Health inspection·December 14, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and/or implement a care plan for one of three sampled residents (Resident 1) who was assessed at risk for elopement (leaving an institution without notice or permission). This deficient practice resulted in Resident 1 attempting to elope from the facility by climbing out of the facility s bathroom window and breaking her right leg when she fell to the ground outside that bathroom. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (progressive loss of memory), anxiety (extreme worry), depression (feeling unhappy and without hope) and a history of falling. During a review of Resident 1's Minimum Data Set ([MDS]) a standard assessment and care screening tool), dated 11/21/2023 Resident 1's cognitive (the ability to think, reason, and understood) skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 needed partial to moderate assistance with toileting, sit to stand and walking. During a review of Resident 1's Elopement Risk Evaluation, dated 11/16/2023, the Elopement Risk Evaluation indicated Resident 1 was at risk for elopement. During a review of Resident 1's clinical record, there was no Care Plan available for review related to Resident 1's risk for elopement. During a review of Resident 1's Change of Condition (COC) dated 12/8/2023, the COC indicated Resident 1 suffered a fall on the 12/7/2023. The COC indicated Resident 1 climbed through the bathroom window and was found outside the bathroom window. The COC indicated Resident 1 was holding her right leg and complained of pain. During an interview on 12/12/2023 at 12:05 p.m., Certified Nurse Assistant 1 (CNA 1) stated she saw Resident 1 get up from bed and walk towards the bathroom in her room and she (CNA 1) went to assist her (Resident 1) to the bathroom. CNA 1 stated Resident 1 closed the bathroom door and insisted that it remain closed. CNA 1 stated she respected Resident 1's request but left a crack in the door. CNA 1 stated a few minutes went by, she knocked on the bathroom door and saw through the opening of the door that the shower chair was positioned against the wall, the window in the bathroom was open Page 1 of 2 056446 056446 12/14/2023 Paramount Convalescent Hosp. 8558 East Rosecrans Avenue Paramount, CA 90723

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Resident 1 was not in the bathroom. CNA 1 stated she immediately alerted Registered Nurse 2 (RN 2) and Licensed Vocational Nurse 2 (LVN 2) that Resident 1 was not in the bathroom. CNA 1 stated Resident 1 was found outside the facility, in a driveway just below the bathroom window. During an interview with the MDS nurse and concurrent record review on 12/13/2023 at 3:10 p.m., Resident 1's MDS and Elopement Risk Evaluation was reviewed. The Elopement Risk Evaluation dated 11/6/2023 indicated Resident 1 was at risk for elopement. Th MDS nurse stated a care plan for exit seeking/wandering should have been created for Resident 1. The MDS nurse stated the purpose of a care plan is to ensure residents' get the proper care and the necessary interventions are implemented. During an interview on 12/11/2023 at 1:09 p.m., the Director of Nursing (DON), stated an elopement care plan should have been created upon admission. The DON stated no one reviewed or audited Resident 1's admission assessment, it was overlooked. During a review of the facility's Policy and Procedure (P/P) titled Comprehensive Care Plans revised 12/19/2022, the P/P indicated the facility needs to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 056446 Page 2 of 2