| 99 |
BRANDYWINE NURSING & REHABILITATION CENTER |
85004 |
505 GREENBANK ROAD |
WILMINGTON |
DE |
19808 |
2018-10-25 |
600 |
H |
1 |
1 |
BQMI11 |
> Based on record reviews, interviews and review of facility documentation, it was determined that for 4 (R33, R78, R105 and R147) out of 57 sampled residents, the facility failed to ensure that the residents were free from abuse. Three (3) of four (4) residents (R33, R78 and R147) sustained harm (emotional abuse). R78 sustained verbal abuse from a staff member, which resulted in emotional abuse. R33 sustained emotional abuse when a wandering resident entered her room unsupervised and shoved R33 out of the way, which resulted in emotional abuse. R105 sustained physical abuse when R105's roommate slapped her arm causing redness and tenderness. R147 sustained emotional abuse when a wandering unsupervised resident entered her room causing her emotional abuse. Findings include: 1. Review of R78's clinical record revealed: 11/22/16 - Care Plan for ADLs included an approach to assist resident in bathing as per resident needs. 11/22/16 - Care plan for potential for alteration in comfort included a goal for pain will be diminished and approaches of assessing for verbal signs and symptoms of pain and assess for possible causes of pain and interventions. 2/27/17 - Care plan for resident to establish own goals, included a problem of the resident refusing shower or bed baths at times able to make own decisions with care and approaches of involve resident in the decision making of ADL and honor preferences. 8/7/18 - The quarterly MDS assessment coded R78's BIMS score as a 10 (moderate cognitive impairment- decisions poor, cues/supervision required); there were no behaviors exhibited; and bathing required physical help during part of the activity with one staff person assisting. 9/12/18 3:47 PM - Incident reported to state agency by E3 (ADON). At 11:00 AM, on the same day, E10 (LPN) had been notified that R78 was crying after an encounter with E24 (CNA). Statements collected by the facility revealed: --9/12/18 - E10 (LPN) labeled the incident as staff to resident. E10 (LPN) revealed that R78 stated s/he asked multiple times to have the bed lowered to prevent pain and the CNA (E24) did not answer. R78 began yelling at E24. E24 insisted on giving R78 a bed bath and handed R78 a washcloth. R78 threw washcloth back to CN[NAME] R78 then told E24 to get out of the room and CNA threw washcloth back to resident. Additionally, E10's (LPN) statement revealed that R78 requested that the CNA (E24) no longer takes (sic) care of me. E10 (LPN) stated that the resident was actively crying after the incident. E10 (LPN) consoled R78. --9/12/18 - E24 (CNA) revealed that R78 kept saying s/he was hurting because of positioning of the bed, but E24 (CNA) revealed nothing about adjusting the bed or resident. --9/12/18 - E25 (CNA) labeled the incident as verbal abuse. E25 (CNA) was present in the room just after the incident. E25 (CNA) revealed that E24 (CNA) stated that she would be leaving the building if it happened again and beating (R78's) a*% before she left. E25 (CNA) offered to complete R78's care and as E24 (CNA) was leaving the room, R51 and a visitor entered the room. The visitor asked E25 (CNA) How could we allow the caregivers to treat the patients that way cursing and carrying on? --9/12/18 - R51's visitor's statement revealed that while in the hallway, they heard the (E24) CNA get loud and nasty stating, 'if her a*% throws that wet wash cloth back at me again I'm going to throw it back at her a*%.' In addition, as E24 (CNA) was leaving the room, the visitor stated hearing E24 (CNA) say my a*% is getting fired today. 9/18/18 - A Disciplinary Notice, included at the back of the facility's Incident Report Investigation packet for this incident, noted that E24 (CNA) was terminated for threatening a resident. 10/22/18 3:08 PM - R78 stated, during an interview with the surveyor, that the morning of the incident E24 (CNA) didn't pay attention to me. E24 (CNA) wanted to wash me and I wanted a different time. R78 stated that E24 (CNA) threw a washcloth at R78 before R78 told E24 (CNA) to leave the room. R78 felt in trouble after the incident. 10/24/18 1:36 PM - During an interview with the surveyor, E10 (LPN) confirmed that after the incident R78 was visibly upset and crying. The facility failed to ensure that R78 was free from emotional abuse. Findings were reviewed with E1 (NHA) on 10/24/18 at 1:55 PM. 2. Review of R33 and R157's clinical records revealed: 7/27/18- The facility developed a care plan for the problem that R157 wandered into other rooms at times due to dementia. Interventions included for staff to provide redirection and 1:1 supervision. 8/3/18 A care plan was developed for the problem that R157 exhibited physical and verbal aggression. The care plan specified that R157 on 8/3/18 had a resident-to-resident altercation where she pulled another resident's legs and was verbally abusive. Interventions for this care plan included for R157 to receive 1:1 supervision. 10/8/18- An annual MDS assessment was completed and revealed that R33 was cognitively intact. 10/17/18 at 8:20 AM- A progress note documented that, during medication pass, E26 (RN) heard yelling and screaming coming from a room. E26 went to investigate and R157 was in R33's room. R33 tried to ask R157 to leave and R157 shoved R33 on her left shoulder. R33 was noted to be extremely upset and shaken. R157 was supposed to be on 1:1 supervision per her care plan when this incident occurred. 10/17/18 at 4:02 PM- After the incident occurred, R157 was observed by the surveyor without her care planned 1:1 supervision. R157 was seen walking by herself down the hall by the dining room towards the D/E wing nursing station. R157 then wandered into the nursing station and began putting hand sanitizer on her hands and rubbing it into a chair. At approximately 4:05 PM, staff noticed R157 and began to redirect her. 10/18/18 at 10:34 AM- During an interview, R33 stated when R157 came in her room she tried to get her to leave, but she just pushed past her. R33 stated that she did not get physically hurt this time, but she feels very scared and afraid and does not want her (R157) in her room. R33 stated that residents wandering into her room had been a problem for a while, but R157 was the only wanderer that made her feel scared because she was very strong. She stated, I can't defend myself against her. R33 stated that she was especially fearful of R157 now because she recently had a fall and does not want to get hurt again. R33 reiterated that she was very afraid and would be talking to her family about this event and stated that she already told staff that she was fearful. The surveyor reported this information to E2 (DON) who stated that he did not see this as abuse, but he would investigate further. 10/18/18 at 3:34 PM- During an interview on 10/18/18, R33 stated that staff had been in her room talking to her about the incident on 10/17/18 with R157. R33 again stated how afraid she was of R157, and commented that R157 always seemed like she was on a mission and you can't stop her. R33 stated that she worries because she cannot defend herself against R157. R33 stated that the interventions the facility puts in place, such as the stop signs across her doorway, do not help her feel safe. R33 stated the stop signs across the door do not help because they (wandering residents) just take them down. R33 stated that she and her roommate (R147) keep their door shut at night because they don't want people to come in, but they feel that they should not have to always keep their door shut just to be safe. 10/18/18 at 5:49 PM- A progress note documented that R33 was still very anxious regarding the situation that had happened yesterday .regarding the other Resident coming into her room. The note stated that R33 was to be reviewed by psych. The facility failed to ensure that R33 was free from emotional abuse. 10/25/18 at approximately 6:30 PM- Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC). 3. Review of R105 and R157's clinical records revealed: 7/27/18- The facility developed a care plan for the problem that R157 wandered into other rooms at times due to dementia. Interventions included for staff to provide redirection and 1:1 supervision. 8/3/18 A care plan was developed for the problem that R157 exhibited physical and verbal aggression. The care plan specified that R157 on 8/3/18 had a resident-to-resident altercation where she pulled another resident's legs and was verbally abusive. Interventions for this care plan included for R157 to receive 1:1 supervision. 8/8/18- An incident report summary from an event that occurred at 7:45 AM, documented that the assigned CNA was providing care to R157 when the resident became aggressive and pulled away. R157 then went over to R105 (her roommate) and began going through R105's belongings. R105 tried to stop R157 from taking her personal belongings and R157 reached out and slapped R105 on the right forearm. Staff stepped in and redirected R157 to her side of the room. R105's right forearm was noted to have redness and R105 verbalized that her right forearm was tender. The facility failed to ensure that R105 was free from physical abuse, as evidenced by, R105's roommate, R157, a known aggressive and wandering resident who was care planned for 1:1 supervision, slapping her arm causing redness and tenderness. 10/25/18 at approximately 6:30 PM- Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC). 4. Review of R147 and R157's clinical records revealed: 7/27/18- The facility developed a care plan for the problem that R157 wandered into other rooms at times due to dementia. Interventions included for staff to provide redirection and 1:1 supervision 8/3/18 A care plan was developed for the problem that R157 exhibited physical and verbal aggression. The care plan specified that R157 on 8/3/18 had a resident-to-resident altercation where she pulled another resident's legs and was verbally abusive. Interventions for this care plan included for R157 to receive 1:1 supervision. 9/10/18- A quarterly MDS assessment was completed and revealed that R147 was cognitively intact. 10/17/18 at 8:20 AM- A progress note documented that, during medication pass, E26 (RN) heard yelling and screaming coming from a room. E26 went to investigate and R157 was in the room shared by R147 and R33. R33 tried to ask R157 to leave. R157 shoved R33 on her left shoulder. R147 was noted to be upset after the incident. R157 supposed to be on 1:1 supervision per her care plan when this incident occurred. 10/17/18 at 4:02 PM- After the incident occurred, R157 was observed by the surveyor without her care planned 1:1 supervision. R157 was seen walking by herself down the hall by the dining room towards the D/E wing nursing station. R157 then wandered into the nursing station and began putting hand sanitizer on her hands and rubbing it into a chair. At approximately 4:05 PM, staff noticed R157 and began to redirect her. 10/18/18 at 3:39 PM- During an interview, the surveyor was talking to R147 about her fingernails when R147 stated that today had been a long day with people coming in and out of the room talking to her roommate about what happened the other day with R157 coming into their room. R147 stated that the incident was scary and that R157 makes her feel afraid. She stated that the facility feels like a prison because she does not feel safe. R147 stated she does not like to leave her room because someone may wander in and take her personal belongings. R147 stated that she feels bad for her roommate, R33, because she gets it even worse because she was in the first bed in their room. The surveyor reported this information to E2 (DON). The facility failed to ensure that R147 was free from emotional abuse resulting in harm, as evidenced by, R157, a known aggressive and wandering resident who was care planned for 1:1 supervision, entering her room unsupervised and shoving her roommate (R33) causing her emotional distress. 10/25/18 at approximately 6:30 PM- Findings were reviewed with E1 (NHA), E2 (DON), E3 (ADON), E13 (Staff Educator), and E14 (RNAC). |
2020-09-01 |