her balance and hit his/her head . The facility's Quality Assurance Report, dated 10/23/18, stated that as part of the corrective action, a PT evaluation would be completed. Review of the clinical record, including PT notes, lack evidence of a therapy evaluation being completed after R43's 10/22/18 fall. 4/3/19 through 4/6/19 - R43 was hospitalized . 4/6/19 approximately 3:00 PM - R43 was readmitted to the facility. 4/7/19 3:19 PM - A Rehabilitation Note stated, DOR (Director of Rehabilitation) asked by charge nurse to assist in establishing transfer status for resident. Current recommendation is for resident to use Hoyer lift with all transfers at this time. Resident is unsafe to perform standing transfers or ambulate until further assessment is completed. Resident and CNA agreeable to recommendation. 4/9/19 7:30 AM - A Rehabilitation Note stated, PT eval (evaluation) completed 4/8/19, recommend continuing with Hoyer lift at this time and having resident use WC for all mobility on and off unit. 4/9/19 6:40 PM - A progress note stated, Writer was called .to find resident sitting on his/her bottom with back towards wall facing toilet .Resident noted with skin tear to top of right hand measure (sic) at 1.5 cm . 4/9/19 - A written statement, completed by E21 (CNA), stated R43 was transferred to the toilet and R43 stated he/she wanted to sit for a few minutes to have a bowel movement. E21 wrote that he/she left the resident and went down the hall to get some wipes. E21 wrote that by the time he/she returned, R43 had attempted to get up even after I had told him/her to wait for me and not to get up before leaving the room, he/she had agreed. 4/10/19 - The facility's investigation stated, .Resident was transferred to the toilet using the full mechanical lift (Hoyer lift) and 2 person assist. Lift was removed from in front of the resident to give more space to provide care. New CNA left resident to get wipes in the hall, when he/she returned the resident was on the floor. The resident appears to have attempted to self transfer and lost his/her balance and fell to the floor .The CNA was given extensive education on not leaving a resident in the bathroom without supervision and to make sure he/she has all necessary supplies prior to toileting/transferring a resident. 7/8/19 approximately 4:45 PM - Findings were reviewed with E2 (former DON). 7/8/19 4:53 PM - During an interview, E15 (OT) stated that anyone requiring a Hoyer lift transfer usually had poor standing and/or sitting balance. E15 agreed that R43 should not have been left unsupervised on the toilet on 4/9/19. The facility failed to ensure that a PT evaluation was completed post fall on 10/22/18, and failed to ensure that R43 had adequate supervision on 4/9/19. Instead, facility staff left the resident alone in the bathroom when he/she attempted to self transfer resulting in a fall and a skin tear. 7/9/19 approximately 8:15 AM - During an interview, E1 (NHA) and E2 (former DON) provided documentation of a PIP (Performance Improvement Plan) and stated that they self identified having issues with falls in the facility. They stated that although they continue to have resident falls, they have not had a fall due to a resident being left alone in the bathroom since R43's 4/9/19 fall. 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED). 2. Review of R26's clinical record revealed the following: R26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk care plan was initiated on 1/27/18 identifying that R26 was a fall risk related to a history of falls, leg pain and weakness. Interventions included: - Anticipate and meet the resident's needs. - Be sure the call light is within reach and encourage the resident to use it for assistance as needed .Prompt response to all requests for assistance. - Ensure that the resident is wearing appropriate footwear when ambulating (walking) or mobilizing in wheelchair. - Needs a safe environment with even floors, free from spills and/or clutter; adequate glare-free light; a working and reachable call light, the bed in a safe position for transfers with wheels locked, personal items within reach. - Remind the resident to request assistance for all transfers and mobility. - Ensure bed height is lowered to appropriate level for safe exit/entry and not too high to reduce risk of serious injury. 2/1/18 - The admission MDS assessment stated that R26 was moderately cognitively impaired (decisions poor; cues/supervision required), required extensive assist of one staff person for transfers, and had no falls since admission. 2/12/18 - R26's care plan for bladder incontinence was developed related to dementia and impaired mobility with interventions including staff should supervise and offer toileting every 2 hours during waking hours and check and change as needed due to occasional incontinence. 1/22/19 - A Nursing fall risk evaluation score was high risk at 16. 1/23/19 - A Significant change MDS assessment revealed that R26 was severely impaired and exhibited rejection of care with worsening verbal and physical behaviors. R26 required two+ staff person extensive assist for transfers and had 2 falls without injury. 2/1/19 - A care plan intervention on the problem ADL (Activities of Daily Living) self care performance deficit was added indicating the need for 2 person assist at times to transfer and move in bed. Review of R26's fall incident/investigation reports, nursing progress notes, physician orders [REDACTED]. Fall # 1 2/24/19 at 12:00 PM - R26 fell during a transfer from the bed to a chair with assist from his/her CNA and obtained an abrasion on the left knee. The IDT (Interdisciplinary Team) who reviews falls, noted for PT to screen the amount of assistance appropriate for safe transfers for R26. R26 required 2+ persons for transfers according to his/her significant change MDS, dated [DATE]. There was no evidence that PT screened R26 after his/her fall on 2/24/19. The facility failed to follow the care plan for 2 person transfer. Fall # 2 3/10/19 at 8:45 PM - R26 stated he/she fell out of bed. R26 was trying to transfer himself/herself and was found on the floor on his/her left side. R26's bed was not in the lowest position. R26 was last observed at 8:30 PM resting in bed. Interventions added after the fall included adhering to R26's toileting schedule every 2 hours, offer hipsters, fall mats beside the bed and a pharmacy review. The facility failed to follow R26's care plan for appropriate lowered bed height for safe exit/entry. 3/11/19 - A PT screen status [REDACTED]. 4/15/19 - A PT quarterly screen indicated no skilled services were warranted at this time .continue to recommend 2 person transfers. Anti rollbacks were recently applied on the wheelchair and the wheelchair brakes were tightened. 4/17/19 - A quarterly MDS assessment stated that R26 remained severely cognitively impaired and he/she continued to exhibit rejection of care. R26 required two+ staff person extensive assist for transfers. Since the prior assessment on 1/23/19, R26 had three falls, two falls without injury and one fall with minor injury. 4/18/19 - The following care plan interventions were initiated, .staff to toilet and offer to return to bed for nap at mid - morning, continues to be insistent on performing own tasks and adhering to his/her preferences and self propels in wheelchair back to his/her room regardless of staff redirection. 4/19/19 - A Nursing fall risk evaluation score remained high risk at 14. Fall # 3 5/1/19 at 11:07 AM - R26 slid to the bathroom floor while being assisted off the toilet by his/her spouse. R26 had sock on only. A CNA (E25) witness statement summary documented that the last time R26 was cared for or toileted was on the 11-7 shift. E25 stated, Resident was in bed prior to shift change and during rounds. Was with another resident when spouse stopped me in the hall stating that resident was on the floor. Did not witness fall but notified the nurse .he/she was in the bathroom on the floor in front of the toilet. The fall investigation worksheet documented safety education to spouse and footwear - non skid socks to be in place. There was no evidence indicating that R26 was asleep during E25's rounds. The facility failed to follow R26's toileting care plan for staff to supervise and offer toileting every 2 hours during waking hours and check and change as needed for occasional incontinence. 5/1/19 at 4:15 PM - A PT screen post fall recommended when staff were assisting that the arm rest of the wheel chair be removed and the bed leveled to the chair to minimize the loss of R26's center of gravity and minimize muscular demand as opposed to the bathroom where a railing was available and R26's stability was greater. 5/1/19 - The following care plan interventions were initiated, .continue toileting schedule, monitor for non skids socks when not wearing shoes, 2 person transfer and staff to remove arm rest when able for stand pivot transfer. 5/1/19 - The CNA Kardex documented 2 person transfers - and staff to remove arm rest when able for stand pivot transfer .ensure proper footwear when out of bed and gripper socks when in bed .staff to provide more assistance with dressing, personal hygiene and toileting needs now .keep bed at lowest setting when in bed .obtain and encourage use or wear hip savers. 5/5/19 - The care plan intervention Offer to lay resident down after meals was initiated. 5/7/19 - The care plan intervention Request labs check to r/o (rule out) clinical issue that may add to fall risk was initiated. 5/28/19 - The care plan interventions Keep bed at lowest setting when in bed and obtain and encourage the wear of hip savers were initiated. Fall # 4 6/9/19 at 7:30 AM - R26 was being transferred from the bed into the wheelchair with stand/pivot transfer when R26 slid to the floor from the wheelchair. Predisposing factor included staff handling and gait imbalance. A witness statement was obtained from the CNA who performed the transfer. The facility fall investigation worksheet revealed that the actual transfer when the fall happened was with one staff person (required two). The CNA ADL flowsheet dated 6/9/19 at 11:23 AM documented extensive assist of one person. There was no evidence that two staff person assist was performed during the transfer. Interventions included the Nurse Practitioner was to evaluate for possible labs and a PT evaluation. The facility failed to transfer R26 according to the plan of care. 6/17/19 - A Physician ordered a PT evaluation for the recent fall (6/9/19). 6/21/19 at 6:13 PM - A PT note documented that R26 required extensive assistance of two persons for transfers with a gait belt to help secure R26's safety and stability. 7/9/19 at 2:21 PM - During an interview, E7 (RN) stated that R26 used to ambulate with a walker before his/her increasing left leg pain that caused a decline. R26's increased weakness and agitated behavior made it very difficult for staff during transfers and care. He/She was seen by rehab and had a transfer status change from one person assist stand pivot turn (stand pivot transfer), to two person extensive assist. Sometimes we use the total hoyer lift or the stand up lift to transfer him from bed to wheelchair or whenever we pick him up from the floor. He/She has a lot of falls. The amount of help needed is very inconsistent depending on his/her mental status and his/her ability to help himself/herself on that particular shift or day. 7/9/19 at 2:46 PM - During an interview, E9 (PT) stated that R26 had multiple falls mostly occurring in his/her room recently. When asked if R26 was a hoyer lift or a stand up lift transfer candidate based on feedback from nursing staff, E9 replied that resident is not a lift (Hoyer and/or Stand Up lift) transfer candidate and that resident can display transfers from wheelchair to bed a low (sic) pivot with intermittent trouble clearing armrest and needs 1-2 person maximum assistance for transfers. E9 also added that the wheelchair armrest be removed and the bed leveled to chair to minimize the loss of his/her center of gravity. 7/9/19 at 3:10 PM - In an interview, E10 (CNA) stated that R26 does not use the call bell and does not ask for help when needing assistance with transfers to the bed or to the bathroom. E10 further stated that another aide would have to come with her when she does morning care because of R26's combative behavior. 7/11/19 at 9:59 AM - E10 (CNA) revealed to the surveyor that, We use the total hoyer lift when we transfer him/her from bed to the wheelchair because he/she is very heavy. I think it is in our CNA task. That's how we transfer him/her every time I am assigned to take care of him. When asked about monitoring R26 for safety, E10 stated that R26 frequently stays in the activity room or self propels his/her wheelchair in the hallways. Furthermore, E10 stated, When I see him/her in the hallway, I would ask him/her if he/she wants to use the bathroom, and most of the time he/she would answer, 'No.' If I smell him/her of BM (bowel movement) or urine I will take him/her back to his/her room to change. The facility failed to ensure that the environment was free from accident hazards when: - On 2/24/19 at 12:00 PM, R26 had an unsafe transfer from the bed to the wheelchair when one CNA was providing assistance, instead of two staff that were required, which resulted in a fall with a left knee abrasion. - On 3/10/19 at 8:45 PM, R26 fell out of bed and the bed was not in the lowest position, despite R26 being at high risk for falls. - On 5/1/19 at 11:00 AM, R26 slid to the bathroom floor while being assisted off the toilet by his/her spouse. R26 was last toileted by the 11-7 shift. The facility failed to follow R26's toileting care plan for staff to supervise and offer toileting every 2 hours during waking hours and check and change as needed for incontinence. - On 6/9/19 at 7:30 AM, R26 had a fall due to an unsafe transfer from the bed into the wheelchair with 1 staff person extensive assist, despite the care plan and rehab recommendation for 2 person extensive assist with transfers. Findings were reviewed with E1 (NHA), E2 (former DON), E3 (Acting DON), E6 (NP), and E16 (ED) during the Exit Conference on 7/15/19 at approximately 12:30 PM.",2020-09-01
53,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,730,D,0,1,N66611,"Based on facility document review and interview, it was determined that the facility failed to complete an annual performance review for one (E20) out of five (5) CNAs reviewed. Findings include: Review of E20's employee documents revealed: 3/8/18 - E20's date of hire. There was no annual performance review provided by the facility for E20. 7/15/19 8:55 AM - During an interview, E4 (ADON) confirmed there was no performance review for E20. 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED).",2020-09-01
54,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,755,D,0,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and review of facility documentation as indicated, it was determined that for one out of one death record review, the facility failed to provide routine pharmaceutical services to meet the needs of R48. Findings include: The facility pharmacy's policy entitled LTC Facilities: Receiving Pharmacy Products and Services from Pharmacy, last revised on 1/2/13, stated, .Procedure . 3. The pharmacy will provide new routine and PRN medication orders the same day, unless the medication would be started until the next day. 5/28/19 - The hospital's Medication Orders Upon Discharge stated to administer to R48 the following medications: [REDACTED] - [MEDICATION NAME] (inhaler) twice a day, Next Dose Due: tonight 5/28; - Lacosamide (anti-[MEDICAL CONDITION]) twice a day, Next Dose Due: tonight 10 PM 5/28; - [MEDICATION NAME] (antipsychotic) at bedtime, Next Dose Due: tonight 5/28 10 PM. 5/28/19 at approximately 12:00 Noon - R48 was admitted to the facility. 5/28/19 - R48's physician Order Recap Report also stated that Calcium-Vitamin D (dietary supplement) and a nasal spray were ordered. 5/28/19 - Review of R48's (MONTH) 2019 eMAR and corresponding Order-Administration Notes revealed: - R48 did not receive [MEDICATION NAME], Lacosamide, [MEDICATION NAME], Calcium-Vitamin D and nasal spray at 8 PM as the facility was waiting for the pharmacy to deliver the medications. - At 8:58 PM, R48's [MEDICATION NAME] was discontinued by E6 (NP) for a generic equivalent medication, Breo Ellipta (inhaler), for a [DIAGNOSES REDACTED]. It was unclear in R48's clinical record why the Breo medication was ordered to start on 5/30/19 and not 5/29/19. 5/29/19 at 1:27 AM - The pharmacy's Proof of Delivery report for R48 revealed that Lacosamide, [MEDICATION NAME], nasal spray, Breo Ellipta, and Calcium with Vitamin D were delivered to the facility at this time. 5/29/19 - Review of R48's (MONTH) 2019 eMAR and corresponding Order-Administration Notes revealed: - At 8:45 PM - An Order-Administration Note, written by E24 (RN), for R48's Lacosamide stated, .Not delivered yet from (name) pharmacy. Despite having received the Lacosamide medication from the pharmacy on 5/29/19 at 1:27 AM and R48 receiving her 8 AM dose, R48 was not administered the medication at 8 PM. 7/11/19 at 9:26 AM - During an interview, E5 (Physician) stated he/she was told about R48's missing doses of his/her [MEDICAL CONDITION] medication at a later time. 7/11/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (interim DON) and E6 (NP). The facility failed to provide routine pharmaceutical services to meet the needs of R48.",2020-09-01
55,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,758,D,0,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and interviews, it was determined that for one (R42) out of six (6) residents sampled for medication review the facility failed to ensure R42's PRN [MEDICATION NAME] (anti-anxiety medication) physician's orders [REDACTED]. Findings include: Review of R42's clinical record revealed the following: 6/11/19 - The original physician's orders [REDACTED]. 6/24/19 - An order was written to renew R42's PRN [MEDICATION NAME] for seven (7) days. 7/2/19 - An order was written to renew R42's PRN [MEDICATION NAME] for 14 days. The facility failed to ensure that when the PRN [MEDICATION NAME] orders were renewed on 6/24/19 and 7/2/19 for R42, a corresponding note documenting the rationale to extend the medication was not completed by the prescribing practitioner. 7/8/19 approximately 5:00 PM - Findings were reviewed with E2 (former DON). 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED).",2020-09-01
56,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,760,D,0,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews and review of facility documentation as indicated, it was determined that for one out of one death record review, the facility failed to ensure that R48 was free of any significant medication errors. R48 missed an 8 AM dose of an intravenous (IV) antibiotic, [MEDICATION NAME], on 5/30/19 due to the facility not having enough IV tubing equipment on hand to administer the medication. Despite the facility receiving Stat (immediately) IV tubing from the pharmacy at 12:38 PM, the facility retimed R48's next dose for 6 PM, which resulted in a further delay of treatment. R48 received the next dose at 6:30 PM, approximately 6 hours after the Stat IV tubing was delivered. Findings include: The facility's pharmacy policy entitled LTC Facilities: Receiving Pharmacy Products and Services from Pharmacy, last revised on 1/2/13, stated, .Procedure .4. The pharmacy will provide stat medication orders that are not available in the facility's emergency drug supply within one hour of the time ordered during normal pharmacy hours . Review of R48's clinical record revealed: 5/28/19 - The hospital's Medication Orders Upon Discharge for R48 stated to administer [MEDICATION NAME] intravenously every 12 hours. 5/28/19 at approximately 12 Noon - R48 was admitted to the facility for IV antibiotic therapy status [REDACTED]. 5/28/19 - A physician's orders [REDACTED]. 5/30/19 at 8 AM - Review of R48's (MONTH) 2019 eMAR revealed that the resident's IV antibiotic, [MEDICATION NAME], was not administered at 8 AM. 5/30/19 at 8:56 AM - A nurse's note stated, NP (E6) made aware of missing IV tubing. Pharmacy called and new IV tubing to be sent out STAT. 5/30/19 at 12:38 PM - The pharmacy's Proof of Delivery record revealed that R48's IV tubing was received by the facility at 12:38 PM. 5/30/19 at 2:08 PM - An Order-Administration Note for R48's IV antibiotic [MEDICATION NAME] stated, .Waiting for pharmacy. 5/30/19 at 2:41 PM - A nurse's note stated, .Unable to give 0900 (9 AM) abt. (antibiotic) DR (doctor) made aware. Tubing arrived. Dosage schedule has changed . Despite the delivery of the Stat IV tubing at 12:38 PM according to the pharmacy's record, the facility did not administer R48's IV antibiotic. 5/30/19 at 6 PM - R48's (MONTH) 2019 eMAR revealed that the timing of the resident's IV antibiotic was changed from 8 AM and 8 PM to 6 AM and 6 PM. 5/30/19 at 6:30 PM - An Order-Administration Note revealed that R48 received the IV antibiotic. The facility delayed R48's IV antibiotic treatment 6 additional hours after the Stat IV tubing was delivered to the facility. 7/10/19 at 9:03 AM - During an interview, E2 (former DON) stated that the hospital sent R48's discharge information to the facility on Friday, 5/24/19. E2 stated that E4 (ADON) reviewed everything to ensure the facility had everything in place for R48 before he/she was admitted on Tuesday, 5/28/19. E2 stated that the pharmacy provided all IV equipment, including the IV pump, IV tubing and IV medication. 7/10/19 at 2:36 PM - During a combined interview with E2 (former DON) and E4 (ADON), when asked about the missing IV antibiotic dose due to the lack of IV tubing available, E2 confirmed that the facility should have had an emergency backup of IV tubing and he/she had addressed this with the pharmacy. E4 stated that the pharmacy told her the delivery would be in 4 hours for the Stat request. 7/11/19 at 12:30 PM - Findings were reviewed during the Exit Conference with E1 (NHA), E2 (former DON), E3 (interim DON) and E6 (NP). The facility failed to ensure that R48 was free of any significant medication errors when R48 missed an 8 AM dose of an IV antibiotic on 5/30/19 due to the facility not having enough IV tubing equipment on hand to administer the medication. Despite the facility receiving Stat IV tubing from the pharmacy at 12:38 PM, the facility retimed R48's next dose for 6 PM, which resulted in a further delay of treatment. R48 received the next dose at 6:30 PM, approximately 6 hours after the Stat IV tubing was delivered.",2020-09-01
57,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,812,F,0,1,N66611,"Based on observations and interviews, it was determined that the facility failed to properly prepare, store, and serve food in a sanitary manner. Findings include: During the kitchen inspection on 7/1/19 from 11:00 AM - 12:00 PM, it was observed that the floor tiles and grout throughout the facility were in disrepair. The holes in the corner of walls from the broken tiles will create opportunities for pests to infest the kitchen. Furthermore, it was observed that the ceiling tiles at the food service area were greasy and porous. The ceiling must be easily cleanable to reduce contamination from daily wear and tear. Findings were reviewed and confirmed with E18 (Food Service Director) on 7/1/19 at approximately 12:00 PM. Findings were reviewed with E1 (NHA) on 7/3/19 at approximately 3:00 PM.",2020-09-01
58,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,867,E,0,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on reviews of one (R48) death record and 43 current residents' records, interviews and review of facility documentation as indicated, it was determined that the facility's Quality Assessment and Assurance Committee failed to identify a system failure to follow the facility's DNR policy and procedure that was in place since ,[DATE] to ensure completion of 7 (R1, R3, R8, R14, R17, R33 and R48) residents' code status. Findings include: Cross refer to F678 Review of R48's clinical record revealed that on [DATE], R48 had an acute medical event and was found on the bedroom floor at 4:56 AM. Facility staff did not initiate CPR as R48 was a DNR according to what was listed in R48's clinical record. E19 (RN) called 911 emergency services at 5:13 AM and EMS personnel responded. Despite E19 stating that R48 was a DNR and showing multiple documents to EMS personnel, the facility failed to have the proper DNR paperwork on hand for EMS personnel. The facility's failure to complete R48's code status according to the facility's DNR policy and procedure was identified as immediate jeopardy (IJ) on [DATE] at 3:44 PM. Review of all current residents' clinical records in the facility, as of [DATE], revealed that 6 (R1, R3, R8, R14, R17 and R33) out of 43 residents had incomplete code status documentation. [DATE] at 6:41 PM - A meeting was held with E1 (NHA), E2 (former DON), E3 (interim DON) and E6 (NP). The survey team identified 6 additional residents currently in the facility that had incomplete code status documentation in their clinical records. The facility also conducted an audit of all the current residents and acknowledged that there were incomplete code status issues with some residents. [DATE] at 11:10 AM - During a combined interview with E1 (NHA), E2 (former DON) and E3 (interim DON), when asked if the facility identified a system failure with respect to code status, E1 stated that the QAA Committee talked about having a code status for each resident during QAA meetings. However, E1 stated that the QAA Committee never identified an issue with code status, specifically the failure to follow the facility's DNR policy and procedure. E1 stated that the QAA Committee never developed an official performance improvement plan for code status. [DATE] at 12:30 PM - Findings were reviewed with E1 (NHA), E2 (former DON), E3 (interim DON) and E6 (NP) during the Exit Conference. The facility's Quality Assessment and Assurance Committee failed to identify a system failure to follow the facility's DNR policy and procedure that was in place since ,[DATE] to ensure completion of code status' for 7 residents.",2020-09-01
59,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2019-07-15,881,D,0,1,N66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, it was determined that the facility failed to ensure the appropriate use of an antibiotic for one (R42) out of six (6) residents sampled for medication review. Findings include: The facility policy titled Antibiotic Stewardship, last revised 10/2017, stated .Ensure nursing staff access, monitor and communicate changes in a resident's condition in accordance with a standardized criteria, such as McGreer for residents in long-term care .In collaboration with the medical director help ensure antibiotics are prescribed only when appropriate . The facility policy titled Antibiotic Usage, last revised 7/09, stated .1. The licensed nurses and Infection control coordinator/preventionist will review culture reports upon receipt from the laboratory. 2. The physician will be notified via phone and/or fax of all culture reports . Review of R44's clinical record revealed the following: 6/5/19 - R44 was admitted to the facility post hospitalization . 6/5/19 through 6/6/19 - Review of progress notes revealed that R44 did not have any complaints of pain or discomfort or any elevated temperatures. 6/6/19 - A physician's orders [REDACTED]. It is unclear what prompted the order to obtain the urine specimen, as there was no progress note regarding the issue. 6/7/19 - The UA results were reported stating that R44 had blood in the urine and some bacteria. 6/7/19 - A physician's orders [REDACTED]. 6/8/19 - The urine C&S was reported from the laboratory and revealed that there was no growth after 24 hours, otherwise stating that R44 did not have a urinary tract infection. There was no documented evidence that the physician was notified of the urine C&S results. 6/10/19 - Review of the urine C&S laboratory report sheet revealed it was noted as reviewed on 6/10/19, however, there were no additional orders written and no progress note written justifying continued use of the antibiotic in the presence of a negative culture. 6/27/19 8:35 AM - A progress note stated, .14 day MDS completed: resident was being treated for [REDACTED]. The facility failed to discontinue R44's [MEDICATION NAME] when the negative culture was reported on 6/8/19. R44 received [MEDICATION NAME] 100 mg twice daily from 6/7/19 through 6/17/19 without an indication for use and in the presence of a negative culture report. The facility failed to implement their antibiotic stewardship program. 7/8/19 approximately 5:00 PM - Findings were reviewed with E2 (former DON). 7/15/19 approximately 12:30 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (former DON), E3 (acting DON), E6 (NP), and E16 (ED).",2020-09-01
60,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2018-07-18,656,D,0,1,9EWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that for one (R29) out of 23 sampled residents, the facility failed to develop and implement a care plan to reflect R29's refusal to be placed in bed. Findings include: Cross refer F686 Review of R29's clinical record revealed: R29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R29's 5/21/18 Admission MDS stated that R29 required extensive assistance of two people for bed mobility. R29 was documented as having no unhealed pressure ulcers and was at risk for developing pressure ulcers. The MDS stated that R29 was on a turning and repositioning program. An initial wound assessment from 6/4/18 revealed that R29 had a stage 2 pressure ulcer to his scrotum due to pressure from his wheelchair pummel cushion. An initial wound assessment from 6/18/18 revealed that R29 had a stage 2 pressure ulcer to his sacrum. During an interview on 7/17/18 at 3:20 PM, E3 (ADON) stated that R29 mostly stayed in his wheelchair and refused to get back in bed (where he was to be turned every 2 hours to prevent pressure ulcers). E3 stated that when in bed R29 got anxious because he felt that he was supposed to be up for work. Review of R29's care plan lacked evidence that he refused being placed in bed and preferred to be up in his wheelchair. Findings were reviewed with E2 (DON) and E3 on 7/18/18 at approximately 2:00 PM.",2020-09-01
61,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2018-07-18,658,D,0,1,9EWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that for two (R12 and R17) out of 23 sampled residents, the facility failed to provide services to meet professional standards of quality. Findings include: 1. Review of R12's clinical record revealed the following: R12 received peritoneal [MEDICAL TREATMENT] and received daily weights. R12's average weight was between 150-155 pounds. However, since 11/22/17, there were 99 instances of documented weights of over 10% decrepancy without a re-weight to verify the measurement. 2. Review of R17's clinical record revealed the following: R17 received weekly weights. According to the record, R17's weight on 6/19/18 was 181.5 pounds, 6/23/18 was 300 pounds, and the subsequent weight on 7/3/18 was 183.9 pounds. No re-weigh was done on 6/23/18 to confirm the major change in weight. Findings were reviewed and confirmed with E1 (NHA) and E2 (DON) on 7/18/18 at approximately 2:00 PM.",2020-09-01
62,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2018-07-18,686,D,0,1,9EWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of other documentation as indicated, it was determined that for one (R29) out of 23 sampled residents, the facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice. For R29, a dependent resident with pressure ulcers, the facility lacked evidence that R29 was consistently turned side to side to prevent skin breakdown and R29's scrotum pressure ulcer was incorrectly back staged from a stage 2 to a stage 1. Findings include: : The Wound Ostomy and Continence Nurses Society, W[NAME]N Society Position Statement: Pressure Ulcer Staging, Reviewed/Revised on (MONTH) 2011, stated, The staging system, as recommended by the NPUAP and W[NAME]N, does not support down-staging or reverse staging of granulating pressure ulcers. National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED].Continue to turn and reposition the individual regardless of the support surface in use .No support surface provides complete pressure relief .Repositioning the Individual with Existing Pressure Ulcers in a Chair .Minimize seating time .Consider periods of bed rest to promote ischial and sacral ulcer healing .If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischial, limit sitting to three times a day in periods of 60 minutes or less. Review of R29's clinical record revealed: R29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R29's CNA tasks stated that R29 was to be turned and repositioned every 2 hours since admission in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that turning and repositioning was not documented for the following: evening shift on 5/16/18, night shift on 5/21/18, Midnight on 5/23/18, Evening shift on 5/25/18, evening shift on 5/28/18, midnight on 5/30/18, day shift after 9:06 AM on 5/30/18, and evening shift on 5/30/18. R29's 5/21/18 Admission MDS stated that R29 required extensive assistance of two people for bed mobility. R29 was documented as having no unhealed pressure ulcers and was at risk for developing pressure ulcers. The MDS stated that R29 had a pressure reducing device for his bed and chair and was on a turning and repositioning program. The care plan for R29 revealed that starting on 5/24/18, R29 had an ADL self-care performance deficit related to [MEDICAL CONDITION] and poor balance. Interventions included that R29 required extensive assistance of staff to be turned and repositioned in bed and required a stand-up lift with staff assistance of 2 for transfers. Review of R29's CNA tasks stated that R29 was to be turned and repositioned every 2 hours in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that turning and repositioning was not documented for the following: night shift on 6/3/18, day shift on 6/3/18, midnight on 6/6/18, Evening shift on 6/6/18, evening shift on 6/9/18, midnight on 6/11/18, night shift on 6/13/18, night shift on 6/14/18, night shift on 6/16/18, 2 PM on 6/17/18, night shift on 6/20/18, evening shift on 6/20/18, night shift on 6/22/18, day shift on 6/23/18, day shift on 6/24/18, midnight on 6/25/18, night shift on 6/27/18, evening shift on 6/27/18, night shift on 6/28/18, midnight on 6/30/18, and 2 PM on 6/30/18. An initial wound assessment from 6/4/18 revealed that R29 had a stage 2 pressure ulcer to his scrotum due to pressure from his wheelchair pommel cushion. On 6/5/18 this cushion was discontinued and a different pressure relieving device for the wheelchair was ordered. An initial wound assessment from 6/18/18 revealed that R29 had a stage 2 pressure ulcer to his sacrum. Review of R29's care plan, last updated on 6/28/18, revealed that R29 had stage 2 pressure ulcers to his scrotum and sacrum and had the potential for pressure ulcer development related to his immobility and incontinence. Review of R29's 6/30/18 30 day MDS revealed that R29 required extensive assistance of two people for bed mobility and transfers. The MDS stated that R29 now had one stage 2 pressure ulcer, a pressure reducing device to his chair and bed, and was on a turning and repositioning program. Review of R29's CNA tasks stated that R29 was to be turned and repositioned every 2 hours in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that turning and repositioning was not documented for the following: day shift on 7/1/18, evening shift on 7/5/18, night shift on 7/6/18, day shift on 7/6/18, night shift on 7/10/18, evening shift on 7/11/18, midnight on 7/13/18, day shift on 7/14/18, day shift on 7/15/18, and night shift on 7/17/18. Review of R29's weekly wound assessment for his stage 2 pressure ulcer to the sacrum revealed that it was closed on 7/2/18, 7/9/18, and 7/16/18. Observations of R29 on 7/11/18 at 12:15 PM, 7/12/18 10:30 AM, 7/12/18 at 3:10 PM, 7/13/18 at 11:15 AM, 7/16/18 at 10:40 AM, 7/17/18 at 2:27 PM, 7/17/18 at 4:00 PM revealed that R29 was observed in his wheelchair with a pressure relieving cushion. There were no observations on these dates of R29 laying in bed. Review of the weekly wound assessment for R29's stage 2 scrotum pressure ulcer revealed that the last assessment was completed on 7/16/18 by E3 (ADON). The documentation showed that R29's scrotum pressure ulcer was not healed and it was a stage 1. During an interview on 7/17/18 at 3:20 PM, E3 stated that R29 mostly stayed in his wheelchair and refused to get back in bed (where he was to be turned every 2 hours to prevent pressure ulcers). E3 stated that when R29 was in bed he got anxious because he felt that he was supposed to be up for work. R29's care plan lacked evidence that he refused being in bed and preferred to be up in his wheelchair. On 7/17/18 at 3:27 PM, E6 (CNA) stated during an interview that she was R29's usual CNA for evening shift and that he was always in his wheelchair, not in bed. E6 stated that R29 would tell staff when he wanted to go to bed. E6 confirmed R29 was not repositioned in the chair. On 7/18/18 at 12:53 PM, wound care was observed of R29's scrotum stage 2 pressure ulcer. During this observation, R29's sacrum pressure ulcer had reopened. E5 (LPN) notified E3 to come back to reassess the area. After wound care R29 was observed to be placed in bed on his back, where his pressure ulcer was located. During an interview on 7/18/18 at approximately 1:10 PM, E5 (LPN) stated that R29 mostly was up in a chair during the day and that he does not typically like to be in bed. E5 stated that R29 moved around in his seat in the chair himself, but he does not get repositioned from side to side. E5 stated that when in bed R29 was to be turned and repositioned every 2 hours. During an interview on 7/18/18 at approximately 2:00 PM, E3 stated that she was aware that it was not correct to back stage a pressure ulcer and it was a mistake to check that box. The facility failed to ensure that R29, a dependent resident with pressure ulcers, was consistently turned side to side to prevent skin breakdown and R29's scrotum pressure ulcer was incorrectly back staged from a stage 2 to a stage 1. Findings were reviewed with E2 (DON) and E3 (ADON) on 7/18/18 at approximately 2:00 PM.",2020-09-01
63,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2018-07-18,756,D,0,1,9EWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to act on irregularities identified during a medication regimen review (MRR) by the pharmacist for one (R29) out of 23 residents sampled. Findings include: Cross refer F758 Review of R29's clinical record revealed: On 5/14/18, a physician's orders [REDACTED]. MRR's were completed by the consultant pharmacist for R29 for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) with identified irregularities on 5/16/18 and 7/10/18. On 5/16/18, the pharmacist recommendation stated that R29 received an antipsychotic ([MEDICATION NAME]), but did not have a supporting indication for use documented. If current therapy was to continue, R29's chart needed to be updated to include: the specific diagnosis/indication that required treatment, and a list of the symptoms or target behaviors. On 6/1/18, E7 (medical director) responded to the pharmacist recommendation and changed the [DIAGNOSES REDACTED]. E7 signed this recommendation on 6/1/18. On 6/8/18 a new order was entered for R29 to receive [MEDICATION NAME] 5 mg 1 tablet at bedtime for depression. On 7/10/18, the pharmacist recommendation stated that R29 received [MEDICATION NAME] for depression without a concomitant anti-depressant. The pharmacist recommended that R29 should have been evaluated for the continued use of [MEDICATION NAME] for depression and if anti-psychotic therapy was to continue, detailed documentation of the specific [DIAGNOSES REDACTED]. E7 responded to the pharmacist recommendation stating to change R29's [MEDICATION NAME] [DIAGNOSES REDACTED]. On 7/13/18, a new order was entered for R29 to receive [MEDICATION NAME] 5 mg 1 tablet at bedtime for [MEDICAL CONDITION]/hallucinations. The facility failed to act on an irregularity identified by the pharmacist during the MRR on 6/1/18 to change R29's [MEDICATION NAME] diagnosis. R29's [MEDICATION NAME] [DIAGNOSES REDACTED]. Findings were reviewed with E2 (DON) and E3 (ADON) on 7/18/18 at approximately 2:00 PM.",2020-09-01
64,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2018-07-18,757,D,0,1,9EWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that for one ( R27) out of 23 sampled residents, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs. Findings include: 1. Review of R27's clinical record revealed: R27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R27 was prescribed an anti-psychotic medication. R27's documentation survey report indicated she was to be monitored for behaviors every shift. Between (MONTH) 23 ,2018 and (MONTH) 15, (YEAR) there were 223 opportunities to monitor R27's behavior. Only 193 opportunities were noted on the behavior documentation survey report, with 30 shifts left blank. There was no evidence that the facility consistently monitored R27's behaviors. Findings were reviewed with E2 (DON) and E3 (ADON) on 7/18/18 at approximately 2:00 PM.",2020-09-01
65,WILLOWBROOKE COURT AT COUNTRY HOUSE,85003,4830 KENNETT PIKE,WILMINGTON,DE,19807,2018-07-18,758,D,0,1,9EWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined that the facility failed to ensure medication regimens were free from unnecessary [MEDICAL CONDITION] medications for one (R29) out of 23 sampled residents. The facility failed to accurately monitor behaviors for [MEDICAL CONDITION] medications for R29. Findings include: Review of R29's record revealed: On 5/14/18, R29 was admitted to the facility with [DIAGNOSES REDACTED]. Review of R29's physician orders [REDACTED]. Review of R29's CNA tasks stated that R29's behavior symptoms were to be monitored every shift since admission in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that behaviors were not documented for the following: day shift on 5/14/18, night shift on 5/14/18, day shift on 5/15/18, evening shift on 5/15/18, evening shift on 5/16/18, night shift on 5/16/18, night shift on 5/21/18, evening shift on 5/25/18, night shift on 5/27/18, evening shift on 5/28/18, and evening shift on 5/30/18. In addition, the only shifts where behaviors were documented was on 5/17/18 day and evening shift, which stated that R29 was repeating movements. All other shifts in (MONTH) (YEAR) documented that R29 had no behaviors observed. On 5/16/18, the consultant pharmacist recommendation stated that R29 received an antipsychotic ([MEDICATION NAME]), but did not have a supporting indication for use documented. If current therapy was to continue, R29's chart needed to be updated to include: the specific diagnosis/indication that required treatment, and a list of the symptoms or target behaviors. On 5/30/18, the facility developed a care plan that stated R29 used [MEDICAL CONDITION] medications related to behavior management. Interventions included to monitor and record the occurrence of target behavior symptoms: combative or aggressive behavior with staff and others and false beliefs/hallucinations. Review of R29's CNA tasks revealed that R29's behavior symptoms were to be monitored every shift in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that behaviors were not documented for the following: day shift on 6/3/28, night shift on 6/3/18, evening shift on 6/6/18, night shift on 6/6/18, evening shift on 6/9/18, night shift on 6/11/18, night shift on 6/13/18, night shift on 6/14/18, night shift on 6/16/18, evening shift on 6/20/18, night shift on 6/20/18, night shift on 6/22/18, day shift on 6/23/18, day shift on 6/24/18, evening shift on 6/27/18, night shift on 6/27/18, and night shift on 6/28/18. All other shifts in (MONTH) (YEAR) documented that R29 had no behaviors observed. On 6/8/18, the physician wrote an order for [REDACTED]. Review of R29's CNA tasks revealed that R29's behavior symptoms were to be monitored every shift in (MONTH) (YEAR). R29's (MONTH) (YEAR) Documentation Survey Report revealed that behaviors were not documented for the following: day shift on 7/1/18, evening shift on 7/5/18, day shift on 7/6/18, night shift on 7/6/18, night shift on 7/10/18, evening shift on 7/11/18, day shift on 7/14/18, and day shift on 7/15/18. All other shifts in (MONTH) (YEAR) documented that R29 had no behaviors observed. On 7/10/18 the consultant pharmacist commented that R29 received [MEDICATION NAME] for depression without a concomitant antidepressant. The consultant pharmacist recommended to evaluate the continued use of R29's [MEDICATION NAME] for depression, and to provide detailed documentation of the specific diagnosis/indication requiring treatment, the symptom criteria/target behaviors, and perform ongoing monitoring of specific target behaviors. The facility failed to document the [DIAGNOSES REDACTED]. Findings were reviewed with E1 (NHA) and E2 (DON) on 7/18/18 at 2:00 PM.",2020-09-01
66,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,583,D,1,0,81S611,"> Cross refer to F761, examples 1 and 2. Based upon observations and interviews, it was determined that for 2 (R10 and R11) out of 11 sampled residents, the facility failed to protect their privacy and confidentiality of their medical records. Findings include: 1. On 4/24/18 at 11:22 AM in the G Wing hallway, the surveyor observed R10's eMAR displayed on the computer screen of G medication cart unattended. E26 (LPN) exited a resident's room and returned to the unattended medication cart. E26 stated that she left her medication cart to respond to a resident calling for help. 2. On 4/24/18 at 5:05 PM in the F Wing hallway, the surveyor observed R11's eMAR displayed on the computer screen of F medication cart unattended. AE4 (LPN) exited a resident's room and returned to the unattended medication cart. AE4 stated that she left her medication cart to assist a resident with toileting. Findings were reviewed with E3 (Staff Educator) on 4/24/18 at 5:15 PM. The facility failed to protect the privacy and confidentiality of R10 and R11's medical records. Findings were reviewed with E1 (NHA) and E2 (DON) on 4/25/18 at 4 PM during the Exit Conference.",2020-09-01
67,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,600,D,1,0,81S611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, clinical record reviews, interviews and review of facility documentation, it was determined that for 2 (R2 and R7) out of 11 sampled residents, the facility failed to ensure both residents were free from abuse. For R2, the facility failed to ensure the resident was free from emotional and verbal abuse during a care conference meeting when facility staff (E7) spoke loudly to R2 and in a demeaning, derogatory manner. Additionally R2 stated that E4 (UM), E8 (SW#1) and E9 (SW#2) mistreated him/her in the meeting. There were a total of 15 staff members present when E7 stated to her staff, in the presence of R2, to keep the activity sheets with you even when you go to the bathroom .wipe you butt . Despite 15 facility staff members being present during R2's care conference, not one stopped the abusive treatment of [REDACTED]. For R7, the facility failed to ensure that R7 was free from emotional abuse when multiple wandering residents entered her room unsupervised causing her emotional distress. Findings include: The facility policy titled, Abuse, Neglect, Mistreatment, Serious Injury, Misappropriation of Property, Injuries of Unknown Origin, last revised 10/14, stated, .POLICY: 1. Brandywine Nursing and Rehabilitation Center (BNRC) affirms that all persons admitted to the facility shall be treated with respect and dignity .Staff shall assure that resident care and treatment is administered in a safe, professional, and humane manner .DEFINITIONS: (1) 'Abuse' shall mean: .b. Emotional abuse which includes, but is not limited to, ridiculing or demeaning a patient or resident, making derogatory remarks to a patient or resident or cursing directed towards a patient or resident, or threatening to inflict physical or emotional harm on a patient . 1. Review of R2's clinical record revealed the following: 2/26/18 - The annual MDS assessment stated that R2 was able to express ideas and wants and was understood, and had clear comprehension and understanding of others' verbal content. The MDS also stated that R2 was independent for daily decision making skills and had no behaviors. 3/14/18 5:16 PM - The facility self reported an allegation of abuse for R2 to the State Agency. This incident report stated, Resident attended his/her quarterly care plan meeting and resident stated that he/she felt intimidated and abused by certain staff in the meeting .DON (E2) and Administrator (E1) interviewed the resident who confirmed his/her perception of the meeting as intimidating and that 'he's/she's always wrong.' Staff members identified have been suspended pending the investigation. Review of the facility's incident report and investigation revealed the following statements: 3/14/18 - A written statement completed by E1 (NHA) stated that he/she had been informed by an anonymous staff person that R2's care conference had been conducted in an inappropriate and disrespectful manner. The statement went on to say that he met in his office with E7 (Activity Director) and the HR (Human Resource) manager (E27). E1 stated he told E7 that staff felt she was inappropriate during the care conference and to prepare a statement of what happened for review. E7 said that she was stern with R2 and he/she was unable to identify staff that 'did not know what to do in activities.' E1 wrote that shortly after, E2 (DON) informed him that E3 (Staff Educator) had spoken with R2 and asked how care plan meeting went? R2 stated 'that he/she felt mistreated by the staff in that meeting.' E1 wrote that he and E2 went to speak to R2. E1 wrote that R2 stated, .the activity staff don't know what they are doing, but again I am always wrong. I feel like people do not want me here. When asked who he/she felt mistreated him/her in the meeting, R2 responded E4 (UM), E7 (AD), E8 (SW#1), and E9 (SW#2). E1 wrote that after the interview he informed E6 (ADON) to begin an investigation and that E4, E7, E8, and E9 were informed they were suspended pending an investigation and to provide written statements. 3/14/18 - A written statement completed by E2 stated, .E3 came to my office visibly shaken and related a discussion she just had with R2 regarding his/her feeling that he/she had been intimidated during care conference and he/she felt he/she had been abused .He/she remarked that 'everyone came in to point out I was wrong' .'they brought in all the activities staff .all of them to tell me I was wrong .' I asked how he/she felt about the meeting and he/she stated 'Intimidated .abused' . 3/14/18 - A written statement completed by E3 stated, .R2 wasn't his/her normal self so I asked him/her if he/she was ok and he/she stated 'no' it was another bad meeting. I asked him/her what meeting .'the monthly meeting' .He/she was visibly upset .R2 stated, ' .just tired of this and they shouldn't have attacked him/her it was wrong and its been going on for years.' At that point I had to ask him/her if he/she felt abused, neglected or mistreated and he/she stated 'Yes.' I told him/her I would be right back and went to find E2 to notify him. 3/14/18 - A written statement completed by E8 (SW#1) stated, .E7 then asked if he had anything for activities. (R2) made a sound and said 'we'd be here forever if I start' .He/she began telling her how she should run/fix her department. R2 then told E7 that several of her staff don't know what activities are going on throughout the day .E7 then called all her staff to the conference room. She asked her staff questions about what R2 reported. She and R2 went back and forth. E9 (SW) and I tried to calm E7. I asked E7 could we let her staff go and they did leave. E4 (UM) borrowed R2's daily calendar and asked him/her what was occurring at a specific time. He/she was unable to recall and E4 explained that it is difficult to remember the entire days activities .E4 asked R2 if he/she is unhappy here, would he/she like us to help him/her find another placement. He/she didn't answer. E9 reminded R2 that he/she hadn't answered E4 and asked what he/she would like us to do . 3/14/18 - A written statement completed by E9 stated, .The AD (E7) asked R2 if he/she had any questions or concerns for activities .R2 stated that when he/she asks activity staff about the activities of the day or about changes he/she often gets 'I don't know' responses. AD explained that all of her staff have a copy of the daily agenda and are aware of the changes. AD asked him/her for specific staff members that have given him/her this response. R2 reports he/she wasn't able to recall. AD called to her department and asked for all of her staff to report to the conference room .The AD was standing and speaking loudly in the conference room .The AD was still standing and stated 'So just take the agenda with you wherever you go. If you have to go to the bathroom take it with you.' This writer attempted to redirect the AD and stated 'Do not take the agenda to the bathroom.' Activity staff members were dismissed and one staff stated 'Just fold it up and put it in your bra' .UM (E4) asked R2 if she could see his/her daily agenda as he/she also reported during care conference that he/she highlights which activities are of interest .UM asked R2 what the 3:45 activity is. R2 attempted to state the activity but the UM informed R2 that he/she was wrong. He/she attempted 2 more times with the incorrect answer. R2 stated 'pick an activity I have highlighted.' UM informed R2 that the 3:45 activity is one he/she has picked. UM stated 'See (name of R2) . It is not that easy to remember the daily agenda.' UM then discussed with R2 that 'Since he/she is not happy here is there another facility he/she would like a referral too (sic)' . 3/14/18 - A written statement completed by E4 (UM) stated, As I was coming down the hall to enter the conference room E9 (SW#2) walked past me and made a comment that it was getting heated in there .E7 (AD) was stand (sic) and speaking loudly at R2 regarding activities. R2 was concerned about staff not knowing the activity schedule when he/she asks them .activity staff and E9 began entering the conference room .Concerned this was continuing to escalate I tried to speak to R2 .at this point E7 and E8 (SW#1) began speaking loudly again. E7 was still standing leaning over the table .E8 stated they have done everything possible and bend over backwards for him/her .At this point I cut in and said to R2 I believe you and I have formed a good relationship and I see you aren't happy what is it we can do to make you happy or are you not happy here anymore? E8 spoke up and said she could help him/her with referrals near family .or another facility in Wilmington. E9 (SW#2) asked him/her to answer my question and he/she said he/she wasn't sure. He/she said he/she needed to speak to his/her family. E9 said he/she is alert and able to make his/her own choices in care. He/she repeated he/she wanted to talk to family .E8 stated he/she had spoken to family before .and since his/her two family members could never make it in the same time because he/she insisted on their presence it was never completed .He/she looked at his/her schedule for a bit and a comment was made about him/her not knowing what he/she wanted to do, I do not recall which staff member said this . 3/14/18 - A written statement completed by E10 (RD#1) stated, .R2 stated that his/her meals still were not correct .E8 (SW#1) stated that staff have 'bent over backwards' to ensure his/her order was correct .E7 (AD) asked R2 if he/she had concerns about the activities .R2 stated the activities staff do not know what activities are occurring when he/she asks them, and he/she expressed he/she does not like when the location of the activity is changed because he/she has to move to the different room .E7 raised her voice .E7 continued to speak with a raised voiced (sic) which continued throughout the Care Conference until about when her staff exited the conference room and asked R2 'Who doesn't know what's going on in activities?' R2 stated he/she didn't want to give names. E7 stated 'Why not? I want to know who doesn't know what's going on.' E7 stood abruptly .she wanted all of her staff to come to the conference room .E7 stated to her staff with a mocking tone of voice 'R2 thinks you all don't know the activity schedule.' The statement went on to say that E7 asked each activity staff aide if they knew what they were doing today. Finally one activity aide stated she did not know and would have to look at the daily activities sheet. E4, E8, and E9 stated to R2 that it would be difficult for any staff member to memorize the entire day's schedule of activities.E7 stated to her staff with a continued mocking tone of voice 'You all need to keep this sheet with you every day including going to the bathroom. If you're going number two, wipe your butt with it, I don't care. You need to have it' .At the end, R2 had mentioned carrying the daily activities schedule around with him/her so that he/she could remember. E7 sarcastically responded 'Oh really? Hmmm, you don't remember, huh?' R2 stated 'When you get to be my age you see how much you remember.' 3/15/18 - An emailed statement from E7 (AD) stated, .Activity Director did request Activity Assistants to join in the conference so that R2 could better identify the staff that he/she was accusing of not knowing the activities for the day. Resident was unable to do so. During care conference, R2 fluctuated between his/her concerns stating that the activities were horrible then saying they were great. Due to Resident being unhappy with the service at Brandywine, E4 (UM) asked if he would like to return to the community with the assistance of a state assisted program and R2 avoided the question. Question was asked multiple times before a response was given . 3/15/18 - Review of a typed statement, dated 3/15/18, revealed that E6 (ADON) conducted an interview with R2 regarding the 3/14/18 care conference. The following was stated during the interview: - A discussion began about activities and R2 stated that activity staff doesn't know what activities are scheduled for the day or where they are; - R2 stated that E7 (AD) didn't like being told certain things and the next thing he knew was all activity staff came in the conference room; - When asked how that made him/her feel, he/she stated it felt like everyone thought he/she was lying; - R2 said he/she felt terrible because they think I'm a liar; - When asked if he/she felt abused, neglected or mistreated and he/she said just felt terrible; - When asked how E8 (SW#1) made him/her feel, he/she stated .terrible like she always does when I talk to her .it's either her way or no way .just like during resident council meetings. She doesn't give you a chance to talk, runs over what you're saying and closes the meeting out because it can't run for too long; - When asked how E9 (SW#2) made him/her feel, he/she stated .terrible, she follows the lead, she's just like E8 but wasn't that way when she first came here .; - When asked if E4 (UM) made him/her feel terrible, he/she stated, no because she didn't say that much, E4 spoke, not too much in my favor; - When asked how E7 made him/her feel, he/she stated, .terrible .feels that everybody thinks he's/she's lying, and that it's frustrating every day, like they want him/her out of here; - When asked if he/she were to see E7, E8, E9, E4, or E10 (RD) in the hallway would he/she feel uncomfortable and he/she stated no. The ADON wrote, .R2 was not on trial but when he/she expressed that activity staff did not know the schedule or schedule changes the activity staff were called to the conference room for R2 to identify the staff he/she was 'accusing.' The resident clearly states that the quarterly care conference caused the resident to feel 'terrible, that everyone thinks I'm a liar' and that R2 is always wrong. The staff in question did not follow the BNRC policy and procedure for abuse, neglect, mistreatment .The resident was not treated with respect and dignity. Emotional abuse includes ridiculing or demeaning a resident, making derogatory remarks to a resident, cursing directed to a resident. Treating a resident in a nursing home in a manner that does not uphold a residents self worth and individuality . 3/16/18 - A written statement completed by E14 (AA) stated, .Act. (Activity) Director was with resident and a few other workers as she proceed (sic) to ask me a question which I gave her my answer .Afterwards she began to speak with the resident where there (sic) conversation got little (sic) heated. Act Director said something not so friendly to/in reply to the resident as the conversation gotten (sic) little out of control . 3/16/18 - A written statement completed by E17 (AA) stated, Myself and a few other staff members were called to the conference room .E7 (AD) to my view point very abusively was telling R2 that her staff members do not normally carry our newsletters everywhere we go. However in a very harsh manner she than (sic) told us to carry our newsletters everywhere we go, even if going to the rest room. She sarcastically told us to wipe with it .She continued raising her voice at the resident. R2 was trying to interrupt but the ladies (E7, E9 (SW#2) and E8 (SW#1)) did not let him and continued to try to explain themselves .in my heart I was very upset that I did not have the ability to interrupt the conversation to calm everyone down. 3/16/18 - A written statement completed by E18 (AA) stated, .Several of the activities staff came in and I felt like we were unwittingly ganging up on R2. E7 (AD) was talking loud and arguing with R2 about people not carrying their daily sheets .She (E7) yelled to R2 so you want me to tell my staff to take the daily sheet/clipboard where ever they go? .Shall I have them take it in when they pee? .E8 (SW#1) I believe said something then. Shall I have them take it in when they have a bowel movement. Okay, I'll have them do that and they can wipe their butts on it. At which point I said eew (sic) loud enough for her to know she had gone too far. Even before that comment I was ready to walk out in protest. E7 was obviously feed (sic) up, but she handled it inappropriately. Being disrespectful, rude and crude. At one point E7 mentioned how R2 forgets sometimes. And he/she said he/she did not. E8 said yes you do, in your last testing you had forgotten some things. I felt that this had little to do with the conversation and could have been talked about more privately with out so many activities people in the room. 3/16/18 - A written statement completed by E19 (AA) stated, The activities staff was summoned to the conference room by a call from E7 (AD). Her tone was inpatient/upset .E7 was very agitated and began raising her voice, not only to R2. She said that we should take our clipboards to the bathroom with us and wipe out butts with it. E8 (SW#1) at one point asked E7 to 'reel it in' but the agitation continued. At one point someone, either E9 (SW#2) or E8, asked R2 what was going on that day at 3:00. He/she wasn't able to answer the question, and the point was made that how were we supposed to have it memorized. In my opinion esp.(especially) E7's tone was very abusive to this resident and it was unprofessional and embarrassing . 3/17/18 - A written statement completed by E16 (AA) stated, We were called up into the conference room .She (E7) then started to ask R2 questions about the newsletters being very unprofessional say (sic) things on how we should keep out newsletters . 3/19/18 - A written statement completed by E11 (AA) stated, .Upon our arrival staff was questioned about the daily schedule .Inappropriate comments from management were made towards residents concern. I'm unsure the reasoning why activity staff was needed and was quit (sic) shocked as to the behavior from management . 3/19/18 - A written statement completed by E12 (AA) stated, .During the meeting management made inappropriate comments towards the resident . 3/19/18 - A typed and signed statement was completed by E13 (AA) and stated, I was call (sic) to the care plan meeting by Activity Director (E7) .I ask (sic) a question why are we in here this is a mess I think the meeting went to a point that it should not have been and things got a little out of hand. E7 was a little upset with the Resident. 3/20/18 - A written statement completed by E15 (AA) stated, .When I entered the room there were several people all ready there sitting around the table. All the activity assistants, E8 (SW#1), E9 (SW#2), E10 (RD), and R2. E7 was standing on the opposite side of R2. Her voice was raised loudly directed to R2 .E7 shouted to R2 'All the activity staff are here. Now point out which one you are having a problem with concerning the activity schedule.' R2 was very quiet when he/she spoke. She (E7) got louder and louder toward R2 .This incident was the exact opposite of what we were taught or how a caregiver should conduct their encounter with a resident. R2 was not being treated with respect, consideration or dignity. One very inappropriate comment E7 made that really stuck in my mind was 'from now on all the activity staff will have their schedule and clipboards with them everywhere. They will have to take it to the bathroom when they pee and for all I care they can wipe their butts with it!' I felt shocked, dumbfounded and frozen to my seat. I could not believe what I was hearing. To see a person of authority treating a resident in this manner was unbelievable . 4/25/18 approximately 1:20 PM - During an interview regarding the 3/14/18 care conference, R2 confirmed that he/she felt terrible and they made me feel like I'm a liar and I feel like they want me out of here. When asked if he/she was having any issues with his/her appetite, sleeping or participation in activities, he/she stated, I have big shoulders, but there is only so much you can take. The facility failed to ensure that R2 was free from emotional and verbal abuse during a care conference when facility staff spoke loudly and in a demeaning, derogatory manner. Fifteen staff members, present during the care conference, failed to intervene and stop the abuse of R2. The facility failed to suspend involved staff for the duration of the investigation and failed to discipline the staff. 4/25/18 approximately 4:00 PM - Findings were confirmed by E1 (NHA) and E2 (DON) during the exit conference. 2. Cross refer to F689, examples 1 and 2. Review of R7's clinical record revealed the following: 2/20/18 - R7 was admitted to the facility for long term care. 2/26/18 - The admission MDS assessment revealed that R7 was cognitively intact, required limited assistance of one staff person for bed mobility, and supervision for transfers. 3/8/18 and 3/9/18 - Review of R7's progress notes lacked evidence of two incidents involving R7 and two wandering residents that were submitted on the facility's 3/12/18 Resident and Family Grievance/Concern Form. 3/12/18 - The facility's Resident and Family Grievance/Concern form stated, .RP (F1) called this AM & complained that 2 residents wandered into R7's room. Friday night at 1 AM (R8) wandered in while being combative c (with) staff which woke R7. Possibly? Thurs. night a male wandered in c staff who followed him in - he was still able to get on R7's bed . The Grievance form under Section D. Steps to Resolve Problems stated that the facility offered a stop sign which R7 and F1 agreed to try. Under Section E. Final Disposition, it stated, .UM (E4) explained that BNRC has residents c (with) all types of needs & staff do their best to deter residents from wandering into other res. rooms. UM obtained stop sign for room. 4/3/18 - Review of an email from F1 to E2 (DON) stated an incident occurred on 4/2/18 involving R7 and R8. The email stated, .R8 entered the room of R7 on 4/2/18 at approx.(approximtely) 11:30 PM. R7 was asleep in her bed. R8 touched the head of R7 causing her to be awakened and become immediately fearful. R7 put her call bell on to summon staff for assistance. According to R7, R8 resisted being escorted out of the room. When asked what she meant by 'resisted', R7 stated 'physically resisted, that they had to almost drag R8 out of the room' .R7 stated to .F1 .this morning that she was scared to death when R8 woke her up by touching her. R7 also stated that she did not believe the stop sign on the entrance door to her room was in place at the time. On previous occasions when confused residents have entered her room staff gave the remedy of closing her door. R7 does not want to have her door closed at night. This is not the first time a confused resident has entered her room at night while she was asleep. Staff have instructed R7 to tell confused residents to 'Go home' when they wander into her room . 4/3/18 to 4/19/18 - Review of R7's clinical record lacked evidence of a follow-up investigation to the 4/2/18 incident by either nursing staff or the facility's medical social workers to prevent wandering residents from entering R7's room as the current interventions were not effective and caused emotional distress to R7. 4/16/18 at 10:06 AM - Observation of R7's Stop sign revealed it was hanging down on one side of her entrance doorframe and not across her doorframe to keep wandering residents from entering. 4/19/18 at 11:22 AM - During a combined interview with F1 and R7, F1 stated that there were multiple incidents with wandering residents. The first incident (unknown date/time) was an unidentified resident who came into R7's room and tossed her personal belongings around in front of R7, who then became upset and F1 stated that she witnessed the tossed items when she arrived at the facility. R7 stated another incident involved R8 who walked into R7's room on 4/2/18 at approximately 11:30 PM turned the light on and approached R7 sleeping in bed and touched her head. R7 woke up to R8 touching her head and was scared, upset and crying. The unidentified CNA who responded laughed and R7 asked What is so funny? When the surveyor asked if the nurse came in to check on her that night after the incident, R7 stated no. When F1 brought this incident to the facility's attention, F1 stated she was told the wanderer, R8, was harmless. F1 stated that R8 was a resident from another wing in the facility and questioned who was watching R8. R7 stated the the facility provided a fabric Stop sign attached by velcro across her outside entrance doorframe, but R7 stated that the wandering residents just remove it. R7 stated that the facility suggested that she close her door, but R7 prefers to have the door open. Due to the lack of a follow-up investigation from the 4/2/18 incident, the facility failed to identify the staff person who laughed while the incident was occurring, failed to identify the potential for resident to resident abuse and failed to respond appropriately to the incident, causing added emotional abuse to R7. 4/19/18 at 3:20 PM - Observation of R7's Stop sign was hanging down on side of entrance doorframe and not across the doorframe to keep wandering residents from entering. 4/19/18 at 11:40 PM - A nurse's note stated, Approx. 2130 (9:30 PM) I was helping another patient in there (sic) room when I was notified by the NURSE on G WING that this resident (R7) had a C/O being upset due to another resident startling her from wandering in her room. I went to see the resident and she stated, 'This has happened to me two times now.' I observed the Stop sign on her door and asked if she was alright, and would she like anything for comfort. She wanted her door to remain open still and just wanted to continue to rest. I went to make sure that the resident that wandered was assisted by her nurse and aide to her own room. 4/20/18 to 4/22/18 - Review of R7's clinical record lacked evidence of a follow-up investigation to the 4/19/18 incident by nursing staff and/or the facility's medical social workers to prevent wandering residents from entering R7's room as the current interventions were not effective and caused emotional distress to R7. 4/23/18 at 8:20 AM - During an interview, R7 stated that last Thursday, 4/19/18, she was asleep in her bed with the door open. R9 (another wandering resident) came into her room and R7 told her to get out. R9 responded no. R7 pulled the call bell and stated no one responded immediately. R7 stated she told the resident to get out again and R9 responded no. R9 was at the window. R7 yelled Help and the CNAs came running. R7 stated that she was extremely upset. R7 stated that the CNAs were dragging the resident (R9) out of her room. R7 stated that F1 emailed E2 (DON) the following day. 4/23/18 at 11:38 AM - During an interview, E2 (DON) stated there were no incident reports involving R7 and wandering residents since her admission on 2/20/18. E2 provided copies of R7's grievances, dated 3/12/18 and an email on 4/3/18, which addressed incidents of wandering residents. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). The facility failed to ensure that R7 was free from emotional abuse when multiple wandering residents continued to enter her room unsupervised causing her emotional distress and when a facility staff person laughed during the 4/2/18 incident. 4/25/18 at 4 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference.",2020-09-01
68,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,610,D,1,0,81S611,"> Based on interviews, review of facility policy and procedure, and review of employee personnel files, it was determined that the facility failed in response to allegations of abuse, neglect, exploitation, or mistreatment to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. The facility failed to remove four staff (E4 (UM), E7 (AD), E8 (SW#1), and E9 (SW#2)) from working in the facility while an investigation involving R2, regarding an allegation of abuse, was ongoing. Findings include: Cross refer F600, example #1 The facility policy titled, Abuse, Neglect, Mistreatment, Serious Injury, Misappropriation of Property, Injuries of Unknown Origin, last revised 10/14, stated PURPOSE: The purpose of this policy is to assure the protection, safety, and well-being of the facility residents .C. To ensure proper .Protection (of our residents) regarding abuse .REPORTING PR[NAME]EDURE: B. In case of suspected ABUSE, the Unit Manager/Supervisor shall immediately, upon receiving notification of the incident respond in the following manner: 1. Ensure resident's safety .If staff to resident abuse is suspected, staff will immediately be removed from the schedule pending investigation . 3/14/18 5:16 PM - The facility self reported an allegation of abuse for R2 to the State Agency. This incident report stated, Resident attended his/her quarterly care plan meeting and resident stated that he/she felt intimidated and abused by certain staff in the meeting .DON (E2) and Administrator (E1) interviewed the resident who confirmed his/her perception of the meeting as intimidating and that 'he's/she's always wrong.' Staff members identified have been suspended pending the investigation. Review of E4's, E7's, E8's and E9's employee personnel files lacked evidence of any suspensions related to the investigation of R2's 3/14/18 care conference . An interview with E1 (NHA) and E2 (DON) was conducted on 4/25/18 at approximately 2:30 PM. E1 and E2 were questioned regarding the lack of evidence of any suspensions or disciplinary actions for E4, E7, E8 and E9 regarding R2's 3/14/18 care conference. E1 and E2 stated that E6 (ADON) was directed to begin an investigation and the four (4) employees were suspended on 3/14/18 after they became aware of the incident. E1 and E2 stated that the four employees did not work on 3/15/18, but on 3/16/18 they returned to work, excluding E7, who had resigned. They stated that when they asked the other three employees why they were back at work, they replied that they were directed to do so by the Corporate office. The facility failed to follow their policy and procedure for the protection of a resident during an ongoing investigation of an allegation of abuse. Findings were confirmed by E1 and E2 during an exit conference on 4/25/18 at approximately 4:00 PM.",2020-09-01
69,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,657,D,1,0,81S611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview it was determined that the facility failed to revise the care plan to reflect current resident's needs for two (R8 and R9) out of 11 sampled residents. Findings include: 1. Review of the clinical record revealed the following: 10/24/17 - R2 was admitted to the facility with [DIAGNOSES REDACTED]. 10/25/17 - A care plan was developed for the problem potential for altered mood state. This care plan stated R8 was fixated on another wandering male resident ,who she believes is her husband, and often follows him which then provokes this other resident. An intervention stated to increase supervision with redirection in regards to this resident wandering with this particular resident. 1/26/18 - A quarterly MDS assessment stated R8 had severe cognitive impairment, disorganized thinking, verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, cursing at others which occurred on 1 to 3 days during the 7 day review time period. This MDS also stated R8 wandered daily and was independently ambulatory. Review of nurse's progress notes from 3/1/18 through 4/21/18 revealed multiple episodes of R8 wandering into other residents' rooms, taking things, eating their food, and on some occasions becoming combative. The facility failed to review and revise R8's care plan to reflect her above listed behaviors and failed to identify interventions to help manage the behaviors. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 4/25/18 at approximately 4:00 PM. 2. Review of R9's clinical record revealed the following: 9/2/15 - R9 was admitted to the facility with [DIAGNOSES REDACTED]. 4/11/17 - R9 was care planned for wandering into other rooms and wandering in the hallway. The interventions included: - redirect as needed; - 1 on 1 as needed; - encourage activities; - return to room or quiet area as needed; - toilet as needed or incontinent care as needed; - give food or fluid; - change position; - adjust room temperature; - backrub; - refer to charge nurse for further intervention; and - psych consult as ordered. 2/19/18 at 2:36 PM - A Social Services note stated that R9 had short and long term memory impairment and wandered daily. 2/29/18 - The quarterly MDS Assessment stated R9 had short-term and long-term memory problems, decisions were poor and required cues and supervision for daily decision making, experienced hallucinations, wandering behavior occurred daily and was independently ambulatory in her room and the corridor. 3/7/18 - Despite R9's continued wandering into other residents room, the facility failed to initiate new interventions and her care plan remained the same. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). The facility failed to revise R9's wandering care plan by initiating new interventions as she repeatedly continued to wander into other residents rooms.",2020-09-01
70,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,676,D,1,0,81S611,"> Based on clinical record review and interviews, it was determined that for 1 (R7) out of 11 sampled residents, the facility failed to provide care and services in accordance with an activity of daily living, specifically bathing. Findings include: Review of R7's clinical record revealed the following: 2/20/18 - R7 was admitted to the facility and was scheduled for showers twice a week on Sunday and Thursday evenings. 2/20/18 - R7 was care planned for ADLs with an intervention that included, but not limited to, assisting R7 with showering and/or bathing as per her needs. 2/26/18 - Review of R7's MDS admission assessment revealed that she was cognitively intact, did not reject care offered by facility staff and required extensive assistance of one staff person for bathing. 4/19/18 evening shift - Review of R7's CNA ADL Flow Sheet revealed that R7 was provided a shower as per E5's (CNA) documentation. 4/19/18 through 4/23/18 - Review of R7's nurse's notes during this timeframe lacked evidence that R7 refused her scheduled shower on Thursday evening, 4/19/18. 4/23/18 at 8:20 AM - During an interview, R7 stated that she was scheduled for showers on Sunday and Thursday evenings. R7 stated that she did not receive her shower on Thursday evening, 4/19/18. R7 stated that she received a shower on Sunday evening, 4/15/18, and the next shower provided was on the following Sunday evening, 4/22/18. 4/23/18 at 2:28 PM - During an interview, E4 (UM) stated that she heard about R7's lack of shower earlier today and stated that she left a voicemail with E5 (CNA) to call her back about the issue. 4/23/18 at 2:43 PM - During a follow-up interview, E5 stated that she spoke with E4, who stated that R7 refused her shower and she incorrectly documented that R7 had a shower on the CNA ADL Flow Sheet. 4/25/18 at 11:10 AM - During a follow-up interview, R7 stated that she did not refuse a shower. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). The facility failed to provide R7's scheduled shower during the evening shift of 4/19/18. 4/25/18 at 4 PM - Findings were reviewed with E1 (NHA) and E2 during the exit conference.",2020-09-01
71,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,689,G,1,0,81S611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, review of clinical records and interviews it was determined that the facility failed to ensure adequate supervision for two ( R8 and R9) out of 11 residents sampled. The facility failed to ensure that R8 and R9, both of whom were known to wander throughout the facility and into other residents' rooms, received adequate supervision to prevent these residents from wandering into other resident's personal spaces and creating the potential for resident to resident abuse. Findings include: 1. Review of R8's clinical record revealed the following: 10/24/17 - R8 was admitted to the facility with [DIAGNOSES REDACTED]. 10/25/17 - A care plan was developed for the problem potential for altered mood state. This care plan stated R8 was fixated on another wandering male resident ,who she believes is her husband, and often follows him which then provokes this other resident. An intervention included for this care plan stated to increase supervision with redirection in regards to this resident wandering with this particular resident. 10/30/17 - The admission MDS assessment stated R8 had severe cognitive impairment (never/rarely made decisions), wandering behavior occurred daily and placed the resident at significant risk of getting to a potential dangerous place (stairs, outside of facility), and that the wandering did not significantly intrude on the privacy or activities of others. The MDS also stated R8 was independently ambulatory in her room and in the corridor. 1/26/18 - A quarterly MDS assessment stated R8 had severe cognitive impairment, disorganized thinking, verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, cursing at others which occurred on 1 to 3 days during the 7 day review time period. This MDS also stated R8 wandered daily and was independently ambulatory. Nurse's progress notes stated the following: 3/2/18 11:00 PM - Remains on 1:1 supervision for safety. 3/4/18 10:30 AM - Continued on one to one supervision for safety. 3/7/18 9:25 AM - Found standing over roommate. Roommate stated that her chair was missing and that clothes had been moved out of the chair. The nurse also found R8 playing with her roommates balloons while standing over her. The roommate became very agitated and threatened to hit her. A request to move R8 to another room was made. 3/11/18 10:22 PM - Resident pacing up and down hallways, opens everything she can open, goes in and out of other residents rooms, yells at staff and residents, is disruptive and requires constant supervision. 3/15/18 10:25 PM - Went into other residents rooms and had many other residents upset. 3/16/18 10:49 PM - Resident ambulates through hallways and into other resident rooms, she engages arguments with other residents and staff. 3/16/18 11:35 PM - Resident has disrupted the shift many times by rummaging through drawers, and other residents rooms. She was left in her room eating, then was found in another residents room where she had defecated on the floor. 3/19/18 10:10 PM - Rummages through rooms and any items she passes, taking food. 3/20/18 9:23 PM - Has been collecting brushes in her room and continues to steal food. 3/21/18 10:10 PM - Continues to steal items out of other rooms and off carts, during dinner hour she was found in another residents room eating her food. 3/24/18 8:20 PM - Continues to go into other residents rooms, takes food from med carts, snack carts and out of other resident rooms. She has been cursing staff and residents often. 3/28/18 11:40 PM - Resident noted going into other residents room several times and eating food and drinks, redirected several times with difficulty. 3/29/18 11:04 PM - Likes going to other resident bedrooms and looks through their belongings or eats their foods or snacks. 3/30/18 4:34 pm - Continues on walking around, picking on other residents rooms, gets their food, going through their stuff. 4/7/18 12:00 PM - Spoke with several other residents on different floors, said R8 in and out of their rooms, taking things and waking them up, when approached becomes combative. 4/9/18 3:50 PM - Resident noted wandering into other residents rooms this shift. 4/13/18 7:36 PM - Another resident's family member asked her to remove R8 because she (R8) had opened the door to the conference room while a family gathering was in progress and began to disrobe in front of everyone. 4/19/18 3:01 PM - R8 was observed attempting to pull a fire extinguisher off the wall. Redirection did not work, however an offer of fluids and a snack did. 4/19/18 10:10 PM - The resident was observed entering room G16 (not R8's room) where she picked up a cup and began drinking before being able to be redirected. Although the facility developed a care plan for altered mood state upon R8's admission to the facility and noted R8's fixation on another resident, they failed to identify that R8 wandered into other residents rooms repeatedly and failed to develop a plan to prevent this from occurring. The potential for resident to resident abuse was present, yet the facility failed to identify that the need for increased supervision of R8 was needed, in an attempt to prevent R8 from entering other resident's rooms. Findings were confirmed by E1 (NHA) and E2 (DON) during the exit conference on 4/25/18 at approximately 4:00 PM. 2. Cross refer to F600, example 2. Review of R9's clinical record revealed the following: 9/2/15 - R9 was admitted to the facility with [DIAGNOSES REDACTED]. 4/11/17 created, 3/7/18 last reviewed - R9 was care planned for wandering into other rooms and wandering in the hallway. The interventions included: - redirect as needed; - 1 on 1 as needed; - encourage activities; - return to room or quiet area as needed; - toilet as needed or incontinent care as needed; - give food or fluid; - change position; - adjust room temperature; - backrub; - refer to charge nurse for further intervention; and - psych consult as ordered. 7/30/17 - A Psychiatric Follow-Up Consult stated that R9 was seen after recent medication changes, has had periods of agitation and very difficult to redirect and illogical thoughts. The plan was to continue to redirect inappropriate behavior and continue to monitor changes in mood and cognition. 11/7/17 - R9's Resident Care Profile stated under the Behavior Section that she wanders and resists care. 2/1/18 to 2/28/18 - Review of R9's Behavior Intervention Monthly Flow Record, documented by her assigned CNAs, revealed that R9 exhibited wandering behavior into others rooms or hallways on 15 out of 28 days. 2/29/18 - The quarterly MDS Assessment stated R9 had short-term and long-term memory problems, decisions were poor and required cues and supervision for daily decision making, experienced hallucinations, physical/verbal/other behavior symptoms occurred 1 to 3 days, wandering behavior occurred daily and was independently ambulatory in her room and the corridor. 2/19/18 at 2:36 PM - A Social Services note stated that R9 had short and long term memory impairment, continued to be physically and verbally combative towards staff, was combative with an outside lab technician on 2/13/18 and wanders daily. 3/1/18 to 3/31/18 - Review of R9's Behavior Intervention Monthly Flow Record revealed that R9 exhibited wandering behavior into others rooms or hallways on 12 out of 31 days. 3/7/18 - R9's care plan for wandering was reviewed and interventions remained the same. 4/1/18 to 4/23/18 - Review of R9's Behavior Intervention Monthly Flow Record revealed that R9 exhibited wandering behavior into others rooms or hallways on 2 out of 23 days. The Flow Record failed to account for R9's wandering incident on 4/19/18 during the 3-11 PM shift. 4/19/18 at 11:36 PM - A Nurse's Note stated that R9 wandered into another resident's room. While staff attempted to redirect R9, she became combative, hitting, scratching and swinging at multiple staff members. R9 was currently in her room with safety measures in place. 4/23/18 at 8:20 AM - During an interview, R7 stated last Thursday, 4/19/18, that she was asleep in her bed in the G wing with the door open. R9, a resident from F wing, came into her room and R7 told her to get out. R9 responded no. R7 pulled the call bell and stated no one responded immediately. R7 stated she told R9 to get out again and R9 responded no. R9 was at the window. R7 yelled Help and the CNAs came running. R7 stated that she was extremely upset. R7 stated that the CNAs were dragging the resident (R9) out of her room. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). Although the facility care planned and were documenting R9's wandering behaviors into other residents rooms repeatedly, the facility failed to identify the potential of resident to resident abuse by providing adequate supervision for R9 in an attempt to prevent her from entering other residents rooms.",2020-09-01
72,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,692,G,1,0,81S611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, interviews, review of facility documentation and hospital records, it was determined that for one (R1) out of 11 sampled residents, the facility failed to ensure that R1 maintained acceptable parameters of nutritional status, specifically electrolyte balance, and failed to offer sufficient fluid intake to maintain proper hydration according to his estimated daily fluid requirements when R1's diet changed on 2/28/18 requiring nursing staff to provide honey-thickened fluids via a spoon for swallowing safety. R1 was hosptalized on [DATE] with [DIAGNOSES REDACTED]. This deficient practice resulted in harm to R1. Findings include: Review of R1's clinical record revealed the following: 6/28/16 - R1 was admitted to the facility with [DIAGNOSES REDACTED]. 1/3/18 - R1's nutritional risk care plan was reviewed with interventions that included the following: monitor food and fluid preferences, provide assistance as needed with food/fluids, and monitor for signs and/or symptoms of diet/supplement intolerance. 1/31/18 - R1 was care planned for being at risk for dehydration with interventions that included: encourage fluid intake from meal tray and between meals; monitor for signs and/or symptoms of dehydration: change in mental status, poor skin turgor, decreased urinary output, dry mucous membranes, dizziness when standing/sitting; monitor labs if ordered; assist with fluid intake as needed; and weight as per protocol. 2/9/18 at 6:36 AM - R1's facility labs revealed the following: - creatinine was 0.6 (normal range was 0.5 - 1.5), - sodium was 142 (normal range was 135-145), - BUN was 17 (normal range was 10-26), and - GFR was 136 (Level 90 or more was Stage 1 - healthy kidneys). 2/16/18 at 8:37 AM - The Nutrition Assessment stated that R1 was on a NAS diet, pureed texture, nectar thick liquids; 75-100% meal intake; received Ensure [MEDICATION NAME] three times a day as a supplement and his intake was 100%; had chewing and swallowing problems; and his estimated nutritional requirements for fluid intake was 2255-2600 mls per day. The nutrition plan stated, .resident continues to lose wt with 4.1% loss this month. BMI underwt for his age. He eats 75-100% of meals and drinks mostly 100% of his Ensure [MEDICATION NAME] .Wt loss may be r/t [MEDICAL CONDITION]. He also receives magic cup at lunch and dinner. Fluids usually 600ml or greater. He receives 8oz of nectar water between all meals for additional fluids r/t thickened liquids. Labs reviewed. Observed resident during lunch meal, ate very well and was able to feed self. Will add double portions with meals to provide additional calories and protein and avoid further weight loss. 2/23/18 at 12:12 AM - R1 was admitted to the hospital for shortness of breath and change in mental status. His admission labs were: - BNP = 500 high (range 0-177), - BUN was 27 high (range 8-22), - creatinine was 0.80 (range 0.70-1.30), and - sodium was 145 (range 136-146). 2/24/18 at 9:58 AM - A hospital progress note stated, .Poor nutrition .seems to have POOR PO intake .Speech did evaluate him yesterday 1) Dysphagia 1 diet with honey thick liquids- ALL PO VIA SPOON 2) Choking precautions 3) 1:1 feeding assist- pt may need verbal cues to swallow due to oral holding 4) Meds crushed in puree . 2/27/18 at 7:38 AM - R1's hospital labs prior to discharge were as follows: - sodium was 145, - BUN was 19, and - creatinine was 0.61 low. 2/27/18 at 3:14 PM - The hospital's Discharge Summary stated that R1 had the following discharge Diagnoses: [REDACTED]. 2/27/18 at 6 PM - R1 was readmitted to the facility. 2/27/18 - R1 was care planned for the Pneumonia [DIAGNOSES REDACTED]. 2/27/18 at 11:38 PM - A nurse's readmission note stated that R1's oral mucosa moist and pink. 2/28/18 at 7:50 AM - The re-admission Nutrition Assessment stated that R1's estimated nutritional requirements for fluid was 1800 - 2100 mls per day. The nutrition plan stated, s/p hospitalization r/t pneumonia. Continues on ABT and [MEDICATION NAME]. Per previous assessment, resident started on double portions with meals r/t continued weight loss to provide additional calories/protein. Observed resident during lunch today. Ate 100% of meal, does require cueing to slow down .Resident is now being downgraded per SLP to honey thick liquids. Will D/C Ensure [MEDICATION NAME] and instead add super cereal ., super potatoes at lunch and dinner ., and Ensure pudding BID Resident also receives magic cup at lunch and dinner . 2/28/18 to 3/6/18 - R1's clinical record lacked evidence that fluids were encouraged. 2/28/18 at 10:45 AM - A nurse's note stated that R1 had moist oral membrane. 2/28/18 at 3:10 PM - A Speech Therapy note stated, Diet changed to puree diet with honey thick liquids, from nectar thick liquids. Liquids to be given via spoon, for safety. Patient to receive verbal cues and prompts with swallowing; as well as verbal cues to decrease rate of intake. Meds crushed in puree. Spoke with nurse in regards to recommendations . 2/28/18 at 11:17 PM - A nurse's note stated that R1 had moist oral membrane. 3/1/18 at 10:30 AM - A nurse's note stated that R1 had moist oral membrane. 3/1/18 at 11:31 PM - A nurse's note stated that R1 had moist oral membrane. 3/2/18 - R1's ADL care plan was revised and stated that he required supervision with meals after set-up. The facility failed to revise R1's care plan on 2/28/18 when his needs changed requiring facility staff to provide honey-thickened fluids via a spoon for swallowing safety. 3/2/18 at 3:39 AM - A nurse's note stated that R1's mucus membrane was pink and moist. 3/5/18 at 11:20 AM - A nurse's note stated that R1 had a moist oral membrane. 3/5/18 (updated) - The CNA's Resident Profile for R1 under the Fluid section lacked evidence of specific care and services to be provided to R1, specifically it lacked the services to 1) encourage fluids, 2) failed to identify the type of thickened liquid he required with safety precautions, and 3) a hydration program at 10 am, 2 pm and 8 pm for R1. The Meals section stated to See Nurse for diet. 3/6/18 at 2:55 AM - A nurse's note stated that R1's mucous membranes were pink and moist. 3/6/18 at 12:10 PM - A nurse's note stated that R1 was unable to tolerate PO medications and unable to respond to verbal stimuli . The physician ordered STAT labs and to obtain a urine sample by straight cath if necessary. 3/6/18 at 2:33 PM - A nurse's note stated that a urine sample was unable to be obtained. 3/6/18 at 2:58 PM - A nurse's note stated that R1 was .unable to tolerate PO medications and unable to respond to verbal stimuli. MD made aware .Lab lady seen drawing stat labs. 3/6/18 on 3-11 PM shift Late Entry documented on 3/7/18 at 12:05 AM - A facility nurse's note stated, At start of shift, resident was in bed with eyes open. Was not responding or making eye contact. VS were 138/80 (blood pressure), 98.2 (temperature), 90 (heart rate), 18 (respirations), 91% on 4 L via NC. Sat resident up in bed and attempted to give him water. He was not responsive or cooperative with fluid intake, would not make eye contact. Took O2 sat again and it was 88% on 4L. Made MD aware. Sent to (hospital) for evaluation via 911 transport. RP made aware. Review of the (MONTH) and (MONTH) (YEAR) eMARs of R1's fluid intake during meals only and monitored by nursing staff from the 2/27/18 readmission to his 3/6/18 hospitalization at 6 PM revealed the following: - 2/27/18 = 720 mls plus 50 mls from Ensure [MEDICATION NAME] supplement, total fluid intake was 770 mls (accounted for 43% of his minimum 1800 mls estimated fluid requirements for the day). - 2/28/18 = 840 mls plus 480 mls from Ensure [MEDICATION NAME] supplement, total fluid intake was 1320 mls (73%). - 3/1/18 = 960 mls (53%). - 3/2/18 = 960 mls (53%). - 3/3/18 = 840 mls (47%). - 3/4/18 = 960 mls (53%). - 3/5/18 = 720 mls (40%). - 3/6/18 = 120 mls (15%). Despite monitoring R1's fluid intake from his daily meals, the facility failed to identify that R1's fluid intake was not meeting his minimum daily fluid needs (1800 - 2100 mls per day) after his 2/27/18 readmission to the facility when his diet changed requiring staff to provide honey-thickened fluids via a spoon for swallowing safety. The facility lacked evidence that honey-thickened fluids were encouraged and provided between meals. 3/6/18 at 5:17 PM - 911 was called for a change in R1's mental status and difficulty breathing. 3/6/18 at 6:13 PM - The hospital's ED physician note stated, .History of Present Illness: 63 y/o male with hx of EtOH related dementia presents from (facility) with AMS, [MEDICAL CONDITION] .unable to give a history .Collateral hx - via RN said EMS were unable to get much information from (facility) staff - they were not familiar with the patient and his paperwork does not show much more. Hx of [MEDICAL CONDITION]. Recent [MEDICATION NAME] on MAR from (facility) - not completed course yet .Physical Exam .cachectic .dry tongue .no [MEDICAL CONDITION] .Final Impression: End stage liver disease .Serum sodium elevated. 3/6/18 at 6:21 PM - The hospital's labs revealed the following: - sodium was 163 critical (136-146); - BUN was 60 high (8-22); - creatinine was 1.44 high (0.70-1.30); and - WBC was 15.7 high (3.9-10.6). 3/6/18 at 10:18 PM - The hospital's Goals of Care Discussion with R1's family stated, .The patient has had progressive decline over several months due to progressive dementia. Now presented with severe dehydration in the setting of poor oral intake .discussed that his dementia is progressing and is likely end stage, they do not wish to have aggressive care for him because it will not correct the underlying process. Their focus is to keep him comfortable and are willing to transition him to hospice care . 3/7/18 at 1:02 AM - The hospital's History and Physical stated, .Patient is nonverbal at baseline .referred to the emergency room tonight because of hypoxemia, altered mental status .Patient has been on [MEDICATION NAME] for pneumonia per his outpatient .records. Presents .emergency room where he is noted to have acute kidney injury, lactic acidosis, hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION], chest x-ray revealing a right lower lobe infiltrate despite outpatient oral antibiotics .Physical Exam .eyes open, looking towards the examiner, not following simple commands .cachectic in appearance, frail, ill-appearing .ENT dry mucosa .Assessment/Plan: Pneumonia .End stage liver disease .Serum Sodium elevated: Hypernateremia related to his acute kidney injury, dehydration, volume depletion .Acute Kidney Injury: .related to .above.[MEDICAL CONDITION], dehydration, volume depletion .Dementia .[MEDICAL CONDITION] . 3/7/18 at 10:31 AM - The facility's STAT labs for R1 (collected on 3/6/18 at 2:21 PM prior to his hospitalization ) were: - creatinine was 1.2, - sodium was 164 High, - BUN was 60 High, - GFR was 61.1 (Level 60 - 89 was Stage 2 - kidney damage and mild decrease in GFR), and - WBC was 14.7 High (range was 4.8-10.8). 4/25/18 at 11:30 AM - During an interview, E20 (RD #2) stated that R1 was on the facility's Nourishment List to receive 8 oz of honey thickened water at 10 AM, 2 PM and 8 PM. When E20 was asked to provide evidence of how much R1 consumed of the honey thickened water three times a day via a spoon as R1 required staff supervision for safety, E20 could not provide further information. While the surveyor was provided with a copy of the facility's Nourishment List, printed with the date of 4/25/18, with R1 listed to receive 8 oz of honey-thickened water between meals, the facility lacked evidence of R1's actual consumption of the fluids to meet his minimum fluid requirement of 1800 mls per day. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). Even with the consideration of R1's comorbidities, decline over the past several months and his current acute illness (pneumonia), the facility failed to identify that R1 was not meeting his minimum daily fluid needs (1800 - 2100 mls per day) after his 2/27/18 readmission to the facility when his diet changed requiring staff to provide honey-thickened fluids via a spoon for swallowing safety. 4/25/18 at 4 PM - Findings were reviewed with E1 (NHA) and E2 during the Exit Conference.",2020-09-01
73,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,756,D,1,0,81S611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Cross refer to F757 Based on clinical record review and interview, it was determined that for one (R7) out of 11 sampled residents, the facility's pharmacist failed to identify and report irregularities with respect to R7's monthly drug regimen review to the attending physician and the director of nursing. Findings include: Review of R7's clinical record revealed the following: 2/20/18 - R7 was admitted to the facility with a [DIAGNOSES REDACTED]. 2/20/18 - R7's admission physician orders [REDACTED]. - [MEDICATION NAME] tablet - give 1 tablet daily for hypertension with the parameters to hold the medication for SBP less than 100 and heart rate less than 60; and - [MEDICATION NAME] tablet - give 1 tablet daily for hypertension with the parameters to hold the medication for SBP less than 100 and heart rate less than 60. 3/5/18 - The facility's pharmacist completed R7's drug regimen review and noted no irregularities. The facility's pharmacist failed to identify and report that R7's heart rate was not being consistently monitored prior to receiving two anti-hypertensive medications with physician ordered parameters. 4/4/18 - The facility's pharmacist completed R7's drug regimen review and again failed to identify and report that R7's heart rate was not being consistently monitored prior to receiving two anti-hypertensive medications with physician ordered parameters. 4/23/18 at 2:58 PM - During an interview, findings were reviewed with E2 (DON). The facility's pharmacist failed to identify and report the inconsistent monitoring of R7's heart rate as per physician ordered parameters prior to administering two anti-hypertensive medications after completing two monthly drug regimen reviews.",2020-09-01
74,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,757,D,1,0,81S611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and interview, it was determined that for one (R7) out of 11 sampled residents, the facility failed to ensure that R7's drug regimen was free from unnecessary drugs, specifically related to inadequate monitoring and inadequate indication for its use. The facility failed to consistently monitor R7's heart rate as per physician ordered parameters from (MONTH) 20, (YEAR) through (MONTH) 19, (YEAR) before administering two anti-hypertensive medications. Findings include: Review of R7's clinical record revealed the following: 2/20/18 - R7 was admitted to the facility with a [DIAGNOSES REDACTED]. 2/20/18 - R7's admission physician orders [REDACTED]. - [MEDICATION NAME] tablet - give 1 tablet daily for hypertension with the parameters to hold the medication for SBP less than 100 and heart rate less than 60; and - [MEDICATION NAME] tablet - give 1 tablet daily for hypertension with the parameters to hold the medication for SBP less than 100 and heart rate less than 60. 2/20/18 to 2/28/18 - Review of R7's (MONTH) (YEAR) eMAR and Progress Notes revealed the following: - [MEDICATION NAME] medication given during the morning medication pass lacked evidence of monitoring R7's heart rate prior to administration on 2 out of 7 days (2/27 and 2/28). - [MEDICATION NAME] medication given during the evening medication pass lacked evidence of monitoring R7's heart rate prior to administration on 3 out of 7 days (2/26, 2/27 and 2/28). 3/1/18 to 3/31/18 - Review of R7's (MONTH) (YEAR) eMAR and Progress Notes revealed the following: - [MEDICATION NAME] medication given during the morning medication pass lacked evidence of monitoring R7's heart rate prior to administration on 29 out of 31 days (3/1 through 3/10, 3/12 through 3/24, and 3/26 through 3/31). - [MEDICATION NAME] medication given during the evening medication pass lacked evidence of monitoring R7's heart rate prior to administration on 29 out of 31 days (3/1 through 3/13, 3/15 through 3/29, and 3/30). 4/1/18 to 4/19/18 - Review of R7's (MONTH) (YEAR) eMAR and Progress Notes revealed the following: - [MEDICATION NAME] medication given during the morning medication pass lacked evidence of monitoring R7's heart rate prior to administration on 17 out of 19 days (4/2 through 4/7, 4/9 through 4/19). - [MEDICATION NAME] medication given during the evening medication pass lacked evidence of monitoring R7's heart rate prior to administration on 6 out of 7 days (4/1 through 4/4, 4/6, 4/7). 4/23/18 at 2:58 PM - During an interview, findings were reviewed and acknowledged with E2 (DON). The facility failed to consistently monitor R7's heart rate as per physician ordered parameters from (MONTH) 20, (YEAR) through (MONTH) 19, (YEAR) before administering two anti-hypertensive medications.",2020-09-01
75,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,758,D,1,0,81S612,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and interview, it was determined that for one (R8) out of 13 sampled residents, the facility failed to implement non-pharmacological interventions prior to administering a PRN [MEDICATION NAME], anti-anxiety medication, to R8. Findings include: Review of R8's clinical record revealed: 8/1/18 - A physician's orders [REDACTED]. 8/8/18 at 1:20 PM - A nurse's note stated that [MEDICATION NAME] was administered to R8 for crying constantly while visiting with family. Review of R8's clinical record revealed that the facility lacked evidence of non-pharmacological interventions attempted prior to administering the [MEDICATION NAME] medication. 9/13/18 at approximately 1:30 PM - Finding was reviewed with E1 (NHA) and E2 (DON). The facility failed to implement non-pharmacological interventions prior to administering a PRN anti-anxiety medication.",2020-09-01
76,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,761,D,1,0,81S611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Cross refer to F583, examples 1 and 2. Based on observations and interviews, it was determined that for 3 out of 3 medication carts observed, the facility failed to keep medications under safe and secure storage with limited access and failed to keep medication carts under direct observation of authorized staff in areas where residents could access them as the potential for more than minimal harm existed. Findings include: 1. An observation on 4/24/18 at 11:22 AM in the G wing hallway revealed an unattended unlocked G wing medication cart with two clear cups containing medications on top of the cart and R10's eMAR displayed on the computer screen. The first cup (approx. 6-8 oz) contained an assortment of pills and the second medication cup contained one pill. E26 (LPN) exited a resident's room and returned to the unattended medication cart. E26 stated that she was responding to a resident calling for help. E26 stated that she was orienting another nurse who happened to be on lunch break at the time. When asked by the surveyor whose medications were in the cups, E26 stated that some pills were left in a medication cup in the top drawer from a (unidentified) resident that refused them earlier and she placed them in the first cup. E26 stated she was picking up the loose pills in the medication cart drawer and placing them in the first cup. When asked whose pill in the second cup belonged to, E26 could not remember immediately. The surveyor then asked the nurse to bring both cups with the medications in them to E4 (UM) so we could identify each pill and dosage individually. The first cup contained 12 pills listed below: - Sennokot 8.6mg - 2 tablets - [MEDICATION NAME] 100mg - 1 tablet - Aspirin 81mg - 2 tablets - [MEDICATION NAME] - 1 tablet **Controlled Medication** - Nullo - 1 tablet - Carvedilol 25mg - 1 tablet - [MEDICATION NAME] 1mg - 1 tablet **Controlled Medication** - [MEDICATION NAME] 10mg - 1 tablet - [MEDICATION NAME] 325mg - 1 tablet - Vitamin D3 1,000IU - 1 tablet The second cup contained 1 pill listed below: - [MEDICATION NAME] 0.2mg - 1 tablet. Once each pill was identified, E4 disposed of the medications and confirmed the findings with the surveyor. The facility failed to keep medications safe and secure, including 2 Controlled Medications, and the medication cart locked when unattended. Findings were reviewed on 4/25/18 at 4 PM with E1 (NHA) and E2 (DON) during the Exit Conference. 2. An observation on 4/24/18 at 5:05 PM in the F wing hallway revealed an unattended unlocked F wing medication cart with one clear cup containing medications on top of the cart and R11's eMAR displayed on the computer screen. The cup contained 4 pills. AE4 (LPN) exited a resident's room and returned to the unattended medication cart. AE4 stated that she was assisting a resident with toileting. When asked by the surveyor whose medications were in the cup, AE4 stated R11. The cup contained the following 4 pills: - [MEDICATION NAME] 100mg - 1 tablet - [MEDICATION NAME] 25mg - 1 tablet - Eliquis 5mg - 1 tablet - Atorvastatin 20mg - 1 tablet When reviewing each pill with AE4, she stated that R11 does not receive Atorvastatin until bedtime so she removed the pill from the cup and disposed of it in front of the surveyor. Findings were immediately confirmed with AE4. The facility failed to keep medications safe and secure and failed to lock the medication cart when unattended. Findings were reviewed with E3 (Staff Educator) on 4/24/18 at 5:15 PM. 3. An observation on 4/24/18 at 5:10 PM outside the Elsmere dining room revealed an unattended unlocked [NAME] wing hallway medication cart. E27 (LPN) and the nurse orientee returned to the unlocked medication cart from the Elsmere dining room. Findings was immediately confirmed with E27. The facility failed to keep the [NAME] wing medication cart locked when unattended. Findings were reviewed with E3 (Staff Educator) on 4/24/18 at 5:15 PM.",2020-09-01
77,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,804,D,1,0,81S611,"> Based on observation, resident interview and one out of two test tray results, it was determined that the facility failed to provide food that was served at an appetizing temperature and palatable. Findings include: 4/16/18 at 4:20 PM - During an interview, R7 stated that by the time her three meals, including her coffee, were delivered as she was the last room to be served, her meals were cold. R7 stated that she brought the problem to facility's attention multiple times. The facility responded by attempting different interventions to ensure she received hot meals, for example stating on her meal ticket to reheat her food before she was served and hand delivering her meal tray directly from the kitchen instead of placing her meal tray on the delivery cart. R7 stated that the meals would be better for one day after she would address the issue with the facility, but she was not consistently served hot meals even after the new interventions were initiated. 4/24/18 - An observation on the G wing hallway during the lunch meal revealed the following: - at 12:28 PM, an intercom announcement was made that the G wing hallway meal cart was being delivered; - at 12:37 PM, observed the G wing meal delivery cart sitting at the beginning of the G wing hallway unattended; - at 12:45 PM, observed E4 (UM) and E23 (CNA) delivering meal trays in the G wing hallway; - at 12:50 PM, observed 2 meal trays left on the delivery cart to which E23 stated that one resident refused his meal and the surveyor told her the last one was a test tray. - at 12:53 PM, the surveyor's test tray was tested for appetizing temperature and palatability. The surveyor found the meal was not served at an appetizing temperature and the following food items were unpalatable: turkey and scalloped potatoes. The turkey was 139.1 F, broccoli was 134.1 F, scalloped potatoes was 139.7 F, coffee was 145.6 F, milk was 45.0 F, grape juice was 49.1 F, and the apple pie was 47.7 F. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). The facility failed to provide food that was served at an appetizing temperature and palatable. 4/25/18 at 4 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference.",2020-09-01
78,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-04-25,812,E,1,0,81S611,"> Based on observations and interviews it was determined that the facility failed to ensure storage, preparation, distribution and the serving of food in accordance with professional standards for food service safety. The facility failed to ensure that insulated domes and bases used to serve meals to residents were not in disrepair. 69 out of 144 domes and 50 out of 101 bases were observed in disrepair. Findings include: The following observations and interviews were conducted: 4/20/18 11:53 AM - During a dining observation of the midday meal it was observed that multiple insulated dome plate covers were in disrepair. The outer rims of the dome covers were observed with discoloration and evidence of having surface chipping. The inner aspect of the domes were observed with peeling and/or blistering. 4/23/18 10:40 AM - Observation in the kitchen of insulated dome plate covers and plate bases revealed them stacked or placed on a ready to use rack in preparation for the midday meal. 69 out of 144 dome covers were observed in disrepair with either fading and chipping of the exterior rim or peeling and/or blistering of the inner surface. 50 out of 101 insulated plate bases were observed in disrepair. 4/23/18 approximately 10:40 AM - During an interview, E22 (Cook) stated that some of the domes and bases had been thrown out and new ones ordered. 4/24/18 approximately 10:30 AM - During an interview, E21 (FSD) stated that approximately 2 to 3 weeks ago he began replacing the plate domes and bases by the dozen, as they were expensive. E21 stated then they received a complaint from a resident's family and so ordered the rest to replace. Review of an email order provided by E21 revealed that on 3/20/18, one case (containing one dozen) each of the dome lids and bases was ordered. Review of an email, dated 4/19/18 (approximately 30 days after the order was first placed), revealed that E21 sent the email to the supplier questioning when the dome lids and bases would be delivered. An email response from the supplier stated that on 4/3/18 and 4/16/18, orders were placed for a dozen domes and bases (total of 2 dozen). A handwritten notation revealed that the 4/3/18 order was received by the facility on 4/21/18. E21 placed an additional order for 3 dozen more domes and bases. Although the facility identified that the plate domes and bases were in disrepair and needed to be replaced, they failed to do so in a timely manner in order to ensure safe food delivery practices. The facility continued to utilize plate domes and bases that were in disrepair that had the potential to contaminate resident's food. Findings were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 4/25/18 at approximately 4:00 PM.",2020-09-01
79,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,241,D,1,1,ZBS111,"> Based on observations, it was was determined that for 2 (R175 and R117) out of 55 Stage 2 sampled residents, the facility failed to promote care in a manner and in an environment that maintained or enhanced their dignity and respect in full recognition of their individuality. For R175, the facility failed to provide her with feeding assistance for 21 minutes while her 2 tablemates ate their meals. For R117, the facility failed to serve her meal at the same time as her 3 tablemates. Findings include: 1. An observation on 7/11/17 at 11:32 AM in the Elsmere dining room revealed that a table of 3 residents (R52, R162 and R175) were served their meals. R52 and R162 were observed immediately eating on their own. From 11:32 AM to 11:53 AM, R175 was observed with her meal in front of her untouched until feeding assistance was provided. R175 sat unassisted for 21 minutes with her meal in front of her while her 2 tablemates ate their meals. 2. An observation on 7/11/17 at 11:40 AM in the Elsmere dining room revealed only 3 out of 4 (R29, R39, R93 and R117) residents seated at the table were served their meals at the same time. R117 watched her 3 tablemates eat their meals for approximately 11 minutes until she was served her meal at 11:51 AM. Findings were reviewed with E2 (DON) and E3 (RN/Staff Ed) on 7/19/17 at 3 PM. The facility failed to feed and serve R175 and R117 at the same time as their tablemates were eating their meals.",2020-09-01
80,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,253,D,1,1,ZBS111,"> Based on observations and interviews, it was determined that the facility failed to provide maintenance services for 4 rooms (B12, C3, E3, and E10) out of 36 rooms surveyed. Findings include: The following were observed and confirmed from the stage 1 room checks from 7/11/17 to 7/12/17 and stage 2 environmental tour on 7/14/17 from 10:00 AM to 11:00 AM: Room B12 The bathroom call bell was functional, but the panel was peeling away; Room E10 There was black tape on the fall mat on the right side of the bed; Room E3 The wall was in disrepair on the right side when entering the bathroom; Room C3 The bathroom sink was draining slow. All issues were reviewed and confirmed by E4 (Maintenance Director) and E5 (Housekeeping Director) on 7/14/17 at approximately 11:00 AM.",2020-09-01
81,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,257,D,1,1,ZBS111,"> Based on observation and interview, the facility failed to ensure that temperature levels in the Greenbank dining room were comfortable and did not exceed 81 degrees F. Findings include: During the dining observation in the Greenbank dining room on 7/11/17 at 12:15 PM, R174 was observed at a table, fanning herself with a napkin. Behind her table was a baseboard heater, which was observed to be turned on. R174 was asked on 7/11/17 at 12:15 PM why she was fanning herself and she stated, too hot in here. Inspection of the dining room revealed one other baseboard heater that was on, as well as another heater at the entrance to the dining room from the hallway. Measurement of Greenbank dining room's ambient room temperatures on 7/13/17 from 12:10 PM to 12:50 PM showed temperatures ranging from 80.4 degrees F to 84.6 degrees F in the areas with heaters turned on. R174 was observed fanning herself again, stating, it's hot in an interview at 12:30 PM. The ambient room temperature measured 83 degrees F where R174 sat. During an interview on 7/14/17 at 1:15 PM, E4 (Maintenance Director) stated that someone must have tampered with the circuit breakers, accidentally turning on the heaters as he had turned them off in May. On 7/17/17 at 2:30PM, ambient room temperatures taken in the Greenbank dining room revealed temperatures ranging from 75.4 degrees F to 78.6 degrees F in the areas where the heaters were turned on previously. All baseboard heaters had been turned off, as confirmed by E4 on 7/18/17 at 8:35 AM. Findings were reviewed with E2 (DON) on 7/19/17 at 5 PM.",2020-09-01
82,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,258,D,1,1,ZBS111,"> Based on an observation, it was determined that for 5 (R5, R70, R115, R126 and R143) out of 55 Stage 2 sampled residents, the facility failed to ensure comfortable sound levels during an activity in the Greenbank lounge. Findings include: An observation on 7/12/17 from 1:05 PM to 1:42 PM in the Greenbank lounge revealed an activity was occurring at the table where R5, R70, R115, R126, R143 and R197 were seated. For approximately 37 minutes, R197 was observed screaming at the top of her voice I want to be dead and I'll kill him repeatedly at the table interrupting an activity that was occurring. At 11:42 AM, E10 (LPN) was observed redirecting R197 out of the Greenbank lounge and away from the activity. In an interview on 7/12/17 at 1:44 PM, E11 (Unit Clerk) confirmed that R197's screaming occurs frequently. Findings were reviewed with E2 (DON) and E3 (RN/Staff Ed) on 7/19/17 at 3 PM. The facility failed to ensure comfortable sound levels during an activity in the Greenbank lounge.",2020-09-01
83,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,279,D,1,1,ZBS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and interview it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one (R204) out of 55 residents sampled, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The facility failed to identify that R204 was at risk for dehydration and they failed to care plan accordingly. Findings include: Review of R204's clinical record revealed the following: 12/29/16 - R204 was admitted to the facility with [DIAGNOSES REDACTED]. 12/29/16 - The admission Nutritional Assessment stated, .Estimated Nutritional Requirements: Fluid (ml) 1400-1700 (amount required per 24 hours) .no nutritional problems at present .Current diet regular/thins/NAS .Resident dines independently with % meal completion 75%. Per nursing, appetite good . 12/29/16 - The nursing admission assessment stated R204 appeared well nourished, had a good appetite, and was alert, but uncooperative and combative. 12/29/16 - A care plan for the problem Unable to do own ADLs without assistance stated R204 required supervision while eating and nursing was to assist the resident with meal tray and feeding if necessary. Additionally, a care plan for the problem Resident at nutritional risk was developed which included approaches to provide diet/meals as ordered, monitor food and fluid preferences, encourage food and fluid intake, provide assistance as needed with food/fluids, and monitor for signs of diet intolerance. 1/4/17 - The admission MDS assessment stated R204 had short and long term memory problems, was moderately impaired for daily decision making skills (decisions poor; cues/supervision required), and was exhibiting behaviors daily. Additionally, the MDS stated R204 required extensive assistance of one staff person for walking in her room and corridor, dressing, toilet use, hygiene and bathing. R204 was identified as requiring supervision and set up help for eating. Although the CAA summary did not trigger the area of dehydration/fluid maintenance as a potential problem area, the facility failed to identify that R204 was at risk for dehydration due to her declining cognitive status and they failed to care plan accordingly. 1/5/17 3:19 PM - A nurse's progress note stated the resident had a new order to encourage fluids every shift. Review of the corresponding MAR indicated [REDACTED]. This order did not identify how much fluid was to be encouraged, nor was there any consistent documentation as to whether R204 was accepting fluids and how much? A care plan was not developed for R204's risk for dehydration. Findings were confirmed by E1 (NHA) and E2 (DON) during an interview on 7/17/17 at approximately 4:20 PM.",2020-09-01
84,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,281,D,1,1,ZBS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews, interviews, review of the facility's pharmacy policies and the manufacturer's medication guide, it was determined that for 2 (R17 and R142) out of 55 Stage 2 sampled residents, the facility failed to provide services that met professional standards of quality. The facility failed to ensure that licensed nursing staff did not administer another resident's (R17) [MEDICATION NAME] medication, a controlled substance used for [MEDICAL CONDITION] disorders, to R142. Findings include: 8/14 - The [MEDICATION NAME] Medication Guide approved by the U.S. Food and Drug Administration (https://www.[MEDICATION NAME].com/[MEDICATION NAME]-medication-guide.pdf) stated, .4. [MEDICATION NAME] is a federally controlled substance (C-V) because it can be abused or lead to drug dependence .Never give your [MEDICATION NAME] to anyone else, because it may harm them .Take [MEDICATION NAME] exactly as your healthcare provider tells you .Do not give [MEDICATION NAME] to other people, even if they have the same symptoms that you have. It may harm them . 1/1/16 - The facility pharmacy policy entitled, Emergency Pharmacy Service and Emergency Kits stated, Emergency pharmacy service is available on a 24-hour basis .D. Medications are not borrowed from other residents . 1/1/16 - The facility pharmacy policy entitled, Medication Administration-General Guidelines, stated, Medications are administered as prescribed in accordance with good nursing principles and practices .B. Administration .2) Medications are administered in accordance with written orders of the attending physician .12) Medications supplied for one resident are never administered to another resident . Cross refer to F431, example 1 1. Review of R17's clinical record revealed the following: 5/25/17 - A physician's orders [REDACTED]. 6/2/17 at 10:15 PM - A nurse's note stated that R17 was sent to the emergency room at 11:50 PM. 6/8/17 at 4:06 PM - A social services note stated that R17 did not retun from the hospital on [DATE]. 6/9/17 through 6/19/17 - Review of R17's Controlled Drug Receipt/Record/Disposition Form (accountability record), issued by the pharmacy, revealed that a total of 14 tablets of R17's [MEDICATION NAME] 200 mg medication was signed out by one or two licensed nurses after R17 was discharged from the facility: - 6/9 at 8 PM - one tablet was signed out by two nurses and wasted was handwritten; - 6/10 at 9:30 AM - one tablet was signed out by one nurse and wasted was handwritten; - 6/10 at 8 PM - one tablet was signed out by two nurses with no reason given; - 6/11 at 8:01 AM - one tablet was signed out by one nurse and wasted was handwritten; - 6/11 untimed - one tablet was signed out by two nurses and wasted was handwritten; - 6/12 untimed - one tablet was signed out by two nurses and wasted was handwritten; - 6/12 untimed - one tablet was signed out by two nurses and wasted was handwritten; - 6/13 untimed - three tablets were signed out by two nurses and wasted was handwritten; - 6/17 untimed - one tablet was signed out by two nurses and wasted was handwritten; - 6/17 untimed - two tablets were signed out by one nurse and wasted was handwritten; - 6/19 untimed - one tablet was signed out by one nurse and wasted and R142's room number were handwritten. Cross refer to F431, example 4 2. Review of R142's clinical record revealed the following: 6/16/17 - A physician's orders [REDACTED]. Review of R142's (MONTH) (YEAR) eMAR revealed the following: - Saturday, 6/17/17, AM - E14 (LPN) signed off that R142 received [MEDICATION NAME] 150 mg tablet; - Sunday, 6/18/17, AM - E14 signed off that R142 received [MEDICATION NAME] 150 mg tablet; - Monday, 6/19/17, AM - E21 (LPN) signed off that R142 received [MEDICATION NAME] 200 mg tablet. Review of R142's clinical record revealed the absence of the accountability record for his [MEDICATION NAME] 150 mg medication. While R142's clinical record revealed the absence of the accountability record for his 6/19/17 AM [MEDICATION NAME] 200 mg dose, it was identified that the medication was taken from R17, a discharged resident, on 6/19/17 and recorded on R17's accountability record. On 7/18/17 at 10:54 AM, surveyor met with E2 (DON) and E3 (RN/Staff Ed) to find out why 14 tablets of R17's [MEDICATION NAME] medication were signed off as wasted on her Controlled Drug Receipt/Record/Disposition Form after R17 was discharged from the facility. E2 and E3 stated they would look into it and follow-up with surveyor. During a follow-up interview with E2 and E3 on 7/18/17 at 1:50 PM, E2 stated that [MEDICATION NAME] medication was not included in the facility's backup medication stock. E3 stated that licensed nursing staff used R17's [MEDICATION NAME] medication and administered her medication to other residents, including R142. During an interview on 7/19/17 at 9:35 AM, E14 (LPN) stated that R142 did not have [MEDICATION NAME] 150 mg tablet medication readily available to be administered the morning of 6/17/17. E14 stated that she called the pharmacy regarding R142's [MEDICATION NAME] medication. E14 stated that she performed an electronic computer search of all residents in the facility that were on [MEDICATION NAME] medication. E14 stated that she asked E9 (LPN), another nurse assigned to a different medication cart, for [MEDICATION NAME] medication. E14 stated that E9 gave her [MEDICATION NAME] 200 mg tablet from another resident (R17). E14 stated that she altered R17's [MEDICATION NAME] 200 mg tablet by cutting the unscored tablet and administered the altered medication to R142. When asked if she notified the House Supervisor regarding the absence of R142's [MEDICAL CONDITION] medication availability over the weekend, E14 stated no. During an interview on 7/19/17 at 9:52 AM, E9 stated that E14 asked her for [MEDICATION NAME] medication. E9 stated that she removed, signed off as wasted on R17's [MEDICATION NAME] accountability record and gave two tablets (200 mg each) of R17's [MEDICATION NAME] medication to E14 for R142. E9 confirmed her signature on R17's accountability record for 2 tablets of [MEDICATION NAME] on 6/17/17. Findings were reviewed on 7/19/17 at 3 PM with E2 and E3. The facility failed to provide services that met professional standards by ensuring that licensed nursing staff did not administer another resident's (R17) [MEDICATION NAME] medication, a controlled substance used for [MEDICAL CONDITION] disorders, to another resident, R142. Additionally staff provided incorrect information on the accountability record.",2020-09-01
85,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,309,D,1,1,ZBS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record reviews, interviews and review of facility documentation, it was determined that for 2 (R2, R143) out of 55 Stage 2 sampled residents, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being consistent with professional standards of practice and their comprehensive person-centered care plans. For R2, the facility failed to follow her plan of care when it was observed that R2's disposable underpad was pulled up tight between her legs two different times when the disposable underpads were to lay flat underneath her. For R143, the facility failed to follow the physician's orders [REDACTED]. Findings include: 1. Review of R2's clinical record revealed the following: Last reviewed on 5/3/17, R2 was care planned for: - semi-comatose state; - incontinent of bladder and bowel with interventions that included to provide incontinence care every 2 hours and as needed .use pads or briefs; - potential for alteration in skin integrity due to decreased mobility and bladder/bowel incontinence with an intervention that included to keep bed linens wrinkle free. Review of R2's Resident Care Profile for the CNAs to reference, last updated on 5/3/17, revealed the absence of special instructions for incontinence care to meet R2's needs. On 7/17/17 at 5:35 AM, E15 (CNA) with E19 (CNA orientee) were observed providing incontinence care to R2. R2 was observed with 2 disposable underpads under her with one disposable underpad pulled up tight between her legs covering her genital area. The disposable underpad was soiled with a bowel movement. E15 was observed cleaning R2 and then placing another clean disposable underpad under R2 and pulling the underpad up tight between R2's legs covering her genital area. During this time, the surveyor observed a sign on R2's wall above her bed that stated, No attends. No pads. Chuck (sic) (Chux) and draw sheet only!!!! During an interview on 7/17/17 at 7:30 AM, E18 (RNAC) and this surveyor discussed what was observed and reviewed R2's care plan. It was unclear why R2's incontinence care plan, last reviewed on 5/3/17, stated to use pads or briefs, which contradicted the sign posted on R2's wall. The facility failed to follow R2's care plan and her Resident Care Profile. During an interview on 7/17/17 at 8:28 AM, E20 (CNA) confirmed that R2 does not wear attends or pads. E20 demonstrated and stated that a disposable underpad is placed under R2 and must lay flat across the width of the bed to prevent skin breakdown. E20 confirmed that R2's disposable underpad should not be pulled up tight between her legs covering her genital area. Findings were reviewed with E2 (DON) and E3 (RN/Staff Ed) on 7/19/17 at 3 PM. The facility failed to provide treatment and care in accordance with R2's plan of care to meet her needs. 2 Review of R143's clinical record revealed the following: R143 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. 1/31/17 - A physician's orders [REDACTED]. Review of R143's (MONTH) (YEAR) eMAR revealed that two doses of [MEDICATION NAME] were administered on 7/1/17 at 2:52 PM and 7:11 PM, with approximately 4.25 hours between administrations. Findings were reviewed with E13 (RN/Unit Manager) on 7/19/17 at 1 PM. The facility failed to follow the physician's orders [REDACTED].",2020-09-01
86,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,312,D,1,1,ZBS111,"> Based on observations, record review and interviews, it was determined that the facility failed to provide the necessary services to maintain good grooming and personal hygiene for one (R72) resident, who was unable to carry out activities of daily living, out of 55 Stage 2 sampled residents. Findings include: A quarterly MDS assessment, dated 6/23/17, stated R72 required extensive assistance of one staff for dressing and was totally dependent on one staff for toilet use, hygiene and bathing. The MDS stated R72 had weakness of one entire side of the body and was incontinent of bowel and bladder. [NAME] R72 had a care plan, last reviewed 7/12/17, for the problem Unable to do own ADLs without assistance. Approaches included to assist the resident with dressing and hygiene care to the extent required. Observations on 7/11/17 at 3:00 PM, 7/14/17 at 9:40 AM and 7/14/17 at 1:40 PM revealed R72 with elongated jagged fingernails, especially both thumbs, in need of trimming. On 7/14/17 at 1:40 PM, E22 (LPN, Brandywine UM) observed R72's fingernails at the surveyor's request and confirmed they were in need of trimming. B. R72 had a care plan, last reviewed 7/12/17, for the problem Incontinent of bladder and bowel. Approaches included incontinence care every 2 hours and as needed and skin check every 2 hours and as needed with incontinence care. On 7/17/17 at 6:30 AM, E6 (CNA) was observed providing morning care for R72. Observation revealed R72's brief, three (3) Chux, a draw sheet and the mattress cover soaked through with urine. When asked what time R72 was last changed, E6 stated at approximately 2:15 AM. At approximately 7:15 AM, E6 was asked why R72 was not changed for over 4 hours? E6 stated, That's my fault. The facility failed to ensure that R72, a dependent resident, was provided necessary services according to the care plan, which stated incontinence care was to be provided every 2 hours and as needed. Findings were confirmed with E1 (NHA) and E2 (DON) during an interview on 7/17/17 at approximately 4:15 PM.",2020-09-01
87,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,323,D,1,1,ZBS111,"> Based on observations, record review and interviews, it was determined that the facility failed to ensure that the resident environment remains as free from accident hazards as is possible, and that assistance devices are utilized to prevent accidents for one (R72) out of 55 Stage 2 sampled residents. Findings include: 1. A quarterly MDS assessment, dated 6/23/17, stated R72 did not walk in his room or the corridor, and was totally dependent on two (2) staff for transfers to and from bed. A care plan, last reviewed 7/12/17, for the problem Potential for injury, included the approach for R72 to be transferred by 2 staff with a Hoyer lift. On 7/17/17 at approximately 6:50 AM, E6 (CNA) and E7 (CNA) were observed transferring R72 from bed to his chair. E6 sat R72 up at the edge of his bed and then E6 and E7 manually lifted and pivoted the resident into his chair. A Hoyer lift was not utilized for the transfer as per the care plan resulting in potential accident hazard and injury to R72. Findings were reviewed with E1 (NHA) and E2 (DON) on 7/17/17 at approximately 4:15 PM. 2. On 7/11/17 at 3 PM during Stage 1 and on 7/12/17 at approximately 12:48 PM, it was observed that the left side rail for Room B16 C bed was loose. All issues were reviewed and confirmed by E4 (Maintenance Director) and E5 (Housekeeping Director) on 7/14/17 at approximately 11:00 AM.",2020-09-01
88,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,327,G,1,1,ZBS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and interview, it was determined that the facility failed to ensure that one (R204) out of 55 residents sampled was offered sufficient fluid intake to maintain proper hydration and health. The facility failed to identify R204 as being at risk for dehydration, failed to care plan accordingly and failed to consistently monitor and evaluate R204's fluid consumption. When R204's meal and fluid intakes steadily declined there was no notification of the physician and/or RD and no new interventions implemented until 1/17/17. On 1/17/17, R204 became unresponsive and was sent out to the ER where she was found to be severely dehydrated with an acute kidney injury (AKI). This deficient practice resulted in harm to R204. Findings include: Review of R204's clinical record revealed the following: 12/29/16 - R204 was admitted to the facility with [DIAGNOSES REDACTED]. 12/29/16 - The admission Nutritional Assessment stated, .Weight: 141.0 .Estimated Nutritional Requirements: Fluid (ml) 1400-1700 (amount required per 24 hours) .no nutritional problems at present. Assessment/Plan: New admit: reweight: 141 lbs .Current diet regular/thins/NAS .Resident dines independently with % meal completion 75%. Per nursing, appetite good .Resident added to weekly weights and will monitor nutritional parameters. 12/29/16 - The nursing admission assessment stated R204 appeared well nourished, had a good appetite, and was alert, but uncooperative and combative. 12/29/16 - A care plan for the problem Unable to do own ADLs without assistance stated R204 required supervision while eating and nursing was to assist the resident with her meal tray and feeding if necessary. Additionally, a care plan for the problem Resident at nutritional risk was developed which included approaches to provide diet/meals as ordered, monitor food and fluid preferences, encourage food and fluid intake, provide assistance as needed with food/fluids, and monitor for signs of diet intolerance. A care plan was not developed for the potential for dehydration. 12/30/16 - The facility completed a Functional Abilities Review, completed by the SLP, which stated R204 was tolerating the current diet texture with no signs of choking or difficulty swallowing. The review stated that speech therapy services were not warranted at this time. 12/30/16 3:41 PM - A Psychological Initial Assessment stated, .severe dementia with behavioral disturbances .Resident has been hitting staff and yelling. Has needed medication to attempt to decrease behaviors .Staff encouraged to anticipate residents needs (toileting, addressing hunger/thirst) to avoid behavioral disruption. 12/30/16 - R204's re-weight recorded as 141.0 lbs. 1/1/17 - A physician's orders [REDACTED]. 1/3/17 - Laboratory blood test results revealed the following values: Sodium = 146 (normal range: 135-145); BUN = 22 (normal range: 10-26); Creatinine = 0.7 (normal range: 0.5 - 1.5). 1/3/17 5:05 PM - A nurse's progress note stated that medication given for constipation was held due to R204 having loose bowel movements. A second note, timed 11:26 PM, stated the resident was extremely agitated .oral mucosa pink and moist, appetite fair, fluids encouraged . 1/4/17 - Laboratory blood test results revealed the following values: Sodium = 147; BUN = 23; Creatinine = 0.6. 1/4/17 - The admission MDS assessment stated R204 had short and long term memory problems, was moderately impaired for daily decision making skills (decisions poor; cues/supervision required), and was exhibiting behaviors daily. Additionally, the MDS stated R204 required extensive assistance of one staff person for walking in her room and corridor, dressing, toilet use, hygiene and bathing. R204 was identified as requiring supervision and set up help for eating. 1/4/17 12:34 PM - A nurse's progress note stated while sitting up in a wheelchair at the nurse's station, R204 appeared to be unresponsive. R204 was taken back to her room where she responded to painful stimuli, became alert but was still not responding appropriately. The physician was called and ordered R204 be sent to the ER for evaluation. 1/5/17 3:52 AM - A nurse's progress note stated R204 returned from the ER at 1:30 AM and was alert and responsive. 1/5/17 - A physician's orders [REDACTED]. 1/5/17 12:38 PM - A nutrition/dietary note stated R204's weights were being monitored weekly, however, nursing reported they were unable to complete R204's weight that morning due to her being lethargic. There was no evidence the facility attempted to obtain a weight until the following week. 1/5/17 12:43 PM - A nurse's progress note stated, Resident alert and responsive .appetite fair .assistance w/lunch .sitting quietly at nurse's station. 1/5/17 3:19 PM - A nurse's progress note stated the resident had a new order to encourage fluids every shift. Review of the corresponding MAR indicated [REDACTED]. This order did not identify how much fluid was to be encouraged, nor was there any consistent documentation as to whether R204 was accepting adequate fluids. 1/5/17 8:28 PM - A nurse's progress note stated the medication used for constipation was held due to R204 having loose bowel movements. 1/5/17 11:31 PM - A nurse's progress note stated R204 was exhibiting frequent episodes of agitation especially during care, but that her appetite was good and fluids adequate. 1/6/17 11:46 PM - A nurse's progress note stated, .appetite fair, fluids adequate . 1/8/17 10:04 PM - A nurse's progress note stated, .Decreased appetite during breakfast dinner and lunch .Husband visited .complained about her mental status . A second note timed 10:20 PM stated, Late Entry 1/8/17 Did attempt to offer alternatives and ensure (liquid dietary supplement) due to decreased appetite in presence of husband. gave alternatives to husband, but attempts were ineffective as resident continue (sic) to refuse and become combative. Despite this documented decline in intakes there was no evidence that the physician and/or RD were notified. 1/5/17 through 1/11/17 - Review of the MAR indicated [REDACTED]. However, there was no documented evidence of how much fluid was consumed or whether it was accepted. 1/5/17 through 1/11/17 - Review of the CNA ADL Flowsheet of percentage of meal consumption revealed the following for intake of solids: 1/5/17 - breakfast 75%; lunch 25%; dinner 75%; 1/6/17 - breakfast 25%; lunch 25%; dinner 50%; 1/7/17 - breakfast 25%; lunch 25%; dinner 25%; 1/8/17 - breakfast 50%; lunch 50%; dinner 25%; 1/9/17 - breakfast 50%; lunch 75%; dinner 75%; 1/10/17 - breakfast 50%; lunch 25%; dinner 75%; 1/11/17 - breakfast refused; lunch refused; dinner no % documented. Review of the clinical record lacked evidence that the physician and/or RD were notified regarding R204's fluctuating food intakes. Additionally, review of the CNA ADL flowsheet revealed that from 1/1/17 through 1/10/17, R204 was feeding herself or requiring supervision or verbal cuing only. However, starting 1/12/17 documentation revealed R204 was requiring more assistance eating, with multiple occasions noting she was totally dependent for eating. Review of R204's meal time fluid intakes (for all 3 meals) from 1/2/17 through 1/11/17 revealed the following total amounts: 1/2/17 - 720 mls; 1/3/17 - 360 mls; 1/4/17 - 120 mls; 1/5/17 - 480 mls; 1/6/17 - 360 mls; 1/7/17 - 360 mls; 1/8/17 - 240 mls; 1/9/17 - 720 mls; 1/10/17 - 720 mls; 1/11/17 - refused breakfast and lunch and no intake documented for dinner. Review of the above listed totals revealed that unless R204 was being provided additional fluids (e.g. during medication administration or between meals) ranging in amounts from 680 mls to 1280 mls, depending on the amount of fluids consumed at each meal, she was not meeting her daily fluid requirement of 1400-1700 mls to maintain good hydration and health. Although nursing staff were documenting on the MAR from 1/5/17 through 1/11/17 that fluids were encouraged there was no documented evidence that R204 was actually consuming the fluids. Review of the clinical record lacked evidence that the facility monitored and evaluated R204's fluid intakes; no evidence that they identified that her fluid needs were not being met, and no evidence that the physician and/or RD were notified in an attempt to implement new interventions. Review of the clinical record revealed that the 1/5/17 physician's orders [REDACTED]. 1/13/17 - R204's weight recorded as 140.2. 1/14/17 8:46 AM - A nurse's progress note stated, Resident alert and responsive .appetite fair .mucous membranes pink and moist . 1/15/17 7:30 PM - A nurse's progress note stated that R204 was given a [MEDICATION NAME] suppository for nausea and vomiting and that it was effective. 1/16/17 1:22 PM - A nurse's progress note stated, Resident has a new order to begin mechanical soft diet per family request. 1/16/17 - A PT Evaluation & Plan of Treatment was completed. The evaluation stated, .Reason for Referral: Received a nursing referral due to decline in function, unsteady gait and frequent falls. According to nursing, patient was previously ambulatory without assistive device upon admission to this facility, and is currently in a WC .Clinical Reasoning .difficulty participating in functional activities due to lethargy and behavioral disturbance, unable to ambulate . Review of R204's meal intake records from 1/12/17 through 1/16/17 revealed the following amounts: 1/12/17 - breakfast and lunch refused; dinner 75%; 1/13/17 - breakfast and lunch 50%; dinner 25%; 1/14/17 - breakfast and lunch 50%; dinner 25%; 1/15/17 - breakfast and lunch 25%; dinner 0%; 1/16/17 - breakfast and lunch 25%; dinner 0%. Review of R204's meal time fluid intakes (for all 3 meals) from 1/12/17 through 1/16/17 revealed the following total amounts: 1/12/17 - 360 mls; 1/13/17 - 480 mls; 1/14/17 - 360 mls; 1/15/17 - 120 mls; 1/16/17 - 240 mls. There was no evidence that staff were encouraging or that the resident was consuming additional fluids in an attempt to meet her estimated minimum fluid requirement of 1400 mls per 24 hours. The clinical record lacked evidence that the facility monitored and/or evaluated R204's fluid intakes, that the facility identified her fluid needs were not being met, and that the physician and/or RD were notified in a timely manner in an attempt to implement new interventions. There was no evidence that the RD was notified of R204's declining intakes until 1/17/17. 1/17/17 10:52 AM - A nutrition/dietary note stated, Per nursing report Resident experiencing decreased appetite. % (percent) meal completion ranging between 0-50% .added 8 oz ensure [MEDICATION NAME] PO BID .Added 30 ml Promod BID .Reviewed labs: Na 147 slightly elevated (results from 1/4/17). Wrote dietary slip to kitchen to send extra fluids on meal trays. Will continue to monitor weekly weights, encourage po food/fluids, and nutritional parameters. 1/17/17 11:01 AM - A nutrition/dietary note stated, Addendum: Diet: mech (mechanical) soft/thins/NAS. Diet liberalized and NAS d/ced to increase palatability of meals. 1/17/17 11:09 AM - A nurse's progress note stated, Resident has a new order for STAT CBC and BMP, UA C&S and Chest X ray due to change in mental status, dark foul smelling urine and cough . 1/17/17 2:55 PM - A nurse's progress note stated, Resident alert to her name .appetite poor . 1/17/17 - Review of laboratory blood and urine reports revealed results were faxed to the facility on [DATE] at approximately 5:15 PM. Results were as follows: BUN = 163 (normal range: 10-26); Sodium = 165 (normal range: 135-145); Creatinine = 5.2 (normal range: 0.5 - 1.5); UA = negative; Additionally, the chest X ray results did not identify any pneumonia or fluid in the lungs. 1/18/17 1:25 AM - A nurse's progress note stated, Resident was resting in chair with eyes closed at start of shift, attempt was made to arouse resident, change in mental status observed, unable to speak, unable to take in fluids .sent to (hospital) via 911 at 1730 (5:30 PM) . 1/20/17 1:28 AM - Late entry for 1/15/17 3-11 shift, Resident vomited a small amount of undigested soup while eating dinner, warm ginger ale offered and accepted, [MEDICATION NAME] suppository administered, no further episode of nausea or vomiting throughout shift .loose BM at the end of the shift, fluids offered and accepted . The facility failed to identify that R204 was not meeting her minimum fluid requirement and they failed to implement interventions in an attempt to meet this fluid requirement. There was no evidence that R204's oral intake was being monitored consistently and that decreased food and fluid intakes were reported to the physician and/or RD in a timely manner. R204 was sent out to the ER when she became unresponsive and was diagnosed with [REDACTED]. R204 was admitted to the hospital on [DATE]. The hospital ED Physician Record, dated 1/17/17 and timed 6:04 PM stated, .found unresponsive in her nursing home .she has been slightly lethargic for the last several days. Somnolent. She has not been taking much oral intake including food or water. She does have some mild nausea and vomiting over the weekend .severely dry mucous membranes with dry tongue .Initial laboratory results revealed significant [MEDICAL CONDITION] (sic/should read [MEDICAL CONDITION]) with sodium 171. Acute [MEDICAL CONDITION] with BUN of 156 creatinine 6.2 .She received approximately 2L (liters) of IV fluids .sodium improving to 170 .improving creatinine of 5.6 . A second hospital ED Physician Record, dated 1/17/17 and timed 6:09 PM stated, .As per the family she has not been doing well for the past 3 weeks since her admission to the nursing home .family states she has not been eating or drinking since her admission, but significantly less over the past 1 week The family states that over the past 2-3 days she has been much more altered than her baseline mental status .dry oral mucosa .After approximately 15 minutes of being in the emergency department the patient is much more awake and alert and is able to tell me her name .2L of NS (Normal Saline) was given for [MEDICAL CONDITION]ly 2/2 (secondary to) dehydration. The patient's mental status continues to improve while in the ER . A hospital nephrologist's consult note, dated 1/18/17, stated, .progressive Alzheimer's dementia, presenting to the ED yesterday evening unresponsive .recently transferred to a nursing home .Over the past few days, she reportedly became increasingly lethargic .Upon arrival to (hospital name) ED was [MEDICAL CONDITION] (rapid heart rate), unresponsive, with elevated creatinine .[MEDICAL CONDITION] .On previous visits when tested her renal function was normal with baseline creatinine 0.8 .oral mucosa dry .Assessment/Plan: 1. Acute kidney injury: This is clearly acute, with normal baseline creatinine just earlier this month. Most likely due to volume depletion .2. [MEDICAL CONDITION]: Severe at presentation sodium 171 .Attributable to poor oral intake over some time .Additional Recommendations or Comments: 5. Long-term she will require some means of reliably maintaining adequate oral/fluid intake . 7/17/17 approximately 4:00 PM - During an interview with E16 (RD) and E17 (RD), E17 stated that when she noted on 1/5/17 the order to encourage fluids, she sent a request slip to dietary to send extra fluids on the meal trays. E17 stated she was not notified that R204 was not eating well until 1/17/17 at which time she ordered supplements. After R204's meal and fluid intakes were reviewed, E17 confirmed she should have been notified sooner. 7/17/17 at approximately 4:20 PM - During an interview with E1 (NHA) and E2 (DON) regarding the facility's failure to identify R204's risk for dehydration and subsequent care planning, the facility's lack of monitoring of fluid intakes and lack of identifying that minimum fluid needs were not being met and resulting in severe dehydration, the findings were confirmed.",2020-09-01
89,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,329,D,1,1,ZBS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record reviews and interview, it was determined that for 2 (R197 and R143) out of 55 Stage 2 sampled residents, the facility failed to provide adequate indications for use and non-pharmacological interventions (such as redirect, 1 on 1, activity, food/fluids, toilet, reposition) prior to administering prn [MEDICAL CONDITION] medications. Findings include: 1. Review of R197's clinical record revealed the following: 3/10/17 - A physician's orders [REDACTED]. 3/10/17 - A physician's orders [REDACTED]. R197's progress notes lacked evidence of her behaviors and non-pharmacological interventions used prior to the prn [MEDICATION NAME] administrations on the following dates and times: - 3/13/17 at 6:35 PM; - 3/15/17 at 2:01 PM; - 3/20/17 at 5:53 PM; - 3/21/17 at 9:33 PM; - 4/3/17 at 7:30 PM; - 4/19/17 at 6:58 PM; - 6/14/17 at 1:18 PM; - 6/26/17 at 3:21 PM; - 7/10/17 at 3:23 PM. 2. Review of R143's clinical record revealed the following: 2/11/16 - A physician's orders [REDACTED]. 1/31/17 - A physician's orders [REDACTED]. R143's progress notes lacked evidence of her behaviors and non-pharmacological interventions used prior to the prn [MEDICATION NAME] administrations on the following dates and times: - 7/1/17 at 2:52 PM; - 7/4/17 at 4:57 PM; - 7/8/17 at 2:10 PM; - 7/10/17 at 6:48 PM. During an interview on 7/19/17 at 1 PM, E13 (RN) acknowledged that non-pharmacological interventions should be used prior to the administration of prn [MEDICAL CONDITION] medications. Findings for R197 and R143 were immediately reviewed with E13. Findings were reviewed with E2 (DON) and E3 (RN/Staff Ed) on 7/19/17 at 3 PM. The facility failed to provide adequate indications for use and non-pharmacological interventions prior to administering prn psychoactive medications.",2020-09-01
90,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,333,G,1,1,ZBS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record reviews, interviews and review of other facility documents it was determined that the facility failed to ensure that 6 (R40, R71, R91, R117, R181, and R196) out of 55 Stage 2 sampled residents were free of significant medication errors. Thirteen (13) Units of Humalog insulin was administered to R196 when the blood sugar value was 88 causing R196's blood sugar level to drop to 21 resulting in the resident becoming unresponsive and requiring emergency interventions. Additionally, there was no documented evidence that R196 was receiving and/or consuming bedtime snacks. The facility failed to ensure for R71 and R181 that Humalog insulin was administered according to manufacturers specifications, specifically within 15 minutes before a meal or immediately after a meal. For R40, R91, and R117, the facility failed to ensure that [MEDICATION NAME]was administered according to manufacturers specifications, specifically within 5-10 minutes before a meal. Findings include: The manufacturer's package insert (http://uspl.lilly.com/humalog/humalog.html) for Humalog insulin stated, .INDICATIONS AND USAGE: HUMALOG is a rapid acting human insulin .DOSAGE AND ADMINISTRATION: .Administer HUMALOG .within 15 minutes before a meal or immediately after a meal . The manufacturer's package insert (http://www.novo-pi.com/[MEDICATION NAME].pdf) for [MEDICATION NAME]stated, .INDICATIONS AND USAGE: [MEDICATION NAME] is rapid acting human insulin .DOSAGE AND ADMINISTRATION: .Inject .within 5-10 minutes before a meal . 1[NAME] Review of R196's clinical record revealed the following: 4/14/17 - R196 was admitted to the facility with [DIAGNOSES REDACTED]. 4/14/17 - A physician's orders [REDACTED]. The order stated that when R196's Accu-Chek result was 0 to 199, no SSI coverage was to be given. 4/19/17 - R196's progress notes stated: 7:00 AM - Orders-Administration Note: (MONTH) initiate I.V. access in potentially critical situations as needed. Then notify physician for further orders. 7:30 AM - .I was called to pt's bedside due to AMS and low BG of 21 at approximately 0730. Nurse in charge of pt at that time stated to me that she gave pt 13 units of insulin when her BG was 88. This progress note was completed by the P[NAME] 7:55 AM - This nurse went in to resident room to do rounds and saw resident unresponsive. Upon assessment, resident BS is 21, [MEDICATION NAME] 1 amp IM was administered and after 30 mins BS was 23, (name of PA) was in the building gave a verbal order for another [MEDICATION NAME] 1 amp IM to be administered 911 was called. At 0801 resident became responsive with BS at 224. Resident decline (sic) to go to the hospital and is eating her breakfast in her room at this time. 4/19/17 10:02 AM - A physician's medical visit note stated, .BS this am 88 but apparently given extra dose 13 units and BS dropped to 21 [MEDICATION NAME] administered; BS 200s pt denies any complaints now. Review of the facility's incident investigation revealed the following statements: 4/19/17 (Completed by E12 (Agency LPN)) - Blood sugar was checked by this nurse at about 0630 a.m. Resident is on a sliding scale of insulin, blood sugar protocol was followed as order (sic). At about 0708 Unit Manager was doing her rounds and discovered pt being hypoglacemic (sic). Followed the order/care as 13 unit (sic) of insulin was administered. While the Agency LPN wrote in her statement that blood sugar protocol was followed this was not correct since insulin was administered for a blood sugar of 88. 4/19/17 (Completed by E13 (Greenbank UM)) - I responded to a page overhead. Resident observed unresponsive. BS was in the 20's. I started an IV in the right arm. EMS arrived as soon as I finished and they took over. 4/19/17 (Completed by E3 (Staff Education RN)) - This nurse was overhead paged .Upon arriving in room noted resident in bed not responding to nurse manager. Resident had a BS of 21 .I contacted PA who was in facility who gave me order to call 911. Myself & PA (name) asked nurse how much [MEDICATION NAME] they administered and nurse went to check & returned and stated 13 units. This nurse asked nurse again did you administer 13 units of [MEDICATION NAME] to a resident who had a BS of 88 and nurse stated 'Yes she did.' I asked the nurse again if she was sure & she stated 'Yes.' 4/19/17 12:45 PM - The facility's Incident Report submitted to the State Agency stated, Agency Nurse administered 13 units of insulin for .88. Resident found unresponsive. According to agency nurse insulin was administered at 0630 and resident was found .at approximately 0700. IV access initiated and PA in building and made aware. Paramedics arrived and administered D50. Resident became AAO3 and refused hospitalization .resident currently in no acute distress. Agency nurse banned from building. Agency and MD aware. The facility failed to ensure that R196 was free of a significant medication error. R196 was given Humalog insulin 13 units when no insulin coverage was required. R196 became unresponsive with a severely low BS requiring the administration of 2 amps of [MEDICATION NAME], insertion of an IV and administration of D50. This deficient practice resulted in harm to R196. On 7/18/17 at approximately 4:15 PM, findings were reviewed with E1 (NHA) and E2 (DON). E1 and E2 acknowledged the findings and stated that E12 has been banned from working in the facility. 1B. R196 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to the B wing (where R196 resided) at 8:10 AM. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Although the Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of approximately 40 minutes before breakfast was served. R196 was receiving Humalog, a fast acting insulin, which is to be given within 15 minutes before a meal or immediately after a meal. Review of the MAR from 4/14/17 through 5/18/17 revealed that R196 received SSI coverage, signed off at 6:30 AM, on the following dates: 4/17/17, 4/18/17, 4/19/17, 4/20/17, 4/26/17, 4/30/17, 5/1/17, 5/9/17, 5/10/17, 5/14/17 and 5/16/17. R196 had a physician's orders [REDACTED]. On 5/20/17, a physician's orders [REDACTED]. This order was in addition to the Humalog SSI coverage before meals which was also written on 5/20/17 and stated to HOLD if not eating. Review of the MAR indicated [REDACTED]. Additionally, the MAR indicated [REDACTED]. The facility failed to ensure that R196 was eating breakfast before administering the Humalog insulin as it was being administered by the night shift, who were off duty at 7:30 AM, and breakfast was not delivered until 8:10 AM, a potential one and three quarter hour delay. On 6/13/17, R196 had in total, the following insulin orders before breakfast: - Basaglar KwikPen insulin 6 units daily; - Humalog insulin 3 units daily, to be held if not eating; - Humalog SSI coverage, amount dependent on Accu-Chek result and to be held if not eating. Review of the 6/13/17 MAR indicated [REDACTED] - Basaglar KwikPen 6 units, signed off given by the day shift (7 AM - 3:30 PM) nurse; - Humalog 3 units, signed off by the night shift nurse at 6:30 AM. Despite the fact that it was to be held if not eating. Breakfast trays are scheduled to be delivered to the wing at 8:10 AM, potentially one and three quarter hours after administration of the fast acting Humalog insulin. Humalog SSI coverage was not given, as R196's 6:30 AM Accu-Chek was 82 and no coverage was ordered. Review of the meal intake record for 6/13/17 revealed R196 consumed only 25% of breakfast. A progress note, dated 6/13/17 and timed 11:54 AM, stated, This nurse was called to the resident room .BS 54. [MEDICATION NAME] was given x 2. Resident was rechecked and BS was 175. Resident was seen by NP (name) and advised to be sent to ER for further evaluation. The facility failed to ensure that R196's insulin orders were followed when on multiple occasions insulin was administered when nursing staff was unaware if the resident was eating and they failed to administer fast acting insulin (Humalog) according to manufacturer's specifications. R196 was admitted to the hospital from 6/13/17 through 6/29/17. A hospital progress note, dated 6/28/17, stated, .difficult to control .diabetes .dose has been altered multiple times .usually indicative of an acquired disorder, rather than having any connection with food intake or activity. It is very difficult to control . R196 returned to the facility on [DATE]. Readmission physician orders, dated 6/29/17, included: - Humalog SSI coverage before meals, dependent on Accu-Chek results and hold if not eating; - Humalog 3 units before breakfast, hold if not eating; - Nepro 8 ounces three times a day, timed on the MAR for 6:30 AM, 11:30 AM and 9:00 PM. The MAR indicated [REDACTED]. Both of these insulin orders stated to hold if not eating, however both were signed off at 6:30 AM and breakfast was not delivered to the unit until 8:10 AM. Observation on 7/12/17 at 8:00 AM revealed R196 asleep in bed with an unopened can of Nepro on the over bed tray table next to her. On 7/18/17 at approximately 4:15 PM, findings were confirmed by E1 and E2. During an interview on 7/19/17 at approximately 4:00 PM, E3 (RN, Staff Educator) stated that Nepro was timed to be given at 6:30 AM in an attempt to decrease R196's episodes of low blood sugars. When E3 was told of the observation on 7/12/17 at 8:00 AM of an unopened can of Nepro, she stated that the nurse needs to ensure the resident drinks it. 1C. Review of the facility's B Wing Nourishment List revealed that R196 was listed as receiving an assorted 8:00 PM snack. Review of the clinical record lacked documented evidence that R196 was receiving and/or consuming the bedtime snacks. During an interview on 7/19/17 at approximately 11:15 AM, E16 (RD) stated that bedtime snacks are not documented in the clinical record, however if a resident refuses or does not consume, it should say so in a nurse's progress note. 2. Review of R71's clinical record revealed the following: R71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R71 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to B wing (where R71 resided) at 8:10 AM. Review of the April, May, (MONTH) and (MONTH) 1-19, (YEAR) MARs revealed that Accu-Cheks were completed by the night shift (11 PM- 7:30 AM) and signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of approximately 40 minutes before breakfast was served. R71 was receiving Humalog, a fast acting insulin, which is to be given within 15 minutes before a meal or immediately after a meal. Review of the (MONTH) 1- (MONTH) 19, (YEAR) MARs revealed that R71 received SSI coverage, signed off at 6:30 AM on the following dates (except 5/20- 5/24/17 when in hospital) : 4/29, 4/30, 5/1-5/3, 5/5-5/19, 5/25-5/31, 6/1-6/30, 7/1-7/19/17. 3. Review of R40's clinical record revealed the following: R40 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R40 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to C wing (where R40 resided) at 7:50 AM. Review of the May, June, and July1-19, (YEAR) MARs revealed that R40 received SSI coverage, signed off at 6:30 AM on the following dates (except 5/2- 5/15/17 when in hospital): 7/3 and 7/17/17. Although Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of approximately 20 minutes before breakfast was served. R71 was receiving [MEDICATION NAME], a fast acting insulin, which is to be given within 5-10 minutes of a meal. 4. Review of R181's clinical record revealed the following: R181 had a physician's orders [REDACTED]. R181 also had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to C wing (where R181 resided) at 7:50 AM. Review of the April, May, June, and (MONTH) (YEAR) MARs revealed that Accu-cheks were completed by the night shift (11:00 PM- 7:30 AM) and the Humalog SSI if received, was signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and SSI coverage given at that time, there was still a delay of 20 minutes before breakfast was served. R181's standing order of 8 units of Humalog insulin if received was signed off at 7:30 AM. R181 was receiving Humalog, a fast acting insulin, which is to be given within 15 minutes before a meal or immediately after a meal. 5. Review of R117's clinical record revealed the following: R117 had a physician's orders [REDACTED]. R117 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to B wing (where R117 resided) at 8:10 AM. Review of the April, May, June, and (MONTH) (YEAR) MARs revealed that Accu-cheks were completed by the night shift (11:00 PM- 7:30 AM) and the [MEDICATION NAME] insulin, if received, was signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and [MEDICATION NAME]given at that time, there was still a delay of 40 minutes before breakfast was served. R117 was receiving [MEDICATION NAME], a fast acting insulin, which is to be given within 5-10 minutes before a meal (although ordered to be given 10-15 minutes before meal). 6. Review of R91's clinical record revealed the following: R91 had a physician's orders [REDACTED]. Review of the dietary meal delivery schedule revealed that breakfast trays were delivered to B wing (where R91 resided) at 8:10 AM. Review of the April, May, June, and (MONTH) (YEAR) MARs revealed that Accu-Cheks were completed by the night shift (11:00 PM- 7:30 AM) and the [MEDICATION NAME]sliding scale, if received, was signed off at 6:30 AM. Although Accu-Cheks may have been completed closer to 7:30 AM and [MEDICATION NAME]given at that time, there was still a delay of 40 minutes before breakfast was served. R91 was receiving [MEDICATION NAME], a fast acting insulin, which is to be given within 5-10 minutes before a meal. All findings for this citation were reviewed with E1 (NHA) and E2 (DON) during the exit conference on 7/19/17 at approximately 6:45 PM.",2020-09-01
91,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,428,D,1,1,ZBS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to act on an irregularity identified by the consultant pharmacist during the monthly drug regimen review for one (R112) out of 55 Stage 2 sampled residents. Findings include: Review of R112's clinical record revealed: 2/7/17- R112 was being treated for [REDACTED]. R112's monthy drug regimen review had a pharmacist recommendation that stated due to the resident currently receiving Epogen, which uses up the body's iron stores, to consider checking blood iron stores or starting iron therapy. 2/10/17- The physician checked agree for the pharmacists recommendation, dated 2/7/17, and wrote for Iron 325 mg by mouth twice daily. During clinical record review an order for [REDACTED].>7/19/17 9:07 AM- Interview with E3 (RN, Staff Development) revealed the unit manager had the responsibility to review the monthy drug regimen review recommendations after the physician reviewed them and to enter all written orders. E3 reviewed R112's clinical record and confirmed that R112 does not have an order for [REDACTED].>7/19/17 2:45 PM- The findings were reviewed and confirmed with E2 (DON) and E3.",2020-09-01
92,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,431,E,1,1,ZBS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record reviews, interviews, review of facility documentation and the manufacturer's medication guide, it was determined that for 6 (R17, R38, R136, R142, R152, R88) out of 55 Stage 2 sampled residents, the facility failed to provide pharmaceutical services to meet the needs of each resident. It was determined that for 5 (R17, R38, R136, R142 and R152) out of 5 residents who were prescribed Vimpat, a controlled medication used for seizure disorders, the facility failed to have an effective system using the Controlled Drug Receipt/Record/Disposition Forms (accountability records) that accurately accounted for, reconciled and recorded the disposition of controlled medications. In addition, the facility failed to dispose of R17's remaining Vimpat medication 72 hours after she was discharged from the facility in accordance with the facility pharmacy policy. For R88, the facility failed to ensure the correct labeling of a medication in accordance with currently accepted professional principles. Findings include: ,[DATE] - The Vimpat Medication Guide approved by the U.S. Food and Drug Administration (https://www.vimpat.com/vimpat-medication-guide.pdf) stated, .4. VIMPAT is a federally controlled substance . because it can be abused or lead to drug dependence . [DATE] - The facility pharmacy policy entitled, Controlled Medications stated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations .D. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration. 2) Amount administered. 3) Signature of the nurse administering the dose, completed after the medication is actually administered. E. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed according to facility policy and the disposal documented on the accountability record on the line representing that dose. The same process applies to the disposal of unused partial tablets . [DATE] - The facility pharmacy policy entitled, Controlled Medication Disposal stated, .C. Destruction of .discharged or deceased resident controlled medication shall be jointly performed by two authorized licensed personnel within 72 hours of the discontinuation or discharge. D. A record of the destruction must be signed by both parties. This document becomes part of the resident's permanent medical record . Cross refer to F281, example 1 1a. Review of R17's clinical record revealed the following: [DATE] - R17 was admitted to the facility with [DIAGNOSES REDACTED]. [DATE] - A physician's orders [REDACTED]. Review of R17's accountability record for Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - Wednesday, [DATE], AM dose; - Thursday, [DATE], AM dose. [DATE] through [DATE] - R17 was hospitalized for [REDACTED]. [DATE] - A physician's orders [REDACTED]. Review of R17's accountability record for her Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - Saturday, [DATE], AM dose; - Sunday, [DATE], AM dose; - Sunday, [DATE], PM dose. Review of R17's (MONTH) (YEAR) eMAR revealed that licensed nursing staff administered and signed off the 5 doses of Vimpat medication listed above. It was unclear why R17's accountability forms did not match her eMAR and account for the 5 doses administered when the accountability form clearly stated, Every dose must be accounted for and requires charting on the Medication Administration Record. The facility failed to ensure that licensed nursing staff accounted for and reconciled every dose of Vimpat medication for R17. 1b. R17 was sent to the hospital on [DATE] at 11:50 PM. [DATE] at 4:06 PM - A social service note stated that R17 passed away in the hospital on [DATE] and her family picked up her belongings on [DATE]. Review of R17's accountability form for her Vimpat medication revealed that from [DATE] through [DATE] a total of 14 tablets were signed out as wasted by either one or two licensed nurses. It was unclear why the facility failed to remove R17's Vimpat medication within 72 hours after she left the faciity on [DATE]. On [DATE] at 10:54 AM, surveyor met with E2 (DON) and E3 (RN/Staff Ed) to find out why 14 tablets of R17's Vimpat medication were signed off as wasted on her accountability record after R17 was discharged from the facility. E2 and E3 stated they would look into it and follow-up with surveyor. During a follow-up interview with E2 and E3 on [DATE] at 1:50 PM, E3 stated that licensed nursing staff administered R17's Vimpat medication to other residents, including R142. With the exception of R142, it was unclear on R17's accountability record the other residents who received the remaining 11 tablets. Findings were reviewed with E2 and E3 on [DATE] at 3 PM. The facility failed to dispose of her remaining Vimpat medication 72 hours after she was discharged from the facility in accordance with the facility pharmacy policy. 2. Review of R38's clinical record revealed the following: [DATE] - A physician's orders [REDACTED]. Review of R38's accountability record for Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - Thursday, [DATE], PM dose; - Friday, [DATE], AM dose. Review of R38's (MONTH) (YEAR) eMAR revealed that licensed nursing staff administered and signed off the 2 doses of Vimpat medication listed above. It was unclear why R38's accountability forms do not match her eMAR and account for the 2 doses administered when the accountability form clearly stated, Every dose must be accounted for and requires charting on the Medication Administration Record. The facility failed to ensure that licensed nursing staff accounted for and reconciled every dose of Vimpat medication for R38. 3. Review of R136's clinical record revealed the following: [DATE] - A physician's orders [REDACTED]. Review of R136's accountability records for Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - Friday, [DATE], PM dose; - Friday, [DATE], PM dose; - Saturday, [DATE], AM dose; - Saturday, [DATE], PM dose; - Sunday, [DATE], AM dose; - Sunday, [DATE], PM dose; - Monday, [DATE], AM dose. Review of R136's (MONTH) and (MONTH) (YEAR) eMARs revealed that licensed nursing staff administered and signed off the 7 doses of Vimpat medication listed above. It was unclear why R136's accountability forms did not match her eMAR and account for the 7 doses administered when the accountability form clearly stated, Every dose must be accounted for and requires charting on the Medication Administration Record. The facility failed to ensure that licensed nursing staff accounted for and reconciled every dose of Vimpat medication for R136. 4. Cross refer F281 example #2 Review of R142's clinical record revealed the following: [DATE] - A physician's orders [REDACTED]. Review of R142's accountability records for Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - Friday, [DATE], PM dose; - Saturday, [DATE], AM dose; - Saturday, [DATE], PM dose; - Sunday, [DATE], AM dose; - Sunday, [DATE], PM dose; - Monday, [DATE], AM dose; - Wednesday, [DATE], PM dose. Review of R142's (MONTH) (YEAR) eMAR revealed that licensed nursing staff administered and signed off the 7 doses of Vimpat medication listed above. It was unclear why R142's accountability forms did not match his eMAR and account for the 7 doses administered when the accountability form clearly stated, Every dose must be accounted for and requires charting on the Medication Administration Record. The facility failed to ensure that licensed nursing staff accounted for and reconciled every dose of Vimpat medication for R142. 5. Review of R152's clinical record revealed the following: [DATE] - A physician's orders [REDACTED]. Review of R152's accountability records for Vimpat medication revealed a lack of evidence of accurate accounting by licensed nursing staff for the following dates and times: - [DATE], PM dose; - [DATE], AM dose. Review of R152's (MONTH) (YEAR) eMAR revealed that licensed nursing staff administered and signed off the 2 doses of Vimpat medication listed above. It was unclear why R152's accountability forms did not match his eMAR and account for the 2 doses administered when the accountability form clearly stated, Every dose must be accounted for and requires charting on the Medication Administration Record. The facility failed to ensure that licensed nursing staff accounted for and reconciled every dose of Vimpat medication for R152. Findings were reviewed with E2 (DON) and E3 (RN/Staff Ed) on [DATE] at 3 PM. The facility failed to have an effective system in place using the Controlled Drug Receipt/Record/Disposition Forms (accountability records) that accurately accounted for, reconciled and recorded the disposition of controlled medications for 5 residents (R17, R38, R136, R142 and R152). In addition, the facility failed to dispose of R17's remaining Vimpat medication 72 hours after she was discharged from the facility. 6. During medication administration observation for R88 on [DATE] at 8:30 AM, it was observed that R88's Lantus Insulin was labeled incorrectly. The label stated the opposite, to inject 30 units subcutaneously in the morning and 10 units subcutaneously at bedtime. The physician's orders [REDACTED]. During an interview on [DATE] at 8:30 AM, E9 (LPN) confirmed that the Lantus Insulin was labeled incorrectly. The findings were reviewed with E2 (DON) and E3 (RN, Staff Development) on [DATE] at 2:45 PM.",2020-09-01
93,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,441,D,1,1,ZBS111,"> Based on observation and interview, it was determined that the facility failed to ensure proper infection control techniques during medication administration for two (R39 and R72) out of 55 Stage 2 sampled residents. Findings include: 1. During medication administration for R39 on 7/13/17 at 9:50 AM, E8 (LPN) was observed touching the trash can lid on the medication cart when throwing out trash and then continuing to touch medications and the medication cart without hand sanitizing or washing his/her hands. 2. During medication administration for R72 on 7/13/17 at 1:45 PM, E8 was observed touching the trash can lid on the medication cart when throwing out trash and then continuing to touch medications and the medication cart without hand sanitizing or washing his/her hands. During an interview with E8 on 7/18/17 at 1:50 PM, the findings were reviewed and confirmed. The findings were reviewed with E2 (DON) and E3 (RN,Staff Development) on 7/19/17 at 2:45 PM.",2020-09-01
94,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2017-07-19,520,E,1,1,ZBS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview it was determined that the facility failed to have a quality assurance program that identified and corrected quality deficiencies. Findings include: Cross refer F333 The facility failed to identify that fast acting insulins were being administered by the night shift when breakfast was not being delivered from 1/2 to 1 and 1/2 hours later. This QAA (quality assessment and assurance committee) did not identify that this deficient practice had the potential of placing six (R40, R71, R91, R117, R181, and R196) residents at risk of developing [DIAGNOSES REDACTED]. Findings were confirmed with E3 (RN Staff Educator) during an interview on 7/19/17 at approximately 4:00 PM.",2020-09-01
95,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-07-19,622,D,1,0,B13F11,"> Based on interview, record review and other documentation as indicated, it was determined that the facility failed to ensure that one (R1) out of 3 residents was transferred in a manner that provided an effective transition of care. R1 was transferred from facility (F#1) to another facility (F#2) on 6/29/18. F#1 failed to have a transfer/discharge policy, to provide report to F#2 on R1's status prior to transfer, there was no physician order to transfer R1, and there was a lack of evidence that all pertinent paperwork was sent to F#2. All references to C#'s are staff at the receiving facility (F#2). Findings include: Review of R1's clinical record revealed the following: R1 was admitted to F#1 on 5/24/18 for short-term rehabilitation following a hospitalization . Review of a progress note written by E6 (NP) on 6/25/18, stated, .Anticipatory discharge from rehab (rehabilitation) services 6/28/18 . Review of the progress notes, dated 6/29/18, the day R1 was transferred to F#2, lacked evidence of a nurse's note, including documentation of respiratory status and evidence that report was called to F#2. Review of physician orders revealed the lack of a physician order to transfer R1. 7/11/18 3:17 PM- E2 (DON) was asked for a copy of the transfer information provided to F#2. E2 stated there was no form, however, the nurse calls report and sends hardcopy papers over that the facility needs, like care plans, meds (medications), etc. E2 confirmed that a physician order was not written to transfer R1 and that a nurse's note should have been written, including what time R1 left. 7/12/18 12:39 PM- E4 (agency nurse, LPN) was assigned to R1 on 6/29/18. E4 was asked via telephone if he did R1's transfer and E4 stated, No, I've never discharged anyone. 7/12/18 approximately 12:50 PM- E3 (LPN/UM) was asked if she did R1's transfer on 6/29/18 and E3 stated that she did not. When asked what her expectations were when a resident was transferred, E3 stated, .to call report (to the receiving facility), and send copies of notes. 7/12/18 2:21 PM- E5 (SS) was asked if she sent any paperwork to F#2. E5 stated that she faxed a copy of the face sheet, medications, and progress notes about a week before R1 left; when a decision was made by C1 (ED) to accept R1. 7/12/18 4:20 PM- During an interview with E5, she provided a copy of R1's Medication Review Report (summary of physician's orders) that was faxed from F#2's medical records department on 7/12/18 at 3:11 PM per request by E5 (E5 had previously faxed the report to F#2 on a different date). This was the only evidence of paperwork sent from F#1 to F#2. 7/13/18 1:05 PM- E3 was asked what the 6/28/18 date and time meant on R1's Medication Review Report. E3 stated that it was the date and time she printed the document. E3 was unable to provide a fax confirmation of when the Medication Review Report was sent to F#2. 7/13/18 12:55 PM- E2 confirmed that the facility does not have a transfer policy. An investigator from the Division of Health Care Quality (state) did interviews of key staff at F#2, obtained written statements and supplied copies of email correspondence to the surveyor. Documentation from F#2 revealed: 7/13/18 10:47 AM- C4 (RN) stated during an interview that the only documentation that came from F#1 was on 6/28/18 (the Medication Review Report) and the family gave them some paperwork from F#1 that was unclear. An undated written statement by C4 stated that she attempted to call F#1 for report, that the fax number was given to the nurse and she stated that she will fax the report/paper work (sic) . called facility another time reminding them that I am still waiting for the paper work . we did not have any report . F#1 failed to have a transfer/discharge policy, provide report to F#2 on R1's status prior to transfer, failed to ensure a physician's order was written to transfer R1, and there was lack of evidence that all pertinent paperwork was sent to F#2 to ensure an effective transition of care.",2020-09-01
96,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-07-19,684,D,1,0,B13F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of other documentation as indicated, it was determined that the facility failed to ensure that one (R1) out of 3 residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the comprehensive assessment to meet their needs. R1 was transferred from this facility (F#1) to another nursing home (F#2) on [DATE] without ensuring that R1's oxygen tank had enough oxygen to get him safely to F#2 and without calling report to F#2. Consequently, R1's portable oxygen tank was empty upon arrival to F#2 (R1 required oxygen continuously) resulting in [MEDICAL CONDITION] (a deficiency of oxygen reaching the tissues of the body). Additionally, due to lack of a telephone report, F#2's staff were uncertain of R1's usual or prior baseline level of orientation (awareness of person, place and time) and pulse oximetry (pulse ox- a non-invasive test used to measure oxygen levels in the blood). R1 was pale upon arrival to F#2, was oriented to person only, had a pulse ox of 79% (R1 had a physician order [REDACTED].> 92%), and had abnormal lung sounds. R1 was subsequently sent to the hospital via 911 approximately 2 hours and 15 minutes after arrival to F#2. Findings include: Review of R1's clinical record revealed the following: R1 was admitted to the facility (F#!) on [DATE] for short term rehabilitation after being hospitalized . A hospital progress note, dated [DATE], stated that R1 was admitted to the hospital for a change in mental status due to a urinary tract infection, [MEDICAL CONDITION] of the right leg and pneumonia. Additionally, R1 had a history of [REDACTED]. R1's physician orders, dated [DATE], included oxygen at 3L/min. (liters per minute) via nasal cannula to keep pulse ox > 92% and check pulse ox every shift. R1's care plan, developed on [DATE] and updated on [DATE], for potential for alteration in cardiac/ or respiratory status stated that R1 was on oxygen on admission. Interventions included: allow extra time with activities of daily living (dressing and toileting, for example) to avoid SOB (shortness of breath), assess lung sounds as applicable, monitor vital signs and pulse ox as applicable, oxygen as applicable, and respiratory treatments as ordered. Review of R1's [DATE] admission/5 day, [DATE] Medicare 14 day and [DATE] Medicare 30 day MDS assessments, R1 used oxygen in the facility. The [DATE] MDS coded R1 as being independent to make reasonable and consistent decisions. [DATE]- 4 days prior to transfer to F#2, the last follow-up medical visit was done by E6 (NP). E6 stated, .Anticipatory discharge from rehab (rehabilitation) services [DATE] doing well overall supervision to standby assist with transfers able to bathe herself (sic) ambulates ,[DATE] feet with walker and supervision DOE (dyspnea on exertion- difficulty breathing when moving around) baseline remains on O2 (oxygen) . Lungs- clear . Review of nursing progress notes revealed: [DATE]- R1's pulse ox's (ordered to be done every shift; all were done while on oxygen) were between ,[DATE]% and temperatures (temps; normal range is 97.0- 99.0 degrees) was 98.1 degrees. Lungs clear. [DATE]- pulse ox's were 95- 97% and temps. were 98.4 and 98.7 degrees. Respirations even and unlabored with no SOB or signs/symptoms of distress. [DATE]- pulse ox's were ,[DATE]% and temps. between 97.6- 98.3 degrees. Lungs clear and respirations non-labored. [DATE]- 2:18 AM- pulse ox 92% and temp. 98.4 degrees. Lungs clear and respirations non-labored. 11:40 AM- there was no nurse's note written, however, pulse ox was 92% and temp. 97.8 degrees. Additionally, pulse was 68 (normal range ,[DATE] beats per minute) and respiratory rate was 18 (normal range ,[DATE] breaths per minute). [DATE] 2:20 PM by E5 (SS)- resident transferred to (F#2) today for LTC (long term care). Interviews from F#1 revealed: [DATE] 3:17 PM- E2 (DON) confirmed that a nurse's note should have been written when R1 was transferred to F#2 on [DATE], including what time R1 left. A few minutes later, the surveyor was advised by E2 that there was video footage of R1 leaving the facility in E1's (NHA) office. The surveyor viewed the video footage of [DATE] and timed 11:52 AM of R1 being pushed in a wheel chair (w/c) down the hall and through the front door by C6 (driver of F#2). R1 was sitting upright in the w/c and had a nasal cannula in place for the oxygen and a small, portable oxygen tank was on the back of the w/c. E1 and E2 were present while the surveyor watched the video footage and they gave details as needed like who was pushing R1 down the hall. E2 confirmed it was F#1's oxygen tank on the back of the w/c. [DATE] 9:45 AM- E2 provided requested information for the nurse assigned to R1 on [DATE]. E2 stated it was an agency nurse (a nurse provided by a contracted nursing agency). [DATE] 12:39 AM- E4 (agency nurse, LPN) returned the surveyor's call. E4 explained that he worked in the F and G wing (Greenbank- where R1 resided) on day shift on [DATE] for the first time and that [DATE] was only his second time in the facility. Surveyor asked if he did the transfer for R1 and he stated, No, I've never discharged anyone. E4 further denied recalling if he checked R1's oxygen tank and stated that he really did not remember the resident. E4 stated to check with E3 (LPN/UM), that maybe she discharged R1. [DATE] approximately 12:50 PM- E3 (LPN/UM) stated that she's been the UM of the Greenbank unit since (MONTH) (YEAR). E3 recalled R1 and stated that she did not do his transfer. E3 stated that R1 was transferred on a Friday and stated, it was very chaotic. E3 stated that she was gone from the unit and when she returned, he was gone. E3 stated that E4 (agency nurse) did the 11:40 AM vital signs and gave R1 medications on [DATE]. She confirmed that E4 was very new to the facility. When asked what her expectations were when a resident was transferred, E3 stated, an assessment, vital signs, to call report (to the receiving facility), and send copies of notes. E3 stated that E5 (SS) worked on the discharge. [DATE] 2:21 PM- E5 (SS) stated that she began working in the facility a little over 2 months ago. When asked what she recalled about R1's transfer, E5 stated that R1's family decided to move him to F#2 for long term care because it was near his family. E5 stated that she dealt with C1 (ED of the receiving facility) for the transfer and C1 made the decision for F#2's driver (C4) to transport R1. E5 stated that R1 was going to be transferred in the AM of [DATE], but C1 changed it to [DATE]. When asked if she knew what nurse did the discharge, E5 stated she did not know. When asked if any paperwork was sent by her, E5 stated that she faxed a copy of the face sheet, medications, and progress notes about a week before R1 left; when the decision was made by C1 to accept R1. [DATE] 4:10 PM- E2 (DON) stated that E5 (SS) just received a call from C1 (executive director at F#2) and he'd like the surveyor to speak with E5. While still speaking with E2, the surveyor discussed the interviews with E4 (agency nurse, LPN) and E3 (LPN/UM) in which both stated they did not transfer R1 on [DATE]. Additionally, there was no evidence that anyone called report to a nurse at F#2 and that R1's oxygen tank was checked prior to his leaving to ensure there was a sufficient amount of oxygen to get R1 to the next facility. E2 confirmed this might have fallen between the cracks and he stated that the facility was already working on a plan of correction . [DATE] 4:20 PM- E5 (SS) stated that C1 (ED at F#2) called her and asked for clarification of how R1 was transported to them. E5 stated that she told C1 that they (F#2) used their own transportation. E5 stated that C1 told her that she did not know R1 was on oxygen and that R1 should have been sent by ambulance. E5 provided a copy of R1's Medication Review Report (summary of physician orders) that she stated was faxed from medical records staff at F#1. The fax was dated [DATE] and timed 3:11 PM. On page 4 of 6, there was a physician order [REDACTED].> 92%. Check sat (same as pulse ox) O2 (oxygen) level QS (every shift). E5 provided a fax activity log with highlighting on [DATE] showing 27 pages that were sent and [DATE] showing 6 pages were sent to the same fax number which E5 stated were at F#2. E5 explained that the [DATE] fax she sent included R1's face sheet, medications, and progress notes (as stated in 2:21 PM interview). E5 stated the [DATE] fax was the Medication Review Report sent by E3. [DATE] 12:55 PM- E2 (DON) confirmed that the facility does not have a transfer policy. [DATE] 1:00 PM- Surveyor asked E5 (SS) for clarification of the Fax Activity Log with 6 page Medication Review Report sent by E3 (LPN/UM) to F#2 on [DATE] per interview with E5 on [DATE] at 4:20 PM. Surveyor advised the Medication Review Report was dated [DATE] and timed 2:39 PM, not [DATE]. E5 stated that she must not have been clear, the faxes from her included the 6 pages sent on [DATE]. E5 stated that E3's papers were probably sent from a different fax machine. [DATE] 1:05 PM- E3 was asked what the [DATE] date and time meant on R1's Medication Review Report. E3 stated it was the date and time that she printed the document. Requested fax confirmation to show when the Medication Review Report was sent to F#2. E3 stated that she was only able to go back one week, so she was unable to provide it. An investigator from the Division of Health Care Quality (state) did interviews of key staff at F#2, obtained written statements and supplied copies of email correspondence to the surveyor. Documentation from the receiving facility (F#2) revealed the following: [DATE] 4:12 PM- email from C1 (ED) stated, (F#1) wanted to transfer (name of resident) in their van at 8 am on ,[DATE] to (F#2). We felt that was too early for him, so we agreed to pick him up 11am in our van . (resident) was not ready. They (F#1) had to clean him up and pack his clothes . they put him in a wheelchair with mini oxygen tank on the back and he left in F#2's van around 11: 45 pm (sic) . He arrived to our 3rd floor HC (healthcare) about 12:15 pm . The driving distance from F#1 to F#2, depending on the route taken, was between 8.6- 9.2 miles. [DATE] 10:39 AM- interview with C3 (ADON) confirmed that C4 (RN) assessed R1; C3 did not observe R1. [DATE] 10:41 AM- interview with C2 (DON) stated that C4 and C5 (LPN) were the nurses involved with R1 prior to his being sent to the hospital. C2 stated that R1 was only at the facility briefly and he stated that he only knew what he heard. C2 stated that the facility does not have a transportation policy. [DATE] 10:47 AM- interview with C4 (RN) confirmed that C5 (LPN) was the first person to see R1. C5 then went and found C4. C4 stated that she assessed R1. C4 stated the only documentation that came from F#1 arrived the day before ([DATE]- the Medication Review Report) and the family gave them some paperwork from F#1. An undated written statement was received from C4 on [DATE]. C4 stated that she attempted to call the facility for report, that the fax number was given to the nurse and she stated that she will fax the report/paper work .called facility another time reminding them that I am still waiting for the paper work . received by the charge/med (medication) nurse (C5). Vital signs were obtained by the med nurse and she told me that the new resident seems to be in respiratory distress because his oxygen (pulse ox) was 79%. Med nurse stated that the portable (oxygen) tank was empty when resident was received in the facility . alert to self, very confused and not able to complete a sentence . we did not have any report. Family stated that resident is usually very alert and oriented . Family was made aware that according to this nurse assessment patient seemed to be very sick and according to their information it seems that there is a change in mental status . lungs are not clear and we will need STAT chest xray to R/O (rule out) PNA (pneumonia). This nurse told the family that I was not comfortable admitting the resident to the facility whom according to my nursing judgement I knew he needed more medical attention than we cannot (sic) provide. The family agreed to send . to emergency room . 911 was called by this nurse and resident was transported to the hospital . [DATE] 10:59 AM- interview with C5 (LPN) stated that R1 arrived about 12:30 PM on [DATE]. C5 checked R1's vital signs and his pulse ox was 79% (physician's orders [REDACTED].> 92%). She stated that R1 arrived with a nasal cannula on and the portable oxygen tank he came with was empty. C5 stated that she ran and got an oxygen concentrator and applied oxygen at 2 L/min. Initially the pulse ox remained at 79%, then it came up to 89%. C5 increased the oxygen to 3 L/min. and then to 4 L/min. C5 stated she didn't know what R1's diet was, they were waiting for orders and C4 (RN) was calling F#1. C5 stated that R1 told her his name and what he liked to be called. C5 stated that she didn't know what R1's baseline was and if this was normal; he had a rash on his palms and the backs of his hands. When she listened to R1's lungs she heard crackles and asked (family?) if he had pneumonia. One of the daughters stated that the hand rash wasn't there the day before. C5 stated that R1 wasn't struggling to breathe, but he appeared tired. She offered food and R1 declined, but he drank a few sips of coffee. C5 stated that she talked to R1's family and explained that she doesn't know R1, but he didn't look right. She stated the family took a little while to decide before sending R1 to the hospital. Additionally, R1 wanted to use the urinal, but he was unable to stand. C5 stated that R1 never complained of pain or of feeling sick. A progress note, written by C5 (LPN) and dated/timed [DATE] at 2 PM stated that R1 arrived with the facility's driver about 12:10 PM. Skin was slightly pale. His vital signs were T 97XXX,[DATE]- 20- ,[DATE] and pulse ox 79%. R1's oxygen was increased to 4 L/min. to maintain his pulse ox > 92%. Crackles were heard in the lower lobes of his lungs and he did not have a cough. [DATE] 11:10 AM- interview with C1 (ED) stated that E5 (SS from F#1) called and they were going to send R1 at 8 AM. C1 stated that she's not used to doing 8 AM transports and F#2 doesn't usually transport residents, but she arranged for them (F#2) to transport R1 at 11 AM. C1 stated that she was unaware R1 was on oxygen and was not told that. C1 stated F#2's driver (C6) went to pick up R1 after getting clarification from their corporate office that F#2 could transport residents. [DATE] 11:20 AM- interview with C6 (driver) stated that he arrived at F#1 at 11:15 AM and a daughter was there waiting. C6 stated that F#1 staff had no idea that R1 was going anywhere; they had to prepare R1 to leave by giving him a shower and taking him to the bathroom, which took about 45 minutes. C6 stated when they were leaving, R1 got his medications. C6 stated he got back to F#2 about 12:15 PM. When asked how R1 was during the transport, C6 stated he was bright and alert. Review of the BLS (basic life support- less critical than EMS or emergency life support) Prehospital Care Report, dated [DATE], stated that dispatch was notified at 2:03 PM and the BLS unit was notified at 2:07 PM. BLS arrived at F#2 at 2:13 PM and to R1 at 2:15 PM. R1's vital signs at 2:15 PM were 82 (pulse), ,[DATE] (BP) and a GCS of 15 (Glasgow Coma Scale (GCS)- a summation of scores for eye, verbal and motor responses. The minimum score is 3 which indicates a deep coma or a brain dead state. The maximum is 15, which indicates a fully awake patient). BLS' narrative stated, . Upon arrival (at F#2) family members stated pt (patient) was not acting right. Pt was on 4L of O2 via (by) nasal cannula .rash on hands from unknown cause . vital (signs) were obtained and stable and was put on 6L of O2 via nasal cannula .alert and oriented on way to . hospital . complained of no pain . The assessment by BLS stated, .field impression . no apparent illness or injury. Treatment began utilizing the following protocols: Altered Mental Status, General Patient Care. R1's pulse ox at 2:18 was 99% with a low concentration O2 of ,[DATE] LPM (liters per minute). The report did not include what R1's respiratory rate was and a lung assessment. The only medical treatment by BLS was monitoring R1's vital signs, GCS, and administering oxygen. BLS departed F#2 at 2:26 PM and arrived at the hospital at 2:49 PM. Hospital records were reviewed for the [DATE] admission. R1's initial vital signs at 3:10 PM in the ER were T. 99.2- 92- 16- ,[DATE] and pulse ox 99%. A nurses note timed 4:01 PM stated that R1's oxygen was reduced to 4 L/min. with a pulse ox of 94%. (from 6 L/min .). Vital signs at 7:55 PM were T 97.0- 95- 18- ,[DATE] and pulse ox 97%. R1 was transferred to ICU at 9:25 PM on [DATE] to ICU without incident. The ER physician's [DIAGNOSES REDACTED]. R1 expired on [DATE]. A copy of the death certificate was obtained. The cause of death was pneumonia with no secondary causes listed. F#1 failed to ensure that R 1 was transferred to F#2 in a manner that provided a safe and effective transition of care. Specifically, F#1 failed to: Ensure that R1 was ready for the transport- - R1 had to be showered, toileted, and medicated after F#1's van arrived to collect the resident. Assess the resident prior to transfer- - No documentation of mental status giving F#2 no baseline to guide them in their assessment. - No documentation of a prominent rash on R1's hands, noted upon arrival to F#2. - No documentation of rales, noted upon arrival at F#2. Check R1's oxygen tank prior to leaving F#1 to ensure that there was enough oxygen in the tank for transfer- - R1 arrived at F#2 with an empty tank of oxygen (R1 required continuous use of oxygen). - R1 was hypoxic with a pulse ox of 79% (pulse ox was to be maintained > 92%). Call report to the receiving facility- - R1 was sent to the hospital approximately 2 hours and 15 minutes after arrival to F#2 due to a change in condition. R 1 was subsequently hospitalized .",2020-09-01
97,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-10-25,583,D,1,1,BQMI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews and interviews, it was determined that for 1 (R121) out of 57 sampled residents, the facility failed to protect their privacy and confidentiality of their medical records. Findings include: 1. Review of R121's clinical record revealed: 3/17/17 - A physician's orders [REDACTED]. 10/15/18 at 3:29 PM - An observation revealed that R121's Prezcobix medication container was left on top of an unattended medication cart in the hallway, which showed the resident's name, name of the medication and the diagnosis. E4 (RN) exited a room and returned to the medication cart. The finding was immediately confirmed with E4. 10/25/18 at 9:19 AM - Finding was reviewed with E1 (NHA) and E2 (DON). The facility failed to maintain R121's privacy and confidentiality of the medical record.",2020-09-01
98,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-10-25,584,D,1,1,BQMI11,"> Based on observations, the facility failed to have all equipment in good repair. There were raised toilet seats in disrepair in 2 (B5, F6) out of 36 resident rooms reviewed. Findings include: 1. On 10/15/18 at 3:04 PM and on 10/23/18 at 1:51 PM, the raised toilet seat in the bathroom of room B5 was observed with peeling paint and having rust. 2. On 10/15/18 at 3:58 PM and on 10/23/18 at 2:01 PM the raised toilet seat in the bathroom of room F6 was observed with peeling paint and rust. Findings were reviewed with E1 (NHA) on 10/24/18 at 1:55 PM.",2020-09-01
99,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-10-25,600,H,1,1,BQMI11,"> Based on record reviews, interviews and review of facility documentation, it was determined that for 4 (R33, R78, R105 and R147) out of 57 sampled residents, the facility failed to ensure that the residents were free from abuse. Three (3) of four (4) residents (R33, R78 and R147) sustained harm (emotional abuse). R78 sustained verbal abuse from a staff member, which resulted in emotional abuse. R33 sustained emotional abuse when a wandering resident entered her room unsupervised and shoved R33 out of the way, which resulted in emotional abuse. R105 sustained physical abuse when R105's roommate slapped her arm causing redness and tenderness. R147 sustained emotional abuse when a wandering unsupervised resident entered her room causing her emotional abuse. Findings include: 1. Review of R78's clinical record revealed: 11/22/16 - Care Plan for ADLs included an approach to assist resident in bathing as per resident needs. 11/22/16 - Care plan for potential for alteration in comfort included a goal for pain will be diminished and approaches of assessing for verbal signs and symptoms of pain and assess for possible causes of pain and interventions. 2/27/17 - Care plan for resident to establish own goals, included a problem of the resident refusing shower or bed baths at times able to make own decisions with care and approaches of involve resident in the decision making of ADL and honor preferences. 8/7/18 - The quarterly MDS assessment coded R78's BIMS score as a 10 (moderate cognitive impairment- decisions poor, cues/supervision required); there were no behaviors exhibited; and bathing required physical help during part of the activity with one staff person assisting. 9/12/18 3:47 PM - Incident reported to state agency by E3 (ADON). At 11:00 AM, on the same day, E10 (LPN) had been notified that R78 was crying after an encounter with E24 (CNA). Statements collected by the facility revealed: --9/12/18 - E10 (LPN) labeled the incident as staff to resident. E10 (LPN) revealed that R78 stated s/he asked multiple times to have the bed lowered to prevent pain and the CNA (E24) did not answer. R78 began yelling at E24. E24 insisted on giving R78 a bed bath and handed R78 a washcloth. R78 threw washcloth back to CN[NAME] R78 then told E24 to get out of the room and CNA threw washcloth back to resident. Additionally, E10's (LPN) statement revealed that R78 requested that the CNA (E24) no longer takes (sic) care of me. E10 (LPN) stated that the resident was actively crying after the incident. E10 (LPN) consoled R78. --9/12/18 - E24 (CNA) revealed that R78 kept saying s/he was hurting because of positioning of the bed, but E24 (CNA) revealed nothing about adjusting the bed or resident. --9/12/18 - E25 (CNA) labeled the incident as verbal abuse. E25 (CNA) was present in the room just after the incident. E25 (CNA) revealed that E24 (CNA) stated that she would be leaving the building if it happened again and beating (R78's) a*% before she left. E25 (CNA) offered to complete R78's care and as E24 (CNA) was leaving the room, R51 and a visitor entered the room. The visitor asked E25 (CNA) How could we allow the caregivers to treat the patients that way cursing and carrying on? --9/12/18 - R51's visitor's statement revealed that while in the hallway, they heard the (E24) CNA get loud and nasty stating, 'if her a*% throws that wet wash cloth back at me again I'm going to throw it back at her a*%.' In addition, as E24 (CNA) was leaving the room, the visitor stated hearing E24 (CNA) say my a*% is getting fired today. 9/18/18 - A Disciplinary Notice, included at the back of the facility's Incident Report Investigation packet for this incident, noted that E24 (CNA) was terminated for threatening a resident. 10/22/18 3:08 PM - R78 stated, during an interview with the surveyor, that the morning of the incident E24 (CNA) didn't pay attention to me. E24 (CNA) wanted to wash me and I wanted a different time. R78 stated that E24 (CNA) threw a washcloth at R78 before R78 told E24 (CNA) to leave the room. R78 felt in trouble after the incident. 10/24/18 1:36 PM - During an interview with the surveyor, E10 (LPN) confirmed that after the incident R78 was visibly upset and crying. The facility failed to ensure that R78 was free from emotional abuse. Findings were reviewed with E1 (NHA) on 10/24/18 at 1:55 PM. 2. Review of R33 and R157's clinical records revealed: 7/27/18- The facility developed a care plan for the problem that R157 wandered into other rooms at times due to dementia. Interventions included for staff to provide redirection and 1:1 supervision. 8/3/18 A care plan was developed for the problem that R157 exhibited physical and verbal aggression. The care plan specified that R157 on 8/3/18 had a resident-to-resident altercation where she pulled another resident's legs and was verbally abusive. Interventions for this care plan included for R157 to receive 1:1 supervision. 10/8/18- An annual MDS assessment was completed and revealed that R33 was cognitively intact. 10/17/18 at 8:20 AM- A progress note documented that, during medication pass, E26 (RN) heard yelling and screaming coming from a room. E26 went to investigate and R157 was in R33's room. R33 tried to ask R157 to leave and R157 shoved R33 on her left shoulder. R33 was noted to be extremely upset and shaken. R157 was supposed to be on 1:1 supervision per her care plan when this incident occurred. 10/17/18 at 4:02 PM- After the incident occurred, R157 was observed by the surveyor without her care planned 1:1 supervision. R157 was seen walking by herself down the hall by the dining room towards the D/E wing nursing station. R157 then wandered into the nursing station and began putting hand sanitizer on her hands and rubbing it into a chair. At approximately 4:05 PM, staff noticed R157 and began to redirect her. 10/18/18 at 10:34 AM- During an interview, R33 stated when R157 came in her room she tried to get her to leave, but she just pushed past her. R33 stated that she did not get physically hurt this time, but she feels very scared and afraid and does not want her (R157) in her room. R33 stated that residents wandering into her room had been a problem for a while, but R157 was the only wanderer that made her feel scared because she was very strong. She stated, I can't defend myself against her. R33 stated that she was especially fearful of R157 now because she recently had a fall and does not want to get hurt again. R33 reiterated that she was very afraid and would be talking to her family about this event and stated that she already told staff that she was fearful. The surveyor reported this information to E2 (DON) who stated that he did not see this as abuse, but he would investigate further. 10/18/18 at 3:34 PM- During an interview on 10/18/18, R33 stated that staff had been in her room talking to her about the incident on 10/17/18 with R157. R33 again stated how afraid she was of R157, and commented that R157 always seemed like she was on a mission and you can't stop her. R33 stated that she worries because she cannot defend herself against R157. R33 stated that the interventions the facility puts in place, such as the stop signs across her doorway, do not help her feel safe. R33 stated the stop signs across the door do not help because they (wandering residents) just take them down. R33 stated that she and her roommate (R147) keep their door shut at night because they don't want people to come in, but they feel that they should not have to always keep their door shut just to be safe. 10/18/18 at 5:49 PM- A progress note documented that R33 was still very anxious regarding the situation that had happened yesterday .regarding the other Resident coming into her room. The note stated that R33 was to be reviewed by psych. The facility failed to ensure that R33 was free from emotional abuse. 10/25/18 at approximately 6:30 PM- Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC). 3. Review of R105 and R157's clinical records revealed: 7/27/18- The facility developed a care plan for the problem that R157 wandered into other rooms at times due to dementia. Interventions included for staff to provide redirection and 1:1 supervision. 8/3/18 A care plan was developed for the problem that R157 exhibited physical and verbal aggression. The care plan specified that R157 on 8/3/18 had a resident-to-resident altercation where she pulled another resident's legs and was verbally abusive. Interventions for this care plan included for R157 to receive 1:1 supervision. 8/8/18- An incident report summary from an event that occurred at 7:45 AM, documented that the assigned CNA was providing care to R157 when the resident became aggressive and pulled away. R157 then went over to R105 (her roommate) and began going through R105's belongings. R105 tried to stop R157 from taking her personal belongings and R157 reached out and slapped R105 on the right forearm. Staff stepped in and redirected R157 to her side of the room. R105's right forearm was noted to have redness and R105 verbalized that her right forearm was tender. The facility failed to ensure that R105 was free from physical abuse, as evidenced by, R105's roommate, R157, a known aggressive and wandering resident who was care planned for 1:1 supervision, slapping her arm causing redness and tenderness. 10/25/18 at approximately 6:30 PM- Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC). 4. Review of R147 and R157's clinical records revealed: 7/27/18- The facility developed a care plan for the problem that R157 wandered into other rooms at times due to dementia. Interventions included for staff to provide redirection and 1:1 supervision 8/3/18 A care plan was developed for the problem that R157 exhibited physical and verbal aggression. The care plan specified that R157 on 8/3/18 had a resident-to-resident altercation where she pulled another resident's legs and was verbally abusive. Interventions for this care plan included for R157 to receive 1:1 supervision. 9/10/18- A quarterly MDS assessment was completed and revealed that R147 was cognitively intact. 10/17/18 at 8:20 AM- A progress note documented that, during medication pass, E26 (RN) heard yelling and screaming coming from a room. E26 went to investigate and R157 was in the room shared by R147 and R33. R33 tried to ask R157 to leave. R157 shoved R33 on her left shoulder. R147 was noted to be upset after the incident. R157 supposed to be on 1:1 supervision per her care plan when this incident occurred. 10/17/18 at 4:02 PM- After the incident occurred, R157 was observed by the surveyor without her care planned 1:1 supervision. R157 was seen walking by herself down the hall by the dining room towards the D/E wing nursing station. R157 then wandered into the nursing station and began putting hand sanitizer on her hands and rubbing it into a chair. At approximately 4:05 PM, staff noticed R157 and began to redirect her. 10/18/18 at 3:39 PM- During an interview, the surveyor was talking to R147 about her fingernails when R147 stated that today had been a long day with people coming in and out of the room talking to her roommate about what happened the other day with R157 coming into their room. R147 stated that the incident was scary and that R157 makes her feel afraid. She stated that the facility feels like a prison because she does not feel safe. R147 stated she does not like to leave her room because someone may wander in and take her personal belongings. R147 stated that she feels bad for her roommate, R33, because she gets it even worse because she was in the first bed in their room. The surveyor reported this information to E2 (DON). The facility failed to ensure that R147 was free from emotional abuse resulting in harm, as evidenced by, R157, a known aggressive and wandering resident who was care planned for 1:1 supervision, entering her room unsupervised and shoving her roommate (R33) causing her emotional distress. 10/25/18 at approximately 6:30 PM- Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC).",2020-09-01
100,BRANDYWINE NURSING & REHABILITATION CENTER,85004,505 GREENBANK ROAD,WILMINGTON,DE,19808,2018-10-25,622,D,1,1,BQMI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, it was determined that the facility failed to ensure appropriate resident information was communicated to the receiving health care provider for 4 (R60, R141, R164, and R214) out of 57 sampled residents. For R214, the facility failed to include and communicate the required discharge information that was in R214's record to the receiving facility. For R60, R141, and R164, the facility failed to send a copy of care plans when these residents were discharged to the hospital. Findings include: 1. Review of R214's clinical record revealed: 8/7/18 at 10:30 AM - The facility facsimile (FAX) transmittal form stated that 18 pages were sent to the assisted living facility on behalf of R214. The documents sent were as follows: - Facility Cover Page (1 page); - R214's face sheet (2 pages); - R214's admission History & Physical, dated 2/22/18 (6 pages); - R214's Medication Review Report, dated 8/7/18 at 10:03 AM (8 pages); and - R214's Progress Notes, page 10 of 73, dated 8/7/18 at 10:04 AM (1 page). The facility failed to include and communicate the following required discharge information: - Follow-up appointments scheduled, including R214's oncologist appointment on 10/17/18 at 12:20 PM, urologist appointment on 9/6/18 at 10:15 AM, and follow-up with the eye doctor in 5 weeks from the 8/13/18 appointment; - Pertinent information from R214's hospitalized from [DATE] to 8/28/18; - Comprehensive care plan; - Durable power of attorney; - Labs; and - Copy of the facility's discharge summary. 8/29/18 - R214 was discharged to an assisted living facility. 10/22/18 at 1:38 PM - During an interview, E6 (Social Worker) confirmed that comprehensive care plans are not sent when a resident was a planned discharge. E6 stated that social work handles the medical equipment needs and home health needs. 10/25/18 at 9:19 AM - Finding was reviewed with E1 (NHA) and E2 (DON). The facility failed to include and communicate the required discharge information that was in R214's clinical record to the receiving facility. 2. Review of R60's clinical record revealed: R60 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE] and 6/22/218. Review of R60's clinical documentation lacked evidence that a copy of the resident's care plan was sent to the hospital with R60 on 5/11/18 and 6/22/18. Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC) on 10/25/18 at approximately 6:30 PM. 3. Review of R141's clinical record revealed: R141 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE], 7/13/18, 8/4/18, and 9/23/18. Review of R141's clinical documentation lacked evidence that a copy of the resident's care plan was sent to the hospital with R141 on 2/19/18, 7/13/18, 8/4/18, and 9/23/18. Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC) on 10/25/18 at approximately 6:30 PM. 4. Review of R164's clinical record revealed: R164 was admitted to the facility on [DATE] from the hospital s/p fall with left rib fractures, right maxillary fracture, and nasal bone fractures. R164 also had [DIAGNOSES REDACTED]. On 9/3/18, R164 experienced a significant change in condition and was sent to the ER. Review of R164's clinical documentation lacked evidence that a copy of the resident's care plan was sent to the hospital with R164 on 9/3/18. Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC) on 10/25/18 at approximately 6:30 PM.",2020-09-01