Nancy Hart Operation LLC

In the surveyor’s words

From the most serious findings on record at Nancy Hart Operation LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jul 21, 2023

  Based on record review, staff interviews, and review of the policy titled Care Plans, Comprehensive Person- Centered, the facility failed to develop a person-centered care plan that focused on wandering and exit seeking behaviors for one resident (R) (R#1) with a known history of elopement from a sample of 14 residents. On 7/18/2023, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ) for F656, F689, and F835 on 7/18/2023 at 3:15 p.m. The noncompliance related to the IJ was identified to have existed on 7/7/2023. […]

• Immediate jeopardy, isolatedF689Jul 21, 2023

  Based on record review, interviews, document review, and review of the facility policy titled Elopement and Wandering Residents, the facility failed to provide adequate supervision and monitoring for one of 14 sampled residents (R) (R#1) and failed to ensure magnetic locking exit doors were functioning properly to prevent the elopement of R#1. Specifically, R#1 exited the facility on 7/7/2023, undetected through an unlocked door, walked approximately 3.5 miles away from the facility, was struck by a motor vehicle. Resident #1 sustained a fractured right hip, fractured right humerus, and fractured right scapula. […]

• Immediate jeopardy, isolatedF835Jul 21, 2023

  Based on record review, interviews, and review of the Administrator Job Description, Administration failed to provide protective oversight of the facility environment to prevent the elopement for one of eleven residents (R) (R#1) reviewed for elopement. Specifically, facility failed to ensure that exit doors were equipped with functioning locking systems, failed to complete elopement assessment for R#1 with a documented history of elopement, and failed to develop a person-centered care plan with interventions for elopement for R#1. R#1 eloped from the facility on 7/7/2023 and was found 3.5 miles away from the facility, had been hit by a car and sustained a fractured right hip, right arm, and right shoulder. […]

• Actual harm, isolatedF656Apr 27, 2021

  Based on observation, record review, staff interview and interview with the Wound Care Physician, the facility failed to implement the care plans to provide treatment as ordered for three residents (R#1, R#2 and R#3) with pressure ulcers; to provide honey thickened liquids for one resident (R#9); to provide nutritional supplements as ordered for two residents (R#1 and R#8); and to determine the cause of the behavior of digging into his wound for R#1. This failure resulted in harm for R#1 when staff failed to provide treatments as ordered, failed to administer a protein supplement to promote wound healing, and failed to determine the underlying cause of the resident's behavior of digging into his coccyx wound in order to initiate appropriate treatment and R#1 had a decline in his pressure… […]

• Actual harm, isolatedF686Apr 27, 2021

  Based on observation, record review, review of the the facility Skin Integrity Policy (no date), and staff and Physician interviews, the facility failed to provide treatments as ordered by the Physician and/or failed to perform weekly wound assessments in order to determine the progression/deterioration of a wound for three residents (R) (R#1, R#2 and R#3) of three residents reviewed for pressure ulcers. This failure resulted in harm for R#1 who was admitted with a Stage II coccyx pressure ulcer on 12/23/2020 that declined and was identified by the Wound Care Physician on 1/21/21 as an infected unstageable pressure ulcer. […]