Autumn Care of Drexel

In the surveyor’s words

From the most serious findings on record at Autumn Care of Drexel, in the surveyor’s own words.

• Immediate jeopardy, patternF580Jul 7, 2022

  Based on record reviews, and interviews with staff, family member, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to notify the physician or Nurse Practitioner when a sacral pressure ulcer was identified on Resident #36 on 3/3/22 and when the pressure ulcer deteriorated on 3/10/22. The facility failed to notify the Wound PA of two wound culture swabs being discarded by the laboratory. Resident #36 was later diagnosed on [DATE] with sacral [CONDITION(S)]. In addition, the facility failed to notify Resident #36's family member when her pressure ulcer deteriorated on 3/10/22. This failure was for 1 of 3 residents reviewed for notification of changes (Resident #36). […]

• Immediate jeopardy, patternF686Jul 7, 2022

  Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to assess, obtain treatment orders from the physician, and identify deterioration of the pressure ulcer which resulted in a serious adverse outcome. Resident #36's open area on her sacrum deteriorated from an open area to an unstageable pressure injury with necrotic tissue in a week (from [DATE] to [DATE]). The facility also failed to have two wound cultures processed on Resident #36's sacral pressure ulcer resulting in delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility failed to provide pressure ulcer care as ordered by the Wound PA for Resident #11. […]

• Immediate jeopardy, patternF835Jul 7, 2022

  Based on observations, record reviews and interviews with resident, family member, staff, Wound Physician Assistant (PA) and Nurse Practitioner, the facility failed to provide effective leadership and implement effective systems to manage pressure ulcers, laboratory tests and physician notification. This failure affected 2 of 3 residents reviewed for administration (Resident #36 and Resident #11). Immediate Jeopardy began on 3/3/22 when the facility failed to provide the necessary care and services for a pressure ulcer that deteriorated in condition that involved Resident #36. The immediate jeopardy was removed on 7/3/22 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. […]

• Immediate jeopardy, isolatedF760Apr 24, 2025

  Based on record review, staff, Medical Director and Consulting Pharmacist interviews, the facility failed to prevent a significant medication error when Nurse #1 administered 30 units of insulin glargine (a long acting insulin that lasts for 24 hours and does not have a peak of onset) intended for Resident #31 to Resident #16. Resident #16 did not have a diagnosis of diabetes or a physician's order for insulin. Resident #16 was assessed by the Nurse Practitioner (NP) and immediately started on intravenous (IV) dextrose (a solution that contains sugar) fluids for 24 hours. The NP also ordered finger stick blood sugars every hour for 24 hours with instructions to notify the provider if Resident #16's blood sugar was below 90 (Normal range is between 70-99). […]

• Actual harm, isolatedF689Apr 24, 2025

  Based on observations, record review, Medical Director, resident and staff interviews, the facility failed to provide care in a safe manner when staff were assisting a resident (Resident #34) with left side weakness and vascular dementia with incontinent care. The resident was rolled onto her left side then left in her bed unattended with the side rails down. Resident #34 was unable to hold herself up and she fell off the side of the bed onto the floor. The resident sustained a laceration to her nose, bruises to her face, and was transferred to the hospital for treatment. She received medical glue to the laceration on her nose, and a hospital CT (computed tomography) scan revealed the resident had suffered a fractured nose due to the fall. […]