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 significant upper extremity weakness and recent surgery was discharged home to a multi-story residence without confirmed DME delivery, home health services, or caregiver support. Although referrals for home health, skilled nursing, and DME were made and family attended a discharge care plan meeting, staff did not verify that services were active, did not set or confirm a start-of-care date with the agency, and did not confirm delivery of a hospital bed. The resident, who lived alone and could not manage fine motor tasks, arrived home without in-home assistance, reported difficulty with eating and self-care, and was later found by an HHA RN in unsafe conditions, unable to access food or medications, leading to emergency transport back to the hospital.
A resident with dementia, Parkinson’s disease, CHF, and a history of AKI had documented fluid goals and was identified as at risk for dehydration and malnutrition, yet daily intake records repeatedly showed fluid consumption well below the recommended amounts. Despite severely impaired cognition, poor oral intake, and documented changes in mentation, lethargy, falls, and restlessness, the facility did not consistently implement or document enhanced monitoring, assistive feeding measures, or timely provider consultation focused on hydration. The resident was hospitalized twice with AKI, dehydration, hypotension, and anemia, and staff interviews confirmed that while expectations existed to encourage fluids and notify providers when goals were not met, there was no clear evidence that these expectations were carried out for this resident.
A resident with cardiac conditions was discharged home with a documented post-discharge plan for home health aide, home health RN/LPN, and PT/OT, but the facility did not complete the home health referral before discharge. The resident went home with a family member and, according to a complaint, did not receive PT, OT, or a nursing wellness check for about a week. The SW later confirmed the referral for home health and therapy services was not requested until several days after discharge, and services did not begin until even later, despite therapy recommendations that are typically communicated to social services to arrange home care.
The facility failed to consistently revise care plans to reflect residents’ current needs and behaviors and did not ensure a cognitively intact resident was involved in ongoing care planning. One resident participated in an initial care conference but was not included in later care plan updates. Another resident with an order for a palm protector was frequently observed without it and often refused it, yet the care plan did not address refusals. Two cognitively impaired residents whose MDS assessments showed dependence for bathing had care plans that still listed only setup or one‑person assist. A cognitively impaired resident with combative behaviors and an incident of striking another resident had a behavior care plan that was not updated to include attempts to hit other residents or the risk of resident‑to‑resident altercations.
A resident with a neurogenic bladder and chronic Foley catheter experienced repeated catheter-related problems, including difficult reinsertion, multiple dislodgements, frequent leakage, and episodes of bleeding with clots that led to hospital evaluation. Imaging showed the catheter balloon positioned in the penile urethra. LPNs reported ongoing difficulty changing the catheter and indicated that the resident had been recommended for urology follow-up and catheter changes by urology due to the complexity. Despite an expectation to schedule outside providers promptly, the resident was not seen by urology until many months after these ongoing catheter issues, resulting in a deficiency for failure to obtain a timely urology referral.
The facility failed to maintain a homelike environment by routinely using an overhead paging system for non-emergent staff communication during daytime hours. Surveyors repeatedly heard overhead pages during observations, and a resident reported during a council meeting that the paging was unpleasant. The NHA confirmed that overhead paging was used to communicate with staff during the day and discontinued only in the evening, contributing to an environment that residents found uncomfortable.
The facility’s Facility Assessment did not accurately reflect its resident population by failing to identify a distinct group of residents receiving Comfort Care, instead listing only Hospice and Palliative Care services. Facility records showed that 10 residents were on Comfort Care and two residents were on Hospice, but the Comfort Care group was not captured in the assessment. The DON and Administrator reported that the facility used the terms Palliative and Comfort Care interchangeably and tracked Comfort Care residents via an order listing with a “Palliative Care-Form on File.” The Administrator acknowledged that the Facility Assessment referenced Palliative but not Comfort Care and that staff had not differentiated the unique care needs of residents on Comfort Care versus those on Palliative Care, resulting in a deficiency under F684 Quality of Care.
Surveyors found that shower rooms on multiple floors had cracked and broken tiles, standing water, dripping shower heads, discolored walls, and clutter that blocked access to handwashing sinks, as confirmed by CNAs who reported difficulty washing hands due to equipment stored in these areas. Hallway carpets and several residents’ room floors were repeatedly observed to be visibly soiled, and the ESD acknowledged there was no established carpet-cleaning schedule. Additionally, a shower bed cushion with multiple surface openings exposing permeable foam was left in use for an extended period, with staff confirming its damaged condition and the inability to properly disinfect it.
The facility failed to follow professional standards and state scope-of-practice requirements by allowing LPNs to complete admission assessments and initial post-fall assessments that must be performed by an RN, and by not ensuring RN involvement in discharge education. In two separate admissions, an LPN completed the full admission nursing assessment and related evaluations instead of an RN. For another resident, the discharge plan was documented by non-licensed staff, and there was no evidence in the record that an RN provided or documented discharge teaching. In a fall event involving a resident with dementia and cancer, an LPN completed the initial neurological and post-fall assessment, with no RN assessment documented.
A resident who was totally dependent on staff for ADLs due to a stroke was care planned to receive regular showers or bed baths according to his preferences and to follow a twice-weekly bathing schedule. Review of documentation showed that, over multiple scheduled opportunities, the resident was bathed only twice, refused once, and on two scheduled days no bath or shower was provided and no reason was documented in the record for the missed care. Progress notes lacked any explanation for these missed bathing events, and facility leadership confirmed the documentation gaps during the survey.
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Maintain Adequate Hydration Resulting in Recurrent AKI and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate hydration for a resident with significant medical conditions, including acute kidney injury (AKI), congestive heart failure (CHF), dementia, and Parkinson’s disease. Upon admission, the resident’s care plan identified potential for altered nutrition and included interventions such as assisting at meals, encouraging oral fluids, and monitoring for additional nutrition interventions. A nutrition assessment established an initial fluid goal of 1943–2098 mL/day and documented that the resident was at risk for dehydration and malnutrition, with early labs showing a BUN of 29, creatinine of 1.4, and eGFR of 53. The admission MDS documented that the resident was severely cognitively impaired and required setup assistance for feeding and hydration. Daily fluid intake records from CNA task flow sheets and the MAR showed that the resident’s intake frequently fell below the recommended fluid goals, with multiple days of intake under 1200 mL and some days as low as 360–720 mL. A malnutrition risk assessment identified the resident as at risk for malnutrition due to severe dementia and tremors. A subsequent nutrition note on 5/12/25 documented that the resident’s average fluid intake was 330 mL/day, recommended discontinuing a prescribed hydration pass due to CHF, and set a new fluid goal of 1635–1766 mL/day, while continuing to recommend encouraging oral fluids. Despite these documented risks and low intakes, there is no evidence in the record of intensified monitoring or additional interventions to ensure the resident met the revised fluid goals. The resident experienced multiple clinical deteriorations associated with poor intake and changes in condition. On 6/1/25, after a day with only 360 mL of recorded intake, the resident was transferred to the hospital following falls, hypotension, and confusion, and was admitted with AKI and dehydration. After readmission to the facility, nursing documentation noted low oral intake and a plan to discuss adding the resident to an assist-to-feeding list, but the record lacked evidence that this occurred. Subsequent notes documented lethargy, increased confusion, agitation, restlessness, and continued poor intake, yet a physician progress note following two unwitnessed falls did not include an assessment of hydration status or interventions to improve hydration. On 6/19/25, labs showed a BUN of 62 mg/dL and creatinine of 1.7 mg/dL, and the resident was again sent to the hospital and admitted with AKI, hypotension, and anemia, requiring IV fluid resuscitation. Staff interviews confirmed expectations to monitor intake, encourage fluids, and notify providers when fluid goals were not met, but there was no documentation that the provider was consistently notified or that appropriate interventions were implemented in response to the resident’s ongoing inadequate fluid intake and changes in condition.
Failure to Arrange Timely Home Health Services Prior to Discharge
Penalty
Summary
The facility failed to ensure a timely referral for home health care services prior to discharge for one resident. Facility policy dated 5/1/25 required sufficient preparation and orientation to residents to ensure an orderly transfer or discharge. The resident was admitted on 7/28/25 with diagnoses including aortic valve replacement, aortic regurgitation, and congestive heart failure. A discharge summary dated 8/11/25 documented a post-discharge plan for home health aide, home health RN/LPN, and occupational and physical therapy. The resident was discharged home with a family member on 8/12/25. A complaint received by the Division on 9/30/25 stated that the resident was discharged to a family member's home without a home health care agency referral and that, after one week at home, the resident had not received any physical or occupational therapy or a wellness check from a nurse. During an interview on 2/16/26, the social worker reported needing to check if a referral was made and later confirmed that the referral for home health and therapy services was not requested until 8/15/25, with services opened on 8/20/25. The director of therapy confirmed that physical and occupational therapy were recommended for the resident and stated that such recommendations are typically communicated to social services to set up home care. Findings were reviewed with facility leadership during the exit conference.
Failure to Revise Care Plans and Involve Resident in Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise person‑centered care plans and to involve a cognitively intact resident and/or representative in the care planning process. One resident with an intact BIMS score of 15 was admitted and had a documented care conference shortly after admission, but there was no evidence of any subsequent care conferences during the following year despite multiple care plan updates. The resident reported not recalling quarterly care plan meetings, and staff confirmed that no care conferences occurred after the initial one, with no documentation that the resident or representative participated in the later care plan revisions. Additional residents’ care plans were not revised to reflect current, individualized needs and behaviors. One resident had a physician’s order for a right palm protector or substitute, was repeatedly observed without it in place, and routinely refused it according to nursing and CNA interviews, yet the care plan did not address potential refusals. Two cognitively impaired residents whose MDS assessments documented dependence for bathing had care plans that continued to list only setup assistance or one‑person assist, without updating to reflect full dependence. Another cognitively impaired resident with documented combative behaviors toward staff and a reported incident of striking another resident with a remote had a behavior care plan that was not revised to include the new behavior of attempting to hit other residents or the potential for resident‑to‑resident altercations.
Failure to Obtain Timely Urology Referral for Resident With Ongoing Foley Catheter Issues
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely urology referral for a resident with a neurogenic bladder and chronic Foley catheter, despite ongoing catheter-related problems. The resident was admitted with an indwelling Foley catheter and had a care plan addressing catheter management, including monitoring for discomfort, UTI signs, and pain. On one occasion, the resident returned from an appointment with the Foley catheter out and reinsertion attempts by staff were unsuccessful due to resistance; the provider was notified and ordered the catheter left out with bladder scans every eight hours. The catheter was successfully reinserted the following day. Subsequently, the resident experienced a large amount of bleeding and blood clots from the penis, and the on-call provider ordered labs and a urine culture. The resident later presented with excessive bleeding and clots around the urinary catheter and was sent to the hospital, where a CT scan showed the catheter tip in the penile urethra with the balloon distended just proximal to the tip. Interviews with nursing staff revealed that the resident’s catheter had been difficult to replace and that staff had ongoing difficulty changing it, with multiple catheter dislodgements and frequent leakage reported over the course of the year. LPNs reported that the expectation was for staff nurses to attempt catheter changes and refer out if unsuccessful, and one LPN stated that the resident was recommended to follow up with urology and have catheter changes done there due to the increased difficulty. Another LPN confirmed that the expectation was to schedule residents with outside providers as soon as possible and acknowledged that this resident did not see urology until many months after the documented catheter complications and difficulties. The surveyors concluded that the facility failed to refer the resident to an outside provider in a timely manner while there was an ongoing urinary catheter issue.
Non-Emergent Overhead Paging Disrupts Homelike Environment
Penalty
Summary
The facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by repeatedly using an overhead paging system for non-emergent staff communication. During random observations on multiple dates and times, surveyors heard overhead paging announcements used to communicate between staff members during the day. During a resident council meeting, an anonymous resident reported that the overhead paging by facility staff was unpleasant. In a subsequent interview, the Nursing Home Administrator (E1) confirmed that the facility routinely used overhead paging to communicate with staff during the day, stopping only after 7:00 PM. These observations and interviews were reviewed with the NHA (E1), Regional Operations Director (E2), and DON (E3) during the exit conference. No specific resident medical histories or clinical conditions were described in relation to this deficiency, and the report focuses on the environmental impact of overhead paging on residents’ comfort and homelike surroundings.
Failure to Accurately Include Comfort Care Population in Facility Assessment
Penalty
Summary
The facility failed to ensure its Facility Assessment included an accurate and comprehensive review of the resident population by omitting an identified group of residents receiving Comfort Care. The Facility Assessment for 2025–2026, dated 10/08/25 through 10/29/25, did not indicate or recognize a Comfort Care population and instead only identified residents on Hospice and Palliative Care services. Facility documentation showed that 10 residents, approximately 9.3% of the facility population, were receiving Comfort Care, while only two residents, approximately 1.9% of the population, were identified as receiving Hospice services. The Comfort Care population was therefore not reflected in the current Facility Assessment. During interviews, the DON and Administrator confirmed that the facility used the terms Palliative and Comfort Care interchangeably and that residents on Comfort Care were tracked via an Order Listing Report that documented residents with a “Palliative Care-Form on File.” The Administrator stated that a Comfort Care/Palliative Care Assessment was used in the nursing home setting like a wish list advanced directive to document care preferences, and acknowledged that the Facility Assessment used the term Palliative but not Comfort Care. The Administrator also stated that she had been told Palliative and Comfort Care were the same thing. As a result, the Facility Assessment did not distinguish or address unique and distinctive characteristics and care needs between residents receiving Comfort Care and those receiving Palliative Care, contributing to the cited deficiency under F684 Quality of Care.
Failure to Maintain Clean, Accessible Shower Rooms and Resident Care Equipment
Penalty
Summary
Surveyors identified that the facility failed to maintain clean, sanitary, and home-like shower rooms and resident areas on the second, third, and fourth floors. During multiple tours, the second-floor shower room was observed with cracked tiles, standing water on the floor, discolored walls, and water dripping from the shower head. The handwashing sink in this room was inaccessible due to multiple pieces of equipment, including wheelchairs and mechanical lifts, and a large amount of black debris was seen in an area between the wall and window where a heater had previously been located. CNAs reported that they were not able to access the handwashing sinks in the shower rooms because of the amount of equipment stored there. Similar conditions were observed in the third- and fourth-floor shower rooms, including broken tiles, dripping shower heads, discolored walls, and inaccessible handwashing sinks due to wheelchairs and other equipment. Across all three units, hallway carpets and multiple residents’ room floors were repeatedly observed to be visibly soiled over several days, and the environmental services director stated there was no schedule for carpet cleaning. The shower rooms on all three units continued to be cluttered on repeated observations. In addition, a plastic cushion on a shower bed in the fourth-floor shower room was found with five to six surface openings exposing the underlying permeable foam. Staff interviews confirmed that the cushion had been in that condition for some time and that the openings were present, raising questions about how it could be disinfected. These findings regarding environmental cleanliness, clutter, and damaged resident care equipment were confirmed with facility leadership during the survey.
Failure to Use RNs for Required Admission, Discharge Teaching, and Post-Fall Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services were provided in accordance with Delaware State Board of Nursing scope of practice requirements and professional standards. For one resident admitted on 11/22/25, an LPN completed the Nursing Admission/Readmission/Annual/Significant Change Assessment, as well as the lift/transfer/reposition evaluation, AIMS assessment, PHQ-9 evaluation, and bedrail evaluation in the EMR, despite state regulations specifying that admission assessments must be completed by an RN. For another resident admitted on 6/27/25 with diagnoses including breast cancer and dementia, an LPN completed the Nursing Admission/Readmission/Annual/Significant Change Assessment and documented completion of the admission nursing assessment, with no evidence in the EMR that an RN performed the required admission assessment. The deficiency also includes failures related to discharge education and post-fall assessment. One resident admitted on 11/11/25 and discharged on 11/19/25 had a discharge plan documented entirely by a social work assistant and a nursing clerical assistant, with no evidence that any licensed nursing personnel reviewed the discharge plan documentation. EMR progress notes for this resident contained no evidence that an RN provided discharge education prior to discharge; instead, a social worker documented that the resident chose to discharge and was educated on the risks of not completing rehab. For the resident with breast cancer and dementia who experienced a fall on 7/8/25, a fall incident report and neurological evaluation flow sheet showed that an LPN completed the initial post-fall neurological assessment and documentation, even though state regulations require an RN to complete the initial post-fall assessment. Review of the EMR confirmed there was no RN post-fall assessment documented for this resident.
Failure to Provide Scheduled Bathing for Dependent Resident
Penalty
Summary
A dependent resident with an ADL self-care performance deficit related to a stroke was care planned on admission to be totally dependent on staff for bathing or showering, with an intervention specifying that it was very important for him to choose how he was bathed and that he preferred a shower or bed bath. The resident’s care plan also emphasized the importance of engaging in daily routines meaningful to his preferences. Documentation from admission through early September showed he was scheduled to receive a shower or bath twice weekly on the evening shift and as needed. Out of five scheduled bathing opportunities during the review period, the resident received bathing on two occasions and refused once, but there was no documentation explaining why bathing was not provided on two other scheduled dates. Review of the progress notes confirmed the lack of documented reasons for missed bathing on those dates, and the NE/IP later confirmed these findings during the surveyor interview.
Some of the Latest Corrective Actions taken by Facilities in Delaware
- Re-educated the discharge-planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for safe discharges (J - F0627 - DE)
- Implemented an ongoing review process for residents scheduled for discharge to verify home health services/caregiver support, ADL support, DME availability by or on discharge date, medication availability upon discharge, and other identified supports were in place prior to discharge (J - F0627 - DE)
- Implemented NHA/designee oversight during utilization review to ensure discharge-planning preparation and services were in place prior to discharge (J - F0627 - DE)
Failure to Ensure Safe Discharge with Confirmed Home Services and Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s discharge home included confirmed durable medical equipment (DME), home health services, and adequate caregiver support. The resident was admitted with spinal stenosis, cervical disc disorder, muscle weakness, carpal tunnel syndrome, and a recent post-fasciotomy to the right arm, and was documented as cognitively intact with a BIMS score of 14/15. Despite these physical limitations, the facility discharged the resident home in the evening via medical transport to a three-story residence, where no caregiver support was present. The facility’s own policy required a post-discharge plan of care developed with the resident and representative, and orientation to ensure a safe and orderly transfer or discharge, but the record lacked evidence that services were confirmed as in place prior to discharge. Prior to discharge, the social worker documented that the resident would have a safe discharge home with services and supports in place, and that referrals for home health care, skilled nursing services, and DME had been made, with family members in attendance at the discharge care plan. However, the clinical record did not contain confirmation that these services were actually arranged and active before the resident left the facility. The resident was discharged with medications called to the pharmacy for home delivery, but there was no documentation that the hospital bed had been delivered or that home health nursing, therapy, or home health aide services were scheduled to start at the time of discharge. The social worker later acknowledged not informing the agency of a specific start-of-care date, assuming the agency and VA would contact the resident, and confirmed not calling to verify delivery of the hospital bed. After discharge, it was discovered that the hospital bed ordered days earlier was not delivered until the morning after the resident arrived home, and that therapy, RN, and HHA services had not yet begun or contacted the resident by the time the facility followed up. The resident reported living alone, being unable to use their hands, needing a caretaker, and having to rely on a sister-in-law for limited assistance with hygiene, meals, and rearranging furniture for the bed that arrived later. The significant other confirmed that no one lived with the resident, that they had their own health issues, and that neither they nor their son stayed with the resident after discharge. When a home health RN eventually visited, the resident was found sitting on a couch in minimal clothing, reporting not having eaten adequately for two days, having little or no accessible food, and being unable to open medications or bottles due to impaired fine motor skills. The RN observed the resident’s inability to grip or perform fine motor tasks, assisted with toileting, and then contacted the agency director and emergency services due to the unsafe conditions in which the resident had been left. These events led surveyors to determine that the facility failed to ensure services and caregiver support were in place prior to discharge, resulting in an immediate jeopardy situation.
Removal Plan
- Audited discharge documentation related to home health services, appropriate caregiver/family support, and any necessary services to meet residents' care needs to determine if any residents were affected.
- Reviewed planned discharges by the Administrator, DON, Director of Social Services, and Director of Rehabilitation to ensure home health services, appropriate caregiver/family support, and necessary services to meet the resident's care needs are in place before discharge.
- Completed a root cause analysis identifying failure to have a robust discharge care plan meeting with the interdisciplinary team (IDT), resident, and resident representative.
- Reviewed the procedure for safe and effective discharge planning with the IDT.
- Re-educated the discharge planning IDT on the discharge policy and procedure to ensure sufficient preparation and orientation for a safe discharge.
- Implemented review of residents scheduled to be discharged to ensure appropriate discharge planning is in place.
- Implemented review of residents scheduled for discharge to ensure ADL support is in place, durable medical equipment is available prior to or on the discharge date, medications are available upon discharge, and identified needs/support are available.
- Implemented review of residents scheduled for discharge to ensure safe discharge planning is in place and to address any issues identified.
- Implemented oversight during utilization review by the NHA/designee to ensure discharge planning preparation and services are in place prior to discharge.
- Initiated audits and educational in-services to the IDT team and conducted staff interviews to confirm education received regarding discharge to the community and/or transfers to other facilities.
Failure to Monitor and Manage Tube Feeding Leading to Repeated Aspiration and Harm
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and manage tube feeding and fluid needs for a resident with a gastrostomy tube, and to intervene appropriately when repeated aspiration events occurred. The resident was admitted with a diagnosis of feeding tube (gastrostomy status) and had a care plan directing staff to administer tube feeding and hydration as ordered, maintain the head of bed elevation during and after feeding, and flush the tube with specified amounts of water before and after medications and feedings. Dietary progress notes documented that the resident’s weight was stable and overweight by standard, with tube feeding ordered as Nutren 1.5 at 70 mL/hr for 18 hours and free water flushes (FWF) of 65 mL/hr for 18 hours, providing 1890 calories and 1170 mL of water per day. However, review of the Medication Administration Record (MAR) showed that staff documented providing tube feeding and FWF volumes far in excess of the ordered daily amounts on multiple days, with recorded totals of tube feeding and water flushes that greatly exceeded the prescribed 1260 mL of tube feeding and 1170 mL of FWF in 24 hours. The resident experienced multiple episodes of tube feeding formula oozing from the mouth and nares, along with respiratory compromise, that were documented in progress notes but were not followed by documented reassessment or adjustment of tube feeding orders by the dietitian or medical providers. On one occasion, the resident was found unresponsive with low oxygen saturation and tube feeding seen oozing from the mouth; CPR was initiated, suctioning was performed, and the resident was sent to the hospital. The resident was later readmitted with the same tube feeding and water flush rates, and a subsequent note indicated treatment for aspiration pneumonia. Later MAR entries again showed staff-documented tube feeding and FWF volumes that exceeded the ordered amounts. Another nursing note described the resident with labored breathing, crackles in both lungs, and milky secretions pooling from both nares and mouth, with suctioning performed and an order obtained to send the resident to the hospital via 911. A hospital history note documented concern for overfeeding and aspiration, with admission for septic shock, pneumonia, and urinary tract infection. Despite these events, dietary notes continued to state that the resident’s weights were stable or that weight gain was being evaluated for accuracy, and that no nutritional interventions were needed at that time, even when a dietary note recorded a net weight gain of 22.6% over seven months. A later dietary progress note indicated that the resident remained NPO and continued on the prescribed tube feeding regimen, with concurrent water flushes providing a total of 2132 mL of fluid per day. Nursing progress notes in a subsequent month documented repeated observations of Nutren feed coming out of the resident’s mouth, coarse crackles bilaterally, dyspnea, and the need for frequent suctioning, with the NP initially instructing staff to monitor the resident. Another note described fluid from the mouth, crackles, and continued monitoring, followed by a note that the resident was aspirating from the mouth with shortness of breath and lung crackles, leading to a recommendation from the NP to send the resident to the hospital. Interviews with the NP and dietitians revealed that the NP documented the resident as tolerating tube feeding after aspiration incidents, that the dietitian was not notified of earlier aspiration events or the hospital note about overfeeding, and that the dietitian acknowledged an assessment of tube feeding and water flush rates should be conducted after aspiration incidents. The facility’s own enteral nutrition policy required the RDN to assess energy, protein, and fluid requirements, compare them to ordered formula and flushes, and monitor weight, labs, and physical symptoms, and required nursing to communicate changes such as vomiting and high residuals, but the documented care and communication did not reflect consistent adherence to these requirements for this resident. The facility’s leadership, including the DON, Medical Director, NP, Regional Registered Dietitian, and facility dietitian, acknowledged in interview that the resident had chronic encephalopathy and aspirated off and on, and that dietary staff usually changed orders and tracked tube feeding, aspiration, and labs. However, the Medical Director responded to a question about tube feeding coming out of the resident’s nose by stating that people vomit when they are sick, and there was no documentation that the tube feeding regimen was reassessed or modified in response to the repeated documented episodes of tube feeding formula oozing from the resident’s mouth and nares, the excessive volumes recorded on the MAR, or the significant weight gain. The survey findings concluded that the facility failed to ensure that the resident was assessed and monitored for nutritional and fluid needs and failed to implement interventions when the resident aspirated tube feeding multiple times and gained a significant amount of weight, resulting in harm including cardiac arrest during an aspiration event and multiple hospitalizations after aspiration of tube feeding.
Removal Plan
- Transferred the affected resident to the hospital
- Assessed all tube-fed residents for tolerance, weights, and aspiration signs
- Registered Dietitian and clinical leadership reviewed tube-fed residents’ status
- Convened a QAPI meeting
- Provided education to the dietitian and nursing staff on the enteral feeding policy with completion
- Implemented a structured audit and monitoring process of MARs and progress notes to ensure ongoing compliance and early identification of tube feeding intolerance
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