cms_DE: 44
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 |