COLUMBIA, KY – SIGNATURE HEALTHCARE AT SUMMIT MANOR REHAB & WELLNESS

Based on observation, interview, record review, and review of the facility’s policy, it was determined the facility failed to provide supervision to prevent accidents and elopement for one (1) of four (4) sampled residents (Resident #1). The facility identified Resident #1 to be at risk for elopement and placed a Wanderguard alarm bracelet on the resident on 02/12/2021 (after the resident’s original admission). On 3/26/2021, at approximately 11:00 PM, staff heard an exit alarm sounding. The staff member who heard the alarm, disabled the alarm; however, failed to follow the facility policy and procedure to determine if a resident had eloped from the facility. Approximately five (5) minutes later, the west gate alarmed and the staff member went to the area to look for a resident but no residents were visualized outside at that time. Staff initiated a head count of residents in the facility and identified that Resident #1 was missing from the facility. Staff located Resident #1 outside of the facility in an adjacent parking lot (approximately 125 feet from the exit door) at approximately 11:18 PM-11:30 PM. Facility staff assisted the resident back inside the facility and assessed the resident to have no new injuries. However, documentation on the following day on 03/27/2020 at 3:39 PM revealed Resident #1 had multiple new bruises to the right knee (inside and outside area of knee), left knee, left back flank, right hip, left hip and left thigh (outside area).

Interview with LPN #2, on 04/20/2021 at 5:05 PM and 04/22/2021 at 4:14 PM, revealed she was working the night of 03/26/2021. The LPN stated she was assigned to provide care for Resident #1. According to LPN #2, she last saw Resident #1 at approximately 10:30 PM, and he/she was in bed, resting with eyes closed. At approximately 11:00 PM, SRNA #1 asked to go outside to the gazebo area on break. LPN #2 revealed she was in a resident room when she heard a door alarm sounding but thought it was SRNA #1 leaving for break. A few moments later, she went to the computer to identify which door was sounding; however, no door was indicated on the computer screen as alarming. At this time, she went to the exterior downstairs dining room door, entered the code to the door she was exiting and alerted SRNA #1 about the alarm. Further interview revealed SRNA #1 re-entered the facility with LPN #2 to help identify the alarm. LPN #2 revealed upon entering, both SRNA #1 and herself went to the exterior door across from laundry and entered the code to that door and the alarm ceased. LPN #2 revealed, she went back to the nursing station and at that time did not initiate a head count of residents in the facility. Per the LPN, she had not received a lot of training and was unsure what to do when a door alarm sounded prior to this incident. Approximately 5 minutes later, another alarm sounded at which time LPN #2 checked the computer screen for identification of alarm and it was alerting the west gate. LPN #2 stated she instructed SRNA #1 to perform a head count of the facility residents and she went outside to the west gate to assess the area. At approximately 11:05 PM to 11:10 PM, Resident #1 was identified as missing from the facility. LPN #2 revealed she directed SRNA #2 to alert other staff to help search for Resident #1. Per the LPN, she then left the building to search for Resident #1 in her personal vehicle. She identified that she found Resident #1 at 11:18 PM to be standing in an adjacent parking lot to the facility. LPN #2 was unable to recall the clothing Resident #1 was wearing. LPN #2 assisted Resident #1 into her personal vehicle to transport him/her back to the facility. She revealed that Resident #1 was upset and attempting to get out of the vehicle when Police Officer #1 arrived on scene. She revealed the officer assisted her to get Resident #1 back into the facility through the exterior main entrance. Once LPN #2 assisted him/her in the facility, SRNA #1 assisted Resident #1 into a wheelchair and LPN #2 left the facility to return her personal vehicle to the parking lot. Upon re-entering the facility, LPN #2 revealed she assessed Resident #1 to have old bruising to the left and right anterior face, left and right anterior arms, right posterior arm and a skin tear to the left posterior arm. LPN #2 revealed that she spoke with the Former Administrator who did not provide any instruction about increased supervision. LPN #2 revealed that she did not complete an incident/accident report, notify the physician about Resident #1 exiting the facility, notify Resident #1 representative or review and update the care plan. The LPN stated she should have called the physician when the resident eloped and the former Administrator stated he would call the family. LPN #2 denied any knowledge of Resident #1 having exit-seeking behaviors. LPN #2 did reveal that she notified Medical Doctor #1 later in the shift that Resident #1 was still trying to get out of the facility/exit-seeking but again failed to notify MD #1 that Resident #1 had left the facility unsupervised.