SIGNATURE HEALTHCARE AT HERITAGE HALL REHAB & WELLNESS CENTER
LOCATED: 331 SOUTH MAIN STREET, LAWRENCEBURG, KY 40342
SIGNATURE HEALTHCARE AT HERITAGE HALL REHAB & WELLNESS CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS.
LEVEL OF HARM –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review, and review of the facility’s policy, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision and assistance devices to prevent a fall when one (1) staff member attempted to transfer the resident without assistance and without use of a mechanical lift as directed by the facility’s policy and the resident’s Comprehensive Care Plan.
On 08/19/16, at approximately 5:00 AM, State Registered Nurse Aide (SRNA) #10 independently attempted to transfer Resident #1 from the bed to the wheelchair without requesting assistance and without utilizing a mechanical lift. Review of the facility’s investigation findings, revealed Resident #1 slid off the side of the bed onto the floor during the transfer. After Resident #1 sustained the fall, SRNA #10 failed to report the fall to the nurse in order for the resident to be assessed for injuries, and instead transferred the resident to the wheelchair with a gait belt, with the assistance of SRNA #7. The resident was not assessed for injuries until 08/19/16 at approximately 1:30 PM. an order for [REDACTED]. On 08/19/16 at 10:45 PM Emergency Medical Services (EMS) was contacted to transfer the resident to the local hospital emergency room and the resident was admitted to the hospital.
Review of Resident #1’s Diagnostic Imaging Report from the ED, dated 08/20/16, revealed a Intertrochanteric Left Femoral Neck Fracture of the Left Hip.
Further interview with RN #2, revealed the ARNP was present in the facility at the time she assessed Resident #1, and she obtained orders from the ARNP for an X-ray at 2:00 PM; however, she stated at that point she had not been notified the resident had sustained a fall during the previous shift. She revealed she was notified by the Director of Nursing (DON) on the afternoon of 08/19/16, that Resident #1 had suffered a fall on 08/19/16 at approximately 5:00 AM. RN #2 revealed Resident #1’s X-ray had not been obtained by 7:00 PM, so she obtained orders for a stat X-Ray. Continued interview with RN #2 revealed the X-Rays were completed at 8:10 PM, and the results of the X-Rays were received at 10:09 PM on 08/19/16, at which time Resident #1 was sent to the local hospital Emergency Department (ED) for evaluation.
Interview with the Administrator and Director of Nursing (DON), on 08/25/16 at 2:50 PM, revealed based on the facility’s investigation of the incident, including statements given by SRNA #10 and SRNA #7, it was concluded SRNA #10 attempted to transfer Resident #1 without using the hoyer lift and without requesting assistance on 08/19/16, and the resident suffered a fall. Further interview revealed neither SRNA #10 nor SRNA #7 reported the resident sustained [REDACTED].#1 from the floor to the wheelchair without an assessment completed by the nurse. Continued interview revealed SRNA #10 and SRNA #7 had been trained on proper performance of lift procedures and policies, but failed to follow facility’s policy related to transfers. Per interview, SRNA #10 was terminated by the facility.
Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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