DANVILLE, KY - A resident with severe cognitive impairment walked unsupervised out of a locked memory care unit, traveled 120 feet toward a busy two-lane highway, and fell in a roadside ditch before passersby discovered her and called 911, according to a state inspection report documenting immediate jeopardy violations at Danville Centre for Health & Rehabilitation.
Security System Disabled During Routine Testing
On the afternoon in question, facility maintenance staff announced over the building's speaker system that a fire alarm test was underway and instructed everyone to ignore the alarm. What staff failed to recognize was that this annual sprinkler system inspection would completely disable the wander guard system—the electronic door alarm designed specifically to alert staff when residents attempt to leave the secured dementia unit.
The resident, identified in the report as R2, was last observed by medication staff at approximately 3:00 PM. With the alarm system silenced, she walked through an exit door that would normally have triggered an immediate alert. No staff members were assigned to monitor the door or track the resident's whereabouts during this critical period when the electronic safeguards were non-functional.
At 3:33 PM, a motorist driving past the facility noticed the resident trip and fall in the grassy area alongside the highway. The driver stopped, called emergency services, and got out to check on the fallen resident. Only when another visitor's family member ran back into the building did staff learn that R2 had left the premises.
The inspection revealed the resident had traveled approximately 120 feet from the exit door before falling near the roadway—a two-lane highway that investigators observed to be heavily congested with traffic.
Care Plan Documented Significant Risk Factors
Records show R2 had been admitted to the facility with multiple diagnoses including vascular dementia with behavioral, psychotic, and mood disturbances, along with difficulty walking, abnormal gait, repeated falls, and lack of coordination. Her cognitive assessment score indicated severe impairment.
The facility had identified R2 as being at high risk for elopement based on several factors: poor safety awareness due to cognitive impairment, ability to walk independently, documented history of exit-seeking behavior, and physical capability to leave the building. An elopement risk evaluation specifically noted she made statements about leaving, questioned why she needed to stay, and displayed body language indicating potential elopement attempts.
A physician's order dated months before the incident specifically required staff to place a wander guard security bracelet on R2's left ankle and check its placement and function daily. This security device was designed to work in conjunction with the building's alarm system to alert staff if the resident approached exit doors.
When dementia affects the brain regions responsible for judgment and spatial orientation, individuals lose the ability to assess danger appropriately. A person with severe cognitive impairment cannot evaluate risks like traffic, weather exposure, or becoming lost. This medical reality makes environmental safeguards and direct supervision essential components of care for residents with exit-seeking behaviors.
Inadequate Staffing During Critical Period
According to staff interviews documented in the inspection, only one Kentucky Medication Aide was responsible for monitoring and supervising up to 18 residents in the locked memory care unit during the time R2 eloped. The certified nursing assistant normally assigned to the unit had gone to lunch, leaving the medication aide as the sole direct care staff member.
The medication aide stated she attempted to gather mobile residents and those in wheelchairs into the dayroom so she could monitor them while working alone. She told investigators she never heard any announcement that the wander guard system was non-functional or that additional monitoring of residents would be necessary during the system shutdown.
Staff interviews revealed the medication aide was unaware that R2's care plan called for diversional activities when the resident exhibited exit-seeking behaviors. She stated she believed the elopement could have been prevented if the facility had ensured adequate staff coverage to monitor all doors and units while the alarm system was disabled.
The Plant Operations Director acknowledged to investigators that once staff realized R2 had exited through the door on the locked unit, "they knew immediately that no one had been monitoring or watching that door during the time that the wander guard system was not functioning." He confirmed that prior to this incident, the facility had no procedure requiring monitoring responsibilities, staffed stations at exit doors, or leadership notification to ensure resident supervision when door alarms were not working.
Memory care units serve residents whose cognitive impairment creates safety vulnerabilities that require specialized environmental protections. Industry standards recognize that electronic monitoring systems serve as one layer of protection but cannot replace direct supervision, particularly for residents with documented elopement risk. When facilities disable security systems for maintenance, established protocols require compensatory measures such as assigning staff to monitor exits, increasing supervision ratios, and ensuring all personnel understand the temporary security gaps.
Lack of Emergency Protocols Created Preventable Risk
The inspection found the facility had no system in place to ensure adequate coverage on all units or assign staff to monitor exit doors when the alarm system was silenced or shut down. The registered nurse on duty told investigators there were supposed to be two staff members monitoring hallways to ensure residents could not reach doors while the alarm was not working, but this did not occur.
The former Regional Nurse Consultant confirmed to investigators that during R2's elopement, "the facility did not have a system in place to ensure adequate staff coverage on all units or that all exit doors were covered, assigned, and monitored when the alarm was silenced and/or shut down."
Following the incident, R2 received a head-to-toe assessment and was transported to the emergency department for evaluation. She returned to the facility with no new injuries documented, though inspectors noted old bruises from a previous fall. The facility placed her on one-to-one supervision for 72 hours after the event.
Elopement events involving residents with dementia carry significant mortality risk. Research indicates that individuals with cognitive impairment who wander away from supervised settings face dangers including hypothermia, hyperthermia, dehydration, injury from falls, and traffic accidents. The medical vulnerability of individuals with impaired mobility and balance—as documented in R2's case with her history of repeated falls and gait abnormalities—compounds these risks substantially.
Facility's Corrective Actions
According to the plan submitted to address the immediate jeopardy finding, the facility implemented multiple corrective measures. Leadership installed additional door alarms not connected to the fire alarm system on the two exterior exit doors of the memory care unit. Staff applied vinyl window frosting to these doors to camouflage them and reduce exit-seeking behaviors.
The facility established a new protocol requiring the Plant Operations Director to notify the Administrator and Director of Nursing before allowing any work that could affect safety systems, ensuring staff assignments for door monitoring during system interruptions. All current staff received education on policies including abuse and neglect prevention, comprehensive care plans, missing resident protocols, and safety and supervision requirements.
The facility completed elopement risk assessments for all 74 residents, identifying 16 individuals at risk for elopement. Care plans and physician orders were reviewed for these residents, wander guard placements were verified, and activity assessments were updated. Door checks and elopement drills were conducted on each shift initially, then weekly, with ongoing monthly monitoring.
A new fence with keypad access was installed outside the memory care unit. The facility required that during staff breaks on the locked unit, the Director of Nursing, Unit Managers, Staff Development Coordinator, Medical Records Nurse, or Manager on Duty must provide additional coverage.
Additional Issues Identified
The inspection documented that 22 residents were identified as being at risk for elopement according to the facility's elopement binder. The care plan documentation revealed staff were expected to implement specific interventions for residents exhibiting exit-seeking behaviors, but these interventions were not consistently executed. The MDS Coordinator noted the importance of direct care staff knowing resident-specific interventions for each individual in the locked dementia unit due to the challenges presented by their behaviors.
State regulators classified the violations as immediate jeopardy—the most serious category of deficiency—indicating the facility's practices caused or were likely to cause serious injury, harm, impairment, or death to residents. The facility's acceptable removal plan was submitted and the immediate jeopardy determination was lifted after corrective actions were verified, though the underlying deficiencies remained cited.
The current Administrator and Director of Nursing, who assumed their positions after the incident, stated the facility has not experienced any elopement events since implementing the new protocols and that operations now follow established policies with clear staff responsibilities and leadership oversight.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Danville Centre For Health & Rehabilitation from 2025-01-24 including all violations, facility responses, and corrective action plans.
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