FRANKFORT, KY – FRANKFORT REHABILITATION AND CARE

Based on observation, interview, record review, review of the facility’s policies, and review of the facility’s investigation, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement for three (3) of six (6) sampled residents (Resident #1, #5 and #6).

The facility admitted Resident #1 on 08/16/19, and on that date assessed the resident as severely cognitively impaired and as being at low risk for elopement as per the Admission Nursing Assessment. On 08/17/19, Resident #1 displayed exit seeking and elopement type behaviors and a wanderguard (a tracking device designed to prevent persons at risk for wandering from leaving the facility, unless they are unaccompanied) was placed on the resident; however, there was no documented evidence the facility increased the level of supervision. Subsequently, on 08/17/19, Resident #1 exited the building without staff’s knowledge, activating the wanderguard alarm on the door; however, staff failed to respond to the alarm. Resident #1 was last seen by staff on 08/17/19 at approximately 3:00 PM and was found by Police on 08/17/19 at approximately 5:01 PM, approximately eight tenths (0.8) of a mile from the facility. Resident #1 left the facility property, ambulated down a busy four (4) lane highway, crossing the intersection of another busy four (4) lane highway and was found sitting on the side of the highway. Review of the local weather history revealed the temperature was ninety three (93) degrees Fahrenheit and sunny on 08/17/19, during the time the resident was missing, and interviews with staff and family members revealed the resident was wearing a sweat suit and was drenched with sweat when found. (Refer to F-655)