HIGHLANDS HEALTH AND REHABILITATION CENTER
LOCATED: 1705 STEVENS AVENUE, LOUISVILLE, KY 40205
HIGHLANDS HEALTH AND REHABILITATION CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, record review, and review of the facility’s policy, it was determined the facility failed to have an effective system to ensure residents received adequate supervision to prevent an incident of elopement for three (3) of twelve (12) sampled residents, Residents #1, #2, and #3.
On 10/21/16, Resident #1 eloped from the facility without staff knowledge. The resident was found, at approximately 4:00 PM, off the facility’s grounds walking down the sidewalk. At 3:00 PM, Licensed Practical Nurse (LPN) #3 observed Resident #1 seated in his/her room, upset, and stating he/she needed to go home. LPN #3 did not provide supervision or redirectional activities per the care plan and walked into the closed medication room. No other staff was available on the unit at the time. The facility’s investigation determined the resident took the elevator to the lobby where Receptionist #2 keyed in the alarm code to the front door and allowed the resident to exit the building. The recorded weather conditions on 10/21/16 at 2:31 PM included a high of sixty-two (62) degrees Fahrenheit with cloudy skies. The resident was returned to the facility uninjured.
Additionally, the facility failed to provide supervision to mitigate the risk of elopement for Residents #2 and #3. The facility assessed Resident #2 as at risk for elopement; however, allowed the resident to sign himself/herself out of the facility and sit on the front porch unsupervised on eleven (11) occasions. Resident #3 was care planned for supervision when he/she went off the unit; however, the facility allowed the resident to wander the building unsupervised and he/she attempted to elope from the facility on 10/30/16.
Interview with the Activities Assistant, on 11/02/16 at 9:20 AM, revealed he observed Resident #1 through a window and the resident was out of the facility unsupervised. He stated he was in the smoking room on the ground floor of the facility located across the dining room, hallway, and through two (2) locked doors. He stated he was letting a resident out of the smoking room doors and happened to look across the hallway, across the dining room, and out a window in time to see a person wearing a hat he thought looked like Resident #1’s hat. He stated he ran to the dining room and had to stand on a chair to see out an adjacent window, when he identified that Resident #1 was out of the facility. He called another staff to stay with residents in the smoking room and ran to the reception area where he confirmed with the Receptionist that Resident #1 was out of the facility unsupervised. He stated he called the resident’s unit, but staff did not answer the phone so he ran down the hallway to look for the Administrator. The Administrator’s door and the door to Social Services offices were closed. He then ran back to the reception area, and the Business Office Manager met him there. He stated they both ran out to the location the Activities Assistant observed the resident, looked in every direction, and did not see the resident. He instructed the Business Office Manager to go back in the building to call a Code W. The Activities Assistant then ran to the right, down one of the streets in search of the resident. He stated he did not find the resident and returned to the last point of observation outside of the facility. The Business Office Manager met him at that location and they ran straight down the street away from the facility. Approximately one (1) block from the facility, he observed the resident, identifiable by his/her hat, turning a corner approximately one (1) block further up the street. He stated he began shouting the resident’s name and the resident came back around the corner and waved at them. The employees reached the resident and the resident told them he/she was looking for a pay phone to call home. He further stated it was cold that day and he told the resident it was too cold to walk that far. The resident agreed with him and returned to the facility without further incident. The Activities Assistant stated the resident had decreased safety awareness and was not oriented to place. He stated the resident was at risk of serious injury or death. He stated the resident could have tried to enter another home or could have been hit by a car. He stated the resident was out of sight of any facility employee for a few minutes. The Activities Assistant stated he did not have the resident in sight at the time of elopement. The Activities Assistant reviewed the Incident Investigation and stated the summary of his statement was not accurate in that the summary left out the part of the search when staff lost the resident. The Activities Assistant stated the DNS asked him in front of everyone in the lobby if he maintained a visual on the resident the whole time and he told her No, I lost him.
Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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