Health inspection·March 30, 2023

The following reflects the findings of the California Department of Public Health during the investigation of Facility Reported Incident (FRI) No: CA00819635 which resulted in a dual State Class A citation. Representing the California Department of Public Health: Surveyor 38660, HFEN. 42 CFR § 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 1/18/23, the California Department of Public Health (CDPH) conducted an onsite investigation in response to the FRI related to a resident's elopement and death. The facility failed to ensure one of two sampled residents (Resident 1) remained free from accident hazards. Resident 1 had a history of elopement and left the facility multiple times without notifying the nursing staff. The facility's back door area had direct access to the street and did not have a camera or alarm system to set off if someone entered or exited the building. The facility failed to: 1. Ensure the gate on the smoking patio was properly monitored by the staff or alarmed. 2. Ensure the facility's P&P titled Elopement - Policy and Assessment was implemented for Resident 1, including ensuring the resident wore an identification (ID) bracelet. 3. Ensure Resident 1 signed in and out of the facility. As a result, Resident 1 eloped from the facility and was hit by a car. Paramedics transported Resident 1 to an acute care hospital where the resident passed away. Findings: Review of the facility's P&P titled Elopement - Policy and Assessment (undated) showed elopement is defined as slipping away secretly, running away, leaving without accompaniment or knowledge of the staff. Residents whose assessments identify wandering behaviors shall also be considered at risk for elopement. If a resident is identified at risk for elopement, the following steps will be taken: - The resident's care plan shall address behavior using resident specific goals and/or approaches as assessed by the interdisciplinary team. - An ID bracelet containing the facility address and phone number will be placed on the resident for ease of identification should successful elopement occurs. - A current picture of the resident will be maintained in the facility. - Facility staff will ensure that all exit alarms are responded to immediately. Further review of the policy showed the residents with an elopement incident from the facility either on or off the grounds shall be considered at higher risk for further attempts at elopement. These residents will have the following precautionary measures implemented to prevent repeat incidents of elopement. - Resident will wear an alarm bracelet (in all facility with this monitoring capability) to alert staff if he/she is trying to leave the facility. The bracelet will be checked for proper function at least every shift to assure that it is functional, and checks will be logged. - Implement Visual Check Sheet or Medication Administration Record (MAR) monitoring as ordered by physician or per the facility protocol. - Staff will encourage activities which the resident enjoys in order to occupy the resident. - Resident's wandering episodes will be tracked and resident specific approaches/interventions added to the care plan as determined effective by the interdisciplinary team. - If exacerbation of the behavior continues, 1:1 supervision will be considered until the physician can assess the resident for cause. - Family or responsible party will be notified of exacerbation of this behavior. - Binder at each station for those residents identified at risk for elopement to alert staff of the behavior and for monitoring. - In the unlikely event the resident is missing from the facility, the elopement policy will be initiated. Closed medical record review for Resident 1 was initiated on 1/18/23. Resident 1 was admitted to the facility on 2/5/14, and readmitted on 3/10/22. Resident 1 had diagnoses of depression, was wheelchair bound with the left leg above the knee amputation (AKA), and had the right leg with severe contracture (a shortening of a muscle, tendon or scar tissue). Review of Resident 1's History and Physical Examination dated 3/4/22, showed Resident 1 had a diagnosis of depression with the left leg AKA. Review of Resident 1's Minimum Data Set (MDS) dated 11/19/22, showed Resident 1 was cognitively intact. Resident 1 required two-person extensive assistance for transfers and was independent to move and return from off unit locations. Review of Resident 1's Elopement/Wandering Evaluation dated 11/24/22, showed Resident 1 was mobile in wheelchair with a history of elopement one to two times and expressed a desire to leave the facility. Review of Resident 1's care plan problem dated 7/16/19, and last revised 8/10/22, showed Resident 1 had a history of elopement and was at risk for further elopement episodes as Resident 1 attempted to maintain leisure interests not consistent with the facility's current environment. The care plan problem further showed Resident 1 was at risk for injury and other complications related to being wheelchair bound and having poor mobility. The goals were for Resident 1 to not leave the facility unattended and remained safe. Closed medical record review for Resident 1 was initiated on 1/18/23. Resident 1 was admitted to the facility on 2/5/14, and readmitted on 3/10/22. Resident 1 had diagnoses of depression, was wheelchair bound with the left leg AKA, and had the right leg with severe contracture (a shortening of a muscle, tendon or scar tissue). Review of Resident 1's History and Physical Examination dated 3/4/22, showed Resident 1 had a diagnosis of depression with the left leg AKA. Review of Resident 1's MDS dated 11/19/22, showed Resident 1 was cognitively intact. Resident 1 required two-person extensive assistance for transfers and was independent to move and return from off unit locations. Review of Resident 1's Elopement/Wandering Evaluation dated 11/24/22, showed Resident 1 was mobile in wheelchair with a history of elopement one to two times and expressed a desire to leave the facility. Review of Resident 1's care plan problem dated 3/10/22, and last revised 11/24/22, showed Resident 1 was at risk for repeated falls and injuries related to physical impairment, poor balance, left leg AKA, right leg with severe contracture, opioid (a class of drugs to reduce pain) medication, and multiple comorbidities. Review of Resident 1's Order Summary Report showed an order dated 4/20/22, for Resident 1 to go out on pass for a few hours for therapeutic purposes and an order dated 5/6/22, to have a location device attached to the resident's wheelchair. Review of Resident 1's medical record showed Resident 1 had multiple episodes of elopement. Resident 1 left the facility without signing out or notifying the staff on multiple occasions. For example: - Review of Resident 1's interdisciplinary team (IDT) note dated 8/12/22, showed a late entry documenting the resident left the facility and did not return until the next day. Resident 1 stated she told the staff she was going out, but the facility's Out of Pass (OOP) log had not been signed. Resident 1 was reminded to make sure she was signing out on pass and ensure her tracker was with her so the staff could monitor her location. - Review of Resident 1's IDT note dated 9/28/22, showed Resident 1 left the facility, took the bus, and did not sign out in the OOP log. Resident 1 was found in the street by staff. When asked if Resident 1 signed out, Resident 1 stated she had already signed out in the OOP log. Resident 1's tracker showed Resident 1 was in the Los Angeles area. The police department and physician were notified. Resident 1 came back at midnight. - Review of Resident 1's Progress Notes dated 10/18, 10/22, 11/1, 11/13, 11/17, 11/19, and 12/28/22, showed Resident 1 left the facility without signing the OOP log and came back in the evening or late at night. - Review of Resident 1's Progress Notes dated 12/17/22 at 0950 hours, showed Resident 1 was back from OOP overnight, without signing out. The resident was alert, awake, and able to make needs known. Resident 1 was tired, and the resident's pants were soaking wet. Review of the facility's report sent to the CDPH on 1/5/23 at 1311 hours, showed on 1/4/23, Resident 1 eloped from the facility and into the street, "most likely after dinner." Resident 1 was seen by a Certified Nursing Assistant (CNA) finishing up dinner and heard stating that the resident wanted to stay in her wheelchair for a while. At 1840 hours, somebody notified the nurses a resident got hit by a car in the street. The staff went out and saw the paramedics attending to Resident 1. Resident 1 was taken to the acute care hospital by the paramedics. The Registered Nurse (RN) supervisor verified that the paramedics brought Resident 1 to the acute care hospital and pronounced dead upon arrival. On 1/18/23 at 0915 hours, an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 was alert, oriented, with the left leg AKA, and used a wheelchair. Resident 1 refused the Wander guard (a device designed to trigger an alarm when a resident wearing it approaches a monitored door or egress) so the facility put the tracker in her wheelchair to locate the resident, but the tracker would not alarm if the resident left the facility. On 1/18/23 at 1114 hours, an interview was conducted with Resident 3. When asked about the incident, Resident 3 stated the residents could go out to the street through the gate of the smoking patio. Resident 3 stated he saw Resident 1 leaving the facility around 1637 hours. Resident 3 went back to his room and went out again when he heard someone was hit by a car. Resident 3 stated Resident 1 wheeled herself to the store, took the bus, went out overnight, and came back. Resident 3 stated that Resident 1 went out all the time. Resident 3 stated the staff would say Resident 1 was almost hit by a car at least five times before, and this time she was actually hit. On 1/18/23 at 1135 hours, an observation of the facility's smoking patio at the back of the facility facing a busy street and concurrent interview with Resident 4 was conducted. The door to the smoking patio was observed with no alarm. The residents could go in and out from inside of the facility to the smoking patio. The smoking patio had an iron fence with two gates, one gate was locked and another gate was not locked. Two residents and a staff member were observed at the smoking patio. Resident 4 was observed smoking at the patio. When asked about the incident, Resident 4 stated he knew Resident 1 was hit by a car. Resident 4 showed the gate was not locked and had direct access to the street. Resident 4 stated a resident could just open the gate to leave the facility. The residents were supposed to sign out and could go out through the back door instead of the front door where the receptionist was. Resident 4 further stated if a resident had not signed out, they still could open the gate and leave the facility. On 1/18/23 at 1205 hours, an interview was conducted with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated Resident 1 had episodes of going out without telling the staff. Resident 1 signed out when she remembered. Resident 1 stayed outside at the smoking patio a lot and left. Resident 1 would say she forgot to sign out and would sign out next time, and that she loved to go out and buy stuff. LVN 1 was asked what interventions were implemented to monitor Resident 1 to ensure the facility staff were aware when Resident 1 left the facility. LVN 1 stated the staff offered to buy things for the resident and implement the use of a Wander guard; however, Resident 1 would refuse. LVN 1 stated the nursing staff visually checked the resident every two hours. If Resident 1 had not come back from OOP, they called the police. LVN 1 was asked how long the resident could go OOP. LVN 1 stated the resident could go OOP about four hours, but Resident 1 would be out for four hours to overnight. The night shift staff called the police when Resident 1 went out overnight a couple times. Resident 1 said she slept at her friend's house and did not sign out sometimes. LVN 1 stated there was no cameras or alarm system in the smoking patio to alert the staff when the resident left the facility. On 1/18/23 at 1230 hours, an interview was conducted with CNA 1. CNA 1 stated around 1700 hours on 1/4/23, CNA 1 helped Resident 1 to the restroom and Resident 1 looked tired. CNA 1 asked if Resident 1 wanted to go to bed. Resident 1 stated she wanted to stay in the wheelchair. CNA 1 stated Resident 1 was monitored every two hours. Review of Resident 1's Progress Note dated 1/4/23 at 2015 hours, showed the facility staff were notified that Resident 1 got into an accident. The police, ambulance, bystanders and paramedics were there, and the paramedics were performing cardiopulmonary resuscitation (CPR). Resident 1's wheelchair was tumbled in the street with some belongings. The police informed the facility staff that Resident 1 did not make it and passed away. On 1/18/23 at 1400 hours, an interview was conducted with the DON. The DON was asked what interventions were implemented to alert the staff when Resident 1 was leaving the facility to ensure Resident 1 remained safe. The DON stated the tracker was attached to Resident 1's wheelchair to monitor the resident's location, and the staff visually monitored the resident every two hours documenting in a logbook. The DON was asked if there was an alarm to monitor the back door and fence door with direct access to the street to alert the staff when a resident was leaving the facility. The DON stated the back door was locked at 2200 hours. The fence door of the facility could not lock for emergency exit, but the staff was always there watching the smoking residents. The DON confirmed there was no alarm at the fence door to alert the staff when a resident was leaving the facility. The DON was asked if there were staff at the smoking patio during the incident on 1/4/23. The DON stated no one was smoking at that time. On 1/18/23 at 1400 hours, a telephone interview was conducted with the DON. The DON was asked if Resident 1 had an identification with her on the day of the accident. The DON stated Resident 1 had no identification with her when she got into the accident on 1/4/23. The DON further stated Resident 1 should have had a name tag on her or on the wheelchair. The DON was asked if the DON was aware Resident 1 crossed the street herself. The DON confirmed yes, the resident crossed the street herself sometimes. Review of the Emergency Medical Services (EMS) report dated 1/4/23 at 1829 hours, showed a female was found in the street unresponsive following auto pedestrian accident at unknown rate of speed. The resident was found 10-15 feet from her wheelchair. The resident had agonal respirations (insufficient breathing that often sounds like snoring, snorting, gasping, or labored breathing), stopped breathing, and was found to be asystole (heart stopped pumping). The resident was transported to an acute care hospital. Review of the physician's Trauma Services History and Physical examination from the acute care hospital showed on 1/4/23 at 1858 hours, the resident with the left AKA, reportedly wheelchair bound, was struck by a car. The resident had agonal respirations on scene and found to be pulseless. The resident was brought to the acute care hospital as a critical trauma and traumatic full arrest (heart has ceased beating due to blunt or penetrating trauma). The resident was declared dead at 1915 hours. Based on observation, interview, medical record review, and facility P&P review, the facilit