VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Wybe & Marietje Kroontje Health Care Center
1000 Litton Lane
Blacksburg, VA 24060
(540) 953-3200

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based on information received by the licensing office as a self-reported incident, the facility failed to provide supervision of specialized care needs such as wandering from the premises for one resident in care. EVIDENCE: 1. Resident # 1 was admitted to the facility on 09/12/2018. 2. The physical exam for resident # 1 dated 08/30/2018 states she has a diagnosis of dementia and rates this resident as ambulatory. 3. On 09/12/2018 an assessment of serious cognitive impairment was completed for resident #1 stating she has wandering behavior sometimes awake throughout the night and she is unable to recognize danger or to protect her own safety and welfare and was approved for placement in a secure environment. 4. The uniform assessment instrument (UAI) for resident # 1 dated 09/07/2020 states she is disoriented to some spheres all of the time and has wandering behavior. 5. The Individual Service Plan for resident # 1 dated 09/28/2020 states the resident is disoriented to some spheres all of the time and has wandering/passive behaviors that staff will monitor and redirect as needed. 6. According to nursing notes and correspondence with the facility social worker resident # 1 was found outside the gate of the courtyard next to the dining room by staff # 1 at 4:35 pm unattended by staff on 10/26/2020. According to correspondence with the facility social worker resident # 1 was outside the gate unattended for approximately 3 minutes. Staff # 1 contacted the nurses station to inform them resident # 1 was outside the gate unattended and he stayed with her until nursing staff arrived. Staff # 2 and staff # 3 went to resident # 1 and walked her back inside. 7. The gate was observed to be unlocked and the lock was lying on the ground next to the gate. Collateral # 1 stated he was directed by staff # 4 to lock the gate when he was finished with his performance and he completely forgot. Maintenance staff secured the gate. According to Accuweather the weather for this date was high of 72 degrees.
Plan of Correction:	1. Resident #1 was observed outside the gated courtyard of the facility on 10/26/2020 by a team member and returned to the facility within three minutes unharmed. The lock on the gate, by which the resident left, was replaced at that time. 2. The combination on the gate was changed on 10/27/2020. The posting with the code for emergency access and egress was posted at that same time. 3. The Education Department conducted an in-service on 10/27/2020 for staff on gate locking and unlocking procedures. 4. The Director of Quality Assurance will conduct a monthly audit of the gate to ensure it is intact and secure for the next six months. [sic]