Twin Rivers Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Twin Rivers Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jun 30, 2021

  Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to develop a person-centered comprehensive care with specific interventions to meet the needs of one (1) of three (3) sampled residents (Resident #1). Review of Resident #1's care plan dated [DATE] revealed the facility established goal for the resident was to wander in a safe environment. The care plan revealed interventions established by the facility to meet that goal included providing supervision, and modifying the environment to ensure Resident #1 did not exit seek or wander into a situation he/she should not be in. However, on [DATE], Resident #1 removed the Wanderguard bracelet and exited the facility through an unsecured facility window. […]

• Immediate jeopardy, isolatedF689Jun 30, 2021

  Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to provide supervision to prevent accidents and elopement for one (1) of three (3) sampled residents, (Resident #1). The facility assessed Resident #1 to be at risk for elopement on [DATE], one day after admission to the facility and placed a Wanderguard bracelet on the resident. Review of an elopement assessment conducted for Resident #1 on [DATE], revealed the resident remained at risk for elopement due to a history of elopement from a health care facility, cognitive impairment and making statements regarding leaving the facility. Based on the assessment the facility identified Resident #1 as high risk for elopement. […]

• Immediate jeopardy, isolatedF580Feb 5, 2021

  Based on interview, record review, facility policy review, and hospital record review, it was determined the facility failed to notify the Physician of a significant change in the resident's physical status or possible need to alter treatment until resident's family requested transfer to the hospital for one (1) of three (3) sampled residents (Residents #1). Closed record review revealed the facility admitted Resident #1 on [DATE], for rehabilitation and assessed the resident to be alert. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Speech and Physical Therapy staff were unable to arouse Resident #1, on [DATE] and [DATE]. […]

• Immediate jeopardy, isolatedF684Feb 5, 2021

  Based on interview, record review, facility policy review, hospital record review, and the Kentucky Board of Nursing (KBN) Revised Statute 314.021(2), it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received necessary care and treatment in accordance with professional standards. Record review revealed Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 refused or had decreased meal intake from [DATE] thru [DATE], without a nursing assessment for the cause or need for additional intervention. In addition, Speech and Physical Therapy staff were unable to arouse Resident #1, on [DATE] and [DATE], and reported to nursing. However, there was no documented evidence nursing assessed the resident. […]

• Actual harm, isolatedF656Aug 26, 2022

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of five (5) sampled residents (Resident #1). The facility care planned Resident #1 to require total assistance of two (2) staff for incontinent care. However, Certified Nursing Assistant (CNA) #5 provided incontinent care for Resident #1 alone, and without the care planned assistance of two (2) staff members on 11/02/2021. During the provision of incontinent care by CNA #5 Resident #1 rolled off the bed onto the floor, hitting his/her knees on the nightstand. At approximately 12:30 PM, Resident #1 complained of pain and was assessed to have bruising and swelling to his/her left knee. […]