Delaware Hospital F/t Chronically Ill (dhci)
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Policy, documented, .The facility will ensure that the resident environment is safe and free of hazards. That each resident receives adequate supervision and assistance to prevent falls or minimize the risk for fall related injuries.3/14/25 - Resident R2's quarterly MDS documented a BIMS score of 00, indicating an inability to conduct a cognitive interview. Resident R2 was non-ambulatory and completely dependent on staff for all activities of daily living.5/11/25 8:57 PM - A facility incident report submitted to the Division documented, Resident fell from the bed to the floor during care and sustained a right eyebrow cut/swollen and Rt [right] knee abrasion. Provider was notified and resident sent to the ER for evaluation.5/13/25 11:00 AM - Resident R2's clinical
record documented, Resident seen today for decreased ROM [range of motion] to right knee. Right knee noted with swelling and warm to touch. Resident moaned and grimaced when the right knee was touched.
Right knee tender to touch, resident unable to flex knee to 90 degrees. X-ray of right knee ordered.5/13/25 8:40 PM - Resident R2's clinical record documented, .Showed that the resident's right femur is fractured.Send the resident out via 911.5/16/25 11:35 AM - The facility's 5 day follow up report to the Division documented, .admitted for right knee surgery due to a right femur fracture. She [Resident R2] had surgery and returned on 5/16/25.10/1/25 2:00 PM - The facility's post fall investigation documented, [Resident R2] was not care planned for falls because she is unable to move herself. E6 (CNA) interview statement documented, .[Resident R2] does not move at all and cannot scoot because she is heavy. E6 advised that she turned [Resident R2] on her right side as
she reached for a washcloth. Resident was being turned towards the window and as she reached for the washcloth Resident R2 rolled off the bed. She fell face down on the floor.The facility failed to provide adequate supervision to prevent Resident R2's fall with injury.10/2/25 1:30 PM - A review of the facility's actions after Resident R2's fall revealed:- Resident R2's care plan was revised and updated for 2 staff members assistance with bed mobility.- All nursing staff were trained on fall prevention during resident care. The training included not rolling the resident away from the staff's body. Ensure that the resident is in the middle of the bed before turning him/her away from your body (if you must turn the resident away from you.)- The certified nursing assistant (CNA) involved in the fall was required to re-take new hire orientation, which included shadowing another CNA before she could return to provide resident care independently.- The fall was discussed and reviewed at the fall committee meeting on 5/16/25 and at QAPI meetings 6/30/25 and 7/28/25.- A review of all falls since 5/11/25 during the fall committee meeting and QAPI meetings revealed no falls relating to resident's positioning in bed or during care.10/2/25 3:30 PM - During an interview, findings were confirmed with E2 (DON).10/3/25 1:30 PM - Findings were reviewed with E1 (NHA), E2 (DON) and E3 (ADON) at the exit conference.
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DELAWARE HOSPITAL F/T CHRONICALLY ILL (DHCI) in SMYRNA, DE inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SMYRNA, DE, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from DELAWARE HOSPITAL F/T CHRONICALLY ILL (DHCI) or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.