TWIN RIVERS NURSING AND REHAB CENTER
LOCATED: 2420 W. 3RD STREET, OWENSBORO, KY 42301
TWIN RIVERS NURSING AND REHAB 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 –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation; interview; record review; review of the facility policy, Fall Investigation, and Incident Report; and review of the hospital emergency room (ER) record, Discharge Summary and Radiology Report; it was determined the facility failed to ensure adequate supervision to prevent accidents for two (2) of five (5) sampled residents (Residents #1 and #4).
The facility failed to have an effective system in place to ensure Resident #1 received adequate supervision while ambulating and toileting. The facility readmitted Resident #1 on [DATE]. Licensed Practical Nurse (LPN) #8 failed to conduct the fall assessment per facility instructions. Resident #1 was care planned for one (1) person physical assist while ambulating and toileting. Interviews with staff revealed Resident #1 had difficulty walking, continuously got out of bed without asking for assistance, and would exit the bathroom into the wrong room and at times was found in another room, on the bed. However, staff failed to use the facility’s Stop and Watch form to make licensed staff aware of the resident’s actions to ensure Resident #1 had adequate supervision when ambulating. On [DATE] at approximately 11:15 PM, Resident #1 was found in an adjacent room (Room #106) at approximately 11:38 PM, on the floor. Resident #1 was transferred to the hospital ER where he/she was admitted to the hospital with [REDACTED]. Resident #1 died in the hospital on [DATE]. Refer to F280
Personal Note from NHAA 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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