On October 3, 2023, the Iowa Department of Inspections and Appeals Health Facilities Division issued a
Citation to Highland Ridge Care Center in Williamsburg, Iowa in light of the following findings:
Based on clinical record review, family interview, staff interviews, and facility policy review, the facility failed to provide appropriate pain management for 1 out of 3 residents (Resident #158). Clinical record review revealed on 6/2/23 at 9:30 p.m., Resident #158 fell and sustained a laceration to her head with a significant amount of blood loss. The facility staff moved the resident to the shower and then to bed and the resident reported pain that was not treated. Upon arrival of the next shift 9 hours later, the facility sent the resident to the Emergency Room (ER) where the resident was assessed to have fractures of the humerus and femur and immediately treated for pain; the resident admitting diagnoses included uncontrolled pain. The failure created an immediate jeopardy to the health and safety of the resident. The facility reported a census of 57 residents.
The document titled Resident Occurrence dated 6/2/23 revealed:
a. Resident #158 yelling, found outside bathroom door.
b. Last observed in the dining room at 9:15 PM.
c. Resident walking, no walker.
d. Prevention from occurring again: frequent checks.
e. Position of resident, on right side with gripper socks on, not wearing glasses.
f. The floor was shiny.
g. Signature Staff B, RN; Staff G, Certified Nursing Assistant (CNA); and Staff D, CNA.
The Local Hospital ER Notes dated 6/3/23 at 7:10 AM revealed Resident #158 arrived via ambulance laying on her left side, unable to roll over onto her back, guarding her right arm, and she yelled no with a light touch to the deformity noted on the right humerus. The notes documented the resident’s left lower extremity shortened and rotated, a laceration with dried blood present above her right eye, and diffuse bruising around the right orbit. The x-ray of the right shoulder revealed a displaced fracture of the right humerus and the x-ray of the right hip revealed a displaced right femur fracture; the resident was treated with oxygen and Dilaudid pain medication.
A Hospital Report on 6/5/23 at 1:58 PM revealed:
a. Resident #158 was admitted due to uncontrolled pain.
b. Significant bruising to the right eye area, laceration near the right eye, right femur and right humeral head fracture.
c. Resident #158 had a history of dementia and prior stroke and was on Plavix (blood thinner).
d. Recommendation to the family was to focus on comfort care with Hospice support for pain management.
e. Resident #158 had significant bleeding from head, two staff reportedly got her off the floor, showered her and placed her in the bed for the night without calling the physician or family.
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