Other·May 4, 2023

The following reflects the findings of the California Department of Public Health during the investigation of a Facility-Reported Incident # CA00826647. Event ID: EG0G11 Representing the Department, HFEN #46658. State Citation B was written. §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. Title 22, §72637(a) The facility, including the grounds, shall be maintained in a clean and sanitary condition and in good repair at all times to ensure safety and well-being of patients, staff and visitors. On 2/13/23, at 11:40 a.m., California Department of Public Health conducted an unannounced visit at the facility to investigate a facility-reported incident regarding an elopement by Resident 1. Resident 1 used a wheelchair for mobility, as he was unsteady walking. Resident 1 needed assistance for locomotion both on and off the unit. Resident 1's cognition was severely impaired, was not self-responsible, and had a responsible party (RP) to make healthcare decisions. On two consecutive days, Resident 1 left the facility through unsecured doors which did not alarm. The lack of an audible door alarm impaired staff notification of door use and allowed Resident 1 to elope unnoticed by staff. Resident 1 was found 15 minutes after the first elopement and had no visible injuries. Resident 1 was found approximately seven hours after the second elopement with minor scratches and abrasions. The facility failed to ensure an environment free of accident hazards when: 1. For 36 of 36 residents, the facility main entrance door was not securely closed to prevent unauthorized entrance or exit by residents or visitors. 2. For one of four sampled residents (Resident 1), the existing door alarm system failed to function and alert staff to Resident 1's unauthorized exits. These failures resulted in Resident 1's two unwitnessed elopements, with minor scrapes and scratches sustained after the second elopement and a potential for greater injury or death. These failures also provided opportunity for elopement by other residents and unauthorized entrance by the public, with the potential for injury or damage to residents and property. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on 1/23/23 for rehabilitation for generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS, an assessment tool to guide care), dated 1/26/23, indicated Resident 1 had a score of seven on the Brief Interview for Mental Status exam. (BIMS, the Brief Interview for Mental Status is an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired. A score of zero to seven is an indication of severe impairment.) The MDS indicated Resident 1 required assistance from at least one person for transfer between surfaces, and locomotion on and off the unit; was unsteady transferring from surface to surface and used a wheelchair for mobility. During an observation on 2/13/23, at 11:45 a.m., the facility main entrance door was ajar several inches, when fully opened from the ajar position, there was no audible alarm. When the fully opened door was released and allowed to passively close, the door did not fully close, but remained ajar by several inches. During an interview on 2/13/23, at 12:09 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she was assigned to care for Resident 1 on the morning of 2/8/23. CNA 1 stated Resident 1 usually used a wheelchair, but she had seen him walk short distances without using any assistive device. CNA 1 stated on 2/8/23, at around 8:00 a.m., she had taken Resident 1, in his wheelchair, to the facility entrance near the nurses' station, and then left him there while she cared for another resident. When she returned, only Resident 1's wheelchair was still by the facility entrance, and Resident 1 could not be found inside the facility. Staff located Resident 1 a block away from the facility, and he was returned without incident. During a phone interview on 2/13/23, at 12:30 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated on 2/8/23 at around 8:15 a.m., she saw Resident 1 seated in a wheelchair at the facility entrance near the nurse's station. LVN 2 stated she had not heard the entrance door alarm anytime that morning. LVN 2 stated if she had heard an alarm, it would have alerted her to Resident 1 leaving the facility. LVN 2 stated at around 8:30 a.m., CNA 1 told her Resident 1 had eloped. A review of Resident 1's care plan titled, "The resident is an elopement risk," dated 2/8/23, indicated Resident 1 had impaired safety awareness and wandered aimlessly. The interventions to attain the goal of, "resident not leaving the facility unattended" included to monitor Resident 1 on an hourly basis. During a phone interview on 2/13/23, at 12:52 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated on 2/9/23, she was walking in the hallway at 8:30 p.m., and saw Resident 1 lying in bed in his room. LVN 3 stated at 9:15 p.m., a certified nursing assistant told her Resident 1 was no longer in his bed. LVN 3 stated she had not heard a door alarm that evening. LVN 3 stated the main entrance door was locked, but the back entry door was not locked to prevent exit, so Resident 1 likely left through the back entry door. LVN 3 stated facility staff were unable to locate Resident 1 inside the facility or in the immediate area, so staff called the police at 9:20 p.m. for assistance. LVN 3 stated the police located Resident 1 on 2/10/23, around 4:00 a.m. and took Resident 1 to an emergency department for medical evaluation. A record review of Resident 1's Interdisciplinary Team's (IDT) progress note, dated 2/10/23, at 3:22 p.m., indicated Resident 1 returned to the facility from the emergency department on 2/10/23, at 12:45 p.m. The IDT progress note indicated Resident 1 had minor injuries: scratches and abrasions (shallow scrapes) on the left cheek, left ear, left shoulder, left knuckles, left lower back and right shin. The IDT note indicated the door alarms would be checked by the maintenance department. During an interview on 2/13/23, at 1:11 p.m., with Maintenance supervisor (MS) and Environmental Services Supervisor (EVSS), MS stated on 2/10/23, the Director of Nursing told him the main entrance and back entry door had non-functioning alarms. EVSS stated he assisted MS checking the door alarms. EVSS stated the door alarms had been functional, but he and MS replaced the main entrance and back entry with louder alarms on the morning of 2/13/23. During an observation and interview on 2/13/23, at 1:45 p.m., with MS and EVSS, at the facility main entrance door, the door was closed. When the door was opened, an alarm sounded. The door was allowed to passively close, but the door did not fully close and remained ajar by several inches. The door was then fully opened from the ajar position, and no alarm sounded. MS stated the facility's main entrance door should automatically close by itself, but upon inspection of the door hinge, MS stated the hinge was misaligned and prevented the door from fully closing. MS stated the alarm would not function correctly unless the door was fully closed. In violation of the above cited standards, the facility failed to ensure an environment free of accident hazards when: 1. For 36 of 36 residents, the facility main entrance door was not securely closed to prevent unauthorized entrance or exit by residents or visitors. 2. For one of four sampled residents (Resident 1), the existing door alarm system did not alert staff to his unauthorized exit. These failures resulted in Resident 1's two unwitnessed elopements, with minor scrapes and scratches sustained after the second elopement and a potential for greater injury or death. These failures also provided opportunity for elopement by other residents and unauthorized entrance by the public, with the potential for injury or damage to residents and property. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.