Health inspection·September 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to ensure two of two residents (Resident 1 and Resident 2), sampled for unsafe wandering (a random, aimless or repetitive search for an exit that is non-goal-directed), and elopement (a resident leaves the premises or a safe area without the facility's knowledge and supervision) was assessed and monitored for unsafe wandering and elopement. Resident 1 and Resident 2 eloped from the facility and had no wander/elopement risk assessments at the time of their elopements. These failures resulted in Resident 1 eloping from the facility from an unknown exit at an unknown time and being found in the facility ' s parking lot by a staff member who happened to go out to the parking lot. And Resident 2 eloping from the facility and being found by law enforcement at a gas station four-tenths of a mile away, in the middle of the night. Findings: A review of the facility ' s policy titled, Elopement Policy, dated 5/8/24, indicated that the facility must Complete an elopement risk assessment upon admission ., and Identify residents who wander and/or who are at risk for elopement . A review of the facility ' s policy titled, Wandering Resident Protocol, dated 12/21/22, indicated that, Each new patient should be evaluated as to whether or not he/she presents a wandering risk. All patients, at any time, should be observed and evaluated as being a wandering risk, and If evaluation indicates the patient is at risk for wandering, use of the Wanderguard signaling device [a device that alarms and alerts staff when the resident exits through a facility door] as recommended. Review of Resident 1 ' s face sheet indicated that he was admitted to the facility on [DATE] with a diagnosis of anoxic brain injury (when the brain does not get oxygen causing brain cell death and problems with thinking and decision making). Record review of Resident 1 ' s Brief Interview for Mental Status (BIMS, a screening tool used to identify cognitive conditions) indicated a score of 3 (a score of 0-7 suggests severe cognitive impairment). Record review of Resident 1 ' s progress notes for 8/18/24 indicated he was found unharmed in the parking lot of the facility at 1:35 PM, the facility did not know when or through which door he exited, he stated to staff that he was looking for a cigarette. The progress note indicated that Resident 1 was wearing a Wander Guard and that the Wander Guard was functioning that day. Page 1 of 2 056416 056416 09/13/2024 Mayers Memorial Hospital 43563 Hwy 299 E Fall River Mills, CA 96028

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 1 ' s Wandering Risk Assessment indicated that the assessment was completed on 8/18/24 at 1:38 pm, and the elopement risk assessment for Resident 1 was completed on 8/18/24 at 1:39 pm, after he eloped from the facility and was returned to the facility by staff. Review of Resident 2 ' s face sheet indicated that she was admitted to the facility on [DATE] with medical diagnoses including cancer, depression, and anxiety. Review of Resident 2 ' s BIMS, indicated a score of 11 (a score of 8-12 suggests moderate cognitive impairment). Review of Resident 2 ' s progress notes for 4/2/24 indicated that she was missing from her room at 12:40 AM on 4/2/24 and was found 3:14 AM at a gas station (four-tenths of a mile away from the facility, by law enforcement. The record indicated that at 8:20 AM on 4/2/24, a Wander Guard was placed on Resident 2. Review of Resident 2 ' s Elopement Risk Assessment indicated the assessment was completed on 8/22/24 at 9:43 am, and Resident 2 ' s Wandering risk Assessment was completed on 8/22/24 at 9:44 am, nearly 5 months after she eloped from the facility and was returned to the facility by law enforcement. During an in interview with Licensed Vocational Nurse (LVN 2), LVN2 stated that there was some previous wandering in the halls with Resident 2 but, not outside to her knowledge. During an interview with Assistant Director of Nursing (ADON) on 8/28/24 at 4:09 PM, in the ADON ' s office, she confirmed that Resident 1's Wandering Risk Assessment and Elopement Risk Assessment was not done until he actually eloped, two months after he was admitted . The ADON confirmed that Resident 2's Wandering Risk Assessment and Elopement Risk Assessment was not done until she actually eloped, 5 months after she was admitted . 056416 Page 2 of 2