Health inspection·April 13, 2023

Health and Safety Code Section 1424 (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 therefrom. Title 22, California Code of Regulations, Division 5, Chapter 3, Article 5, Required Services, Section 72523, Subdivision (a), Patient Care Policies and Procedures: Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The Department determined during an investigation a complaint, the facility failed to ensure its policies and procedures on elopement were implemented when Resident 1 left the facility unnoticed on 1/4/22 around 7:15 am, and nowhere to be found by facility staff. The facility failed to call the local law enforcement to aid in the search; and notify the resident's family members to inform them of the resident being missing. These failures resulted in Resident 1 being missing from the facility for about 75 minutes, and latter being found by a Passerby on a busy city street, bleeding from injuries and unsupervised. The passerby called 911 and Resident 1 was transported to a local acute care hospital emergency room where the resident was diagnosed with left eyebrow laceration (deep cut in the skin), blunt head trauma (injury by force), fall, altered mental status (AMS- change in mental awareness), abrasion of eyebrow (skin tearing), and tenderness over right trapezius (injury to muscle middle back area with pain). During a review of the facility's policy and procedure titled, "Elopements" dated revised 12/2007 indicated in part 4. If the employee discovers that a resident is missing from the facility, he/she shall: a. Determine if the resident is out on authorized leave or pass. b. If the resident was not authorized to leave, initiate a search of the building and premises. c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency management, Rescue Squads, etc.,) d. Provide search teams with resident identification information; and e. Initiate an extensive search surrounding the area. During a review of the clinical record for Resident 1, the face sheet (form containing resident information) indicated multiple diagnoses including generalized muscle weakness, abnormalities of gait and mobility, somnolence (always ready to fall asleep), and fluctuating capacity to understand and make decisions. The "Physician Orders" dated 12/29/21 indicated an order for physical therapy (PT) five times a week for four weeks for gait training (learning how to walk) and to safely ambulate (walk). The document Fall risk assessment (FA) dated 12/28/21, for Resident 1, indicated history of 1-2 falls in the last 90 days, the resident was non ambulatory (unable to walk) and uses a wheelchair for locomotion (moving around). Further review of the clinical record, the document Nursing Progress Notes (NPN) dated 1/4/22 at 12:35 PM (late entry), authored by a licensed nurse (LN 1) had documentations of: At around 6:30 AM, Resident 1 was walking on unit hallway, around nursing station, with a four wheeled walker (FWW). Resident was last seen walking around the nursing desk area at about 7:15 am. At around 8:30 am another RN (Registered Nurse) reported the daughter of Resident 1 was on the phone and inquiring if the resident had fallen and wanted to speak to the resident. Another daughter of the resident with a male companion was at the facility's front door requesting to see the resident. The NPN did not indicate the whereabouts of the resident after 7:15 am, no documentation of the facility search for the resident was noted and if the police were informed about Resident 1 missing. During a review of the NPN dated 1/4/22 at 4:44 PM (late entry), the NPN had documentations authored by LN 3 of: Arrived for the morning shift around 7:50 am, noticed that the resident was not in the room. Staff were searching for the resident and nowhere to be found in the facility. Around 8:40 am a nursing supervisor received a call from daughter stating someone (a Passerby) found the resident at (name of the street) at around 7:45 am, walking with a walker. 911 was called and the resident was sent to a local hospital. No documentation in the NPN was located about the staff and facility calling law enforcement for a missing person and informing family (as indicated in its policy) on 1/4/22 after 7:50 am, when LN3 found the resident was missing from the facility. During an interview with the Passerby on 1/11/22 at 12:29 pm, the Passerby indicated on 1/4/22 at 7:38 am, Resident 1 was noted on the side of a busy street about a mile from the facility dressed in pajamas, walking with a walker, and then falling by the side of the street. The Passerby called 911 as the resident had injuries on the left forehead, was bleeding down to the cheek area and was transported by EMT (emergency medical technicians) to a local hospital. The Passerby further indicated calling the facility at 8:07 am to ask about Resident 1's whereabouts. The Passerby stated, "The nurse said, I believe he is in his room. The facility staff didn't even know the resident was gone. They didn't even know he was missing." Review of the emergency medical transport "Electronic Patient Care Report_v2" dated 1/4/22 at 8:08 a.m., indicated Resident 1 was transported by ambulance to a local hospital. The Emergency Provider Report (EPR) dated 1/4/22 indicated the resident sustained a left eyebrow laceration (deep cut in the skin), altered mental status (AMS- change in mental awareness), abrasion of eyebrow (skin tearing), blunt head trauma (injury by force), fall, and tenderness over right trapezius (injury to muscle middle back area with pain). The EPR had documentations of resident undergoing several blood tests and a Computerized Tomography Scan (CT -radiographic imaging-scanning via a machine) of the neck. During an interview on 2/2/22 at 7:16 am, LN1 confirmed working on 1/3/22 at 11 pm to 7 am of 1/4/22. LN1 stated, "the Certified Nursing Assistant (CNA 1), came in to work between 7:15 am to 7:30 am, proceeded to do his rounds and told me he can't find Resident 1. LN1 stated, "At around 8 am or 8:30 am, I called the code elopement." During an interview on 2/23/22 at 8:15 am, LN2 confirmed working on 1/4/22 for 7am to 3 pm shift. LN2 also confirmed starting late in shift with CNA 1 and another staff. CNA 1 did his rounds and found Resident 1 was missing and reported to LN1. LN 2 stated, "I received a call from the resident's daughter around 8:35 AM stating the resident fell, I transferred the phone call to the resident's room, but I could not find him."LN2 confirmed receiving the call from the Passerby on 1/4/22 about 8:45 am indicating Resident 1 was found injured by the side of the road about a mile away from the facility. During an interview on 6/1/22 at 2:11 pm, about elopement policy and procedure, LN1 indicated, a sweep of the building should have been done and in 15 minutes of not locating the resident the police should have called, the Director of Nursing (DON), the Administrator, the Social Services, and family. LN1 further indicated this was not done. During another interview on 6/22/22 at 1:30 pm about the facility's elopement policy and procedure, LN1 indicated not calling law enforcement/ family when resident was reported missing on 1/4/22 between 7:15 am to 7:30 am by CNA1. LN1 stated, "Yes I was ultimately responsible for notifying the law enforcement, the emergency rescue team and filling out the SBAR /Change of Condition/Incident Report and it was not done." The facility failed to ensure its policies and procedures on elopement were implemented on 01/04/22 when Resident 1 left the facility, unnoticed by the facility staff. When the facility became aware that Resident 1 was missing, the facility did not follow its policies and procedures which includes calling law enforcement officers to assist with the search and also did not notify the resident's family members. As a result of these failures, Resident 1 was missing from the facility for about 75 minutes and was later found by a Passerby on a busy city street, bleeding from injuries. Resident 1 was transported to a local acute care hospital emergency room and was diagnosed with left eyebrow laceration, blunt head trauma, fall, altered mental status, abrasion of eyebrow and tenderness over right trapezius.