Health inspection·February 2, 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 provide adequate supervision to ensure safety for one of three sampled residents (Resident 1), when he left the facility unaccompanied and without staff knowledge and wandered 3 buildings away from the facility that is located next to a busy cross street. This failure placed Resident 1 at high risk for being hit by a moving vehicle, falls, and potentially endangered his life. Findings: A review of the admission Record indicated the facility admitted Resident 1 recently with multiple diagnoses which included dementia (a decline in memory or other thinking and reasoning skills), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and muscle weakness. A review of the physician orders dated 1/14/24 indicated, Resident [1] is NOT Capable of Understanding Rights, Responsibilities, And Informed Consent. A review of the admission assessment dated [DATE] at 4:23 p.m., indicated Resident 1 was oriented to person and had trouble falling asleep. The admitting nurse documented that the resident had poor trunk control and history of falls. A review of Resident 1's 'Fall Risk Assessment,' dated 1/14/24, indicated he was at high risk for falls. A review of LN 1's progress notes dated 1/14/24 at 10:26 p.m., indicated, .Resident [1] was found down the street about 3 apt.[apartment] buildings away accompanied by Fire Dept [Department] paramedics .Resident was knocking on someone's apt door and they called 911. A review of Resident 1's ' Elopement -Wandering Risk,' dated 1/15/24, indicated he scored 7 out of 18 which indicated he was at moderate risk of elopement. A review of nursing progress notes dated 1/18/24 at 1:42 a.m., indicated, Resident [1] is unable to sit still and wanders around the nursing station and hallway .resident .needs multiple redirection. A review of Residents 1's 'Change in Condition' note, dated 1/19/24 at 2:43 p.m., indicated, Resident tried to leave the facility 3 [three] times this morning. Was able to stop him at the door and Page 1 of 2 056495 056495 02/02/2024 Casa Coloma Health Care Center 10410 Coloma Rd Rancho Cordova, CA 95670

F 0689 bring him back to his room. Level of Harm - Minimal harm or potential for actual harm A review of Residents 1's 'Change in Condition' note, dated 1/24/24 at 10:10 p.m., indicated, Resident was last seen by this LN [Licensed Nurse] in the activity room around 22:00 [10 pm] .CNA [Certified Nursing Assistant] .reported witnessing the pt. [patient] walking out the building through the front door .however, resident was not wearing a name band so CNA was hesitant to stop the resident. CNA came to supervisor and informed that resident eloped .Resident was brought back safe. Residents Affected - Few A review of Resident 1's, 'At risk for elopement and wandering out of facility' care plan, dated 1/30/24, listed the following elopement precautions: Check resident's whereabouts every hour .Establish daily routine for the resident .Redirect resident back to supervised areas .Provide activities that will divert resident's attention from wandering. During an interview on 2/1/24 at 3:25 p.m., the Unit Manager (UM) stated Resident 1 was very confused, ambulatory, walked around the facility all the time, and was at risk for elopement. The UM stated that to ensure resident's safety and prevent elopement, staff were to supervise him constantly and monitor resident's whereabouts every 30 mins to one hour. During an interview on 2/1/24 at 3:42 p.m., LN 1 stated Resident 1 was very confused .walked everywhere .We'd occupy him in activity room for a few minutes and then he would say 'I ' m ready to go home' and would walk out of the room and start wandering. LN 1 stated that Resident 1 did not have a wrist band with his name on him when he was found by paramedics and was brought back to facility. During an interview on 2/1/24 at 3:55 p.m., CNA 1 stated that on the evening of 1/24/24, while she was in the back hall of Station 1, she noticed an older male walking through the side door leading to the laundry. CNA 1 stated, He [Resident 1] was not familiar to me .I thought he was someone from the street. I asked him, Are you here to see someone? CNA 1 stated [Resident 1] looked lost and confused and did not respond to her question. CNA 1 stated Resident 1 sat on a couch for a few minutes and then walked outside through the front door. CNA 1 added, I did not stop him because I did not know he was our resident here .I checked for his name band, and he did not have any. CNA 1 acknowledged that Resident 1 could have gotten hurt if he tried to cross the street. A review of the facility's policy and procedure titled, Wandering and Elopements, dated 3/2018, indicated the facility will provide a safe environment for all residents. The policy indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If an employee observes resident leaving the premises, he/she should: Attempt to prevent a resident from leaving .Get help from other staff members in the immediate vicinity .Instruct another staff member . that a resident is attempting to leave. During an interview on 2/1/24 at 1:45 p.m., the Director of Nursing (DON) acknowledged Resident 1 eloped on 1/24/24, and was brought back to the facility safe. The DON stated Resident 1 was a wanderer and required constant supervision. When the DON was asked what safety measures the facility had put in place to prevent elopement, she stated the resident was placed on monitoring for his whereabouts every hour. The DON stated Resident 1 was not placed on one-on-one staff supervision. A review of the facility's 'Safety and Supervision of Residents' policy dated 7/2017 indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance are facility-wide priorities. 056495 Page 2 of 2