Health inspection·April 8, 2025

INSPIRE BEHAVIORAL HEALTH Intake Number: CA00940744 Provider Number: 05A277 Class "B" Citation-Accident for elopement §483.25(d) Accidents. §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. DEFINITIONS 483.25(d) Definitions are provided to clarify terms related to providing supervision and other interventions to prevent accidents. "Accident" refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. This does not include other types of harm, such as adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current professional standards of practice (e.g., drug side effects or reaction). "Avoidable Accident" means that an accident occurred because the facility failed to: • Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or • Evaluate and analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; and/or • Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident; and/or • Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. Residents with a history of substance use disorder may be at increased risk for leaving the facility without notification and/or for illegal or prescription drug overdose if the resident continues using substances while residing in the nursing home. Residents with a history of substance use disorder should be assessed for these risks and care plan interventions should be implemented to ensure the safety of all residents. For example, residents with substance use disorder may leave the facility to satisfy an addiction to alcohol, prescription drugs, or illegal substances. Care planning interventions should address this risk by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the president's health and/or safety. The facility should advise residents of the risks of leaving the facility to seek out substances and/or early, unplanned discharge, and provide appropriate referrals and discharge instructions whenever possible. Facilities are responsible for identifying and assessing a resident's risk for leaving the facility without notification to staff and developing interventions to address this risk. A situation in which a resident with decision-making capacity leaves the facility intentionally would generally not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. A resident who leaves the facility prior to his or her planned discharge, but with facility knowledge of the departure and despite facility efforts to explain the risks of leaving, would be leaving against medical advice (AMA). Documentation in the medical record should show that facility staff attempted to provide other options to the resident and informed the resident of potential risks of leaving AMA. Documentation should also identify the time the facility became aware of the resident leaving the facility. NOTE: This guidance is not intended to restrict a resident's ability to leave and return to the facility in accordance with the resident's medical orders, care plan, facility policy and §§483.10(c)(6), (f)(3), and (f)(8). Additionally, residents with SUD may try to continue using substances during their stay in the nursing home. Facility staff should assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance use such as: frequent leaves of absence with or without facility knowledge, odors, new needle marks, and changes in resident behavior such as unexplained drowsiness, slurred speech, lack of coordination, and mood changes, particularly after interaction with visitors or absences from the facility. Efforts to prevent substance use may include providing substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), alcoholic/narcotics anonymous meetings, working with the resident and the family, if appropriate, to address goals related to their stay in the nursing home, and increased monitoring and supervision The facility failed to implement effective safety measures in place to prevent elopement for one of four sampled residents (1) when she was at high-risk for elopement with motivation for absence without leave (AWOL, wants to leave without permission) and staff did not implement safety measures to prevent elopement during evening visitation and resulted Resident 1 able to successfully elope from the facility during opening exit door to let the visitor out after visitation. Failure to effectively protect and prevent Resident 1's AWOL from the facility would jeopardize her health and safety since she was unable to be found after the elopement. During a review of Resident 1's admission record indicated she admitted to the facility on 9/19/24 and had diagnoses including psychosis (is a condition of the mind or psyche that results in difficulties determining what is real and what is not real), stimulant induced psychotic disorder (is a mental disorder that occurs when a person experiences delusions or hallucinations soon after ingesting or withdrawing from a substance)and depression( is a common mental health condition that causes a persistent feeling of sadness and changes in how you think, sleep, eat and act). During a review of Resident 1's physician progress notes, dated 9/19/24, it indicated," This is a 33-year-old while female with a long history of mental illness and stimulant disorder, was admitted recently on a 5150 after she was observed on stranger doors and that babies are getting murdered. She eventually stabilized ...... She denies auditory hallucinations and has no gross delusions. She wants to go home." During a review of Resident 1's change in condition evaluation, dated 1/15/25, it indicated Resident eloped from facility. During a further review of Resident 1's interdisciplinary team (IDT, is a group of different experts who work together) notes, dated 1/16/25, it indicated at around 7:15 p.m., staff reported that resident suddenly ran out of the visitors lounge during a visit. Staff attempted to redirect resident back to the facility, but resident was not receptive while she remained in sight of staff then suddenly a white van driving by another man with Resident 1's visitor drove by her, and she went inside the van then quickly drove away from the facility. Notified the law enforcement with the van's license plate. During a review of Resident 1's minimum data set (MDS, a federally mandated resident assessment tool ), dated12/26/24, it indicated her Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) scored 15 (means a person's cognition is intact) During a review of Resident 1's risk for elopement, dated 10/15/24, it indicated she was at high risk with score of 13. During a review of Resident's long term care plan at risk for elopement related to mental illness and history of drug abuse dated 9/19/24, it indicated interventions including," If the resident is determined to be an AWOL risk, resident will be placed on close supervision." During a review of Resident 1's physician progress note, dated 1/15/25, it indicated documented," Patient went AWOL, seemingly assisted by visitor to the facility's incident..." During a telephone interview on 1/24/25, at 10:30 a.m. and 2/7/25 4:17 p.m., with the registered nurse A (RN A), RN A stated after the elopement incident happened, he notified the conservator and was being told by the conservator only Resident 1's parent approved to see her. RN A further stated, "During visitation Resident 1 had been told her visitor that she wants to go home." RN A stated, the elopement occurred on 1/15/25 at 7:15 p.m. and he called police at 7:30 p.m. when he knew Resident 1 was unable to redirect back facility. RN A confirmed should have called police right away as usually done. During an interview on 1/24/25, at 1:31p.m., with the director of social services (DSD), DSD stated visitation restriction required a physician's order, and it would need to renew at 30 days if further needed. During a telephone interview on 1/24/25, at 2:48 p.m., with Resident 1's conservator, conservator stated on 1/3/25 and 1/10/25 had been spoken with licensed vocational nurse C (LVN C) and one of staff who in charge with visitation to let them aware that Resident 1 cannot have visitors from her friend visiting her except parent. During a follow-up interview on 1/24/25, at 3:40 p.m., with the administrator (ADM), ADM verified that facility's staff did not endorse the conservator's request for Resident 1's visitation restriction to their IDT or the attending physician for follow-up the possible of visitation restriction to prevent her friends visiting her, because contraband and lighter were found inside of Resident 1's drawer which was given by her friends during visitation. During a telephone interview on 1/27/25, at 4 p.m., with the Program Director (PD), PD stated, " Resident 1 is acknowledged her substance abuse, she has poor insight with episode of anxiety and has been mentioned she wants to leave here." During a telephone interview on 1/28/25, at 9:38 a.m. and 2/7/25, at 3:25 p.m., with the certified nursing assistant B (CNA B), CNA B stated upon shift change was endorsed by CNA D and with other staff mentioning overheard Resident 1 crying to someone over the phone before 3 p.m. on 1/15/25 for, "Let me out, I want to go home." CNA B stated she supervised Resident 1 at the visitation lounge room when her visitor came in to see her on 1/15/25 at 7:05 p.m., they hugged each other intimately during visitation, so the director of nursing (DON) came in the visitation lounge to keep both of them distances. CNA B stated when the visitor about to leave while she was holding the doorknob to open then suddenly Resident 1 grabbed opportunities pushing her from the behind and ran out of the door to outside the street. CNA B further stated at that time Resident 1 sat on the black chair by sideway about seven steps away from the exit door before opening the exit door for letting visitor out. CNA B stated the elopement was planned it and she did not think too much either to ask help for providing supervision at the visitation lounge room nor to let the Resident 1 going inside the unit before her visitor out during ending the visitation since Resident 1 was at high risk for elopement and with motivation for AWOL. During an interview on 2/6/25, 10:10 a.m., with ADM, ADM stated should have provided preventive safety measures in place to prevent Resident 1's elopement and followed through the communication from Resident 1's conservator. ADM stated after the incident of elopement facility started to revise their policies and procedures and changed from one person to two persons for supervising during visitation and would let the resident back to unit first and then to let the visitor out during ending the visitation. During a review of the facility's policy and procedure (P&P) titled," Policy and Procedure for Elopement And AWOL." dated 10/15/24, the P & P indicated," The facility shall take the following steps to identify, prevent, detect and respond to situations of resident elopement/ AWOL. Staff shall not open the exit doors if a resident is in the close proximity of the door." The facility failed to implement safety measures to prevent elopement. This violation had a direct or immediate relationship to the health, safety, or security of the residents.