FRANKLIN, TN – GRACE HEALTHCARE OF FRANKLIN

Based on facility policy review, review of a facility investigation, medical record review, observation, and interview, the facility failed to prevent neglect for 1 of 6 (Resident #1) residents reviewed, which resulted in Resident #1 exiting the facility, was found sitting in a creek containing water and sustained hypothermia (dangerously low body temperature) and a hematoma (swelling and bruising)around her right eye.

The facility’s failure to prevent neglect placed Resident #1 in Immediate Jeopardy (a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). F-600 was cited at a scope and severity of J and is Substandard Quality of Care. The Nursing Home Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 4/23/19 at 12:00 PM, in the Family Room.

Review of the facility investigation dated 3/18/19 revealed, on 3/18/19 at approximately 2:00 AM, the facility staff were unable to locate Resident #1 and initiated the protocol for elopement of a resident. Continued review revealed the facility staff searched all rooms in the facility and the outside grounds and notified the Administrator and local police department of the missing resident. Emergency Management Agency and Search and Rescue Dog (K9) responded. At approximately 4:45 AM, Resident #1 was found sitting in a creek embankment containing water by Emergency Management Services and was transported to the hospital.

Interview with the DON on 3/21/19 at 3:37 PM, in the Family room, the DON stated, She (Resident #1) was found sitting in the creek, water was to her waist while sitting in the creek. Legs were wet. Top was dry. She was disoriented. The Search and Rescue dog with the policeman found her with help of the fire department.