HERITAGE MANOR HEATH CARE CENTER

LOCATED: 401 INDIANA AVENUE, MAYFIELD, KY 42066

HERITAGE MANOR HEATH CARE 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, facility policy review, review of the Hospital emergency room Note, History and Physical, and Operative Report, it was determined the facility failed to provide supervision for one (1) of three (3) sampled residents (Resident #1).

The facility assessed and care planned Resident #1 to need the assistance of two (2) staff and a mechanical lift for transfers. The facility’s standard of practice was if a resident required a lift the resident was supposed to be transported to the shower room per a shower bed and two (2) staff was to provide care. On 02/21/15, Certified Nurse Aide (CNA) #1 provided Resident #1 a shower without a shower bed, and had the resident stand without the assistance of another staff, and did not use a lift. The resident’s knee buckled with the resident falling to his/her knees. Resident #1 had subsequent pain and swelling and was sent to the emergency roiagnom on [DATE]. The resident was diagnosed with [REDACTED]. Closed reduction of the right distal fracture and external fixation surgery was performed.

Review of an Interdisciplinary Team Note, dated 02/23/15 at 9:35 AM, related to a fall on 02/21/15, revealed the resident was being transferred with the assistance of two (2) staff and became weak and was lowered to the floor. However, review of CNA #1’s written statement and interview with CNA #1 and Resident #1 revealed the CNA was alone when providing care.

Review of the Hospital emergency room Note, and History and Physical, dated 02/24/15, revealed Resident #1 stated he/she fell Saturday (three (3) days ago) at the nursing home while trying to get in a chair and landed on both knees. Further review revealed Resident #1 stated he/she fell from an upright position while standing and subsequently had progressive swelling and pain in the right mid-leg and was sent to the emergency room. X-rays were done, which showed a distal femur fracture above a prosthetic right knee. Review of the Operative Report, dated 02/26/15, revealed a closed reduction of the right distal fracture and external fixation was performed on Resident #1’s right leg.

Interview with Resident #1, on 10/19/15 at 10:12 AM, revealed he/she fell in the shower and broke his/her leg with one (1) CNA present. Resident #1 stated usually two (2) staff would get him/her up with the lift. Resident #1 stated the CNA asked him/her to grab the bar and stand up until she could get the wheelchair, but his/her hands slipped. Resident #1 stated his/her legs were under him/her and the CNA laid him/her down to go get help. The resident revealed staff did not use a lift in the shower.

Interview with the Director of Nursing (DON), on 10/21/15 at 4:54 PM and on 10/22/15 at 10:45 AM, revealed she was notified of the fall on 02/21/15 and they reviewed the fall the next work day in the Interdisciplinary Team (IDT) meeting. The DON stated they determined the root cause of the fall was the CNA did not provide the appropriate amount of assistance per the care plan. The DON said it was the facility’s standard of practice that all residents who required a lift for transfers were taken to the shower on a shower bed and were an assist of two (2) for showers.

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.