KLONDIKE CENTER
LOCATED: 3802 KLONDIKE LANE, LOUISVILLE, KY 40218

KLONDIKE 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 WRITE AND USE POLICIES THAT FORBID MISTREATMENT, NEGLECT, AND ABUSE OF RESIDENTS AND THEFT OF RESIDENTS’ PROPERTY

**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 assessed with [REDACTED].#1.

The facility had assessed Resident #1 to have cognitive impairment and communication problems and independent with most Activities of Daily Living. On [DATE], staff observed Resident #1 in the facility at approximately 3:30 PM. However, the staff did not see or try to locate the resident until 10:30 PM, approximately seven (7) hours later, when staff discovered the resident was not in bed.

Interviews with staff revealed the resident was not in his room for dinner at 5:00 PM nor when the tray was discovered untouched at 6:30 PM. In addition, rounds were not conducted by staff during shift change at 6:30 PM, which was facility protocol. At 6:50 PM, staff reported, to the Center Nurse Executive (CNE), a screen was out of one of the windows with the window opened; however, no investigation was conducted. A search was conducted at 10:30 PM after the resident could not be located. The resident could not be found and was reported missing.

Facility video surveillance recorded Resident #1 walking outside of the facility from approximately 4:12 PM to 4:34 PM. The facility’s investigation determined the resident probably exited the building through the opened window with the missing screen. The resident was found deceased on [DATE], four (4) days later, approximately 3.5 miles from the facility at an abandoned building. Per the Deputy Coroner’s interview, the preliminary findings from the autopsy included the resident’s health conditions with minor abrasions/contusions on the extremities. Review of the weather history for [DATE] revealed a high of eighty (80) degrees Fahrenheit (F) and a low of fifty-four (54) degrees F. On [DATE], the high was seventy-three (73) degrees F with a low of fifty-two (52) degrees F. On [DATE], the high was seventy-seven (77) degrees F and the low was fifty-one (51) degrees F.

The facility’s failure to ensure residents were free from neglect has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE].

Interview with Certified Nurse Aide (CNA) #3, via telephone, on [DATE] at 3:08 PM, revealed she worked on [DATE] from 3:00 PM to 11:00 PM on the South Hall (where Resident #1 resided). She stated Resident #1 was assigned to CNA #2, but she remembered seeing the resident in his/her room at approximately 3:30 PM. She verified she delivered the resident’s dinner tray to his/her room at approximately 5:00 PM, but Resident #1 was not in the room. She stated it was her normal practice to check the courtyard when the resident was not in the room; however, she was busy and had forgotten to check on him/her.

Interview with CNA #2, on [DATE] at 2:30 PM and [DATE] at 2:55 PM, revealed he was assigned to Resident #1 on [DATE] from 3:00 PM through 11:00 PM. He stated he last observed the resident walking to his/her room between 3:00 PM and 3:30 PM. He stated the resident was independent and did not require a lot of care. CNA #2 revealed he was supposed to check on each resident every two (2) hours; however, he was busy caring for other residents. He later attempted to pick up the resident’s food tray from his/her room and noticed the resident had not eaten, but did not look for Resident #1 at that time.

Interview with Licensed Practical Nurse (LPN) #6, on [DATE] at 10:12 AM, revealed she was the charge nurse assigned to Resident #1 on [DATE] until 7:00 PM. She recalled observing the resident walking between the dining room and kitchen area between 2:00 PM and 3:00 PM. She gave report on her assigned residents to the CNE shortly before clocking out; however, did not complete a walking round. She revealed she was supposed to complete a walking round with the on-coming nurse, and visualize each resident while giving report.

Interview with the CNE, on [DATE] at 10:45 AM and [DATE] at 12:50 PM, revealed she arrived at the facility on [DATE] between 8:30 AM and 8:45 AM. She revealed she completed her routine walking round that morning when she arrived at work, and she saw Resident #1 at approximately 2:00 PM going toward the kitchen area. She stated a nurse had called in for the night shift and she was required to cover as the Charge Nurse for Resident #1’s hall from approximately 6:30 PM to 11:00 PM. She stated it was expected for the on-coming nurse to complete a walking round with the previous nurse, to observe each resident while getting report. The CNE further stated a walking round was not completed and Resident #1 was not observed before she took over the assignment from LPN #6 at approximately 6:30 PM.

Interview with CNA #1, via telephone, on [DATE] at 2:00 PM, revealed she normally worked third shift; however, was called in to work early on [DATE]. She stated she clocked in at approximately 6:50 PM and immediately went to answer a call light in room [ROOM NUMBER] (across the hall from Resident #1’s room). She revealed both windows in room [ROOM NUMBER] were open and the screen was out of the one on the right side and reported her findings to the CNE. She further revealed Resident #1 was not in bed at approximately 10:00 PM and the CNE was made aware and a search was initiated for Resident #1.

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.