cms_DE: 29
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 |
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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 patient to the ER for further evaluation and treatment. R27 left for the hospital at 10:45 PM. 4/3/17 at 23:35 (11:35 PM) the incident was immediately reported to the DLTCRP. 4/7/17 -The facility's result of the investigation was submitted to the DLTCRP. The facility's follow up/or result of the investigation reported that it was followed up in the facility's fall committee and there was no evidence of abuse or neglect. However, review of the facility's investigation of the incident revealed that it was not investigated thoroughly. For example, there were no evidence that the staff who provided care to R27 prior to these unwitnessed fall were interviewed. On 5/3/17 at 12:30 PM- the facility submitted to the surveyor, copies of interviews/written statements from E8 (LPN), E9 (LPN) and E12 (CNA) conducted by the facility during the survey on/dated 5/2/17 for the 4/3/17 incident of R27's unwitnessed fall with injuries. 1.c. 4/11/17 at 03:30-Nurse's progress note stated that Resident was found on the floor in her room by her dresser at 3:20 AM after her roommate came to the nurse's station. resident sustained [REDACTED]. R27 was unable to tell how she fell or what she was attempting to do. NP ordered to send R27 to the hospital ER for evaluation and treatment. 4/11/17 at 9:59 AM -Incident report was submitted to the DLTCRP. 4/12/17at 22:45 (10:45 PM) Nurse's Progress note stated that R27 returned to the facility with a lacerated wound on her right eyebrow, hematoma to right forehead, right and left Periorbital sides of her nose and right upper lip, hematoma to her right shoulder, left and right forearm, left elbow, right knee and left lower extremity. 4/13/17 follow up/result of investigation was submitted to the DLTCRP. The facility's follow up/or result of the investigation report stated that Resident returned from the hospital with non-displaced nasal bone fracture. P[NAME] updated upon return. No evidence of abuse or neglect. However, review of the facility's investigation of the incident revealed that the facility has no documented evidence that the incident was thoroughly investigated. For example, there was no evidence that the CNA and/or CNAs who provided care to R27 prior to these unwitnessed fall were interviewed and including the roommate who reported the incident. Findings were reviewed with E1 (Administrator) and E2 (DON) on 5/2/17 at 1:30 PM. | 2020-09-01 |