Health inspection·May 14, 2021

F689 K §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. General Maintenance §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. The facility failed to follow the aforementioned regulations by not providing adequate supervision and not providing training to employees on how to activate and monitor the back door alarm system, which resulted in an Immediate Jeopardy (IJ, a situation in which a facility's actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) on 2/5/21 at 3:00 p.m., with the Administrator and Director of Nursing (DON). The failure to supervise, resulted in Resident 1 eloping from the facility, which placed Resident 1 at risk for injury, serious harm from a potential fall, possible death by wandering into traffic, not receiving needed prescribed medications, and not having shelter, food or water. As a result, Resident 1 incurred a four-day hospitalization on the critical care unit after being found by the local authorities after 36 hours. On 2/9/21 at 7:45 a.m., the IJ situation was lifted through observation, interview, and record review; the facility demonstrated they had initiated a plan of action for providing adequate supervision and environmental barriers to prevent elopement. The Administrator showed all residents were assessed for risk of elopement, employees were in-serviced on the functionality of the alarm system and the facility posted a staff by the backdoor twenty-four hours a day to monitor and secure the building. Review of Resident 1's Face sheet, indicated Resident 1 was admitted to the facility on 11/10/20 with multiple diagnoses which included altered mental state, and a history of traumatic brain injury (brain damage due to an external force), and substance abuse. Review of Resident 1's initial Admission Assessment dated 11/10/20, indicated Resident 1 was not at risk for elopement. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/21/21, reflected a score of eight on the Brief Interview for Mental Status. (BIMS, a scoring system used to determine a resident's cognitive abilities of attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status; a score of eight is an indication of moderate impairment of cognitive skills.) The MDS indicated Resident 1 was able to both understand others and to make himself understood. Review of Resident 1's Medication Administration Record (MAR) dated February 2021, indicated Resident 1 had the following medication orders: two medications for treatment of brain injury (Oxcarbazepine 300 milligrams (mg) twice daily for traumatic brain injury and Depakote 250 mg, twice daily for an inability to relax); an antipsychotic medication (a group of medications used to treat mental conditions which have some loss of contact with reality; the antipsychotic medication quetiapine, 25 mg twice daily for agitation and a desire to leave the facility); a medication to control high blood pressure (Doxazocin once a day); and a medication to control nerve pain (Gabapentin 300 mg three times a day). Review of the physical therapy evaluation dated 11/11/20, indicated Resident 1 was at risk for falls due to physical impairment from a cerebrovascular accident (loss of oxygen to the brain as a result of impaired blood flow; commonly known as a stroke). Review of the Fall Risk Assessment, dated 12/29/20, indicated Resident 1 was at high risk for falls due to a balance problem and use of psychotropic medications (medications which affect brain activities associated with mental processes and behavior). Review of Resident 1's nursing progress notes dated 1/24/21 at 9:45 p.m., indicated staff witnessed Resident 1 attempt an elopement from the facility. The nursing notes reflected Resident 1 had exited through the facility's backdoor at 3:15 p.m., and then went through the perimeter back gate, before being returned to the facility by staff. Review of Resident 1's nursing progress notes dated 1/25/21 at 10:26 a.m., Registered Nurse 1 (RN 1) wrote, "suggested wander guard placement [Wander guard is a system to alert caregivers when residents are attempting to exit a facility unsupervised. It is a two-part system: a bracelet worn by the resident, and a sensor installed on an exit. When the bracelet passes across the sensor, an audible alarm sounds.] to alert the staff to redirect the resident from exit doors but the whole team [Inter-disciplinary Team] decided that was not appropriate at this time." Review of Resident 1's care plan titled, "Category: Behavioral Symptoms, At Risk for: Elopement and Wandering Out of Facility," dated 1/25/21, indicated that some nursing interventions were to: provide activities to divert resident's attention from wandering, gently redirect resident back to supervised areas, allow resident to move in hallways safely, check resident's whereabouts q [every] fifteen minutes." During a telephone interview with the Certified Nursing Assistant 1 (CNA 1) on 2/7/21 at 1:10 a.m., CNA 1 confirmed she was assigned to Resident 1 on 2/4/21. CNA 1 stated she had assisted Resident 1 in the bathroom around 5:30 a.m. CNA 1 stated Resident 1 had asked for breakfast, but it had not been served yet. CNA 1 stated she had not heard either the backdoor alarm, or back gate alarm that morning. During an interview with the Physical Therapy Assistant 1 (PT 1) on 2/5/21 at 9:40 a.m., PT 1 stated he saw a person that resembled Resident 1 around 6:40 a.m. at the corner gas station about half a mile from the facility. PT 1 stated he had not stopped at the gas station, but continued to the facility, where he asked staff to check on Resident 1's whereabouts. PT 1 stated Resident 1 had weakness on the right side of his body, decreased mobility and flexibility of the right hand, and walked using a cane or walker (a walking aid with three or four upright supports and two handlebars for gripping while ambulating). Review of Resident 1's record titled, "Observation Detail List Report," by Licensed Vocational Nurse 1 (LVN 1) dated 2/4/21, indicated, "About 6:45 a.m., the receptionist came to North 2 asking if resident was in his room. Writer said, 'I think so, because he was just asking for breakfast 15 minutes ago.' And the writer went into the resident's room right away to check while still talking with receptionist, but unfortunately resident was not in his room." During an interview with Licensed Vocational Nurse 2 (LVN 2) on 2/5/21 at 9:50 a.m., LVN 2 stated she saw someone who resembled Resident 1 by the freeway overpass around 6:55 a.m. LVN 2 stated she continued to the facility and upon entering the facility, asked other staff if Resident 1 was missing. During a telephone interview with the ADM on 2/8/21, at 2:45 p.m., ADM confirmed employees had discovered Resident 1 was missing on 2/4/21, at 6:45 a.m., and were unable to locate the resident despite searching the area on foot and in automobiles. ADM stated police found Resident 1 on 2/5/21, around 7:00 p.m. The police took Resident 1 to the acute care hospital emergency department (ED) because he was combative when confronted by the police. ADM stated he was informed by ED staff that Resident 1 had some difficulty breathing, and was dehydrated (decreased body fluids) when he entered the ED. ADM confirmed Resident 1 had not received any of his scheduled medications for over 36 hours. A review of Resident 1's MAR dated 2/2021, reflected Resident 1 had missed a total of four doses of each of the two seizure medications, 4 doses of the anti-psychotic medication, two doses of blood pressure medication, and six doses of nerve pain medication during his elopement on 2/4/21 and 2/5/21. A review of Resident 1's ED Provider Notes dated 2/5/21, indicated Resident 1 entered the ED on 2/5/21, at 8:08 p.m. Resident 1 had an elevated temperature of 99.3 degrees (normal value is 98.6 degrees), elevated heart rate of 122 (normal range is 72-80 beats per minute) and an elevated respiratory rate of 40 (normal range of 12-20 breaths per minute). The ED Provider Notes Plan indicated Resident 1 was to be admitted to the critical care unit because of abnormal brain function, agitation, and abnormal values of troponin enzymes (enzymes associated with function of the heart; elevation of the enzymes can be an indication of a heart attack). A review of Resident 1's acute care hospital document titled, "Discharge Summary," dated 2/9/21, indicated Resident 1 was discharged from the hospital on 2/9/21. The Summary indicated Resident 1 required intravenous fluids to treat dehydration which was complicated by rhabdomyolysis (muscle breakdown, which can result in damage to the kidneys). The Discharge Summary also indicated Resident 1 had suffered from a type of heart attack known as NSTEMI, which was to be treated medically. During an observation and concurrent interview with Resident 1 on 2/24/21 at 11:20 a.m., Resident 1 lay in bed on his back with his eyes open and responded to questions. Resident 1 stated he was "sick of this place" and had been hungry, so he left; no one had been at the back door. Resident 1 stated he continued out of the facility through the facility's back gate. During a review of the facility's policy and procedure (PNP) titled, "Resident Elopement," dated 8/15/2001, the PNP indicated, "Facility will provide a safe environment and preventative measures for elopement." During an observation on 2/5/21 at 9:30 a.m., an employee monitored the front entrance door of the facility. At the back of the building was an unattended glass-paneled backdoor that opened to an outdoor fenced patio. The backdoor exit had a touch keypad and red alarm box with a key, on the right side of the doorframe within arm's reach. On the wall to the right of the door was another touch keypad. During an observation and concurrent interview with the Maintenance Supervisor (MS) on 2/5/21, at 10:50 a.m., MS stated the touch pad on the wall next to the door was an old system and was not operational. MS stated that the new touch pad alarm system [the touchpad on the doorframe] was installed on 12/21/20. MS stated there was a one-time in-service training on the new alarm system conducted on 12/21/20. MS demonstrated how to activate and deactivate the backdoor alarm system by entering a code on the touch keypad. During an observation on 2/5/21, at 11:05 a.m., with MS, the backdoor opened onto a concrete patio enclosed by fencing with an unlocked gate that led to the facility parking lot and city streets. During observations and concurrent interviews on 2/5/21: At 11:15 a.m., Certified Nursing Assistant 2 was unable to demonstrate how to enter the activation code for the new alarm system and stated she had not been trained on the new alarm system. At 11:25 a.m., Certified Nursing Assistant 3 stated she had not been trained on the new alarm system and did not know any of the codes for the keypad. At 11:30 a.m., Certified Nursing Assistant 4 stated she had not been trained on the new alarm system and did not know any of the codes for the keypad. At 11:40 a.m., Housekeeper 1 stated she had not been trained on the new alarm system and did not know any of the codes for the keypad. During a telephone interview with CNA 1 on 2/7/21, at 1:10 a.m., CNA 1 stated she was trained two or three months ago on how to use the keyed box to deactivate the alarm on the backdoor, but had not received any training on the new touch-pad alarm system or the new codes. During an interview with the Administrator (ADM) on 2/5/21, at 2 p.m., ADM confirmed only 36 facility employees out of the 115 total employees had been trained on the new alarm system. A review of the attendance roster for the In-service Training Record titled, "Alarm Glass Door Egress ... Alarm with Coded Code," dated 12/21/20, reflected 36 employees attended the training. CNA 1, CNA 2, CNA 3, CNA 4, and HK 1's names were not included on the training attendance roster. The Training Record indicated, "Alarm to be activated daily and monitored to make sure alarm is on for safety." Therefore, the facility failed to provide adequate supervision or train employees on how to activate and monitor the back door alarm system which resulted in Resident 1's unwitnessed elopement from the facility, and subsequent four day hospitalization, and had the potential to allow other residents to elope. The above violations either jointly or separately have a direct or immediate relationship to patient health, safety, or security.