| 71 |
BRANDYWINE NURSING & REHABILITATION CENTER |
85004 |
505 GREENBANK ROAD |
WILMINGTON |
DE |
19808 |
2018-04-25 |
689 |
G |
1 |
0 |
81S611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, review of clinical records and interviews it was determined that the facility failed to ensure adequate supervision for two ( R8 and R9) out of 11 residents sampled. The facility failed to ensure that R8 and R9, both of whom were known to wander throughout the facility and into other residents' rooms, received adequate supervision to prevent these residents from wandering into other resident's personal spaces and creating the potential for resident to resident abuse. Findings include: 1. Review of R8's clinical record revealed the following: 10/24/17 - R8 was admitted to the facility with [DIAGNOSES REDACTED]. 10/25/17 - A care plan was developed for the problem potential for altered mood state. This care plan stated R8 was fixated on another wandering male resident ,who she believes is her husband, and often follows him which then provokes this other resident. An intervention included for this care plan stated to increase supervision with redirection in regards to this resident wandering with this particular resident. 10/30/17 - The admission MDS assessment stated R8 had severe cognitive impairment (never/rarely made decisions), wandering behavior occurred daily and placed the resident at significant risk of getting to a potential dangerous place (stairs, outside of facility), and that the wandering did not significantly intrude on the privacy or activities of others. The MDS also stated R8 was independently ambulatory in her room and in the corridor. 1/26/18 - A quarterly MDS assessment stated R8 had severe cognitive impairment, disorganized thinking, verbal behavioral symptoms directed toward others, such as threatening others, screaming at others, cursing at others which occurred on 1 to 3 days during the 7 day review time period. This MDS also stated R8 wandered daily and was independently ambulatory. Nurse's progress notes stated the following: 3/2/18 11:00 PM - Remains on 1:1 supervision for safety. 3/4/18 10:30 AM - Continued on one to one supervision for safety. 3/7/18 9:25 AM - Found standing over roommate. Roommate stated that her chair was missing and that clothes had been moved out of the chair. The nurse also found R8 playing with her roommates balloons while standing over her. The roommate became very agitated and threatened to hit her. A request to move R8 to another room was made. 3/11/18 10:22 PM - Resident pacing up and down hallways, opens everything she can open, goes in and out of other residents rooms, yells at staff and residents, is disruptive and requires constant supervision. 3/15/18 10:25 PM - Went into other residents rooms and had many other residents upset. 3/16/18 10:49 PM - Resident ambulates through hallways and into other resident rooms, she engages arguments with other residents and staff. 3/16/18 11:35 PM - Resident has disrupted the shift many times by rummaging through drawers, and other residents rooms. She was left in her room eating, then was found in another residents room where she had defecated on the floor. 3/19/18 10:10 PM - Rummages through rooms and any items she passes, taking food. 3/20/18 9:23 PM - Has been collecting brushes in her room and continues to steal food. 3/21/18 10:10 PM - Continues to steal items out of other rooms and off carts, during dinner hour she was found in another residents room eating her food. 3/24/18 8:20 PM - Continues to go into other residents rooms, takes food from med carts, snack carts and out of other resident rooms. She has been cursing staff and residents often. 3/28/18 11:40 PM - Resident noted going into other residents room several times and eating food and drinks, redirected several times with difficulty. 3/29/18 11:04 PM - Likes going to other resident bedrooms and looks through their belongings or eats their foods or snacks. 3/30/18 4:34 pm - Continues on walking around, picking on other residents rooms, gets their food, going through their stuff. 4/7/18 12:00 PM - Spoke with several other residents on different floors, said R8 in and out of their rooms, taking things and waking them up, when approached becomes combative. 4/9/18 3:50 PM - Resident noted wandering into other residents rooms this shift. 4/13/18 7:36 PM - Another resident's family member asked her to remove R8 because she (R8) had opened the door to the conference room while a family gathering was in progress and began to disrobe in front of everyone. 4/19/18 3:01 PM - R8 was observed attempting to pull a fire extinguisher off the wall. Redirection did not work, however an offer of fluids and a snack did. 4/19/18 10:10 PM - The resident was observed entering room G16 (not R8's room) where she picked up a cup and began drinking before being able to be redirected. Although the facility developed a care plan for altered mood state upon R8's admission to the facility and noted R8's fixation on another resident, they failed to identify that R8 wandered into other residents rooms repeatedly and failed to develop a plan to prevent this from occurring. The potential for resident to resident abuse was present, yet the facility failed to identify that the need for increased supervision of R8 was needed, in an attempt to prevent R8 from entering other resident's rooms. Findings were confirmed by E1 (NHA) and E2 (DON) during the exit conference on 4/25/18 at approximately 4:00 PM. 2. Cross refer to F600, example 2. Review of R9's clinical record revealed the following: 9/2/15 - R9 was admitted to the facility with [DIAGNOSES REDACTED]. 4/11/17 created, 3/7/18 last reviewed - R9 was care planned for wandering into other rooms and wandering in the hallway. The interventions included: - redirect as needed; - 1 on 1 as needed; - encourage activities; - return to room or quiet area as needed; - toilet as needed or incontinent care as needed; - give food or fluid; - change position; - adjust room temperature; - backrub; - refer to charge nurse for further intervention; and - psych consult as ordered. 7/30/17 - A Psychiatric Follow-Up Consult stated that R9 was seen after recent medication changes, has had periods of agitation and very difficult to redirect and illogical thoughts. The plan was to continue to redirect inappropriate behavior and continue to monitor changes in mood and cognition. 11/7/17 - R9's Resident Care Profile stated under the Behavior Section that she wanders and resists care. 2/1/18 to 2/28/18 - Review of R9's Behavior Intervention Monthly Flow Record, documented by her assigned CNAs, revealed that R9 exhibited wandering behavior into others rooms or hallways on 15 out of 28 days. 2/29/18 - The quarterly MDS Assessment stated R9 had short-term and long-term memory problems, decisions were poor and required cues and supervision for daily decision making, experienced hallucinations, physical/verbal/other behavior symptoms occurred 1 to 3 days, wandering behavior occurred daily and was independently ambulatory in her room and the corridor. 2/19/18 at 2:36 PM - A Social Services note stated that R9 had short and long term memory impairment, continued to be physically and verbally combative towards staff, was combative with an outside lab technician on 2/13/18 and wanders daily. 3/1/18 to 3/31/18 - Review of R9's Behavior Intervention Monthly Flow Record revealed that R9 exhibited wandering behavior into others rooms or hallways on 12 out of 31 days. 3/7/18 - R9's care plan for wandering was reviewed and interventions remained the same. 4/1/18 to 4/23/18 - Review of R9's Behavior Intervention Monthly Flow Record revealed that R9 exhibited wandering behavior into others rooms or hallways on 2 out of 23 days. The Flow Record failed to account for R9's wandering incident on 4/19/18 during the 3-11 PM shift. 4/19/18 at 11:36 PM - A Nurse's Note stated that R9 wandered into another resident's room. While staff attempted to redirect R9, she became combative, hitting, scratching and swinging at multiple staff members. R9 was currently in her room with safety measures in place. 4/23/18 at 8:20 AM - During an interview, R7 stated last Thursday, 4/19/18, that she was asleep in her bed in the G wing with the door open. R9, a resident from F wing, 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 R9 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. 4/25/18 at 2:45 PM - Findings were reviewed with E2 (DON). Although the facility care planned and were documenting R9's wandering behaviors into other residents rooms repeatedly, the facility failed to identify the potential of resident to resident abuse by providing adequate supervision for R9 in an attempt to prevent her from entering other residents rooms. |
2020-09-01 |