Harborview Tifton

In the surveyor’s words

From the most serious findings on record at Harborview Tifton, in the surveyor’s own words.

• Actual harm, isolatedF656Mar 12, 2025

  Based on observations, medical records, and staff interviews, the facility failed to implement the care plan related to wound treatment for two of three sampled residents (R1 and R3) who had stage IV wounds. Harm was determined to have occurred on 3/5/2025 when R1 and R3 experienced pain that was not addressed during wound care treatment. Findings included: 1. A review of the electronic medical record (EMR) revealed R1 was admitted to the facility with the following diagnoses including but not limited to type 2 diabetes mellitus, chronic gout, metabolic encephalopathy, pressure ulcer, hypertensive heart disease, dementia, pain, and glaucoma. […]

• Actual harm, isolatedF697Mar 12, 2025

  Based on observations, record review, staff interviews, and a review of the facility policy titled Administering Pain Management, the facility failed to ensure that two of three sampled residents (R) (R1 and R3) were free from pain during wound care treatment. Harm was determined to have occurred on 3/5/2025 when R1 and R3 experienced pain that was not addressed during wound care treatment. Findings included: A review of the undated policy titled Administering Pain Management, it was documented that the pain management program was based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. […]

• Actual harm, isolatedF656Jul 2, 2024

  Based on record review and staff interviews, the facility failed to develop care plan interventions to address the transfer needs of one resident (R) (R1) who required the use of a mechanical swing lift during transfers from a sample of 11 residents. This failure resulted in actual harm on 6/13/2024 when R1 slid down in the sling of a stand lift causing a chest wall hematoma with subsequent anemia requiring a blood transfusion. Findings include: R1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: intracranial injury, schizophrenia bipolar type, mood disorder, anxiety disorder, and morbid obesity. […]

• Actual harm, isolatedF689Jul 2, 2024

  Based on record review, staff interviews, and review of policy titled Lifting Machine, Using a Mechanical and Accidents and Incidents-Investigating and Reporting, the facility failed to transfer a resident with the correct transfer lift for one of 11 sampled residents (R) (R1). This failure resulted in actual harm on 6/13/2024 when R1 slid down in the sling of a stand lift causing a chest wall hematoma with subsequent anemia requiring a blood transfusion. Findings include: Review of the facility policy titled Lifting Machine, Using a Mechanical with a revision date of July 2017 noted the purpose of the procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. […]

• Actual harm, isolatedF686Mar 9, 2023

  Based on observations, staff interview, and review of the facility policy titled Wound Treatment Management, the facility failed to timely initiate wound treatment for one resident (R#4) and failed to ensure one resident (R#5) continued to receive wound treatment for two of four residents sampled. Actual harm was identified on 3/1/23 for R#4 when pressure ulcers to the left and right buttocks were noted to have slough after being untreated since 2/24/23. Findings include: Review of the facility policy Wound Treatment Management (dated 12/1/22) revealed the following: Policy - To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. […]