cms_DE: 23
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 23 | KENTMERE REHABILITATION AND HEALTHCARE CENTER | 85001 | 1900 LOVERING AVENUE | WILMINGTON | DE | 19806 | 2018-12-06 | 689 | D | 1 | 1 | H65F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and interviews, it was determined that for two (R15 and R83) out of 54 sampled residents, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision to prevent accidents. The facility failed to ensure that R83's physician-ordered and care planned interventions were in place to prevent an accident on 11/17/18. For R15, the facility failed to provide adequate supervision to prevent R15, who has a history of non-Alzheimer's dementia with behavior disturbance, pseudobulbar affect, generalized anxiety disorder and major [MEDICAL CONDITION] from emotionally, verbally, and physically abusing R52 and from wandering into other residents rooms (R52 and R31) placing these residents (as well as others) at risk for abuse from R15. Findings include: 1. Review of R83's clinical record and facility documents revealed: R83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R83's care plan revealed that starting on 10/20/17, R83 had a high predictive factor for falls. Interventions included to have fall mats on the sides of R83's bed when he was in bed, and to keep his bed in a low position. physician's orders [REDACTED]. Review of R83's Fall History report revealed that on 11/17/18 at 11:10 PM, R83 fell when attempting to sit on the side of his bed. Interventions that were in use at the time of the fall were listed and did not include fall mats or having R83's bed in a low position. A progress note dated 11/18/18 at 12:05 AM stated, R83 had an unwitnessed fall that evening. The note stated that R83 stated that he was attempting to reposition himself from a lying to a sitting position with his feet resting on the floor, however, the bed was in a raised position. The resident did not realize the bed was raised and fell off the bed and onto the floor. R83 was found on the floor in a prone position on his right side, and presented with a right flank hematoma/abrasion and a right knee abrasion. During an interview on 12/5/18 at 2:32 PM, R83 stated that on 11/17/18 he fell because his bed was usually low to the ground, but that day it was high off the ground, and he was sitting himself up and went to push his feet on the ground and fell off his bed on to the hard floor. R83 stated that his fall mat was not on the floor by his bed and he hit his head and back on the floor and his bedside table. The facility failed to ensure that R83's physician-ordered and care planned interventions were in place to prevent an accident on 11/17/18. Findings were reviewed with E2 on 12/5/18 at 4:30 PM. 2. Cross refer F600, example #1 and #2 Review of R15's clinical record revealed the following: R15 was admitted to the facility in (YEAR). R15 has [DIAGNOSES REDACTED]. R15 resides on the 2nd floor of the facility. 9/7/16 - R15's dementia/cognitive status care plan, stated R15 had increased confusion per baseline with short and long-term memory deficits, decreased communication abilities, moderate impaired cognitive skills for daily decision making due to dementia. Requires cues/supervision. 11/13/17 - R15's behavior management care plan: physical aggression, stated, has become physically aggressive towards staff and other residents due to agitation and/or false beliefs. The goal for this care plan was will demonstrate physical aggression less than 10 times per week over the next 90 days. Interventions included: provide [MEDICAL CONDITION] medications as ordered, psychiatry consult as needed, redirect resident to refrain from physical aggression and consequences for such behavior (i.e., could injure herself or others), identify trigger of increased agitation and ensure resident this will not continue, and attempt to guide resident away from triggering the environment; attempts to distract resident with another activity or discussion. 12/3/17 counseling note by E22 (Psychologist) - . I also suggest a trial period of introducing her (R15) to activities on the 3rd floor (locked dementia unit) to see if she responds well to that environment and, if so, a move to that unit may be considered. 12/11/17 activities note - . During this review period activities has taken (R15) upstairs to 3rd floor for activities, she has really enjoyed being around all the residents on that unit. There are days when she sees us and asks if we are ready to take her upstairs! 1/4/18 10:11 PM nursing progress note - Continues to be confused and needs constant redirection and cueing during this shift. 1/5/18 counseling note by E22 - R15 would redirect briefly, but then persisted in returning to her irritation and desire to go home. Judgement: poor, Insight: poor. Activities report that R15 enjoys going to the 3rd floor and continues to participate in activities there. 2/3/18 counseling note by E22 - R15's confusion and agitation increases as the day goes on. At times, she is lethargic and weepy and at other times she is tearfully agitated and irritated. Redirection is difficult at these times as her confusion is high and persistent. Activities department reported that R15 enjoyed going to the 3rd floor. 2/9/18 counseling note by E22 (Psychologist) - . Staff reports that she does positively respond to visits to the 3rd floor, but has difficulty transitioning back to 2nd floor. I suggest asking a 3rd floor resident to accompany staff and R15 as she returns to her 2nd floor room, thus reducing R15's impression that she is being taken away from the activities and people with whom she's comfortable. 2/17/18 counseling note by E22 - I discussed (R15's) activities on the 3rd floor with (name of former activity director) who explained that (R15) loved participating in activities on the 3rd floor. However, when she returned to her room on the 2nd floor, (R15) became tearful and agitated. Staff are exploring with (R15's) family the possibility of moving her to 3rd floor when a bed is available. 2/27/18 nursing progress note - R15 up until 2:00 AM ambulating on the unit with a rolling walker. Physically and verbally abusive towards staff. Redirected, snack given and toileted without improvement. [MEDICATION NAME] (antianxiety medication) given with positive result. Although there was evidence of attempts to redirect, there was a lack of evidence as to what supervision took place when measures were ineffective and R15 was ambulating in the halls until 2:00 AM. 3/1/18 2:29 AM nursing progress note - R15 has been walking the halls, very confused and disoriented; crying on and off. [MEDICATION NAME] given earlier in shift with no results. Attempted comforting resident. Currently sitting out at nurses station. Will closely monitor. 3/9/18 activity note - R15 enjoys going up to 3rd floor for activities and socialization, getting her to come back down can be challenging as she would prefer to stay upstairs. When she is on the 3rd floor she shines and is very happy and content, when she (sic) bring her back down to 2nd floor she is unhappy and can be very challenging at times. 3/9/18 11:24 PM nursing progress note - R15 followed this writer down the hall during med (medication) pass. (R15) started to enter a partial shut door to one of the other residents room while medication was given. Other resident became upset and said, 'shut the door, don't let that woman in my room'. The door was shut and (R15) started to bang on the door and yell. This writer opened the door which caused the resident that lives in that room to get up and confront (R15) by saying 'this is my room, I don't want you in here.' (R15 became agitated and started to yell at the other resident . Two other resident (sic) came out of there (sic) room and made comments about (R15's) behavior and how disrupting it is to them. 3/10/18 counseling note by E22 - Staff reports that she (R15) can also be irritated and angry at times. When in a calm mood, (R15) is cooperative and pleasant. When not, she can be tearful and anxious. 3/13/18 social services note by E6 - Director of Social Services (DOSS) spoke with (name of daughter- F8) to discuss the possibility of resident moving to memory care unit (3rd floor) when a room becomes available. (F8) to visit the unit with her mom a few times and will get back to DOSS with a decision. There was a lack of evidence in the EMR as to how the facility was providing adequate supervision to R15, whom the facility believed would benefit from residing on the 3rd floor, a locked dementia unit that provides a higher level of supervision than the other floors. 3/19/18 9:47 PM nursing progress note - R15 became anxious and agitated. She walked behind nursing station and approached E23 (physician). R15 was asking E23 about the bus and the train. While E23 was speaking to the resident, R15 started to yell at E23 and raised her arm in a fist to strike E23. It was unclear who was supervising R15 or what measures were in place to deter R15 from approaching E23 in her agitated state. 3/22/18 3:31 PM nursing progress note - R15 noted kicking, hitting and yelling to other resident and staff. She also pore (sic) water to (sic) residents and staff . refused to take [MEDICATION NAME] for anxiety. 3/22/18 3:47 PM nursing progress note - R15 came out of room and began yelling at other residents. Stay away from me you [***] ! Resident attempted to hit 2 other resident's while screaming at them. Staff attempted to redirect R15 and she turned around and hit 3 staff members on the arm. R15 was making false accusations towards staff and began yelling Leave me alone! R15 was unable to be redirected and refused antianxiety medication. Spoke to E4 (Medical Director) who gave verbal order for [MEDICATION NAME] gel topically every 6 hours as needed for anxiety. E4 also gave an order to send R15 to Wilmington Hospital (has psychiatric unit) if R15 is a harm to herself or anyone else. There was no evidence in R15's EMR that she was sent to Wilmington Hospital. 3/23/18 - R15's care plan for social services: verbal aggression stated R15 presents with socially inappropriate behavior aeb yelling, cursing towards staff and other residents related to agitation and/or false beliefs. The care plan goal was will exhibit behaviors no more than 25 x per week . Interventions include: identify triggers of increased agitation and ensure triggering event will not continue to occur, attempt to guide resident away from triggering environment, attempt to distract resident with another activity or discussion, and use therapeutic lies when she starts getting anxious/agitated with her usual worries i.e. The food is already paid for by your daughter or Wait for her to come get you, etc. 3/29/18 11:22 PM nursing progress note - R15 was going up and down halls entering other residents rooms asking for help because of a note she claims someone gave her that she believes is a ransom note. R15 showed staff the piece of paper which had her name and room number on it. R15 was crying and appeared afraid. R15 was taken to her room and started to calm down and become less agitated after [MEDICATION NAME] gel. There was a lack of evidence that R15 was being properly supervised as she was entering other residents rooms. 4/1/18 2:52 PM nursing progress note - R15 was angrily yelling while sitting in nurses station when grandaughter walked in with flowers. R15 began yelling at grandaughter and smacked her in the face. Writer attempted to redirect again and explain that her grandaughter just wanted to give her flowers, but she continued to yell at writer and attempted to hit another resident who was sitting nearby. 4/4/18 11;30 PM nursing progress note - R15 got up from the nurse's station and started heading down the wrong hall towards her room. Attempted to redirect R15 and she got agitated and started yelling at staff and other residents. 4/12/18 9:44 PM nursing progress note - R15 became agitated after dinner. She was pacing the hall saying, I'm lost, I can't find my Mommy. R15 was going in and out of other residents rooms crying for help. Was redirected several times without success. R15 was given [MEDICATION NAME] gel with positive results. There was a lack of evidence that R15 was being properly supervised as she was entering other residents rooms. 4/19/18 progress note by E4 (Medical Director) - Still needs [MEDICATION NAME] gel. Alert and oriented x 1 (to person), calm, able to make short conversation, labile mood, suddenly cried, easily distracted. 5/26/18 counseling note by E22 (psychologist) - R15 was tearful and anxious, reporting that she had no money and no home. I sat with her, reassured her as I redirected her. This often takes some time as (R15) can be persistent in her delusion of poverty and homelessness. 6/5/18 activity note - R15 maintains her established routine on unit and in the facility. Prefers 1:1 time. She requires encouragement to participate in most all activities. 6/20/18 progress note by E23 (physician) - R15 is having aggressive behaviors towards staff. PRN (as needed) [MEDICATION NAME] is no longer effective. Consult psych for need for possible antipsychotics. Will start Trazadone (antidepressant and used as mood stabilizer) low dose twice a day. Discussed with E4 who is in agreement. 6/23/18 counseling note by E22 - E22 met with F8 (R15's daughter) and discussed her concerns about her mother's current condition and the ongoing progression of her disease. F8 is very aware of her mother's confusion and continued decline in mental status. We discussed the possibility of a 3rd floor placement for her mother, but F8 is not ready to agree to that , stating that she is concerned about an increase in R15's confusion in changing her routine and her surroundings. 6/26/18 nursing progress note - R15 required [MEDICATION NAME] gel x 2, due to aggressive behavior and yelling and screaming at staff. R15 was yelling at staff to get her mom, also that staff took her baby. Suggested resident have a snack and a drink as a distraction to aggressive behavior with no help. R15 was also trying to leave floor trying to push the doors open. R15 was up all 11-7, walking up and down hallways. R15 required one to one attention for the whole shift. 7/18/18 nursing progress note - E24 (physician) was in to assess R15 and reviewed prn [MEDICATION NAME] gel usage. R15 frequently has episodes of anxiety and agitation towards staff and other residents. 8/29/18 - Review of R15's annual MDS assessment, coded R15 as a 3 for cognition (severly impaired- never/rarely made decisions). For mood, R15 was coded as feeling down, depressed or hopeless for 12-14 days (out of a 14 day review period). For behaviors, R15 was coded as having physical symptoms (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) directed towards others for 1-3 days (out of a 7 day review period and verbal symptoms (e.g., threatening others, screaming at others and cursing at others) directed towards others for 4-6 days. R15's behaviors were coded as improved compared to the prior MDS assessment. 10/25/18 nursing progress note - Writer noted R15 yelling at another resident and at staff. R15 appeared very angry and agitated. R15 responded well at first while [MEDICATION NAME] gel was applied, but then became angry at the nurse and started to swing at and punch the nurse. 10/28/18 2:08 PM counseling note by E22 (psychologist) - Writer assisted R15 as she was trying to enter another resident's room as the CNA was providing care. R15 was angry and tearful, saying, They don't like me and I don't know why. Writer redirected R15 back to her room and stayed with her. R15 persisted in her anger and her sadness. There was a lack of evidence that facility staff was supervising R15 when she tried to enter another residents room as care was being provided, rather than the psychologist. October (YEAR) - The Behavioral Monitoring Form, completed by CNA's identified the following behaviors: - physical aggression - 98 occurrences; - verbal aggression - 170 occurrences; - false beliefs - 88 occurrences. 11/25/18 5:05 PM nursing progress note - At approximately 1530 (3:30 PM), resident noted standing in lounge area, agitated while shouting 'you stole my money' headed towards another resident. CNA approached (R15) . calm therapeutic manner, however, (R15) continued to be verbally aggressive (towards other resident- R52) and quickly slapped (R52's) left arm. Attempts to redirect made, (R15) escorted to her room . Nursing staff to monitor . There was a lack of evidence that staff were supervising R15 when she was able to strike another resident. 11/28/18 12:05 PM - R15's daughter (F8) was interviewed. F8 stated that her mother has been agitated with other residents and she was called last week by the facility and notified that words were exchanged and R15 thought someone stole her money. F8 stated that facility staff had brought up the idea of R15 going to the 3rd floor, When asked if she had viewed the 3rd floor, F8 stated yes, it's nice, however, she was only willing to let her mother go upstairs to the 3rd floor if her room faced the street where the front entrance of the facility was. F8 confirmed that she was R15's power of attorney (decision-maker). November (YEAR) - Behavioral Monitoring Form, completed by CNA's identified the following behaviors: - physical aggression - 91 occurrences; - verbal aggression - 137 occurrences; - false beliefs - 23 occurrences. Numerous observations of R15 were made on the following dates: 11/29/18, 11/30/18, 12/3/18, 12/4/18, and 12/5/18. Most of the observations took place on the 7-3 shift and R15 was asleep several times. For all of the observations, R15 was not engaged in any activities other than watching tv in her room. The following observations revealed: 12/3/18 10:55 AM - R15 was dressed and sitting in a chair in her room. When the surveyor entered the room, R15 seemed anxious and asked, Where's (females first name? The surveyor stated that she had not seen her yet and that I just came by to say hi. R15 then smiled and seemed fine. 12/3/18 3:45 PM - R15 was sitting in a chair in her room and became tearful when the surveyor entered her room stating that her legs hurt. A few seconds later, R15 stated, I can't walk (untrue) because of my hips. The surveyor asked R15 if she needed pain medication and R15 said no. 12/5/18 4:32 PM - R15 was ambulating with her walker and entered R52's room (in same hall) and a few seconds later she came back out. R52 was not in her room at the time. R15 was anxious with a shaky voice stating that she needed to go to the bathroom, then a second or 2 later saying that she stepped in water with her left foot. There was no staff in the hall, so the surveyor was walking R15 down the hall towards her room when a CNA came down the hall from another residents room. The CNA stated that she was busy, but finally agreed to take R15 to her room after the situation was explained to her. 12/6/18 12:55 PM - Findings were reviewed with E2 (DON) and advised there was a lack of supervision related to abuse of R52 and wandering into R31's and R52's rooms. 12/6/18 2:05 PM - E17 (CNA) was interviewed. E17 was assigned to the rooms on the other side of the hall where R52 and R15 reside. E17 stated she's worked in the facility for 4 years with 3 years being in this hall and she confirmed that she's very familiar with R15. E17 stated she works both day and evening shifts. When asked about R15, E17 stated that her moods are up and down, that she usually sleeps during the day and is agitated in the evenings. E17 stated that staff try to reassure R15 that she's in the right place and is being taken care of, however, she is difficult to redirect at times, and sometimes R15 hits staff and other residents. E17 further stated that R15 gets upset when she comes out of her room naked or without shoes and staff and other residents tell her what to do, she becomes angry. When asked if R15 has hit her, E17 stated no, but stated that R15 has threatened to hit her, has been verbally abusive, including the use of racial slurs. E17 also stated that she has observed R15 wandering into other residents rooms and gave R31's room as an example. Although the facility has provided ongoing psychiatric services to R15 and made efforts since 12/3/17 (there may be other efforts prior to my review period) with R15's family towards placement on the 3rd floor, a locked dementia unit, R15 remained on the 2nd floor as of the exit date of 12/6/18. The facility failed to provide adequate supervision to prevent R15, who has a history of non-Alzheimer's dementia with behavior disturbance, pseudobulbar affect, generalized anxiety disorder and major [MEDICAL CONDITION] from emotionally, verbally, and physically abusing R52 and from wandering into other residents rooms (R52 and R31) placing these residents (as well as others) at risk for abuse from R15. | 2020-09-01 |