Glasgow State Nursing Facility

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