Highmore Health

In the surveyor’s words

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

• Immediate jeopardy, isolatedF610Mar 2, 2023

  Based on observation, interview, record review, and policy review, the provider failed to investigate two incidents of resident-to-resident altercation involving two of two sampled residents (89 and 90). Findings include: 1. Observation and interview on 2/27/23 at 3:54 p.m. with resident 89 in his room revealed he: *Was sitting in his recliner. *Had been admitted earlier in the month because he had fallen at home and fractured his pelvis. *Had communicated during the interview that his roommate (resident 90) was in the room touching his belongings. He had asked him to stop and the roommate had continued to touched his personal items. *Then pushed the roommate. […]

• Actual harm, isolatedF600Mar 2, 2023

  Based on observation, interview, record review and policy review, the provider failed to ensure one of one sampled resident (90) was protected from verbal and physical abuse by his roommate (resident 89). Findings include: 1. Observation and interview on 2/27/23 at 3:54 p.m. with resident 89 in his room revealed he: *Was sitting in his recliner. *Had been admitted earlier in the month because he had fallen at home and fractured his pelvis. *Had communicated during the interview that his roommate (resident 90) was in the room touching his belongings. He had asked him to stop and the roommate had continued to touched his personal items. *Then pushed the roommate. […]

• Actual harm, isolatedF609Mar 2, 2023

  Based on interview, record review, and policy review, the provider failed to investigate and report alleged abuse to the South Dakota Department of Health (SD DOH) for two of two sampled residents (89 and 90) who had inappropriate verbal and physical behavior between each other and one of the residents (90) was cognitively impaired. Findings include: 1. Observation and interview on 2/27/23 at 3:54 p.m. with resident 89 in his room revealed he had pushed his roommate (resident 90) causing his roommate to fall. Refer to F600 finding 1 and F610 finding 1. Review of resident 89's 2/22/23 nursing progress note revealed: *Resident 89 had been found to be shouting at resident 90 and threatening to hit and kick him when a nurse intervened. *There was no investigation related to that incident. […]

• Actual harm, isolatedF686Mar 2, 2023

  Based on observation, interview, record review, and policy review, the provider failed to assess and document timely, implement, monitor, and review and update care for three of four sampled residents (21, 28, and 89) who had multiple medical conditions and were at risk for pressure ulcer development. Findings include: 1. Review of resident 89's medical record revealed: *He was admitted on [DATE]. *His 2/15/23 Brief Interview for Mental Status (BIMS) score was 15, indicating his cognition was intact. *His diagnoses included the following: fracture of superior rim of right pubis, contusion right shoulder, fracture of unspecified parts of lumbosacral spine and pelvis, chronic kidney disease, pain, repeat falls, pressure-induced deep tissue damage of left heel, and obesity. […]

• Actual harm, isolatedF686Dec 21, 2021

  Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (25) with a facility acquired pressure ulcer had received necessary care and interventions to prevent her wound from developing and worsening. Findings include: 1. Review of resident 25's medical record revealed: *She had been admitted on [DATE]. *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *Her 11/9/21 Braden scale for predicting pressure sore risk was 19 indicating she was low risk for developing a pressure ulcer. *She had skin assessments completed on 11/8/21, 11/15/21, 11/22/21, 11/29/21, 12/6/21, 12/13/21, and 12/20/21. *On 11/28/21 a calloused area had been noted to be pulling away from the skin bed on her right heel. […]