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WAITS HOURS TO BE SENT TO EMERGENCY ROOM

SIGNATURE HEALTHCARE AT SUMMIT MANOR REHAB & WELLNESS

LOCATED: 400 BOMAR HEIGHTS, COLUMBIA, KY 42728

SIGNATURE HEALTHCARE AT SUMMIT MANOR REHAB & WELLNESS 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, hospital emergency room record, and review of the facility’s falls policy it was determined the facility failed to ensure one (1) of six (6) sampled residents (Resident #6) received adequate supervision and assistance to prevent accidents. Resident #6 had an amputation of the right great toe on 12/04/15 and returned to the facility the same day. The facility failed to assess the resident’s need for assistance with ambulation and develop a care plan to address the risks related to the amputation of the toe. As a result, Resident #6 ambulated to the bathroom without assistance and sustained a fall with injury fracturing the right humerus and the right hip on 12/04/15.

Record review revealed Resident #6 was found on the floor of his/her bathroom at 11:20 PM on 12/04/15. The resident was assessed to have an abrasion to the right eyebrow and a raised area to the forehead and no other injuries. There was no documented evidence the physician was immediately notified of the fall. Further review revealed staff assisted the resident back to bed. The resident had complaints of right arm pain and was given Tylenol (pain medication) on 12/05/15 at 12:20 AM, and again at 4:45 AM.

Record review revealed the physician was not notified of the fall until 12/05/15 at 10:00 AM. According to the record, the resident continued to complain of pain and the physician was contacted again at 1:30 PM on 12/05/15 and ordered x-rays that revealed a fracture to the right humerus. Orders were received for the resident to have a sling/immobilizer and follow up with an orthopedic physician. According to nurse’s notes, pain flow sheets, dietary intake record, and the resident’s care flow record, Resident #6 continued to have pain and declined in eating and drinking and activities of daily living. On 12/09/15 at 5:30 PM, the resident’s family requested the resident be sent to the hospital for evaluation and treatment.

According to RN #1, she thought she contacted the resident’s physician, but could not remember. RN #1 stated that she would have documented the notification if she had notified the physician. She stated she was not aware the resident had a fractured right humerus until returning to work on the evening of 12/05/15, and she became aware the resident had a fractured hip after the resident was sent to the hospital on [DATE].

According to RN #2, she notified the resident’s physician of the fall via fax on 12/05/15 at 10:00 AM because the physician had not been notified. Further interview with RN #2 revealed the family notified her that the resident was having arm, leg, and knee pain and the resident’s physician was contacted again on 12/05/15 at 1:30 PM by phone. RN #2 stated the physician ordered x-rays to be completed and it was discovered the resident had a fractured humerus. RN #2 stated on 12/09/15 the resident was scheduled for an orthopedic appointment due to the fractured humerus, but the family declined and the physician was contacted because the resident was having pelvic/hip pain and additional portable x-rays were ordered. RN #2 stated the family did not want to wait on the x-rays and requested the resident be transferred to the hospital. The resident was sent to the hospital and was diagnosed with [REDACTED].

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.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We can help you and your loved one file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.

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