Delaware Hospital F/T Chronically Ill (dhci)

Inspectors wroteBased on document review, interviews, observations, and facility policy review, the facility failed to ensure that four of 10 residents (Residents (R) 5, R4, R71, and R6) reviewed for unsupervised smoking, smoked safely. In addition, all residents refused to don (put on) a smoking apron for protection and would hold onto their cigarettes and/or lighters instead of nursing staff securing the smoking paraphernalia safely. In addition, R34 was identified as a resident who smoked and had a lighter in her room. R34 used an oxygen concentrator, while in her room and while her lighter was kept in her room. This placed all residents who smoke of an increased opportunity for burns. The facility's Administrator and Director of Nursing (DON) were notified on 01/07/26 at 6:40 PM that Immediate Jeopardy existed related to the failure to assess and monitor three residents R5, R71, and R6 who smoked. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize menus with portion sizes for regular, mechanical soft, and puree diets for two of two meals. This failure could potentially cause residents to become malnourished or experience weight loss or weight gain.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interviews, the facility failed to develop a person-centered comprehensive plan of care with measurable goals and plans for four of five residents (Resident (R) 2, R5, R1, and R24) reviewed for care plans, out of a survey sample of 28. The failure to develop a care plan increased the risk for care to be incomplete and/or inconsistent related to the residents taking psychotropic medications.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer five of eight residents (Residents (R) 20, R21, R22, R11, and R57) reviewed for flu/pneumonia vaccinations and/or their representatives, the opportunity for the residents to be vaccinated in accordance with nationally recognized standards of 28 sample residents. This practice had the potential to increase the risk for this resident to contract pneumonia. In addition, the facility policy did not reflect current CDC recommendations.

Inspectors wroteBased on record review, interview, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure three of eight residents (Resident (R) 22, R57, and R11) out of 28 sampled residents had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements and inaccurate assessment and care planning of the residents. (Cross Reference F883)

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure that one resident (R) 8 out of a survey sample of two, had a complete tracheostomy (trach) change. This has the potential for residents to have their airway compromised and potentially develop severe infection that could be life-threatening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the need for side rails and obtain informed consent for two (Resident (R)9 and R27) of two residents reviewed for side rails. This had the potential to place residents at risk of injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was administered to one (Resident (R)35) of one resident observed for pharmacy services. This failure had the potential to compromise patient safety, efficacy of the prescribed treatment, and fulfill the legal and ethical responsibilities.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE), specifically disposable gowns, and gloves, during the administration of medication through a percutaneous endoscopic gastrostomy (PEG) tube for one (Resident (R)27) of 10 residents who had PEG tubes. This deficient practice resulted in a risk of contamination and the potential spread of infection to the patient and other residents.

Inspectors wroteBased on observation, interview, record review and other facility documentation, it was determined that for two (R1and R2) out of three residents sampled for accidents, the facility failed to ensure that R1 and R2 received adequate supervision to prevent accidents. R1, a severely cognitively impaired resident, was able to elope from the building on 9/26/25 during the 11:00 PM to 7:00 AM shift. R1 was found on 9/26/25 at 8:38 AM, approximately 17-20 miles from the facility. This failure put R1 at immediate risk for severe injury or death due to exposure to traffic and environmental hazards while walking on the road unsupervised. An immediate jeopardy (IJ) was called at 12:30 PM on10/1/25. The facility abated the IJ on 10/2/25 at 3:00 PM. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R1) out of three residents reviewed for accident hazards and falls, the facility failed to ensure that R1 received adequate hands-on assistance and supervision to prevent a fall to the extent possible. R1, a cognitively impaired and dependent resident sustained a fall on [DATE] when two staff members improberly used a mechanical lift to perform a transfer. The facility's failure caused R1 to suffer a subdural hematoma and two (2) lacerations to her scalp. R1 was sent emergently to the hospital. Due to this failure, an Immediate Jeopardy (IJ) was called at 10:30 AM on [DATE].