DANVILLE, KY – DANVILLE CENTRE FOR HEALTH & REHABILITATION

Based on observation, interview, record review, and review of the facility’s policy, it was determined the facility failed to provide supervision to prevent accidents and elopement for one (1) of three (3) sampled residents (Resident #1). The facility identified Resident #1 to be at risk for elopement due to the resident’s cognitive impairment, poor decision-making skills, and exit seeking behavior. On 07/04/2021, at approximately 1:30 PM, Licensed Practical Nurse (LPN) #1 heard an exit door alarm sounding in the front lobby of the facility. LPN #1 responded to the alarm and disabled it, however, failed to follow the facility’s policy and procedure to determine if a resident had eloped from the facility. Approximately ten (10) minutes later, visitors came to the facility and notified staff that a resident was outside in the road. Staff found Resident #1 approximately 287 feet from the facility on the main road. Review of a police report revealed police were dispatched at 1:40 PM due to reports of a person in a wheelchair being in the road just past the facility. The facility’s investigation stated the police reported the resident had fallen out of the wheelchair and was in the roadway when they arrived on scene. Emergency Medical Services (EMS) transferred Resident #1 to the local hospital who diagnosed the resident with an abrasion to the left knee. Skin assessments performed by facility staff after Resident #1’s return to the facility revealed the resident had abrasions to the left knee, left elbow, left hand/fingers and bruising to the right forearm and right hand.

The facility’s failure to ensure residents were supervised to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/15/2021, and determined to exist on 07/04/2021 at 42 CFR 483.21 Comprehensive Resident Centered Care plans (F656) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 07/15/2021.

An acceptable Allegation of Compliance was received on 07/19/2021, which alleged removal of the

Immediate Jeopardy on 07/08/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 07/08/2021, prior to exit on 07/28/2021, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689), while the facility monitors the effectiveness of systemic changes and quality assurance activities.

Review of a facility investigation initiated on 07/04/2021, revealed on 07/04/2021, at approximately 1:45 PM, LPN #1 heard the facility’s front lobby door alarming. LPN #1 reset the alarm and did not see anyone outside of the facility. On 07/04/2021 at approximately 1:50 PM, a visitor came to the door and reported a resident was outside by the road. LPN #1 found Resident #1 on the side of the road approximately three (3) houses down from the facility. Further review of the report revealed police officers were with the resident when LPN #1 approached. According to the report, police officers told LPN #1 that the resident had fallen out of the wheelchair and they had transferred the resident back into the wheelchair. Continued review of the investigation revealed LPN #1 assessed the resident and found no harm. The facility transferred Resident #1 to the local emergency room for further evaluation and treatment. Continued review of the report revealed Resident #1 returned to the facility on [DATE], with no identified fractures or dislocations.