Health inspection·April 25, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to keep one of three sampled residents (Resident 1) safe from elopement (Leaving the facility without notice), when he had a history of attempting to elope from the facility and was able to walk without a wheelchair. The facility's intervention to prevent him from elopement included a wander guard (Bracelets that trigger alarms at exit monitored doors to prevent the resident from leaving unattended) placed on his wheelchair. As a result, Resident 1 eloped from the facility by foot, left the wheelchair at the facility, which did not trigger the wander guard system, fell during the process, and hitchhiked to a neighboring town 8.5 miles away. This failure had the potential to result in serious harm, including death, to Resident 1. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Nontraumatic Intracerebral Hemorrhage (Bleeding in the brain, not caused by trauma), Alcohol Abuse, Metabolic Encephalopathy (A neurological disorder that occurs when a chemical imbalance in the blood causes brain dysfunction), and Unsteadiness on Feet, according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Sheet-An assessment tool) dated 3/29/24 indicated his BIMS (Brief Interview of Mental Status-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 9, which indicated his cognition was moderately impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). Record review of Resident 1's care plan for elopement initiated on 3/29/24 indicated, ALARM (Wander guard) WAS PLACED ON THE HANDLE OF HIS WHEELCHAIR. Other interventions in this care plan included, DEVELOP AN ACTIVITIES PROGRAM TO DIVERT ATTENTION AND MEET NEEDS .DISCUSS WITH RESIDENT/FAMILY RISKS OF ELOPEMENT AND WANDERING. There was no mention of increased supervision, or another system other than the wander guard to prevent elopement. This care plan was not revised until 4/14/24, after Resident 1 eloped from the facility. Record review of a facility document titled, Elopement/Wondering Risk Assessment, dated 3/29/24 at 12:03 p.m., indicated Resident 1 had attempted to leave the building 1-2 times within a week, unattended. This document indicated Resident 1 was at risk for wandering, but the intervention was to place the wander guard device on his wheelchair. Page 1 of 3 055919 055919 04/25/2024 Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of a nursing note dated 3/31/24 at 1:10 p.m., indicated, patient [Resident 1] exhibited increased agitation this afternoon and attempted elopement through the front doors of [Name of facility]. Re-direction was provided in the parking lot, and patient agreed to return inside. He states he is ready to walk to Gualala however he is unable to correctly state his current location, appears confused. During a phone interview with Licensed Staff A (Who wrote the note on 3/31/24 at 1:10 p.m., above) on 4/25/24 at 11:30 a.m., she stated that on 3/31/24 Resident 1 attempted to elope from the facility by foot, although he was walking unsteady on his feet. Licensed Staff A stated that when she saw Resident 1, he was outside in the parking lot of the facility with another staff member, attempting to walk off. Licensed Staff A stated staff brought out Resident 1's wheelchair, and he agreed to come back inside the building. Licensed Staff A stated a decision was made to place a wander guard on Resident 1's wheelchair, as he did not want it placed on his body. Record review of a note dated 4/02/24 at 4:54 p.m., indicated, [Resident 1] has attempted to leave facility three times .staff run outside of facility trying to persuade resident to return to facility. Resident receptive to return to facility. Record review of a report sent to the DEPARTMENT on 4/14/24 of an elopement that occurred that same day (On 4/14/24) indicated, Around 8:45 AM (Morning) we received a call from a concerned citizen that a Caucasian male jumped over the fence. Staff alerted to check all residents. All Staff checked inside and surrounding area and at this time resident in 17A [Resident 1] cannot be located. Staff called [Local police department] for assistance. At 9:20 AM, received a phone call from the person who gave resident [Resident 1] a ride to make us aware that resident is in [Name of neighboring town} area, Police Officer [Name of Officer] made aware of resident's whereabouts. SAFE team (mental health team) brought resident back to the facility. Upon resident's return, LN (Licensed Nurse) made a thorough assessment. Resident made comfortable. Medicated for pain as needed. MD/RP (Medical doctor/Patient Representative) notified. Resident had a wander guard on in WC (Wheelchair). Therapy made him independent in the facility yesterday (Saturday). Record review of a nursing note dated 4/14/24 at 13:22 p.m. indicated, Pt (Patient [Resident 1]) has eloped this morning .PT is alert and verbalized that he fell by sliding down when he jumped out of the fence and leaned to his left shoulder, Pt noted to have no injuries. Record review of Resident 1's care plan for elopement, revised after the elopement on 4/14/24 indicated, 4/14/24 Wander guard applied on left ankle. During an interview with Resident 1 on 4/18/24 at 1:30 p.m., he stated that on 4/14/24 he wanted to leave the facility, so he left by foot, leaving the wheelchair with wander guard inside the building, which did not trigger the alarm. Resident 1 stated he jumped over the fence of the facility, and fell in the process, scraping his knee, but managed to get back up on his feet, and was given a ride by a vehicle passing by. Resident 1 stated he was driven to [Neighboring town 8.5 miles away, according to Google maps]. During an interview with the Director of Nursing (DON) on 4/25/24 at 11:00 a.m., she stated that after the elopement attempt on 3/31/24, facility staff should have placed a wander guard on Resident 1's wheelchair, and another one on his body to prevent him from eloping again. Record review of an e-mail sent to the DON and Medical Records Staff B on 4/24/24 at 10:53 a.m., 055919 Page 2 of 3 055919 04/25/2024 Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indicated the Surveyor requested the policy on wander guard use, among other documents. Other requested documents were e-mailed to the Surveyor by Medical Records Staff B on 4/24/24 at 1:50 p.m., but the policy on wander guard use was not provided. Record review of the facility policy titled, Elopements, last revised in December of 2007, indicated, If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner .Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises .When the resident returns to the facility, The Director of Nursing Services or Charge Nurse shall: e. Complete and file an incident report and f. Document relevant information in the resident's medical record. 055919 Page 3 of 3