LOUISVILLE, KY- REGENCY NURSING AND REHABILIATION CENTER

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on observation, interview, record review, facility document and policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement and to prevent residents from becoming missing for two of five sampled residents assessed for elopement risk, (Resident (R)82 and R259) out of the total resident sample of twenty-three (23). R259 on 09/08/2022, and R82 on 10/27/2022, eloped from the facility unescorted, unsupervised, and without staff knowledge.

The facility’s failure to have an effective system in place to ensure each resident received adequate
supervision and monitoring to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident.

Immediate Jeopardy (IJ) was identified on 07/20/2024 and was determined to exist on 09/08/2022 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656; and 42 CFR 483.25 Quality of Care, F 689 at a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was also identified at 42 CFR 483.25 Quality of Care, F689.

On 07/30/2024, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents were provided supervision and protected from further elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.25 F689. The IJ at F689 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25. The IJ was determined to exist on 09/08/2022 when the facility discovered R259 had eloped from the building. The facility provided an acceptable plan for the removal of the IJ on 07/29/2024. This plan alleged the IJ was removed, and the deficient practice was corrected on 01/30/2023, prior to the initiation of the investigation. The plan provided by the facility alleged the following:

1. On 09/08/2022, R259 remained in the visual site of a CNA who was outside the facility when the resident went out until further staff arrived, and she was assisted back into the facility. Immediately following the elopement event, the Unit Manager completed a head-to-toe skin assessment, and pain evaluation, with no injuries or pain noted. The wander guard was noted to be in place at that time. Resident 259’s Physician and family/Responsible party were notified of the event. In addition, on 09/08/2022, the Maintenance Director inspected the wander guard door system and noted that it was non-functioning due to disconnected wires caused by accidental contact with the transmitter. The Maintenance Director immediately repaired the door system. Following the repair, the system was checked for function and determined to be functioning properly. Additionally, on 09/08/2022, the Maintenance Director moved the door sensor to prevent another accidental bumping from a wheelchair. Signage was in place on both entrance doors for notice and education to those entering and exiting the center to be aware of tailgating (look behind). On 09/08/2022, the Vendor acknowledged understanding of notice/education at that time. A prior inspection of the wander guard door system had been completed on 09/07/2022, and the system was noted to be functioning. Following the events on 09/08/2022, a one-time reassessment was completed on residents assessed at risk for elopement and change in condition, and no new residents were noted to be at risk for elopement.

2. On 10/27/2022, R82 was noted to be outside the facility entrance and was assisted back into the facility and placed on increased monitoring. The wander guard system was fully functioning as designed and intended. Immediately following the event of R82’s elopement on 10/27/2022, a change in condition was completed, and the resident’s guardian and physician were notified. In addition, a skin assessment and a pain assessment were completed on 10/27/2022; no injuries or pain noted. Additionally, R82 was reassessed for elopement on 10/27/2022 and based on this assessment, the resident was an elopement risk, and a wander guard was placed on the resident immediately following the assessment. Following the events on 10/27/2022, a one-time reassessment was completed on residents assessed at risk for elopement and change in condition, and no new residents were noted to be at risk for elopement. The Maintenance Director inspected the wander guard system on 10/27/2022 and found the system fully functional and operating properly as intended.

3. On 01/02/2023, R82 was assisted back into the facility and was immediately placed on one-to-one monitoring. Immediately, following the events on 01/02/2023, a skin assessment and pain assessment were completed, with no injuries or pain noted. R82’s wander guard was noted to be in place and functioning at that time. Also, on 01/02/2023, a one-time assessment was completed on residents assessed at risk for elopement and change in condition, and no new residents were noted to be at risk for elopement by a licensed nurse. The resident’s guardian and physician were notified on 01/02/2023 of the elopement event. In addition, on 01/02/2023, the Maintenance Director checked the wander guard system’s functioning, and it was determined to be functioning properly as intended and designed. Additionally, on 01/03/2023, R82 was re-assessed for elopement, and her care plan was reviewed, developed, implemented, and updated to reflect increased supervision. On 01/05/2023, a technologies Healthcare system inspected the wander guard system on all doors and noted that they were functioning properly; adjustments were made at that time to increase sensor range for maximum potential. Residents at risk for elopement and those with changes in
condition were reviewed in the daily clinical meetings by the interdisciplinary care plan teams for events, orders, progress notes, behaviors, labs, clinical and any additional needs identified were addressed, and care plans were developed and implemented, and Kardex were updated as necessary.

Review of R259’s Elopement Assessment Risk dated 08/15/2022 at 10:39 AM, revealed the facility assessed the resident as being at risk for elopement based on her ability to self-propel in a wheelchair independently; history of hovering near exits and pushing on front doors.

Review of the facility’s investigation dated 09/13/2022, revealed on 09/08/2022 at approximately 10:30 AM, Resident 259 exited the facility with a vendor, as he thought resident was a visitor. The vendor stated he observed resident propelling fast in her wheelchair towards the left side of the facility parking lot. Approximately two to three minutes later, after putting his equipment inside the van, the vendor then went to alert staff of his suspicion that he let a resident out of the facility. Per the facility’s investigation, R259 wore a security bracelet (wander guard) to her ankle; however, the security alarm (wander guard) did not sound when the resident exited the facility. Upon the Maintenance Director’s investigation, it was revealed the sensor on the left side of the entrance/exit door was not connected. Continued review of the facility’s investigation revealed after R259 went missing and was later located in the facility’s parking lot unsupervised, she was redirected back into the facility per staff assistance.

In an interview with CNA14 on 07/25/2024 at 9:50 AM, she stated when the elopement occurred in September 2022 with R259, she was sitting in her truck in the parking lot at work, eating her lunch and looking on her phone at approximately 10:40 AM. She happened to look up as R259 was going through the parking lot in her wheelchair. CNA14 stated she then called the Scheduler and asked if R259 was to be outside and the Scheduler told her No. Therefore, CNA14 jumped out of her truck and ran to R259, who had rolled herself all the way down the road and was about three houses from the main road. She stated she asked R259 where she was going, and the resident told her she was going home. At that time, CNA14 state she rolled resident back into the facility in her wheelchair. Further, she observed the Administrator and the Maintenance Director checking the wander guard sensor wires on the front entrance doors.

In an interview with the former Director of Nursing (DON) on 07/25/2024 at 1:38 PM, she stated she recalled R259 exitting the facility with the oxygen vendor as the vendor let her go out with him. She stated after this incident she did a lot of education with staff and vendors on elopement and educated them on which residents were at risk for eloping. She stated she remembered R259 was a younger resident who could easily be mistaken as a visitor. She stated she made sure her education focused on that concern and making sure someone was at the front desk and that they stayed well informed of who came and went out of the building. She stated she believed before R259’s incident they knew about her exit seeking behavior, but it was not until after the resident had eloped that they placed her as a one-on-one (1:1) with staff. She stated R259 used to be very easy to redirect, up until the elopement then afterwards she was always 1:1 supervision because she continued to attempt to elope.

The former DON, on 07/25/2024 at 1:38 PM, also stated she tried to stress to staff the importance of responding to the door alarm as soon as it sounded; however, she learned during the re-education process that some of the staff were not aware of the process of what to do when the alarm went off, some of the CNAs stated to her that they did not realize they were to respond, but thought other staff members were responsible for checking the doors. The former DON further stated at the time that the elopement incident occurred, she felt it had to do with how the staff responded because one of the incidents occurred during shift change.

In an interview with Neighbor 1 on 07/18/2024 at 12:44 PM, he stated he had to notify the facility on two separate occasions of when a resident showed up at his house. He stated the first time it happened, the resident came to his house in the evening. The second time was during the day. Per the interview, he stated could not recall the dates of either incident. He stated R82 asked him for a ride. He stated it was obvious she was suffering from some sort of memory problem. Further, he stated the resident appeared very confused. Neighbor 1 stated the resident then asked him to call people so she could get a ride. He stated the resident would provide him with a non-working telephone number or the wrong number. He stated he kept calling the facility to get a hold of someone to come get her but could not get anyone to answer the phone. He stated he finally left his home and walked to the facility and saw some people there and he asked if they knew her. He stated someone from the facility came to his home and they were able to talk R82 into returning to the facility with them. He stated she was wearing a shirt, pants and a pair of socks with grips on bottom of the socks. He further stated R82 did not have on a coat and he brought out a blanket for her because she was chilly.