cms_DE
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 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 w… | 2020-09-01 |
| 2 | 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 occasional… | 2020-09-01 |
| 3 | 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, ob… | 2020-09-01 |
| 4 | 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 voi… | 2020-09-01 |
| 5 | 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… | 2020-09-01 |
| 6 | 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 | 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 | 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 | 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 do… | 2020-09-01 |
| 10 | 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 | 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 R… | 2020-09-01 |
| 12 | 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/… | 2020-09-01 |
| 13 | 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 | 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 | 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 … | 2020-09-01 |
| 16 | 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 … | 2020-09-01 |
| 17 | 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 pr… | 2020-09-01 |
| 18 | 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 s… | 2020-09-01 |
| 19 | 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 Ag… | 2020-09-01 |
| 20 | 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 s… | 2020-09-01 |
| 21 | 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… | 2020-09-01 |
| 22 | 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. … | 2020-09-01 |
| 23 | 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 righ… | 2020-09-01 |
| 24 | 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 ind… | 2020-09-01 |
| 25 | 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 r… | 2020-09-01 |
| 26 | 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 of… | 2020-09-01 |
| 27 | 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 | 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 sh… | 2020-09-01 |
| 29 | 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 pat… | 2020-09-01 |
| 30 | 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 | 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 | 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 implem… | 2020-09-01 |
| 33 | 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 | 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 | 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 | 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 el… | 2020-09-01 |
| 37 | 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 | 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… | 2020-09-01 |
| 39 | 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 | 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… | 2020-09-01 |
| 41 | 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 impact… | 2020-09-01 |
| 42 | 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 | 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 | 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 coordinatio… | 2020-09-01 |
| 45 | 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 | 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 | 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 … | 2020-09-01 |
| 48 | 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 | 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 | 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 practiti… | 2020-09-01 |
| 51 | 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 r… | 2020-09-01 |
| 52 | 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. Re… | 2020-09-01 |
| 53 | 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 | 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-Administ… | 2020-09-01 |
| 55 | 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 | 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'… | 2020-09-01 |
| 57 | 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 | 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 r… | 2020-09-01 |
| 59 | 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… | 2020-09-01 |
| 60 | 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 | 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 | 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 af… | 2020-09-01 |
| 63 | 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) an… | 2020-09-01 |
| 64 | 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 | 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 monit… | 2020-09-01 |
| 66 | 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 | 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 comprehen… | 2020-09-01 |
| 68 | 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… | 2020-09-01 |
| 69 | 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; - g… | 2020-09-01 |
| 70 | 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 4/1… | 2020-09-01 |
| 71 | 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 10:3… | 2020-09-01 |
| 72 | 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 … | 2020-09-01 |
| 73 | 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 | 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, … | 2020-09-01 |
| 75 | 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 | 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 table… | 2020-09-01 |
| 77 | 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 provi… | 2020-09-01 |
| 78 | 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 … | 2020-09-01 |
| 79 | 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 | 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 | 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 | 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 | 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, hygie… | 2020-09-01 |
| 84 | 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… | 2020-09-01 |
| 85 | 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 s… | 2020-09-01 |
| 86 | 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 | 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 | 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 sign… | 2020-09-01 |
| 89 | 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 | 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. T… | 2020-09-01 |
| 91 | 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 | 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, complete… | 2020-09-01 |
| 93 | 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 | 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 | 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/… | 2020-09-01 |
| 96 | 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 sta… | 2020-09-01 |
| 97 | 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 | 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 | 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… | 2020-09-01 |
| 100 | 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 requir… | 2020-09-01 |
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CREATE TABLE [cms_DE] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );