Hathorne Hill Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Hathorne Hill Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Dec 15, 2023

  Based on observations, interviews and record review the facility failed to ensure it performed skin checks and wound evaluations, implemented physician orders, updated the physician and plan of care when significant changes occurred, and prevented the deterioration of pressure injuries (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) for five residents (#182, #97, #101, #67, #65) of 11 residents with a pressure ulcer out of a total sample of 44 residents. Specifically: 1. […]

• Immediate jeopardy, isolatedF726Dec 15, 2023

  Based on interviews, record review, staff education and Facility Assessment review, the facility failed to ensure the nursing staff were trained and demonstrated the competencies and skillsets necessary to provide the level and types of care and services needed as outlined in the Facility Assessment. Specifically, the facility failed to: 1) Ensure the licensed nursing staff were trained and demonstrated competency to identify, assess, evaluate, intervene, and respond to a significant change in condition of a wound, for one Resident (#182), out of a total sample of 44 Residents. Resident #182 was admitted with a Stage 2 pressure ulcer that progressed and deteriorated to a Stage 4 pressure ulcer. Resident #182 developed a pressure ulcer to the midthoracic spine while in the facility. […]

• Immediate jeopardy, isolatedF835Dec 15, 2023

  Based on observations, interviews and record review the facility failed to ensure its administration used its resources effectively to provide appropriate wound care. Specifically, the facility administration failed to: 1) provide nursing staff education and training to provide competent, safe, and effective wound care management; 2) provide continuation of the wound care program following the resignation of its Wound Nurse and implement an effective wound care program for pressure ulcer (wounds that occur when the skin and tissue are damaged by prolonged pressure, usually on bony areas like the hips, heels, or elbows) prevention and care per the Facility Assessment Tool. […]

• Actual harm, isolatedF655Dec 15, 2023

  Based on observation, interview and record review the facility failed to ensure it completed a baseline care plan for one Resident (#182) out of 44 sampled residents. Specifically, the facility failed to complete a baseline care plan to address a Stage 2 pressure ulcer present on admission. The baseline care plan failed to include goals and interventions. The Stage 2 coccyx pressure ulcer then developed into a Stage 4 pressure ulcer on 11/8/23. Findings include: Review of the facility's policy Skin Integrity and Wound Management dated 2/1/23, indicated: - Complete comprehensive evaluation, and risk evaluation on admission and weekly for the first month. […]

• Actual harm, isolatedF689Dec 15, 2023

  Based on record review and interviews, the facility failed to provide supervision for one Resident (#94) out of a total sample of 44 residents. Specifically, the facility failed to implement the fall intervention, which resulted in the Resident falling and fracturing his/her left hip. Findings include: Review of the facility's policy titled 'Falls Management' with a revision date of 8/7/23, indicated the following: -Patients will be assessed for risk of falling as part of the nursing assessment process. -Interventions to reduce risk and minimize injury will be implemented as appropriate. -A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. […]