Health inspection·November 20, 2024

Regulation Violations Health & Safety Code 1424 (c) and (d) (c) Class "AA" violations are violations that meet the criteria for a class "A" violation and that the state department determines to have been a direct proximate cause of death of a patient or resident of a long-term health care facility. Except as provided in Section 1424.5, a class "AA" citation is subject to a civil penalty in the amount of not less than five thousand dollars ($5,000) and not exceeding twenty-five thousand dollars ($25,000) for each citation. In any action to enforce a citation issued under this subdivision, the state department shall prove all of the following: (1) The violation was a direct proximate cause of death of a patient or resident. (2) The death resulted from an occurrence of a nature that the regulation was designed to prevent. (3) The patient or resident suffering the death was among the class of persons for whose protection the regulation was adopted. If the state department meets this burden of proof, the licensee shall have the burden of proving that the licensee did what might reasonably be expected of a long-term health care facility licensee, acting under similar circumstances, to comply with the regulation. If the licensee sustains this burden, then the citation shall be dismissed. (d) Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result there from. F-689 §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Findings The facility failed to provide adequate supervision in accordance with professional standards of practice. As a result, Resident 23, who was legally blind and at a high risk for accidents, was allowed to leave the facility unsupervised, wandered onto a railroad track, and was fatally struck by a train. The facility failed to create, evaluate, and maintain a comprehensive person-centered patient care plan for Resident 23. As a result, Resident 23's care plan was not updated after a prior incident in November 2019 to reflect Resident 23's needs while out of the facility. The facility failed to notify the attending licensed healthcare practitioner of a marked adverse change in Resident 23's symptoms and behavior after Resident 23 was unable to find his way back to the facility from an unsupervised pass. As a result, the prior physician's order permitting Resident 23 to utilize exit passes was not periodically updated consistent with facility policies and procedures. On 12/20/19, the Department received notification from the facility that a "Resident signed out on pass in the presence of his charge nurse and the nurse supervisor," on 12/19/19, to go to the Post Office, located .6 miles from the facility. The police subsequently found Resident 23 deceased at 8 p.m. Starting 2/21/21, the Department conducted an on-site investigation at the health facility regarding this incident. Review of the Licensed Nurses Progress Notes, by Licensed Nurse B, regarding Resident 23's absence from the facility on 12/19/19, indicated the following notations: 12/19/19, 10:20 p.m., Resident 23 went out on pass, at 12 p.m., to go to the Post Office, but until now, 10:20 p.m., he is not back yet. Unable to reach his sister. Call to Police to report missing resident. Another note, dated 12/20/19, 10:45 p.m., late entry for 12/19/19, set forth the following: Resident went out on pass at 12:45 p.m., and signed 2 p.m. would be the time of return. Called sister's and resident's numbers at 4 p.m. but could not reach. Talked to other residents at 8 p.m. to see if they had seen him, but no one had. A review of Resident 23's admission record indicated Resident 23 was a 71-year-old male readmitted to the facility from a general acute care hospital on 4/23/19 with diagnoses including difficulty walking, muscle weakness, Diabetes, and Chronic Obstructive Pulmonary Disease (a chronic lung disease which causes difficulty in breathing). A quarterly assessment, completed on 10/16/19 indicated Resident 23 had impaired vision. On 10/10/19, a Physician's Order identified Resident 23 as legally blind. A Behavior Management Committee Review, dated 9/5/19, documented Resident 23 smeared fecal material on himself and bed linen after using the bedpan and had a history of chronic mental illness. The December 2019 Medication Administration Records (MAR) indicated Resident 23 refused all medications, including insulin, as well as blood sugar testing. Resident 23's care plan, dated 4/23/19, identified Resident 23 as "at risk for falls," related to poor vision and independence in transfer, despite explanation of risks. The use of a front-wheel walker was identified as an approach. The plan did not address going out on pass. The care plan was not updated after the 10/10/19 order identifying Resident 23 as, "legally blind." A review of the facility policy, "Out On Pass" (revised on 1/11/16), indicated the following: "The Attending Physician will write or give an order ... on the Physician's Order Sheet A: The order should include whether the resident should be accompanied by a responsible person while out on pass or may leave the facility unaccompanied." The policy further provided: "In the absence of a specific order that indicates that the resident may go out on pass unaccompanied, the resident must be accompanied by a responsible person," and, "If the resident is receiving skilled service, the resident may leave for therapeutic purpose only and the reason and benefit must be documented." The policy further indicated: "If the resident experiences a significant change in condition ... the Nursing Staff will notify the Attending Physician," and "Until the Attending Physician ... [is] able to reassess the resident's ability to go out on pass, the out on pass order will be discontinued." A Physician's Order for Resident 23, written on 6/19/19, documented the following note: "May go out on pass X 4 hrs" (times four hours). The Physician's Order, written in June 2019, and ongoing through December, did not specify whether Resident 23 could leave the facility unaccompanied. A Physician's Order from December 2019 documented Resident 23 required skilled nursing, but the order did not indicate any therapeutic reason and benefit of the pass. Contemporaneous records from the facility indicate no attempt by nursing staff to clarify the order with the physicians, or to determine whether Resident 23's pass permitted him to leave unaccompanied. Further, there were no documented attempts to clarify or seek additional guidance regarding the physician's order that Resident 23 was, "legally blind." Clinical records did not indicate Resident 23 was reassessed by the physician after 11/10/19, nor did the clinical records indicate any new physician orders issued after 11/10/19. Resident 23's clinical record indicated this order was in effect until Resident 23's death on 12/19/19. During an interview and concurrent document review with the Director of Nurses (DON) on 2/28/20, the DON stated an order to go out on pass, "for four hours," represented a one-time order. During a telephone interview with Physician A on 3/30/20 at 5:30 p.m., Physician A stated a four-hour order would be a "one-time order." A document entitled, "Coroner's Report," dated 12/19/19, documented an interview conducted by the Sheriff-Coroner, with Licensed Nurse B. The document included a statement by Licensed Nurse B, that she was advised of Resident 23's absence at the start of her shift but waited several hours to report that to the police. The statement documented Licensed Nurse B thought he (Resident 23) might return to the facility since he had returned late on other occasions. The report also documented Licensed Nurse B was aware Resident 23's vision was not very good, and his hearing was impaired. Licensed Staff B's statement further documented she was aware of an incident in November 2019, in which Resident 23 went to a convenience store he often visited but could not remember how to get home. According to Licensed Nurse B's statement, the store called the facility, and facility staff went to pick him up. When she was asked if there were other incidents when Resident 23 could not remember how to get home, Licensed Nurse B responded there were a few other times, but she could not recall the dates of those incidents. During a telephone interview on 3/17/20, Licensed Nurse B, who identified herself as the supervisor on duty, described an incident in November 2019, where Resident 23 was not able to find his way back to the facility from a convenience store, and staff had to go and get him. When asked if anyone else in the facility was aware of this incident, she stated, "Of course." Licensed Nurse B also confirmed the statements documented in the Coroner's Report that she provided to the Sheriff-Coroner on 12/19/19. She stated Resident 23 did not forget how to return [to the facility] during the November 2019 incident, rather he just could not find the way. She stated she did not know if the facility had done an SBAR Communication (a form completed by the facility to address unusual incidents to determine ways to resolve a problem). The Licensed Nurses Notes for the month of November did not reflect any information regarding this incident. Resident 23's Sign Out/In Sheet documented he left the facility on a pass five times in the month of November 2019. The document did not reflect the times when Resident 23 returned on any of these outings, or whether staff assistance was required to return Resident 23 to the facility. Resident 23's clinical record did not demonstrate Resident 23's physician was notified about any incidents in November 2019. The facility's "Out On Pass" policy indicated, under subdivision (V), the following: "Prior to the resident leaving on pass, a Licensed Nurse will assess the resident's physical and mental status." The facility Administrator and Director of Nurses (DON) were asked multiple times for documentation of any assessment of Resident 23 prior to his leaving on any pass. No documentation was provided. During a telephone interview on 4/14/20, Licensed Nurse C stated: Assessments were not done each time a resident went out on pass and were only based on the resident's capacity and the physician's order. A Sign In/Out document indicated Resident 23 left the facility at least 14 times between 6/09/19 and 12/19/19. This document did not indicate any assessments of Resident 23 prior to these outings or upon his return. This document did not indicate that any of these outings were supervised. During an interview on 3/13/20 at 3 p.m., the DON stated the Licensed Nurse was responsible for verifying if the resident returned to the facility when expected. During an interview with the DON on 3/09/20 at 3:15 p.m., the DON stated, when a resident was discovered to be missing, all areas of the facility were notified, and the facility was searched. If the resident was not located, one or two staff persons would drive through the areas where residents were known to wander. If the resident was still not located, the facility would be notified and directed to call the police. He stated, the initial search would take 15 to 30 minutes, and 30 minutes would be reasonable to notify the police. The Licensed Nurses Progress Notes of 12/19/19, by Licensed Nurse B, documented the police were not notified until 10:20 p.m., nearly 12 hours after Resident 23 went out on pass unsupervised, and eight and one-half hours after he was scheduled to return to the facility. Contemporaneous records did not indicate that all areas of the facility were notified, nor that the facility was searched, nor that staff members drove to areas Resident 23 was known to wander. The Coroner's Report documented the time of Resident 23's death as 8 p.m., and the cause of death as multiple blunt impact injuries. Resident 23 was allowed to leave the facility, without a responsible person to accompany him, despite multiple diagnoses placing him at risk and previous incidents of confusion while out on pass. He did not have an appropriate order by a physician, as required by facility policy. The facility did not assess Resident 23 for safety, prior to permitting him to go out on pass without a responsible party. Resident 23 was identified as legally blind, required a walker related to his risk of falls, was at risk of high/low blood sugar related to his refusal of testing and had previously had not been able to find his way to return to the facility prior to 12/19/19. The failure to assess Resident 23 for safety, resulted in Resident 23 being alone and unsupervised for hours. The facility failed to notify police for more than eight (8) hours after Resident 23 was expected back. The failure of the facility to involve the police in searching for Resident 23 contributed to Resident 23 not being located prior to his traveling, in the opposite direction from the facility, and wandering onto the railroad track, where he was fatally struck by a train at 8 p.m. on 12/19/19. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 23 and were a substantial factor causing Resident 23's death.