Citations in Delaware
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Delaware.
Statistics for Delaware (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Delaware
A resident with a history of femur fracture developed acute shortness of breath and low oxygen saturation, but nursing staff failed to consistently assess, monitor, or document vital signs and did not promptly notify the provider or initiate emergency care. Despite observable respiratory distress and declining oxygen levels, interventions were delayed and inconsistently applied, resulting in the resident being transferred to the hospital unresponsive, where she later expired.
A resident admitted with metastatic prostate cancer did not have a completed and signed admission agreement due to being asleep or too tired during multiple attempts, and the agreement remained incomplete until the resident's death. The medical record was missing this legal document, which should have outlined rights, facility policies, and services.
A resident admitted with metastatic cancer was not allowed to sign multiple consent forms, despite an initial assessment indicating normal cognitive function. Instead, a friend and staff signed the consents, based on a later BIMS score showing moderate impairment. Staff relied on incomplete information and did not verify the resident's cognitive status or responsible party, resulting in the resident's exclusion from important care decisions.
A resident with a history of femur fracture experienced new shortness of breath and low oxygen saturation, leading staff to initiate oxygen therapy and call EMS. Despite these significant changes, there was no evidence that the physician was consulted or notified, as confirmed by record review and staff interviews.
A resident's care plan conference was conducted without participation or input from a Physician, Nurse Practitioner, or Physician Assistant. Only social services, an LPN, and a therapy staff member attended, with the dietician providing input in advance. The provider did not participate or contribute, and any concerns raised would be relayed after the conference.
A resident with a history of CVA and abnormal gait experienced an unwitnessed fall, resulting in multiple bruises and a fractured toe. The facility did not promptly notify the physician or state agency about the injuries as required, and the incident report was not completed in a timely manner.
A deficiency was found when a newly admitted resident's initial care plan and admission assessment were completed by an LPN rather than an RN, contrary to state nursing regulations. The LPN confirmed performing these tasks, and the DON stated this was in line with facility policy. The issue was reviewed with facility leadership.
A resident with cognitive impairment and a known risk for dehydration did not receive adequate fluids, as documented intake was consistently below the recommended amount. Despite being dependent on staff for eating and drinking, and family requests for IV fluids, the facility delayed interventions and did not monitor supplement or fluid intake as required. Staff and family interviews confirmed insufficient intake and lack of proper monitoring.
A resident with severe cognitive impairment and a history of falls was left unsupervised during care, resulting in a fall, head laceration, and a fractured femur, after which comfort care was initiated and the resident expired. Additionally, broken glass was left unaddressed in another resident's restroom on a dementia unit, despite staff awareness, creating a hazard for residents, including those who wander. Facility policy requiring hazard identification and adequate supervision was not followed in both cases.
The facility did not report allegations of abuse, including physical aggression and sexual abuse between residents, to the state survey agency within the required two-hour timeframe. In several cases, staff also failed to immediately notify the DON or Executive Director of abuse incidents, resulting in delayed reporting and investigation. Facility leadership acknowledged that these incidents were not reported in accordance with policy.
Failure to Assess and Respond to Acute Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of a right femur fracture experienced a significant change in condition, specifically acute shortness of breath, during the early morning hours. Despite the resident's complaints and observable respiratory distress, there was a lack of timely and thorough assessment by nursing staff. Vital signs and oxygen saturation were either not monitored or not documented, and there was no evidence that the medical provider was promptly consulted during the initial onset of symptoms. The resident's oxygen saturation dropped to critically low levels, and interventions such as oxygen therapy were inconsistently applied and not properly documented. Multiple staff interviews revealed that although the resident was placed on oxygen and her condition was recognized as serious, there was confusion and delay in escalating care. Staff could not recall exact times of interventions, and several admitted to not documenting vital signs or assessments. The resident's respiratory status continued to deteriorate, and only after a significant delay was emergency medical assistance requested. When EMS arrived, the resident's oxygen saturation remained low, and she was ultimately transferred to the hospital unresponsive, where she later expired. The facility's own documentation and staff statements indicated a failure to follow established protocols for monitoring, assessment, and timely notification of changes in resident condition. There was also a lack of adherence to training regarding oxygen therapy and emergency response. These failures led to an Immediate Jeopardy finding due to the inadequate response to the resident's acute respiratory distress and the absence of appropriate clinical interventions and documentation.
Removal Plan
- Licensed nursing staff were re-educated on recognition of respiratory distress, respiratory assessments, including vital signs and oxygen saturation, initiation and monitoring of oxygen therapy, and provider notification
- Residents were screened by licensed nursing staff for respiratory distress
- Residents identified with respiratory distress were assessed and interventions were implemented
Incomplete Admission Agreement for Deceased Resident
Penalty
Summary
A deficiency was identified when a resident admitted with advanced prostate cancer and metastases to the bone and brain did not have a completed and signed admission agreement upon entry to the facility. The resident was admitted on a Friday evening shift and was listed as his own responsible party. Attempts to complete the admission agreement were unsuccessful: the resident was asleep during the initial attempt, remained asleep during a follow-up, and later refused due to fatigue. The admission packet remained incomplete and unsigned up to the time of the resident's death. Additionally, the hospital facesheet listed two individuals as siblings, but it was later discovered they were not family members, and the resident's actual brother was only identified on the day of death. As a result, the resident's medical record lacked a completed and signed admission packet, which is a legal document outlining resident rights, facility policies, and healthcare services to be provided.
Failure to Support Resident Self-Determination in Consent Process
Penalty
Summary
A deficiency occurred when the facility failed to promote and facilitate a resident's right to self-determination regarding the signing of multiple consents upon admission. The resident was admitted with diagnoses including prostate cancer with metastasis to the bone and brain and was listed as his own responsible party. Documentation showed conflicting cognitive assessments: a speech therapy evaluation recorded a BIMS score of 14/15 (normal cognition), while a subsequent BIMS by a social worker and the admission MDS both recorded a score of 10/15 (moderate impairment). Despite the initial indication of cognitive intactness, the facility allowed a friend (not a legal representative) and staff to sign various consent forms, including those for CPR/DNR, treatment, care management, and vaccinations, rather than obtaining the resident's own signature. Staff interviews revealed that the admitting nurse did not obtain the required consents, and another nurse completed them later, relying on the lower BIMS score to justify not seeking the resident's signature. The nurse was unaware of the higher BIMS score documented by speech therapy and stated that she was told the friend was the resident's brother, which was later found to be untrue. The facility's failure to verify the resident's cognitive status and responsible party status led to the omission of the resident's participation in consent decisions, thereby not supporting the resident's right to self-determination.
Failure to Notify Physician of Resident's Respiratory Distress and Oxygen Initiation
Penalty
Summary
A deficiency was identified when the facility failed to consult with a resident's physician after the resident experienced a new onset of shortness of breath and required initiation of oxygen therapy. The resident, who had been admitted with a right femur fracture, was noted by a certified occupational therapy assistant to have labored breathing and an oxygen saturation of 89%, resulting in a shortened therapy session. There was no documentation in the clinical record that the medical provider was notified of this change in condition. Subsequently, nursing staff responded to the resident's complaint of difficulty breathing, observed an oxygen saturation of 88%, and initiated oxygen therapy at 2 liters per minute. Later, emergency medical services were called, and the resident was placed on 5 liters per minute of oxygen via a non-rebreather mask. Interviews with staff confirmed that the resident's complaints and low oxygen saturation were observed and reported among staff, but there was no evidence that the physician was consulted at any point during these events. The deficiency was confirmed through record review and staff interviews, and findings were reviewed with facility leadership during the exit conference.
Failure to Ensure Full IDT Participation in Care Plan Conference
Penalty
Summary
The facility failed to ensure that all required interdisciplinary team (IDT) members contributed to the care plan conference for one resident reviewed for death. Review of the resident's clinical record showed that the Care Conference Summary was unsigned and incomplete, lacking documentation of input from a Physician, Nurse Practitioner, or Physician Assistant. Only social services, an LPN/Charge Nurse, and a therapy staff member attended the care plan conference, with the dietician providing input ahead of time due to absence. Interviews confirmed that the provider did not participate in the conference or provide input, and any concerns raised by the resident during the conference would only be shared with the provider afterward. The deficiency was confirmed during interviews and record review, with no evidence that all required IDT members contributed to the resident's care plan conference.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
A deficiency occurred when the facility failed to timely report an injury of unknown source for one resident with a history of CVA and abnormal gait. The resident experienced an unwitnessed fall in the TV/dining room and was later found to have multiple bruises and a fractured right fifth toe. Documentation shows that the resident returned from the hospital with visible injuries, but the medical doctor on call was not notified upon return, and the incident was not reported to the state agency on the same day as required. Interviews with facility staff confirmed that the expected protocol was not followed, including timely notification of the physician, family, and state agency, as well as completion of the incident report.
Admission Assessment and Care Plan Not Completed by RN
Penalty
Summary
A deficiency was identified when the facility failed to ensure that the initial care plan and admission assessment for a newly admitted resident were completed by a Registered Nurse (RN), as required by the Delaware Board of Nursing Professional Regulations. Record review showed that both the baseline care plan and the admission assessment, which included documentation of vital signs, skin condition, care needs, and general condition upon arrival, were completed by an LPN. During interviews, the LPN confirmed she performed these tasks, with assistance from an aide for the skin assessment. The Director of Nursing stated that, according to facility policy, LPNs were permitted to complete admission assessments and care plans. These findings were discussed with facility leadership during the exit conference.
Failure to Provide Sufficient Hydration to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with mild cognitive impairment and a documented risk for hydration concerns was not provided with sufficient fluids to meet her assessed needs. The facility's policy required processes to ensure adequate hydration, but records showed the resident consistently received less than the recommended 1500 mL of fluids per day, with intake ranging from 140 mL to 540 mL on documented days. The resident was dependent on staff for assistance with eating and drinking, and her care plan reflected this need. Despite family concerns and requests for IV fluids due to poor oral intake, the facility delayed intervention pending lab results and did not initiate supplementation until after a nutrition assessment indicated malnourishment. The order for a nutritional supplement was not implemented until a day after it was recommended, and there was no evidence that the facility monitored the amount of supplement consumed or tracked total fluid intake as required. Interviews with staff and family confirmed that the resident required assistance with feeding and that her intake was inadequate. The registered dietitian and nursing staff acknowledged that the resident's fluid intake was below the minimum threshold for adequate hydration, and documentation practices did not ensure accurate monitoring of supplement or fluid consumption. The resident was ultimately sent to the hospital after a fall and did not return to the facility. The deficiency was reviewed with facility leadership during the exit conference.
Failure to Prevent Resident Fall and Remove Environmental Hazard
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident with severe cognitive impairment and a history of repeated falls. During morning care, a CNA turned her back to the resident to obtain a washcloth, at which point the resident, known to have jerking movements, fell from the bed. The resident sustained a laceration to the forehead requiring sutures and, two days later, was found to have swelling and limited range of motion in the left leg. An x-ray revealed a displaced fracture of the left femur. The resident's responsible party, after consultation with the physician, opted for comfort care due to the resident's poor surgical candidacy and advanced dementia. The resident subsequently expired in the facility. The facility also failed to identify and remove an accident hazard in a resident's room on the dementia unit. Broken glass was observed in a picture frame in the restroom of a resident with severe cognitive impairment. Although a staff member observed the broken glass, no action was taken to remove it. The glass remained in the room, posing a risk to the resident and others, including wandering residents who could enter the room. Interviews confirmed that staff were aware of the hazard but did not report or address it in a timely manner. Facility policy required all staff to be involved in identifying and addressing environmental hazards and to provide adequate supervision to prevent accidents, taking into account each resident's unique needs. In both incidents, staff failed to follow these protocols: in the first case, by leaving a dependent resident unsupervised during care, and in the second, by not removing a known environmental hazard. These failures resulted in actual harm to one resident and the potential for harm to others.
Failure to Timely Report Allegations of Abuse and Notify Supervisory Staff
Penalty
Summary
The facility failed to timely report allegations of abuse to the state survey agency and did not ensure immediate notification of supervisory staff regarding abuse incidents involving multiple residents. According to facility policy, allegations of resident abuse must be reported to the appropriate state regulatory authority within two hours. However, documentation revealed that an incident involving physical aggression between two residents was reported to the state agency four and a half hours after it occurred, exceeding the required timeframe. The Director of Nursing (DON) confirmed that the report was not submitted within the mandated two-hour window. Additionally, the facility did not ensure that staff immediately reported an allegation of resident-to-resident sexual abuse to the DON or Executive Director. In one case, a resident with severe cognitive impairment touched another resident inappropriately, but the incident was not reported to the DON or state agency until the following day. The DON and Executive Director both acknowledged that the incident should have been reported within two hours, and that the responsible LPN failed to follow the notification process. Another incident involved a resident who sustained bruising and swelling to the hand after allegedly having an inhaler forcibly removed by an LPN. The resident reported the injury to nursing leadership several days after the incident, and the state agency was not notified until hours after the injury was identified. The DON and Executive Director both acknowledged that the incident was not reported in a timely manner, as required by facility policy.
Some of the Latest Corrective Actions taken by Facilities in Delaware
- Re-educated licensed nursing staff on recognizing respiratory distress, conducting respiratory assessments (vital signs and oxygen saturation), initiating and monitoring oxygen therapy, and notifying providers (J - F0684 - DE)
Failure to Assess and Respond to Acute Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of a right femur fracture experienced a significant change in condition, specifically acute shortness of breath, during the early morning hours. Despite the resident's complaints and observable respiratory distress, there was a lack of timely and thorough assessment by nursing staff. Vital signs and oxygen saturation were either not monitored or not documented, and there was no evidence that the medical provider was promptly consulted during the initial onset of symptoms. The resident's oxygen saturation dropped to critically low levels, and interventions such as oxygen therapy were inconsistently applied and not properly documented. Multiple staff interviews revealed that although the resident was placed on oxygen and her condition was recognized as serious, there was confusion and delay in escalating care. Staff could not recall exact times of interventions, and several admitted to not documenting vital signs or assessments. The resident's respiratory status continued to deteriorate, and only after a significant delay was emergency medical assistance requested. When EMS arrived, the resident's oxygen saturation remained low, and she was ultimately transferred to the hospital unresponsive, where she later expired. The facility's own documentation and staff statements indicated a failure to follow established protocols for monitoring, assessment, and timely notification of changes in resident condition. There was also a lack of adherence to training regarding oxygen therapy and emergency response. These failures led to an Immediate Jeopardy finding due to the inadequate response to the resident's acute respiratory distress and the absence of appropriate clinical interventions and documentation.
Removal Plan
- Licensed nursing staff were re-educated on recognition of respiratory distress, respiratory assessments, including vital signs and oxygen saturation, initiation and monitoring of oxygen therapy, and provider notification
- Residents were screened by licensed nursing staff for respiratory distress
- Residents identified with respiratory distress were assessed and interventions were implemented
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