WEST LIBERTY, KY – WEST LIBERTY NURSING & REHABILITATION

Based on interview, record review, review of the Resident Assessment Instrument (RAI) User’s Manual, and review of the facility’s policy and investigation, it was determined the facility failed to develop a comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #1). The facility identified that Resident #1 was at risk for wandering and developed interventions that included ensuring the resident was wearing a Code Alert Bracelet (the bracelet triggers an alarm when a resident is near an exit that is equipped with a Code Alert). However, the facility failed to develop a care plan with interventions to address the resident’s safety when taking the elevator to the lower level of the facility unsupervised.

On 07/05/19 at approximately 11:10 AM, Resident #1 was observed outside of the facility unsupervised. According to the facility’s investigation, Resident #1 took the elevator to the lower level of the facility without staff knowledge, then took the stairs back to the upper level and exited the facility through a door in the stairwell. Resident #1 was outside without staff knowledge for approximately ten (10) minutes.

The facility’s failure to ensure a comprehensive care plan was developed and implemented to address resident wandering has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate jeopardy was identified on 07/18/19, and was determined to exist on 07/05/19 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 07/18/19.