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)
Some of the Latest Corrective Actions taken by Facilities in Delaware
- Provided re-education to all staff on abuse and proper reporting procedures (J - F0609 - DE)
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of staff-to-resident abuse involving a resident with severe cognitive impairment. The incident occurred when a Certified Nursing Assistant (CNA) stuck her tongue out at a resident and threw three wipes toward the resident's head during care. Another CNA witnessed the event and reported it to a Licensed Practical Nurse (LPN), but the incident was not reported to the facility's Abuse Coordinator until several days later. During this period, the accused CNA continued to work scheduled shifts in the facility. The resident involved had a history of cerebral infarction, unspecified dementia with agitation, and major depressive disorder, and was assessed as severely cognitively impaired. The incident was witnessed by a second CNA, who reported it to the LPN. The LPN did not escalate the report, believing that keeping the CNA away from the resident was sufficient. Additionally, a Unit Clerk learned of the incident but failed to report it immediately, only recalling to do so days later. The facility's policy required immediate reporting of suspected abuse to the appropriate authorities and immediate suspension of the accused staff member pending investigation. However, the delay in reporting allowed the accused CNA to remain on duty and interact with other residents. The deficiency was identified during a survey, which found that the facility did not follow its own policy or regulatory requirements for timely reporting of abuse allegations.
Removal Plan
- Implemented a Removal Plan to address the deficient practice
- Developed a Performance Improvement Plan (PIP) in response to the incident
- Reviewed the Performance Improvement Plan (PIP)
- Selected residents randomly for review regarding abuse
- Provided re-education to all staff for abuse and the proper reporting of abuse
Latest Citations in Delaware
A resident with heart failure and COPD was mistakenly given her roommate's medications by an LPN who failed to properly verify the resident's identity. The error led to severe hypotension, requiring emergency transfer and hospital treatment with IV fluids and monitoring before the resident returned to the facility.
A resident with moderate cognitive impairment, as indicated by a BIMS score of 11 and an existing POA for medical decisions, completed an Advance Directive Acknowledgment form without the involvement of their designated POA. The resident signed the form incorrectly, and staff interviews revealed inconsistent practices regarding when to involve family or POA in such decisions.
A resident and their responsible party were not informed in advance of a change in Medicaid/Medicare coverage, resulting in them being billed for services not covered by insurance before receiving notification. Facility staff confirmed that notification was provided only after billing for uncovered services had already begun.
A resident was placed on extended contact isolation for a suspected scabies outbreak, despite ongoing treatment and changes in the rash's presentation. Providers did not reference CDC guidelines, and the facility determined the isolation duration. The resident remained secluded for 78 days until a dermatology consult revealed the rash was not scabies, leading to the discontinuation of isolation precautions.
A resident was admitted to hospice care, but the required significant change MDS assessment was not completed within the mandated timeframe. The assessment was delayed until the MDS office was notified of the hospice admission, despite documentation of the change in the clinical record and transfer/discharge list.
A resident with severe cognitive impairment was subjected to alleged abuse by a CNA, who stuck her tongue out and threw wipes at the resident during care. The incident was witnessed and reported to an LPN, but not escalated to the Abuse Coordinator as required. The accused CNA continued working for several days before the incident was formally reported, in violation of facility policy and reporting requirements.
Staff failed to consistently follow infection prevention and control protocols, including proper use of PPE, hand hygiene, and adherence to transmission-based precautions. Multiple staff members, including nursing, housekeeping, and leadership, were observed entering rooms on enhanced barrier or contact precautions without appropriate PPE or hand hygiene, and performing resident care tasks without changing gloves or sanitizing equipment. These actions were contrary to facility policy and involved residents with conditions such as ESBL, MRSA, and those under COVID-19 precautions.
The facility did not properly maintain the outdoor garbage area, as a large dumpster without a lid was left on site containing ripped garbage bags with exposed food waste, and garbage was observed scattered on the ground. Staff confirmed the lack of a policy for dumpster area maintenance and acknowledged that the area was not kept clean or secured against pests.
The facility did not properly inform residents about its grievance policy or the process for filing complaints, with several residents unaware of how to voice concerns or who to contact. In multiple cases, grievances related to housekeeping and personal property were not fully investigated or resolved, and staff interviews revealed inconsistent application of the grievance process.
The facility did not ensure medications were administered as ordered, resulting in a medication error rate of 10%. Two residents received medications after meals that were prescribed to be given before eating, with nursing staff acknowledging the timing errors. The DON confirmed that medications are expected to be administered according to orders and packaging instructions.
Medication Error Resulting in Hospitalization Due to Staff Misidentification
Penalty
Summary
A medication error occurred involving a resident who was admitted with diagnoses including heart failure and chronic obstructive pulmonary disease. On the morning following admission, a staff LPN mistakenly administered the medications intended for the resident's roommate, which included amlodipine 10mg, benazepril 40mg, Coreg 25mg, and sevelamer 800mg. The error was made when the LPN identified the resident incorrectly, relying on the name in the room and not verifying the resident's identity with the armband or photo in the medication administration record. The resident, who was hard of hearing, received the wrong medications after confirming she needed her medication in pudding, further contributing to the misidentification. Following the administration of the incorrect medications, the resident's blood pressure dropped significantly, with documented readings as low as 50/20. The staff recognized the error after rechecking the resident's blood pressure and reviewing the medication administration. Emergency services were called, and the resident was sent to the hospital for evaluation and treatment, where she received IV fluids and monitoring for hypotension. The resident spent approximately 16 hours in the emergency room before returning to the facility. The incident was confirmed through staff interviews and documentation review.
Failure to Involve POA in Advance Directive for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment was admitted to the facility. The resident's admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The resident's electronic medical record (EMR) listed their daughter as the primary emergency contact and included a notarized Power of Attorney (POA) document naming the daughter as the sole POA for both medical and financial matters. Despite this, the facility's social worker completed the Advance Directive Acknowledgment form with the resident alone, who printed her name incorrectly on the signature line, using a different first name and misspelling her last name. Interviews with facility staff revealed inconsistent practices regarding the involvement of family representatives or POAs in the completion of advance directive paperwork for residents with cognitive impairment. The social work director stated that there was no formal cutoff BIMS score for determining decision-making capacity and that the process was based on judgment. The DON indicated that typically, if a resident's BIMS score is below 12, the family or POA is involved in signing paperwork. However, in this case, the POA was not included in the acknowledgment process, despite the resident's documented cognitive impairment and existing POA documentation.
Failure to Provide Advance Notice of Change in Billing for Non-Covered Services
Penalty
Summary
A resident was admitted to the facility and subsequently exhausted their insurance coverage for nursing home stay, as indicated by an Eligibility Verification Notice received by the facility. The facility became aware of the change in coverage and, on the same day, read a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) over the phone to the resident's responsible party, informing them that they would be responsible for payment starting the following day. However, the facility began billing the resident and responsible party for services from the last date of coverage, prior to providing notification of the change in billing status. Facility staff confirmed that the resident and responsible party were not informed in advance of the change in billing, and billing for uncovered services occurred before notification was given.
Resident Subjected to Prolonged Involuntary Seclusion Due to Misdiagnosed Rash
Penalty
Summary
A resident was admitted to the facility and subsequently developed a rash, which was initially documented on both arms and upper thighs. The resident was placed on contact isolation precautions for suspected scabies, as documented in the care plan and physician's orders. Despite treatment with Ivermectin and Permethrin, and ongoing provider assessments, the resident remained on isolation for an extended period. Progress notes indicated that the rash persisted and changed locations, but providers did not consult CDC guidelines for scabies treatment, and the isolation precautions continued based on facility protocol rather than updated clinical assessment. The resident remained on isolation for a total of 78 days, during which time he reported feeling confined and unable to receive showers for a significant portion of the isolation period. It was only after a dermatology consult that the rash was diagnosed as atopic dermatitis, unrelated to scabies, and isolation precautions were discontinued. Interviews with staff confirmed that the decision to maintain isolation was a collaborative process, but providers acknowledged not referencing CDC guidelines and that the facility determined the duration of isolation. The prolonged and unnecessary isolation resulted in the resident being involuntarily secluded due to a misdiagnosis.
Failure to Complete Timely Significant Change Assessment After Hospice Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive assessment for a resident who experienced a significant change in condition, specifically upon admission to hospice care. The resident was admitted to the facility and later to hospice services, but a significant change Minimum Data Set (MDS) assessment was not completed within the required fourteen days of the hospice admission. Documentation and interviews confirmed that the MDS for the significant change was only completed nearly a month later, after the MDS office became aware of the resident's hospice status. The delay was attributed to a lack of timely notification to the MDS office regarding the resident's change in status, despite the hospice admission being documented in the clinical record and on the Ombudsman Transfer/Discharge list.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of staff-to-resident abuse involving a resident with severe cognitive impairment. The incident occurred when a Certified Nursing Assistant (CNA) stuck her tongue out at a resident and threw three wipes toward the resident's head during care. Another CNA witnessed the event and reported it to a Licensed Practical Nurse (LPN), but the incident was not reported to the facility's Abuse Coordinator until several days later. During this period, the accused CNA continued to work scheduled shifts in the facility. The resident involved had a history of cerebral infarction, unspecified dementia with agitation, and major depressive disorder, and was assessed as severely cognitively impaired. The incident was witnessed by a second CNA, who reported it to the LPN. The LPN did not escalate the report, believing that keeping the CNA away from the resident was sufficient. Additionally, a Unit Clerk learned of the incident but failed to report it immediately, only recalling to do so days later. The facility's policy required immediate reporting of suspected abuse to the appropriate authorities and immediate suspension of the accused staff member pending investigation. However, the delay in reporting allowed the accused CNA to remain on duty and interact with other residents. The deficiency was identified during a survey, which found that the facility did not follow its own policy or regulatory requirements for timely reporting of abuse allegations.
Removal Plan
- Implemented a Removal Plan to address the deficient practice
- Developed a Performance Improvement Plan (PIP) in response to the incident
- Reviewed the Performance Improvement Plan (PIP)
- Selected residents randomly for review regarding abuse
- Provided re-education to all staff for abuse and the proper reporting of abuse
Failure to Follow Infection Prevention and Control Protocols
Penalty
Summary
Multiple breaches in infection prevention and control protocols were observed throughout the facility, involving both nursing and non-nursing staff. Staff failed to follow established policies for transmission-based precautions, hand hygiene, and the use of personal protective equipment (PPE) during resident care. For example, an LPN entered a resident's room on enhanced barrier precautions without PPE, handled tube feeding equipment that had fallen on the floor without sanitizing it, and administered medications without proper hand hygiene. A CNA performed incontinent care and changed linens without changing gloves between dirty and clean tasks, and both the LPN and CNA failed to use PPE appropriately during these activities. Additionally, staff were observed entering and exiting rooms on enhanced barrier precautions without washing or sanitizing their hands, and in some cases, without donning required gowns or gloves. Housekeeping staff also failed to adhere to contact precaution protocols. One housekeeper entered a resident's room, which was under contact precautions for ESBL in urine, without wearing a gown or gloves and used the same cleaning equipment in multiple rooms. The housekeeper was unaware of the need to use PPE, and the infection preventionist confirmed that housekeeping staff should have been using PPE in such situations. Nursing staff were also observed entering the same resident's room without donning a gown, despite clear signage and available PPE supplies, and incorrectly believed that PPE was only necessary if direct contact with bodily fluids occurred. Further deficiencies were noted in medication administration practices, with a nurse observed popping medications into their hand before placing them in a medication cup, contrary to facility policy. Leadership staff, including the ADON and LPN supervisors, were observed entering and exiting rooms on enhanced barrier precautions without proper hand hygiene or PPE use. In one instance, linen was picked up from the floor without appropriate PPE. The facility's policies for COVID-19 precautions were also not consistently followed, with some staff uncertain about the requirements for droplet and contact precautions and the use of PPE for residents under quarantine.
Improper Disposal and Maintenance of Outdoor Garbage Area
Penalty
Summary
The facility failed to maintain the outdoor garbage and dumpster area in a manner that would prevent pests from accessing garbage. Observations over several days revealed a large dumpster without a lid, filled with garbage bags, some of which were ripped or torn, exposing food scraps and containers. Garbage, including cigarette butts, paper, and cardboard, was also found scattered on the ground around the compactor area. The Dietary Manager confirmed the presence of garbage on the ground and acknowledged that maintenance was responsible for cleaning the area. The large dumpster had been used while the compactor was being repaired, but even after the compactor was returned, the dumpster remained on site, still uncovered and containing exposed waste. Interviews with facility staff indicated that there was no policy in place regarding the maintenance of the dumpster area. The Maintenance Director stated that the dumpster had been present for a couple of weeks and that waste management did not provide dumpsters with lids. Maintenance staff typically cleaned the area twice a week. The Registered Dietitian reported that her sanitation inspections included checking the dumpster area to ensure it was not overfilled, the lid was closed, and there was no garbage on the ground, but the large dumpster did not have a lid. The Administrator confirmed the absence of a facility policy for dumpster area maintenance and acknowledged that the dumpster should have been covered.
Failure to Inform Residents of Grievance Policy and Inadequate Grievance Resolution
Penalty
Summary
The facility failed to adequately inform residents about its grievance policy and the process for filing complaints, as well as the identity and contact information of the grievance official. Seven residents interviewed during a resident council meeting stated they were unaware of any formal complaint process or postings about grievances, and none knew who the designated grievance officer was, except for the social worker. The facility's grievance policy was posted in a location that was difficult to read, and there was no evidence that the grievance process was discussed in resident council meetings or communicated to residents who did not attend. In the case of one resident, a family member reported multiple grievances regarding poor housekeeping, including unclean rooms and bathrooms, and inadequate cleaning of public areas. While some grievances were documented and investigated, at least one concern related to housekeeping was not addressed or responded to, despite being reported on a Resident Concern Form. Interviews with staff confirmed that the grievance process was inconsistently followed, with some concerns not being investigated or resolved as required by policy. Two additional residents experienced issues related to personal property. One resident had a small refrigerator removed from her room without explanation, and there was no documentation or policy provided to justify the removal. Another resident reported a missing electric razor, which was not documented as a grievance or thoroughly investigated, despite the resident's dependence on the item for personal care and his report that previous razors had been broken during care. Staff interviews revealed a lack of clarity about whether these incidents should have been treated as grievances and how they should have been addressed according to facility policy.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration Timing
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During a medication pass observation, three errors were identified out of 30 opportunities, resulting in a 10% error rate. Specifically, one resident with attention deficit disorder and gastroesophageal reflux disease was administered ritalin and omeprazole after having already eaten breakfast, despite both medications being ordered to be given before meals. The nurse administering the medications acknowledged awareness of the timing requirements but cited other responsibilities as a reason for not adhering to the prescribed schedule. Another resident with diabetes was prescribed glipizide to be given 30 minutes before meals on specific days. However, the medication was administered after the resident had already received her breakfast tray. The nurse involved confirmed the timing of administration and did not provide further explanation when questioned about the correct timing. The Director of Nursing stated that medications are expected to be given as ordered and according to blister package instructions.
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