Regency Nursing And Rehabilitation Center
Regency Nursing and Rehabilitation Center in Louisvile, KY — inspection on August 2, 2024.
Found 2 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
F-F656; and 42 CFR 483.25 Quality of Care, F 689 at a Scope and Severity (S/S) of a J.
Substandard Quality of Care (SQC) was also identified at 42 CFR 483.25 Quality of Care,
Review of the facility's policy, Wandering and Elopements, revised 03/01/2019, revealed the facility identified residents who were at risk of unsafe wandering and strove to prevent harm while maintaining the least restrictive environment for those residents.
Continued review revealed if a resident was identified as at risk for wandering, elopement, or other safety issues, the resident's care plan was to include strategies and interventions to maintain the resident's safety.
The policy also noted if a resident was missing, the facility was to initiate the elopement/missing resident emergency procedure and upon returning to the facility, the resident was to be examined for injuries by the Director of Nursing Services (DNS) or charge nurse.
Staff were to notify the attending physician and report the findings and condition of the resident; notify the resident's legal representative; notify search teams that the resident had been located; complete and file an incident report; and document relevant information in the resident's medical record.
Review of the facility's operations policies and procedures manual titled Elopement of Patient dated 2022, revealed residents would be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the clinical assessment process.
Those residents determined to be at risk received appropriate interventions to reduce risk and minimize injury.
The procedures manual defined Elopement as any situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary.
Review of the facility's Elopement Binder revealed four (4) residents listed who were noted to be at risk for elopement. Resident 259 no longer resided at the facility.
1.Closed record review of an Admission Sheet revealed the facility admitted R259 on 07/18/2022, with diagnoses to include depression, anxiety disorder, bipolar disorder, unspecified dementia, alcohol abuse, aphasia (communication disorder), and dysarthria (difficulty speaking).
Review of R259's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R259 to have a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated severe cognitive impairment.
Further review of the MDS Assessment revealed the facility assessed R259 to require a wheelchair for mobility.
Review of R259's Elopement Assessment Risk dated 08/15/2022 at 10:39 AM, revealed the facility assessed the resident as being at risk for elopement based on her ability to self-propel in a wheelchair independently; history of hovering near exits and pushing on front doors.
Review of R259's Order Summary dated 08/15/2022 at 11:29 AM, revealed a written physician order for a wander guard (security bracelet) to left ankle.
185290
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 185290 B.
Wing 08/02/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Regency Nursing and Rehabilitation Center 1550 Raydale Drive Louisville, KY 40219