cms_DE: 52
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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. Resident is unsafe to perform standing transfers or ambulate until further assessment is completed. Resident and CNA agreeable to recommendation. 4/9/19 7:30 AM - A Rehabilitation Note stated, PT eval (evaluation) completed 4/8/19, recommend continuing with Hoyer lift at this time and having resident use WC for all mobility on and off unit. 4/9/19 6:40 PM - A progress note stated, Writer was called .to find resident sitting on his/her bottom with back towards wall facing toilet .Resident noted with skin tear to top of right hand measure (sic) at 1.5 cm . 4/9/19 - A written statement, completed by E21 (CNA), stated R43 was transferred to the toilet and R43 stated he/she wanted to sit for a few minutes to have a bowel movement. E21 wrote that he/she left the resident and went down the hall to get some wipes. E21 wrote that by the time he/she returned, R43 had attempted to get up even after I had told him/her to wait for me and not to get up before leaving the room, he/she had agreed. 4/10/19 - The facility's investigation stated, .Resident was transferred to the toilet using the full mechanical lift (Hoyer lift) and 2 person assist. Lift was removed from in front of the resident to give more space to provide care. New CNA left resident to get wipes in the hall, when he/she returned the resident was on the floor. The resident appears to have attempted to self transfer and lost his/her balance and fell to the floor .The CNA was given extensive education on not leaving a resident in the bathroom without supervision and to make sure he/she has all necessary supplies prior to toileting/transferring a resident. 7/8/19 approximately 4:45 PM - Findings were reviewed with E2 (former DON). 7/8/19 4:53 PM - During an interview, E15 (OT) stated that anyone requiring a Hoyer lift transfer usually had poor standing and/or sitting balance. E15 agreed that R43 should not have been left unsupervised on the toilet on 4/9/19. The facility failed to ensure that a PT evaluation was completed post fall on 10/22/18, and failed to ensure that R43 had adequate supervision on 4/9/19. Instead, facility staff left the resident alone in the bathroom when he/she attempted to self transfer resulting in a fall and a skin tear. 7/9/19 approximately 8:15 AM - During an interview, E1 (NHA) and E2 (former DON) provided documentation of a PIP (Performance Improvement Plan) and stated that they self identified having issues with falls in the facility. They stated that although they continue to have resident falls, they have not had a fall due to a resident being left alone in the bathroom since R43's 4/9/19 fall. 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 R26's clinical record revealed the following: R26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk care plan was initiated on 1/27/18 identifying that R26 was a fall risk related to a history of falls, leg pain and weakness. Interventions included: - Anticipate and meet the resident's needs. - Be sure the call light is within reach and encourage the resident to use it for assistance as needed .Prompt response to all requests for assistance. - Ensure that the resident is wearing appropriate footwear when ambulating (walking) or mobilizing in wheelchair. - Needs a safe environment with even floors, free from spills and/or clutter; adequate glare-free light; a working and reachable call light, the bed in a safe position for transfers with wheels locked, personal items within reach. - Remind the resident to request assistance for all transfers and mobility. - Ensure bed height is lowered to appropriate level for safe exit/entry and not too high to reduce risk of serious injury. 2/1/18 - The admission MDS assessment stated that R26 was moderately cognitively impaired (decisions poor; cues/supervision required), required extensive assist of one staff person for transfers, and had no falls since admission. 2/12/18 - R26's care plan for bladder incontinence was developed related to dementia and impaired mobility with interventions including staff should supervise and offer toileting every 2 hours during waking hours and check and change as needed due to occasional incontinence. 1/22/19 - A Nursing fall risk evaluation score was high risk at 16. 1/23/19 - A Significant change MDS assessment revealed that R26 was severely impaired and exhibited rejection of care with worsening verbal and physical behaviors. R26 required two+ staff person extensive assist for transfers and had 2 falls without injury. 2/1/19 - A care plan intervention on the problem ADL (Activities of Daily Living) self care performance deficit was added indicating the need for 2 person assist at times to transfer and move in bed. Review of R26's fall incident/investigation reports, nursing progress notes, physician orders [REDACTED]. Fall # 1 2/24/19 at 12:00 PM - R26 fell during a transfer from the bed to a chair with assist from his/her CNA and obtained an abrasion on the left knee. The IDT (Interdisciplinary Team) who reviews falls, noted for PT to screen the amount of assistance appropriate for safe transfers for R26. R26 required 2+ persons for transfers according to his/her significant change MDS, dated [DATE]. There was no evidence that PT screened R26 after his/her fall on 2/24/19. The facility failed to follow the care plan for 2 person transfer. Fall # 2 3/10/19 at 8:45 PM - R26 stated he/she fell out of bed. R26 was trying to transfer himself/herself and was found on the floor on his/her left side. R26's bed was not in the lowest position. R26 was last observed at 8:30 PM resting in bed. Interventions added after the fall included adhering to R26's toileting schedule every 2 hours, offer hipsters, fall mats beside the bed and a pharmacy review. The facility failed to follow R26's care plan for appropriate lowered bed height for safe exit/entry. 3/11/19 - A PT screen status [REDACTED]. 4/15/19 - A PT quarterly screen indicated no skilled services were warranted at this time .continue to recommend 2 person transfers. Anti rollbacks were recently applied on the wheelchair and the wheelchair brakes were tightened. 4/17/19 - A quarterly MDS assessment stated that R26 remained severely cognitively impaired and he/she continued to exhibit rejection of care. R26 required two+ staff person extensive assist for transfers. Since the prior assessment on 1/23/19, R26 had three falls, two falls without injury and one fall with minor injury. 4/18/19 - The following care plan interventions were initiated, .staff to toilet and offer to return to bed for nap at mid - morning, continues to be insistent on performing own tasks and adhering to his/her preferences and self propels in wheelchair back to his/her room regardless of staff redirection. 4/19/19 - A Nursing fall risk evaluation score remained high risk at 14. Fall # 3 5/1/19 at 11:07 AM - R26 slid to the bathroom floor while being assisted off the toilet by his/her spouse. R26 had sock on only. A CNA (E25) witness statement summary documented that the last time R26 was cared for or toileted was on the 11-7 shift. E25 stated, Resident was in bed prior to shift change and during rounds. Was with another resident when spouse stopped me in the hall stating that resident was on the floor. Did not witness fall but notified the nurse .he/she was in the bathroom on the floor in front of the toilet. The fall investigation worksheet documented safety education to spouse and footwear - non skid socks to be in place. There was no evidence indicating that R26 was asleep during E25's rounds. The facility failed to follow R26's toileting care plan for staff to supervise and offer toileting every 2 hours during waking hours and check and change as needed for occasional incontinence. 5/1/19 at 4:15 PM - A PT screen post fall recommended when staff were assisting that the arm rest of the wheel chair be removed and the bed leveled to the chair to minimize the loss of R26's center of gravity and minimize muscular demand as opposed to the bathroom where a railing was available and R26's stability was greater. 5/1/19 - The following care plan interventions were initiated, .continue toileting schedule, monitor for non skids socks when not wearing shoes, 2 person transfer and staff to remove arm rest when able for stand pivot transfer. 5/1/19 - The CNA Kardex documented 2 person transfers - and staff to remove arm rest when able for stand pivot transfer .ensure proper footwear when out of bed and gripper socks when in bed .staff to provide more assistance with dressing, personal hygiene and toileting needs now .keep bed at lowest setting when in bed .obtain and encourage use or wear hip savers. 5/5/19 - The care plan intervention Offer to lay resident down after meals was initiated. 5/7/19 - The care plan intervention Request labs check to r/o (rule out) clinical issue that may add to fall risk was initiated. 5/28/19 - The care plan interventions Keep bed at lowest setting when in bed and obtain and encourage the wear of hip savers were initiated. Fall # 4 6/9/19 at 7:30 AM - R26 was being transferred from the bed into the wheelchair with stand/pivot transfer when R26 slid to the floor from the wheelchair. Predisposing factor included staff handling and gait imbalance. A witness statement was obtained from the CNA who performed the transfer. The facility fall investigation worksheet revealed that the actual transfer when the fall happened was with one staff person (required two). The CNA ADL flowsheet dated 6/9/19 at 11:23 AM documented extensive assist of one person. There was no evidence that two staff person assist was performed during the transfer. Interventions included the Nurse Practitioner was to evaluate for possible labs and a PT evaluation. The facility failed to transfer R26 according to the plan of care. 6/17/19 - A Physician ordered a PT evaluation for the recent fall (6/9/19). 6/21/19 at 6:13 PM - A PT note documented that R26 required extensive assistance of two persons for transfers with a gait belt to help secure R26's safety and stability. 7/9/19 at 2:21 PM - During an interview, E7 (RN) stated that R26 used to ambulate with a walker before his/her increasing left leg pain that caused a decline. R26's increased weakness and agitated behavior made it very difficult for staff during transfers and care. He/She was seen by rehab and had a transfer status change from one person assist stand pivot turn (stand pivot transfer), to two person extensive assist. Sometimes we use the total hoyer lift or the stand up lift to transfer him from bed to wheelchair or whenever we pick him up from the floor. He/She has a lot of falls. The amount of help needed is very inconsistent depending on his/her mental status and his/her ability to help himself/herself on that particular shift or day. 7/9/19 at 2:46 PM - During an interview, E9 (PT) stated that R26 had multiple falls mostly occurring in his/her room recently. When asked if R26 was a hoyer lift or a stand up lift transfer candidate based on feedback from nursing staff, E9 replied that resident is not a lift (Hoyer and/or Stand Up lift) transfer candidate and that resident can display transfers from wheelchair to bed a low (sic) pivot with intermittent trouble clearing armrest and needs 1-2 person maximum assistance for transfers. E9 also added that the wheelchair armrest be removed and the bed leveled to chair to minimize the loss of his/her center of gravity. 7/9/19 at 3:10 PM - In an interview, E10 (CNA) stated that R26 does not use the call bell and does not ask for help when needing assistance with transfers to the bed or to the bathroom. E10 further stated that another aide would have to come with her when she does morning care because of R26's combative behavior. 7/11/19 at 9:59 AM - E10 (CNA) revealed to the surveyor that, We use the total hoyer lift when we transfer him/her from bed to the wheelchair because he/she is very heavy. I think it is in our CNA task. That's how we transfer him/her every time I am assigned to take care of him. When asked about monitoring R26 for safety, E10 stated that R26 frequently stays in the activity room or self propels his/her wheelchair in the hallways. Furthermore, E10 stated, When I see him/her in the hallway, I would ask him/her if he/she wants to use the bathroom, and most of the time he/she would answer, 'No.' If I smell him/her of BM (bowel movement) or urine I will take him/her back to his/her room to change. The facility failed to ensure that the environment was free from accident hazards when: - On 2/24/19 at 12:00 PM, R26 had an unsafe transfer from the bed to the wheelchair when one CNA was providing assistance, instead of two staff that were required, which resulted in a fall with a left knee abrasion. - On 3/10/19 at 8:45 PM, R26 fell out of bed and the bed was not in the lowest position, despite R26 being at high risk for falls. - On 5/1/19 at 11:00 AM, R26 slid to the bathroom floor while being assisted off the toilet by his/her spouse. R26 was last toileted by the 11-7 shift. The facility failed to follow R26's toileting care plan for staff to supervise and offer toileting every 2 hours during waking hours and check and change as needed for incontinence. - On 6/9/19 at 7:30 AM, R26 had a fall due to an unsafe transfer from the bed into the wheelchair with 1 staff person extensive assist, despite the care plan and rehab recommendation for 2 person extensive assist with transfers. Findings were reviewed with E1 (NHA), E2 (former DON), E3 (Acting DON), E6 (NP), and E16 (ED) during the Exit Conference on 7/15/19 at approximately 12:30 PM. | 2020-09-01 |