cms_DE: 96
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 |