Harbor Healthcare of Ironton

In the surveyor’s words

From the most serious findings on record at Harbor Healthcare of Ironton, in the surveyor’s own words.

• Immediate jeopardy, isolatedF624Apr 10, 2023

  Based on closed medical record review, review of an Against Medical Advice (AMA) form, hospital record review, review of the policy and procedure titled Discharging a Resident without a Physician's Approval policy and interviews with facility staff, Physician #399, a Patriot Emergency Medical Service representative, and an Amedysis Home Health representative, the facility failed to ensure a safe and orderly discharge for Resident #94, who had diagnoses including respiratory failure, protein-calorie malnutrition, osteomyelitis, cerebral infarction, sepsis, COVID-19 and dementia when the resident was discharged to an unsafe home environment on [DATE]. […]

• Actual harm, isolatedF689Apr 10, 2023

  Based on record review, staff interviews, review of facilities fall investigation and facility policy review, the facility failed to ensure adequate assistance and safety interventions were in place to prevent falls during resident ambulation. This affected one resident (#27) of four residents reviewed for falls. Actual harm occurred on 02/20/23 when Resident #27, who required extensive assistance from one staff for ambulation sustained a fall resulting in a subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane), posterior head laceration and traumatic closed displaced fracture of shaft of right femur requiring surgical repair. […]

• Actual harm, isolatedF692Jan 13, 2021

  Based on observation, record review and staff interview the facility failed to ensure residents were weighed regularly and interventions implemented related to weight loss. Actual Harm occurred on 12/17/20 when Resident #100, who received all nutrition/hydration via a gastrostomy tube sustained a 7.2 pound/5.3 percent (%) significant weight loss in one month with no evidence the resident's enteral feeding was calculated to meet the resident's nutritional needs and no evidence new nutritional interventions were initiated timely. […]

• No harm, potential for more than minimal, patternF641Apr 10, 2023

  Based on observation, record review and staff interviews, the facility failed to ensure five residents (#46, #52, #57, #85 and #195) Minimum Data Set (MDS) were accurate in the area of diagnoses, contracture's and psychotropic medications. This affected five of 26 sampled residents. The census was 92. Findings Include: 1. Review of the medical record for Resident #52 revealed an initial admitted [DATE] with the latest readmission of 03/23/23. Diagnoses included quadriplegia, cervical disc disorder, acute transverse myelitis in demyelinating disease of central nervous system, polyosteoarthritis, hypothyroidism, anemia, chronic viral hepatitis C, stiffness of unspecified joint, resistance to multiple antibiotics, major depressive disorder, hereditary and idiopathic neuropathy, contracture of… […]

• No harm, potential for more than minimal, patternF656Apr 10, 2023

  Based on observations, medical record review and staff interview, the facility failed to develop comprehensive care plans for four residents (#2, #4, #52, and #79) of 23 sampled residents. The facility census was 92. Findings include: 1. Review of the medical record for Resident #79 revealed an admitted [DATE] with diagnosis of respiratory failure with hypoxia, chronic obstructive pulmonary disorder (COPD), unspecified severe protein calorie deficiency, congestive heart failure, debility and shortness of breath. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #79 was cognitively intact as evidenced by Brief Interview for Mental Status (BIMS) exam of 15 out 15. […]