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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 comprehension and understanding of others' verbal content. The MDS also stated that R2 was independent for daily decision making skills and had no behaviors. 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 the facility's incident report and investigation revealed the following statements: 3/14/18 - A written statement completed by E1 (NHA) stated that he/she had been informed by an anonymous staff person that R2's care conference had been conducted in an inappropriate and disrespectful manner. The statement went on to say that he met in his office with E7 (Activity Director) and the HR (Human Resource) manager (E27). E1 stated he told E7 that staff felt she was inappropriate during the care conference and to prepare a statement of what happened for review. E7 said that she was stern with R2 and he/she was unable to identify staff that 'did not know what to do in activities.' E1 wrote that shortly after, E2 (DON) informed him that E3 (Staff Educator) had spoken with R2 and asked how care plan meeting went? R2 stated 'that he/she felt mistreated by the staff in that meeting.' E1 wrote that he and E2 went to speak to R2. E1 wrote that R2 stated, .the activity staff don't know what they are doing, but again I am always wrong. I feel like people do not want me here. When asked who he/she felt mistreated him/her in the meeting, R2 responded E4 (UM), E7 (AD), E8 (SW#1), and E9 (SW#2). E1 wrote that after the interview he informed E6 (ADON) to begin an investigation and that E4, E7, E8, and E9 were informed they were suspended pending an investigation and to provide written statements. 3/14/18 - A written statement completed by E2 stated, .E3 came to my office visibly shaken and related a discussion she just had with R2 regarding his/her feeling that he/she had been intimidated during care conference and he/she felt he/she had been abused .He/she remarked that 'everyone came in to point out I was wrong' .'they brought in all the activities staff .all of them to tell me I was wrong .' I asked how he/she felt about the meeting and he/she stated 'Intimidated .abused' . 3/14/18 - A written statement completed by E3 stated, .R2 wasn't his/her normal self so I asked him/her if he/she was ok and he/she stated 'no' it was another bad meeting. I asked him/her what meeting .'the monthly meeting' .He/she was visibly upset .R2 stated, ' .just tired of this and they shouldn't have attacked him/her it was wrong and its been going on for years.' At that point I had to ask him/her if he/she felt abused, neglected or mistreated and he/she stated 'Yes.' I told him/her I would be right back and went to find E2 to notify him. 3/14/18 - A written statement completed by E8 (SW#1) stated, .E7 then asked if he had anything for activities. (R2) made a sound and said 'we'd be here forever if I start' .He/she began telling her how she should run/fix her department. R2 then told E7 that several of her staff don't know what activities are going on throughout the day .E7 then called all her staff to the conference room. She asked her staff questions about what R2 reported. She and R2 went back and forth. E9 (SW) and I tried to calm E7. I asked E7 could we let her staff go and they did leave. E4 (UM) borrowed R2's daily calendar and asked him/her what was occurring at a specific time. He/she was unable to recall and E4 explained that it is difficult to remember the entire days activities .E4 asked R2 if he/she is unhappy here, would he/she like us to help him/her find another placement. He/she didn't answer. E9 reminded R2 that he/she hadn't answered E4 and asked what he/she would like us to do . 3/14/18 - A written statement completed by E9 stated, .The AD (E7) asked R2 if he/she had any questions or concerns for activities .R2 stated that when he/she asks activity staff about the activities of the day or about changes he/she often gets 'I don't know' responses. AD explained that all of her staff have a copy of the daily agenda and are aware of the changes. AD asked him/her for specific staff members that have given him/her this response. R2 reports he/she wasn't able to recall. AD called to her department and asked for all of her staff to report to the conference room .The AD was standing and speaking loudly in the conference room .The AD was still standing and stated 'So just take the agenda with you wherever you go. If you have to go to the bathroom take it with you.' This writer attempted to redirect the AD and stated 'Do not take the agenda to the bathroom.' Activity staff members were dismissed and one staff stated 'Just fold it up and put it in your bra' .UM (E4) asked R2 if she could see his/her daily agenda as he/she also reported during care conference that he/she highlights which activities are of interest .UM asked R2 what the 3:45 activity is. R2 attempted to state the activity but the UM informed R2 that he/she was wrong. He/she attempted 2 more times with the incorrect answer. R2 stated 'pick an activity I have highlighted.' UM informed R2 that the 3:45 activity is one he/she has picked. UM stated 'See (name of R2) . It is not that easy to remember the daily agenda.' UM then discussed with R2 that 'Since he/she is not happy here is there another facility he/she would like a referral too (sic)' . 3/14/18 - A written statement completed by E4 (UM) stated, As I was coming down the hall to enter the conference room E9 (SW#2) walked past me and made a comment that it was getting heated in there .E7 (AD) was stand (sic) and speaking loudly at R2 regarding activities. R2 was concerned about staff not knowing the activity schedule when he/she asks them .activity staff and E9 began entering the conference room .Concerned this was continuing to escalate I tried to speak to R2 .at this point E7 and E8 (SW#1) began speaking loudly again. E7 was still standing leaning over the table .E8 stated they have done everything possible and bend over backwards for him/her .At this point I cut in and said to R2 I believe you and I have formed a good relationship and I see you aren't happy what is it we can do to make you happy or are you not happy here anymore? E8 spoke up and said she could help him/her with referrals near family .or another facility in Wilmington. E9 (SW#2) asked him/her to answer my question and he/she said he/she wasn't sure. He/she said he/she needed to speak to his/her family. E9 said he/she is alert and able to make his/her own choices in care. He/she repeated he/she wanted to talk to family .E8 stated he/she had spoken to family before .and since his/her two family members could never make it in the same time because he/she insisted on their presence it was never completed .He/she looked at his/her schedule for a bit and a comment was made about him/her not knowing what he/she wanted to do, I do not recall which staff member said this . 3/14/18 - A written statement completed by E10 (RD#1) stated, .R2 stated that his/her meals still were not correct .E8 (SW#1) stated that staff have 'bent over backwards' to ensure his/her order was correct .E7 (AD) asked R2 if he/she had concerns about the activities .R2 stated the activities staff do not know what activities are occurring when he/she asks them, and he/she expressed he/she does not like when the location of the activity is changed because he/she has to move to the different room .E7 raised her voice .E7 continued to speak with a raised voiced (sic) which continued throughout the Care Conference until about when her staff exited the conference room and asked R2 'Who doesn't know what's going on in activities?' R2 stated he/she didn't want to give names. E7 stated 'Why not? I want to know who doesn't know what's going on.' E7 stood abruptly .she wanted all of her staff to come to the conference room .E7 stated to her staff with a mocking tone of voice 'R2 thinks you all don't know the activity schedule.' The statement went on to say that E7 asked each activity staff aide if they knew what they were doing today. Finally one activity aide stated she did not know and would have to look at the daily activities sheet. E4, E8, and E9 stated to R2 that it would be difficult for any staff member to memorize the entire day's schedule of activities.E7 stated to her staff with a continued mocking tone of voice 'You all need to keep this sheet with you every day including going to the bathroom. If you're going number two, wipe your butt with it, I don't care. You need to have it' .At the end, R2 had mentioned carrying the daily activities schedule around with him/her so that he/she could remember. E7 sarcastically responded 'Oh really? Hmmm, you don't remember, huh?' R2 stated 'When you get to be my age you see how much you remember.' 3/15/18 - An emailed statement from E7 (AD) stated, .Activity Director did request Activity Assistants to join in the conference so that R2 could better identify the staff that he/she was accusing of not knowing the activities for the day. Resident was unable to do so. During care conference, R2 fluctuated between his/her concerns stating that the activities were horrible then saying they were great. Due to Resident being unhappy with the service at Brandywine, E4 (UM) asked if he would like to return to the community with the assistance of a state assisted program and R2 avoided the question. Question was asked multiple times before a response was given . 3/15/18 - Review of a typed statement, dated 3/15/18, revealed that E6 (ADON) conducted an interview with R2 regarding the 3/14/18 care conference. The following was stated during the interview: - A discussion began about activities and R2 stated that activity staff doesn't know what activities are scheduled for the day or where they are; - R2 stated that E7 (AD) didn't like being told certain things and the next thing he knew was all activity staff came in the conference room; - When asked how that made him/her feel, he/she stated it felt like everyone thought he/she was lying; - R2 said he/she felt terrible because they think I'm a liar; - When asked if he/she felt abused, neglected or mistreated and he/she said just felt terrible; - When asked how E8 (SW#1) made him/her feel, he/she stated .terrible like she always does when I talk to her .it's either her way or no way .just like during resident council meetings. She doesn't give you a chance to talk, runs over what you're saying and closes the meeting out because it can't run for too long; - When asked how E9 (SW#2) made him/her feel, he/she stated .terrible, she follows the lead, she's just like E8 but wasn't that way when she first came here .; - When asked if E4 (UM) made him/her feel terrible, he/she stated, no because she didn't say that much, E4 spoke, not too much in my favor; - When asked how E7 made him/her feel, he/she stated, .terrible .feels that everybody thinks he's/she's lying, and that it's frustrating every day, like they want him/her out of here; - When asked if he/she were to see E7, E8, E9, E4, or E10 (RD) in the hallway would he/she feel uncomfortable and he/she stated no. The ADON wrote, .R2 was not on trial but when he/she expressed that activity staff did not know the schedule or schedule changes the activity staff were called to the conference room for R2 to identify the staff he/she was 'accusing.' The resident clearly states that the quarterly care conference caused the resident to feel 'terrible, that everyone thinks I'm a liar' and that R2 is always wrong. The staff in question did not follow the BNRC policy and procedure for abuse, neglect, mistreatment .The resident was not treated with respect and dignity. Emotional abuse includes ridiculing or demeaning a resident, making derogatory remarks to a resident, cursing directed to a resident. Treating a resident in a nursing home in a manner that does not uphold a residents self worth and individuality . 3/16/18 - A written statement completed by E14 (AA) stated, .Act. (Activity) Director was with resident and a few other workers as she proceed (sic) to ask me a question which I gave her my answer .Afterwards she began to speak with the resident where there (sic) conversation got little (sic) heated. Act Director said something not so friendly to/in reply to the resident as the conversation gotten (sic) little out of control . 3/16/18 - A written statement completed by E17 (AA) stated, Myself and a few other staff members were called to the conference room .E7 (AD) to my view point very abusively was telling R2 that her staff members do not normally carry our newsletters everywhere we go. However in a very harsh manner she than (sic) told us to carry our newsletters everywhere we go, even if going to the rest room. She sarcastically told us to wipe with it .She continued raising her voice at the resident. R2 was trying to interrupt but the ladies (E7, E9 (SW#2) and E8 (SW#1)) did not let him and continued to try to explain themselves .in my heart I was very upset that I did not have the ability to interrupt the conversation to calm everyone down. 3/16/18 - A written statement completed by E18 (AA) stated, .Several of the activities staff came in and I felt like we were unwittingly ganging up on R2. E7 (AD) was talking loud and arguing with R2 about people not carrying their daily sheets .She (E7) yelled to R2 so you want me to tell my staff to take the daily sheet/clipboard where ever they go? .Shall I have them take it in when they pee? .E8 (SW#1) I believe said something then. Shall I have them take it in when they have a bowel movement. Okay, I'll have them do that and they can wipe their butts on it. At which point I said eew (sic) loud enough for her to know she had gone too far. Even before that comment I was ready to walk out in protest. E7 was obviously feed (sic) up, but she handled it inappropriately. Being disrespectful, rude and crude. At one point E7 mentioned how R2 forgets sometimes. And he/she said he/she did not. E8 said yes you do, in your last testing you had forgotten some things. I felt that this had little to do with the conversation and could have been talked about more privately with out so many activities people in the room. 3/16/18 - A written statement completed by E19 (AA) stated, The activities staff was summoned to the conference room by a call from E7 (AD). Her tone was inpatient/upset .E7 was very agitated and began raising her voice, not only to R2. She said that we should take our clipboards to the bathroom with us and wipe out butts with it. E8 (SW#1) at one point asked E7 to 'reel it in' but the agitation continued. At one point someone, either E9 (SW#2) or E8, asked R2 what was going on that day at 3:00. He/she wasn't able to answer the question, and the point was made that how were we supposed to have it memorized. In my opinion esp.(especially) E7's tone was very abusive to this resident and it was unprofessional and embarrassing . 3/17/18 - A written statement completed by E16 (AA) stated, We were called up into the conference room .She (E7) then started to ask R2 questions about the newsletters being very unprofessional say (sic) things on how we should keep out newsletters . 3/19/18 - A written statement completed by E11 (AA) stated, .Upon our arrival staff was questioned about the daily schedule .Inappropriate comments from management were made towards residents concern. I'm unsure the reasoning why activity staff was needed and was quit (sic) shocked as to the behavior from management . 3/19/18 - A written statement completed by E12 (AA) stated, .During the meeting management made inappropriate comments towards the resident . 3/19/18 - A typed and signed statement was completed by E13 (AA) and stated, I was call (sic) to the care plan meeting by Activity Director (E7) .I ask (sic) a question why are we in here this is a mess I think the meeting went to a point that it should not have been and things got a little out of hand. E7 was a little upset with the Resident. 3/20/18 - A written statement completed by E15 (AA) stated, .When I entered the room there were several people all ready there sitting around the table. All the activity assistants, E8 (SW#1), E9 (SW#2), E10 (RD), and R2. E7 was standing on the opposite side of R2. Her voice was raised loudly directed to R2 .E7 shouted to R2 'All the activity staff are here. Now point out which one you are having a problem with concerning the activity schedule.' R2 was very quiet when he/she spoke. She (E7) got louder and louder toward R2 .This incident was the exact opposite of what we were taught or how a caregiver should conduct their encounter with a resident. R2 was not being treated with respect, consideration or dignity. One very inappropriate comment E7 made that really stuck in my mind was 'from now on all the activity staff will have their schedule and clipboards with them everywhere. They will have to take it to the bathroom when they pee and for all I care they can wipe their butts with it!' I felt shocked, dumbfounded and frozen to my seat. I could not believe what I was hearing. To see a person of authority treating a resident in this manner was unbelievable . 4/25/18 approximately 1:20 PM - During an interview regarding the 3/14/18 care conference, R2 confirmed that he/she felt terrible and they made me feel like I'm a liar and I feel like they want me out of here. When asked if he/she was having any issues with his/her appetite, sleeping or participation in activities, he/she stated, I have big shoulders, but there is only so much you can take. The facility failed to ensure that R2 was free from emotional and verbal abuse during a care conference when facility staff spoke loudly and in a demeaning, derogatory manner. Fifteen staff members, present during the care conference, failed to intervene and stop the abuse of R2. The facility failed to suspend involved staff for the duration of the investigation and failed to discipline the staff. 4/25/18 approximately 4:00 PM - Findings were confirmed by E1 (NHA) and E2 (DON) during the exit conference. 2. Cross refer to F689, examples 1 and 2. Review of R7's clinical record revealed the following: 2/20/18 - R7 was admitted to the facility for long term care. 2/26/18 - The admission MDS assessment revealed that R7 was cognitively intact, required limited assistance of one staff person for bed mobility, and supervision for transfers. 3/8/18 and 3/9/18 - Review of R7's progress notes lacked evidence of two incidents involving R7 and two wandering residents that were submitted on the facility's 3/12/18 Resident and Family Grievance/Concern Form. 3/12/18 - The facility's Resident and Family Grievance/Concern form stated, .RP (F1) called this AM & complained that 2 residents wandered into R7's room. Friday night at 1 AM (R8) wandered in while being combative c (with) staff which woke R7. Possibly? Thurs. night a male wandered in c staff who followed him in - he was still able to get on R7's bed . The Grievance form under Section D. Steps to Resolve Problems stated that the facility offered a stop sign which R7 and F1 agreed to try. Under Section E. Final Disposition, it stated, .UM (E4) explained that BNRC has residents c (with) all types of needs & staff do their best to deter residents from wandering into other res. rooms. UM obtained stop sign for room. 4/3/18 - Review of an email from F1 to E2 (DON) stated an incident occurred on 4/2/18 involving R7 and R8. The email stated, .R8 entered the room of R7 on 4/2/18 at approx.(approximtely) 11:30 PM. R7 was asleep in her bed. R8 touched the head of R7 causing her to be awakened and become immediately fearful. R7 put her call bell on to summon staff for assistance. According to R7, R8 resisted being escorted out of the room. When asked what she meant by 'resisted', R7 stated 'physically resisted, that they had to almost drag R8 out of the room' .R7 stated to .F1 .this morning that she was scared to death when R8 woke her up by touching her. R7 also stated that she did not believe the stop sign on the entrance door to her room was in place at the time. On previous occasions when confused residents have entered her room staff gave the remedy of closing her door. R7 does not want to have her door closed at night. This is not the first time a confused resident has entered her room at night while she was asleep. Staff have instructed R7 to tell confused residents to 'Go home' when they wander into her room . 4/3/18 to 4/19/18 - Review of R7's clinical record lacked evidence of a follow-up investigation to the 4/2/18 incident by either nursing staff or the facility's medical social workers to prevent wandering residents from entering R7's room as the current interventions were not effective and caused emotional distress to R7. 4/16/18 at 10:06 AM - Observation of R7's Stop sign revealed it was hanging down on one side of her entrance doorframe and not across her doorframe to keep wandering residents from entering. 4/19/18 at 11:22 AM - During a combined interview with F1 and R7, F1 stated that there were multiple incidents with wandering residents. The first incident (unknown date/time) was an unidentified resident who came into R7's room and tossed her personal belongings around in front of R7, who then became upset and F1 stated that she witnessed the tossed items when she arrived at the facility. R7 stated another incident involved R8 who walked into R7's room on 4/2/18 at approximately 11:30 PM turned the light on and approached R7 sleeping in bed and touched her head. R7 woke up to R8 touching her head and was scared, upset and crying. The unidentified CNA who responded laughed and R7 asked What is so funny? When the surveyor asked if the nurse came in to check on her that night after the incident, R7 stated no. When F1 brought this incident to the facility's attention, F1 stated she was told the wanderer, R8, was harmless. F1 stated that R8 was a resident from another wing in the facility and questioned who was watching R8. R7 stated the the facility provided a fabric Stop sign attached by velcro across her outside entrance doorframe, but R7 stated that the wandering residents just remove it. R7 stated that the facility suggested that she close her door, but R7 prefers to have the door open. Due to the lack of a follow-up investigation from the 4/2/18 incident, the facility failed to identify the staff person who laughed while the incident was occurring, failed to identify the potential for resident to resident abuse and failed to respond appropriately to the incident, causing added emotional abuse to R7. 4/19/18 at 3:20 PM - Observation of R7's Stop sign was hanging down on side of entrance doorframe and not across the doorframe to keep wandering residents from entering. 4/19/18 at 11:40 PM - A nurse's note stated, Approx. 2130 (9:30 PM) I was helping another patient in there (sic) room when I was notified by the NURSE on G WING that this resident (R7) had a C/O being upset due to another resident startling her from wandering in her room. I went to see the resident and she stated, 'This has happened to me two times now.' I observed the Stop sign on her door and asked if she was alright, and would she like anything for comfort. She wanted her door to remain open still and just wanted to continue to rest. I went to make sure that the resident that wandered was assisted by her nurse and aide to her own room. 4/20/18 to 4/22/18 - Review of R7's clinical record lacked evidence of a follow-up investigation to the 4/19/18 incident by nursing staff and/or the facility's medical social workers to prevent wandering residents from entering R7's room as the current interventions were not effective and caused emotional distress to R7. 4/23/18 at 8:20 AM - During an interview, R7 stated that last Thursday, 4/19/18, she was asleep in her bed with the door open. R9 (another wandering resident) came into her room and R7 told her to get out. R9 responded no. R7 pulled the call bell and stated no one responded immediately. R7 stated she told the resident to get out again and R9 responded no. R9 was at the window. R7 yelled Help and the CNAs came running. R7 stated that she was extremely upset. R7 stated that the CNAs were dragging the resident (R9) out of her room. R7 stated that F1 emailed E2 (DON) the following day. 4/23/18 at 11:38 AM - During an interview, E2 (DON) stated there were no incident reports involving R7 and wandering residents since her admission on 2/20/18. E2 provided copies of R7's grievances, dated 3/12/18 and an email on 4/3/18, which addressed incidents of wandering residents. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). The facility failed to ensure that R7 was free from emotional abuse when multiple wandering residents continued to enter her room unsupervised causing her emotional distress and when a facility staff person laughed during the 4/2/18 incident. 4/25/18 at 4 PM - Findings were reviewed with E1 (NHA) and E2 (DON) during the Exit Conference. | 2020-09-01 |