Harrison Healthcare Center

In the surveyor’s words

From the most serious findings on record at Harrison Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Jul 7, 2023

  Based on interview and record review, the facility failed to ensure the physician was notified when a resident (Resident B) complained of bilateral shoulder pain and malfunctioning of his automatic implantable cardioverter defibrillator for 1 of 3 residents reviewed for physician notification. This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility staff failed to notify the physician of a resident's complaint of bilateral shoulder pain and malfunctioning of the residents' automatic implantable cardioverter defibrillator. The resident was found unresponsive on [DATE] and died . The Executive Director (ED) and Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 4:35 p.m. […]

• Immediate jeopardy, isolatedF578Oct 3, 2022

  Based on record review and interview, the facility failed to ensure a resident's advanced directive were honored for 1 of 26 residents reviewed for advanced directives. The resident had persistent rib pain, anxiety, and negative emotions related to being revived when he had wanted to be a DNR. (Resident D) The immediate jeopardy began on [DATE], when the facility failed to follow a resident's advance directive of a do not resuscitate. The Executive and Director of Nursing Services were notified of the immediate jeopardy at 2:12 p.m., on [DATE]. […]

• Immediate jeopardy, isolatedF689Oct 28, 2021

  Based on observation, interview and record review, the facility failed to ensure adequate supervision was in place when three (3) residents (Resident B, C, and D) with dementia, exited the facility without supervision for 3 of 4 residents reviewed for supervision. Resident B ambulated 0.8 miles away from the facility, Resident C was found 0.5 miles from the facility in his electric wheelchair, and Resident D was found in the parking lot. The Immediate Jeopardy began on 10/24/21 when three (3) residents with dementia exited the facility without supervision. Resident D was found in the facility parking lot. Resident B exited the side exit door by the breakroom to the parking lot. The route was undetermined, however, there are 3 possibilities all with road and terrain dangers. […]

• Immediate jeopardy, isolatedF678Jan 28, 2021

  Based on interview and record review, the facility failed to ensure a resident's wishes for resuscitation were followed. This resulted in the resident not receiving continuous life saving measures and emergency medical services not being called, for 1 of 3 residents reviewed for full code status. (Resident B) The Immediate Jeopardy began on [DATE], when staff failed to continue Cardiopulmonary Resuscitation (CPR) on a resident (Resident B) with an active full code status. The Executive Director, and Regional Director of Clinical Operations were notified of the Immediate Jeopardy on [DATE] at 2:20 p.m. The Immediate Jeopardy was removed, and the deficient practice corrected, on [DATE], prior to the start of the survey and was there fore Past Noncompliance. […]

• Actual harm, isolatedF690Nov 8, 2023

  Based on record review and interview, the facility failed to ensure the physician was promptly notified of the resident's urinalysis preliminary results and timely assessment of the resident's urinary symptoms resulting in hospitalization for a sepsis secondary to urinary tract infection for 1 of 3 residents reviewed for urinary tract infections. (Resident C) Findings include: The record for Resident 20 was reviewed on 11/2/23 at 1:00 p.m. The diagnoses included, but were not limited to, dementia and unspecified urinary incontinence. The care plan, initiated on 10/6/20 and last revised on 7/8/21, indicated the resident had a potential for complications with bowel and bladder incontinence. […]