| 9 |
KENTMERE REHABILITATION AND HEALTHCARE CENTER |
85001 |
1900 LOVERING AVENUE |
WILMINGTON |
DE |
19806 |
2017-09-07 |
309 |
D |
1 |
1 |
H3FV11 |
> Based on observation and record review, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one (R15) out of 25 Stage 2 sampled residents. For R15, the facility failed to implement interventions listed on R15's care plans to address her confusion, crying and distress on 8/31/17 when R15 thought she was lost. Findings include: Review of R15's clinical record revealed: R15's most recent MDS assessment, dated 6/7/17, coded R15's cognitive patterns as severely impaired (never/rarely made decisions). R15's care plan for Dementia/Cognitive Deficits, effective 9/7/16, listed interventions to: Allow resident ample time to absorb and respond to information . Understand that people with dementia do not have access to logic. R15's care plan for Social Services-Mood/Verbalizing Negative Statements, effective 9/7/16, listed an intervention to: Calmly reassure resident. R15's care plan for Social Services - False Beliefs/Accusations, Resident presents with false beliefs/accusations crying, getting upset ., effective 12/20/16, had interventions to: Listen to resident's thoughts . Calmly explain .; and Redirect her On 8/31/17 at 3:10 PM, the surveyor was on the 2nd floor in the doorway between the dining room and the common area. At 3:11 PM on 8/31/17, R15 approached the surveyor using a walker. R15 was crying and stated, Will you help me? I'm lost. Surveyor responded, The nurses will help you, let's go get the nurse. R15 continued crying and stated, they won't help me, I'm lost. The surveyor walked R15 toward the nurse's station where 8 staff members were standing/sitting during the change of shift. Some of the staff turned to watch the surveyor and R15 approach. R15 was crying and stated again, they won't help me, I'm lost. The surveyor replied, the nurses will help you. No staff responded to R15. The resident stated they don't help me. Surveyor asked E3 (LPN) the resident's room number. E3 responded with R15's room number. The surveyor walked R15 down the hallway to her room. R15 continued crying and stating, I'm lost. The surveyor and R15 entered resident's room where the surveyor remained with R15 for approximately 15 minutes until R15 stopped crying and was calm. No staff came to the room to check on R15 while the surveyor was there. When the surveyor walked back past the nurse's station, no staff approached the surveyor and inquired about R15. The facility failed to follow R15's care plan to provide the highest practicable mental and psychosocial well-being, when R15 was upset, crying and repeatedly stating she was lost, and staff did nothing to assist the resident. Findings were reviewed with E2 (DON) and E4 (ADON) on 9/7/17 at approximately 3:30 pm. |
2020-09-01 |