Ocean Grove Post Acute
OCEAN GROVE POST ACUTE in MILLSBORO, DE — inspection on July 18, 2024.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R146's clinical record revealed:
3/30/24 - R146 was admitted to the facility with diagnoses, including but not limited to altered mental status.
4/1/24 3:09 PM - R146 signed the facility's Admission Agreement, which included an authorization form to release financial data.
The clauses that identified R146's legal representative and responsible party were left blank in this signed document.
The facility's Admission Agreement included information regarding resident's rights, payment obligations, grievance process, advanced directive and other services provided by the facility.
4/2/24 2:59 PM - E5 (Social Work Director) documented in R146's EMR.Her sister [F2] was invited to the meeting (care plan meeting) .SW (social work) was unable to get in contact with her sister .The plan is to have [R146] move in with one of her sisters .[R146] scored 3/15 on her BIMS assessment which indicates that she has severe cognitive deficit .
4/5/24 - R146's admission Minimum Data Set (MDS) assessment documented a BIMS score of three, which reflected severe cognitive impairment.
4/9/24 9AM - E6 (SW) documented in R146's EMR Update delivered to family and CM (case management) in phone call.
The facility failed to identify that R146 with a BIMS of 3, did not have the cognitive ability to be her own responsible party and was unable to provide evidence of any intervention on behalf of R146 to address the need for a responsible party with R146's two known sisters.
4/12/24 - R146 was given a Notice of Medicare Non-Coverage (NOMNC) that advised that R146's effective date of last day of Medicare coverage was 4/17/24.
The document was signed by E44 (Social Worker) and E43 (Business Office manager) with the statement unable to sign BIM of 3 written in box beneath the statement Signing below means that you've received and understand this notice .
085037
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085037 B.
Wing 07/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966
Review of R128's clinical record revealed:
8/11/23 - R128 was admitted to the facility.
4/23/24 - R128's physicians orders documented R128 to be out of bed for a minimum of two hours every day and nursing to document and notify family of refusals every day shift.
5/16/24 - A quarterly MDS revealed that R128 was dependent for transfer from bed to chair or chair to bed. R128's BIMs score was 13 out of 15 which indicated intact cognition.
7/10/24 at 10:32 AM - 7/11/24 at 2:56 PM - Multiple observations of R128 laying in bed.
7/12/24 9:33 AM -
During an interview R128 stated he did not get out of bed at any time on 7/11/24.
A review of the treatment administration record (TAR) revealed a checkmark with E8 (LPN)'s initials for the treatment order that states, Resident to be out of bed for a minimum of 2 hours every day - Nursing to document and notify Sister . of refusals every day shift.
7/12/24 2:29 PM -
During an interview, E25 (CNA) confirmed that R128 was not out of bed on 7/11/24 and they did not offer to get R128 out of bed.
7/12/24 2:31 PM -
During an interview E26 (LPN) stated, we have to document about him refusing in the [electronic] notes.
7/17/24 9:19 AM -
During an interview E8 confirmed that the checkmark on the treatment administration record for 7/11/24 means that the task was completed and R128 got out of bed.
There was a lack of facility documentation of any refusals by R128 to get out of bed on 7/11/24.
The facility documented that R128 was out of bed when he was never out of bed on 7/11/24.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
085037
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085037 B.
Wing 07/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966
Review of R146's clinical record revealed:
3/30/24 - R146 was admitted to the facility with diagnoses, including but not limited to altered mental status.
4/2/24 2:59 PM - E5 (Social Work Director) documented in R146's EMR.[R146] scored 3/15 on her BIMS assessment which indicates that she has severe cognitive deficit .
4/5/24 - R146's admission MDS assessment documented a BIMS score of three, which reflected severe cognitive impairment.
5/29/24 - E46 (Psychologist) documented in R146's EMR, Her judgment and insight are impaired. At this time, patient is not capable of making her own healthcare decisions.
5/31/24 - The facility made a referral for capacity determination.
6/3/24 - E39 (MD) documented in a Physician Affidavit for Guardianship that R146 did not have capacity to function independently including: activities of daily living, pay her own bills, live alone, take medicine appropriately, give consent for medical procedures and resist scams.
6/3/24 10:06 AM - F4 (male friend) signed R146 out of the facility in the Leave of Absence log. R146 was signed back into the facility at 11:35 AM.
6/4/24- The facility petitioned the Court of Chancery to initiate R146's guardianship process.
According to the Release of Responsibility for Leave of Absence log, R146 was signed out and left the faciity on a leave of absence with unrelated persons on 5/20/24, 5/25/24, 6/3/24, 6/21/24, 6/28/24 and 7/12/24.
7/10/24 3:20 PM - A review of R146's face sheet revealed that R146 listed as responsible party and F2 (R146's sister) listed as emergency contact #1 and F3 (R146's other sister) listed as emergency contact #2.
The facility failed to ensure that R146, a resident with severe cognitive impairment, did not leave the facility without her family's consent.
085037
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085037 B.
Wing 07/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966
Review of R128's clinical record revealed:
8/11/23 - R128 was admitted to the facility with diagnoses including cerebral infarction and hemiplegia affecting the nondominant left side.
4/23/24 - A physician order documented that R128 was to be out of bed for a minimum of two hours every day and nursing to document and notify family of refusals every day shift.
5/16/24 - A quarterly MDS revealed that R128 had an impairment on one side for the upper extremities and no impairments for the lower extremities. R128 required substantial or maximal assistance for rolling left and right, sitting to lying, lying to sitting on the side of the bed and was dependent for transfer from bed to chair or chair to bed. R128's BIMs score was 13 out of 15 which indicated intact cognition.
7/9/24 - An interview with R128 stated, I stay in bed and they don't get me up.
Observations of R128 laying in bed: 7/10/24 at 10:32 AM, 7/10/24 at 11:14 AM, 7/11/24 at 9:35 AM, 7/11/24 at 10:41 AM, 7/11/24 at 12:11 PM, 7/11/24 at 2:56 PM.
7/12/24 9:33 AM -
During an interview R128 stated he did not get out of bed at any time on 7/11/24.
7/12/24 2:29 PM -
During an interview, E25 (CNA) confirmed that R128 did not get out of bed on 7/11/24 and that R128 did not refuse. E25 stated, we did not ask if he wanted to get up. He usually tells us that he wants to be up. We did not ask, so he did not refuse.
7/12/24 2:31 PM -
During an interview, E26 (LPN) stated, we have to document about him refusing in the [electronic] notes.
There was no facility documentation of any refusals by R128 to get out of bed on 7/11/24.
7/18/24 1:05 PM - Findings were reviewed with E1 (NHA), E2 (DON), E3 (QA/IP), E4 (Corporate RN) and E7 (ADON) at the exit conference.
085037
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085037 B.
Wing 07/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ocean Grove Post Acute 231 South Washington Street Millsboro, DE 19966