Glasgow State Nursing Facility
Glasgow State Nursing Facility in Glasgow, KY — inspection on July 10, 2024.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
was to be in their sight at all times.
jeopardy to resident health or In interview on 07/05/2024 at 8:58 AM, the MDS Coordinator stated residents' care plans were printed safety with the annual or a significant change MDS Assessments.
She stated the care plans were in a binder at each nurses' station and she updated the printed care plans as changes occurred.
The MDS
doors were closed before leaving the area.
In interview on 07/10/2024 at 1:42 PM, the Director of Nursing (DON) stated her expectations were for residents' care plans to be implemented and followed as required.
She stated staff were aware they were not to leave the pod area until the doors closed.
The DON stated she expected whoever was working the front desk to be observing the facility's security camera monitor.
She stated a policy revision had been completed and all staff had been re-educated on the policy.
The DON stated dietary staff were not aware of what was on a resident's care plan, but all staff had been trained on ensuring the pod doors were closed before leaving the area.
In interview on 07/10/2024 at 2:14 PM, the Facility Director stated her expectations were for staff to ensure resident safety.
She stated R1 was care planned as a wander risk and she expected the resident's care plan interventions to be followed.
The DON stated if residents were outside of the pod area without staff, then staff were to always stay with the resident, keep them in sight, and call for assistance.
185363 07/10/2024
Glasgow State Nursing Facility 207 State Avenue Glasgow, KY 42141
During interview with the Facility Director on 07/10/2024 at 2:14 PM, she stated the DON had made her aware of R1 exiting the facility.
She stated R1 was returned to the facility when she arrived.
The Facility Director stated the facility followed its policy and protocol for Missing Resident.
She stated the facility initiated an investigation and it was determined the dietary aide's and Security Guard's failure to intervene, which allowed R1 to leave out the front door, were the root cause of the event.
The Facility Director stated staff were aware of the elopement binders on each Pod and lobby area.
The Facility Director stated if residents were outside of the pod without staff then staff were to stay with the resident at all times, keep them in sight, and call for assistance.
She stated the facility had an AdHoc (unplanned meeting for a special purpose) Quality Assurance Performance Improvement (QAPI) meeting with the Medical Director, after R1's elopement, to discuss the incident and put a plan in place to complete education and training and develop tools for monitoring.
She stated her expectations were for staff to ensure residents' safety.
Review of the closed record, Face Sheet and History and Physical, dated 03/25/2024 for R1 revealed the facility admitted the resident on 03/14/2023, with the following diagnoses: polysubstance abuse disorder, chronic schizophrenia, and neurocognitive disorder.
Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 05/07/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight out of 15.
This score indicated R1 was moderately cognitively impaired.
Review of the facility's,Wander Risk Assessment, dated 04/22/2024 for R1, completed by the Director of Nursing (DON), revealed a score of thirteen (13) which indicated the resident was at high risk for wandering and wander risk precautions were indicated.
Review of R1's Comprehensive Care Plan, dated 03/20/2023, revealed the facility care planned the resident as at high risk for wandering.
Per review of the care plan, the interventions included: redirecting R1 away from the door and back to his room; ensure all doors were closed securely when entering or exiting the pod (unit); and, observe for the behavior of wandering and redirect as needed.
Continued review of the care plan revealed the interventions additionally included: if the resident had been identified as high/moderate wander risk notify all staff to pay attention to R1 and implement increased monitoring utilizing the Increased Monitoring Log as needed (PRN).
Further review revealed the goal noted R1 was to remain safely engaged in activity-focused care to decrease wandering.
Additional review revealed an intervention dated 05/09/2024, for R1 to be on close observation (in staff's line of sight at all times) from 9:00 PM to 7:00 AM.
The incident occurred at 6:09 AM.
In an interview with the Security Guard on 07/03/2024 at 9:30 AM, he stated he had never had contact with any residents in the facility, but had been trained on the elopement binders.
The Security Guard stated he looked up and saw R1 leaving out the front door wearing a gray shirt. He stated R1 did not say anything to him and just left out the front door.
The Security Guard stated he thought R1 was a staff member. He stated he was made aware a resident was missing when a nurse came to the lobby and asked him if he had seen anyone. He stated he told the nurse someone had gone out the front door.
In interview on 07/03/2024 at 12:38 PM, the Dietary Aide (who R1 followed out the pod door on 06/24/2024) stated when he exited the pod on 06/24/2024, he had not ensured the door was closed in his hurry to get back to the kitchen.
The Dietary Aide stated he should not have left the area until the doors had been secured. He stated he had not seen R1 exit through the door after him, and only learned of a missing resident when someone paged it overhead.
The Dietary Aide stated the DON came to the kitchen that day and did a quick in-service with dietary staff.
185363
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185363 B.
Wing 07/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Glasgow State Nursing Facility 207 State Avenue Glasgow, KY 42141
Review of the facility's policy titled, Wander Risk Precautions, dated 08/29/2016 and revised on 06/24/2024 (the day of R1's elopement), revealed it was the facility's policy to identify residents who walked or wheeled about unrestricted and were at risk to leave the facility unattended without staffs' knowledge.
Further review revealed a wander risk assessment was to be completed on all residents at admission, quarterly, and with any significant change.
185363
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185363 B.
Wing 07/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Glasgow State Nursing Facility 207 State Avenue Glasgow, KY 42141
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.