| 100 |
BRANDYWINE NURSING & REHABILITATION CENTER |
85004 |
505 GREENBANK ROAD |
WILMINGTON |
DE |
19808 |
2018-10-25 |
622 |
D |
1 |
1 |
BQMI11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, it was determined that the facility failed to ensure appropriate resident information was communicated to the receiving health care provider for 4 (R60, R141, R164, and R214) out of 57 sampled residents. For R214, the facility failed to include and communicate the required discharge information that was in R214's record to the receiving facility. For R60, R141, and R164, the facility failed to send a copy of care plans when these residents were discharged to the hospital. Findings include: 1. Review of R214's clinical record revealed: 8/7/18 at 10:30 AM - The facility facsimile (FAX) transmittal form stated that 18 pages were sent to the assisted living facility on behalf of R214. The documents sent were as follows: - Facility Cover Page (1 page); - R214's face sheet (2 pages); - R214's admission History & Physical, dated 2/22/18 (6 pages); - R214's Medication Review Report, dated 8/7/18 at 10:03 AM (8 pages); and - R214's Progress Notes, page 10 of 73, dated 8/7/18 at 10:04 AM (1 page). The facility failed to include and communicate the following required discharge information: - Follow-up appointments scheduled, including R214's oncologist appointment on 10/17/18 at 12:20 PM, urologist appointment on 9/6/18 at 10:15 AM, and follow-up with the eye doctor in 5 weeks from the 8/13/18 appointment; - Pertinent information from R214's hospitalized from [DATE] to 8/28/18; - Comprehensive care plan; - Durable power of attorney; - Labs; and - Copy of the facility's discharge summary. 8/29/18 - R214 was discharged to an assisted living facility. 10/22/18 at 1:38 PM - During an interview, E6 (Social Worker) confirmed that comprehensive care plans are not sent when a resident was a planned discharge. E6 stated that social work handles the medical equipment needs and home health needs. 10/25/18 at 9:19 AM - Finding was reviewed with E1 (NHA) and E2 (DON). The facility failed to include and communicate the required discharge information that was in R214's clinical record to the receiving facility. 2. Review of R60's clinical record revealed: R60 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE] and 6/22/218. Review of R60's clinical documentation lacked evidence that a copy of the resident's care plan was sent to the hospital with R60 on 5/11/18 and 6/22/18. Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC) on 10/25/18 at approximately 6:30 PM. 3. Review of R141's clinical record revealed: R141 was admitted to the facility on [DATE] and was discharged to the hospital on [DATE], 7/13/18, 8/4/18, and 9/23/18. Review of R141's clinical documentation lacked evidence that a copy of the resident's care plan was sent to the hospital with R141 on 2/19/18, 7/13/18, 8/4/18, and 9/23/18. Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC) on 10/25/18 at approximately 6:30 PM. 4. Review of R164's clinical record revealed: R164 was admitted to the facility on [DATE] from the hospital s/p fall with left rib fractures, right maxillary fracture, and nasal bone fractures. R164 also had [DIAGNOSES REDACTED]. On 9/3/18, R164 experienced a significant change in condition and was sent to the ER. Review of R164's clinical documentation lacked evidence that a copy of the resident's care plan was sent to the hospital with R164 on 9/3/18. Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC) on 10/25/18 at approximately 6:30 PM. |
2020-09-01 |