LEXINGTON, KY- MAYFAIR MANOR

ABUSE

Review of the facility’s Initial Self-Reported form, dated 03/12/2022, revealed on the evening of 03/12/2022, around 9:00 PM, Resident #6 was drifting off to sleep when Resident #15 stood up out of bed. Resident #6 instructed Resident #15 to sit back down to prevent falling. Per the report, Resident #15 walked over to Resident #6’s bed, placed his/her hands on Resident #6’s mouth and nose, and starting shaking Resident #6. Resident #6 yelled, Nurse help me. Further review of the report revealed Licensed Practical Nurse (LPN) #5 entered the room, separated the residents, and removed Resident #15 from the room. Resident #15 was placed on one-to-one (1:1) supervision, and both residents were assessed, including skin assessments. Additional review revealed the Physician, families of the residents, the Department for Community Based Services (DCBS/Adult Protective Services), and the Ombudsman were notified of the incident.

Review of Resident #6’s skin assessment, dated 03/12/2022, no time specified, revealed a scratch to the resident’s right cheek area. Requests were made to the Administrator by the State Survey Agency (SSA) Surveyor, to see documentation of Resident #15’s skin assessment, but the Administrator did not provide this documentation.

ELOPEMENT

Based on observation, interview, record review, and review of the facility’s policies, it was determined the facility failed to ensure the Comprehensive Care Plan was revised as determined by the resident’s needs for one (1) of seventeen (17) sampled residents (Resident #1).

Record review revealed Resident #1 had an exit attempt, on [DATE] at 8:00 AM, during which he/she was able to get his/her feet through the threshold of the facility’s door, which triggered the egress door alarm. Record review revealed staff performed an Elopement Risk Evaluation (ERE), on [DATE], and assessed Resident #1 to be at high risk for elopement.

Staff interviews revealed Resident #1 experienced increased wandering, specifically on [DATE] and on [DATE]. Continued interviews, and review of progress notes, revealed Resident #1 was agitated and exit seeking, pushing on doors to the point of triggering the egress alarms. Additional interviews revealed, on [DATE], Resident #1 was stating he/she needed to go to the store. However, there was no documentation the care plan was revised to include increased supervision.

Review of the facility’s security camera video recording revealed Resident #1 rolled to the exit door, on [DATE] at 7:56 AM, sat at the door while pushing on it, then exited the building at 7:57 AM, without staff knowledge. Further review revealed the Physical Therapist found Resident #1 in the rear parking lot when coming to work and returned the resident to the facility.