FLORENCE, KY- BRIDGE POINT CENTER

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 one (1) of eight (8) sampled residents (Resident #1).

The facility admitted Resident #1 on 06/03/19, with a [DIAGNOSES REDACTED]. A Smoking Evaluation completed 06/04/19, revealed the resident required supervision with smoking. However, the facility failed to assess the resident for elopement risk upon admission, as per policy. On 06/13/19 at approximately 12:30 AM, State Registered Nursing Assistant (SRNA) #5 punched in the code on the keypad to the front door, with SRNA #1 present, allowing Resident #1 to propel self outside in the wheelchair unsupervised to smoke. However, neither SRNA #5 or SRNA #1 knew whether Resident #1 required supervision with smoking nor did they know if the resident was safe to go outside without being accompanied by staff. SRNA #1 returned to the 100 Unit where Resident #1 resided to ask Licensed Practical Nurse (LPN) #1 for Resident #1’s supervision level; however, LPN #1 was counting medications with the pharmacy representative and afterwards was unable to find the sign out book which contained the list of residents who were allowed to smoke unsupervised, allowing for a delay in monitoring/supervising Resident #1. At approximately 12:35 AM, Resident #3 reported to LPN #1, he/she saw Resident #1 leaving the facility property. Resident #1 wandered approximately two tenths (0.2) of a mile off the property grounds and was found at the local Fire Department at approximately 8:15 AM. The Fire Department administered first aid and transported Resident #1 to the local Hospital Emergency Department. The Hospital ED Note revealed the resident had Abrasions to the Right Elbow and Knee and Traumatic Petechia to the right portion of the Scalp. In addition, the X-Ray of the resident’s Right Hand revealed Comminuted Fractures to the Fifth Finger and Fracture to the Middle Finger of the Right Hand. Resident #1 returned to the facility on [DATE] at 1:00 PM, with a Splint on the right hand. Review of the local weather history revealed the temperature was between fifty-nine (59) and sixty-three (63) degrees Fahrenheit and partly cloudy on 06/13/19 and sunrise was at 6:12 AM, during the hours the resident was missing from the facility.

The facility’s failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 06/21/19 and determined to exist on 06/13/19.