CHILLICOTHE, OH – PROMEDICA SKILLED NURSING & REHAB CHILLICOTHE

THIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of the police report, review of the local hospital records, policy review, review of the facility investigation, and review of the Self-Reported Incident (SRI), the facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from the facility. This resulted in Immediate Jeopardy when Resident #01, who had history of exit seeking behaviors and dementia, left the facility unknown to staff and was found one tenth of a mile from the facility by a civilian and was transported to a nearby hospital and subsequently found to have a non-displaced [MEDICAL CONDITION] condyle of the right humerus. The facility staff heard door alarms sounding; however, staff cleared all the door alarms and did not follow-up to ensure all residents of the facility were accounted for to ensure the safety of all residents and in accordance with their facility policy. This affected one resident (#01) of five reviewed who were assessed with [REDACTED]. On 01/08/21 at 3:12 P.M., the Administrator and the Director of Nursing (DON) were notified Immediate Jeopardy began on 12/03/20 between 9:45 P.M. and 10:10 P.M., when Resident #01 who had a documented history of exit seeking behaviors had eloped from the facility unknown to staff and was transported to the hospital and subsequently found to have a non-displaced [MEDICAL CONDITION] condyle of the right humerus. Facility staff heard the door alarms sounding; however, staff cleared all the door alarms and no follow-up was completed to ensure all residents were safe and accounted for in accordance with facility policy.

Review of the nurse’s notes dated 12/03/20 at 10:41 P.M. written by the DON revealed she had received a call from the facility that the police had arrived and came to the door to report a missing resident. The neighbors had reported finding Resident #01 sitting on the ground, the police were notified and had reported he was transported to the local hospital for examination. The local hospital also called the facility and stated they had Resident #01 there and he had a skin tear on his right arm and had complained of his right arm hurting. The local hospital completed X-rays and found a [MEDICAL CONDITION] condyle humerus nondisplaced and they had splinted the right arm with a soft splint.

Review of the hospital discharge disposition paperwork revealed Resident #01 was transferred to the facility with a closed fracture of lateral condyle humerus, fall, dementia, and exposure to cold. He had a history of [REDACTED]. Resident #01 stated he was wandering around for approximately two hours trying to find his way home and apparently, he left the facility without being found by staff members. He had an abrasion to his right elbow and upon range of motion stated his right wrist hurt also. An X-ray of the right elbow revealed a nondisplaced [MEDICAL CONDITION] epicondyle. X-ray to right wrist revealed a smoothly marginated deformity of the fifth metacarpal and proximal phalanx likely related to remote trauma. A follow-up radiographic series was recommended in seven to 10 days. After a sugar tong splint and sling were placed on the right arm, the resident was discharged back to the facility.