PRESTONSBURG, KY- RIVERVIEW HEALTH CARE CENTER

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to implement the plan of care for one (1) of nine (9) sampled residents (Resident #1) to prevent accidents. The facility identified Resident #1 was at risk for elopement due to dementia and developed a plan of care with interventions for elopement to monitor and provide supervision to the resident.

Interviews with staff revealed on the evening of 04/18/2022, Resident #1 was wandering, attempted to exit the building by pushing on doors, and made statements of wanting to go home. The staff failed to implement the resident’s plan of care interventions. On 04/18/2022, at approximately 8:24 PM, Resident #1 exited a facility window without staff knowledge, traveled approximately two-tenths (0.2) of a mile from the facility, and was found beside a major highway by a police officer.

The facility’s failure to ensure the resident’s plan of care was implemented to provide supervision/monitoring has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/04/2022 and was determined to exist on 04/18/2022 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 05/04/2022.

Review of the nurse’s notes, dated 04/18/2022 at 8:45 PM, revealed the facility received a call from 911 dispatch that Resident #1 had been found walking near the middle school. Further review revealed the resident was brought back to the facility by a police officer.

Observation of the area the resident was found by the police officer conducted on 04/27/2022 at 12:45 PM revealed the location of the area near the school was two tenths (0.2) of a mile from the facility on a major highway and within approximately three hundred (300) yards of a river.

Interview with State Registered Nurse Aide (SRNA) #1, on 04/27/2022 at 3:34 PM, revealed on the night of 04/18/2022 at approximately 8:00 PM the SRNA was on lunch break in the facility dining area when Resident #1 entered the dining area and was pushing on the exit doors attempting to open the doors. Additional interview with SRNA #1 revealed the resident ask SRNA #1 how he/she could go home. Further interview revealed the resident left the dining room area and went back to the unit. According to the SRNA, she did not see the resident again until the resident was brought back to the facility by the police officer at approximately 8:50 PM, on 04/18/2022. According to the SRNA, she did not inform the resident’s nurse of the resident’s behavior, as per the resident’s care plan, to prevent the resident from elopement.