Health inspection·August 28, 2024

San Diego Post Acute CA00907252 CCYN11 Citation A 42 CFR §483.25(d)(2) Accidents. The facility must ensure that - Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72311(a)(1)(A)(B)(C)(2) Supervision (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (C) An unusual occurrence, as provided in Section 72541, involving a patient. 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 6/28/24, the Department received a facility reported incident (FRI) related to quality of care and resident safety. On 7/8/24, a follow up unannounced onsite to the facility was conducted. Based on Department investigation, The facility's violations were a substantial factor in the death of Resident 1. Resident 1 was readmitted to the facility on 6/10/24, with diagnoses which included schizoaffective disorder (a mental disorder characterized by a disconnection in reality) and mood disorders were present together during one episode, per the facility's Admission Record. Specifically, the facility failed to: 1. Provide adequate supervision and assistance devices to prevent resident elopement (when resident departs the health care facility unsupervised and undetected). 2. Obtain attending physician order when Resident 1 leaves facility. 3. Develop and implement a plan of care incorporating interventions to prevent resident elopement. 4. Notify licensed nurse and attending physician of Resident 1's elopement. 5. Implement facility policy and procedure related to preventing resident elopement, documenting Resident 1 leaving facility, communication after elopement or suspected elopement, and search procedure after elopement or suspected elopement and as further described in facility policy and procedure below. As a result of the failures above, Resident 1 was I able to leave the facility unnoticed by staff, was subsequently hit by a pickup truck outside the facility and died on the night of 6/27/24. Findings: A record review was conducted of Resident 1. Resident 1 was readmitted to the facility on 6/10/24, with diagnoses which included schizoaffective disorder (a condition where symptoms of both psychotic (a mental disorder characterized by a disconnection in reality) and mood disorders were present together during one episode), per the facility's Admission Record. On 7/8/24, 7/11/24, and 7/15/24, a review of Resident 1's clinical record was conducted. Resident 1's History and Physical (H & P), dated 6/11/24, indicated the attending physician (AP) documented Resident 1 was admitted to the facility for rehabilitation and Resident 1 had the capacity to understand and make decisions. Resident 1's minimum data set (MDS - an assessment tool), completed 6/21/24, indicated Resident 1's brief interview for mental status (BIMS, ability to recall) score was 12/15 (a score of 13 to 15 suggested the patient was cognitively (process of acquiring knowledge and understanding) intact, 8 to 12 suggested moderately impaired and 0 to 7 suggested severe impairment). A record review of Resident 1's physician orders were conducted. Per Resident 1's physician order dated 6/27/24 at 11:27 A.M., "Telephone order...may go oop (out on pass/leaving the facility) for 4 hours, one time only for oop for 1 Day." A record review was conducted of Resident 1's licensed progress notes. Per a licensed nurse (LN) progress note dated 6/27/24 at 6:45 P.M., LN 3 documented, "Resident observed in facility at approximately 1830 (6:30 pm) at nurse's station talking with staff, in stable condition." A record review was conducted of Resident 1's progress notes. Per a LN progress note dated 6/28/24 at 12:52 A.M., LN 4 documented, "When doing rounds noted resident is not in his room. per pm shift nurse. resident signed out himself." Per a change in condition (CIC) progress notes dated 6/28/24 at 8:57 A.M., LN 1 documented, "Nursing observations. evaluation, and recommendations are: Unable to locate resident...code green initiated, res. was not present in facility..." Code green is the facility policy/procedure implemented after a resident is suspected of elopement. A record review was conducted of Resident 1's licensed nurse (LN) progress notes. Per a LN progress note dated 6/28/24 at 9:30 A.M., LN 1 documented, "Certified Nursing Assistant (CNA) notified this nurse at approximately 0815-0830 this morning that res is not in his room. Rounds made, res is not in his room or anywhere in the facility..." On 7/8/24 at 3:22 P.M., an interview with CNA 1 was conducted. CNA 1 stated he worked on 6/28/24 from 12 midnight (MN) to 6:30 A.M., and Resident 1 was assigned to him. CNA 1 stated Resident 1 was alert, oriented, and was ambulatory without assistive devices. CNA 1 stated he did not find Resident 1 in his bed. Per CNA 1, he looked for Resident 1 in the facility, did not find him, and did not report to the licensed nurse (LN) 4 that Resident 1 was nowhere to be found. Per CNA 1, since LN 4 did not ask him to look for Resident 1, he kept his, "Assumption" that LN 4 knew Resident 1's whereabouts. CNA 1 stated the facility's policy was that when the staff did not find a resident in his/her bed, staff needed to inform the LNs, a code green was called, and the staff would look for the resident in and out of the building. CNA 1 stated he completed his shift without knowledge of a code green being initiated. On 7/8/24 at 4:39 P.M., an interview with CNA 2 was conducted. CNA 2 stated on 6/27/24, Resident 1 was assigned to him. CNA 2 stated he last saw Resident 1 around 8 P.M. at the nurses' station talking with LN 2. CNA 2 stated he left around 10:30 P.M. and did not check if Resident 1 was in his bed because Resident 1's door was closed. CNA 2 stated Resident 1 would regularly go out of the facility around 6 P.M. and came back around 9-9:30 P.M. to sleep. CNA 2 stated, "Sometimes he stays out longer, we don't see him until the next day. If I leave at 10:30 P.M., the time I will get to see him is when I come back the next day. I work 8 hours." CNA 2 stated from 8 -10:30 P.M., no code green was called. On 7/8/24 at 2:07 P.M., a joint review of Resident 1's clinical record and an interview with LN 1 was conducted. LN 1 stated she was familiar with Resident 1 going OOP. LN 1 stated the facility's process was when a resident went out on pass, LNs would have to assess the resident, obtain a physician's order, sign the resident in and out, document in the binder titled Leave of Absence (LOA - going out on pass to leave the facility), and document in the resident's progress notes. LN 1 stated on 6/27/24, she obtained an order from Resident 1's AP for OOP and knew Resident 1 left during her shift. LN 1 stated on 6/28/24, on the morning shift (7 A.M to 3 P.M.), Resident 1 was nowhere to be found and a code green was initiated. On 7/11/24 at 9:48 A.M., a telephone interview with the AP was conducted. The AP stated she was not aware Resident 1 went OOP a few times a day. The AP stated the LNs should have been getting a physician's order every time residents under her care went OOP. The AP stated each OOP was applicable with each event. The AP stated, "They have to call me." The AP stated she knew Resident 1 went OOP on 6/27/24 and that he was back for dinner. The AP stated she did not know what happened until the following morning that Resident 1 was nowhere to be found. On 7/11/24 at 11:19 A.M., a telephone interview with the Social Services Director (SSD) was conducted. The SSD stated she was informed Resident 1 was not in the facility on 6/28/24 around 9-9:30 A.M. The SSD stated a code green was called at this time and a search was conducted, but the staff did not find Resident 1 in or out of the building. The SSD stated she called the Police Department and a police officer called back to inform SSD that on 6/27/24 at around 10:47 P.M., Resident 1 was crossing the street, got hit by a pickup truck, and died. On 7/11/24 at 11:58 P.M., a telephone interview with LN 2 was conducted. LN 2 stated she was familiar with Resident 1. LN 2 stated Resident 1 was not assigned to her, but she talked to him on 6/27/24 around 7-8 P.M. LN 2 stated Resident 1 was alert and oriented and walked independently. LN 2 stated the policy was for the residents to inform the LNs about going OOP, LNs then obtained a physician's order, residents signed in and out using the LOA binder, and a LN would have to sign them off. LN 2 stated with Resident 1's AP, the LNs were to get a physician's order when her residents requested to go OOP. LN 2 also stated during endorsement or change of shifts, the outgoing and the incoming LNs were to make rounds, give reports and check the residents' whereabouts. LN 2 stated on 6/27/24, she left the facility around 11:20 P.M., and on her way out, she noticed there was an accident and several police cars and officers in the street (a block away from the facility). On 7/11/24 at 12:20 P.M., a telephone interview with LN 3 was conducted. LN 3 stated she worked as a floater (move from one section of the facility to another, working in different areas). LN 3 stated she knew Resident 1 in passing and would go OOP accompanied by other LNs. LN 3 stated on 6/27/24, she worked at 3 P.M - 11 P.M. shift. LN 3 stated Resident 1 was assigned to her, and this was the second time she had him. LN 3 stated she did not consider Resident 1 an elopement risk. LN 3 stated she had seen Resident 1 walked out and come back to the facility. Per LN 3, on 6/27/24, she received a report from the morning LN that Resident 1 went OOP in the morning and that, "He will come back." Per LN 3, around 6:30 P.M., she saw Resident 1 while she was passing medications (meds). Per LN 3, during the shift change (11 PM - 7 AM), the oncoming LN (LN 4) reported to her that Resident 1 was not in his bed. LN 3 stated, "I wasn't worried, he knew that he was supposed to sign in. I was busy, I looked over and saw him there, he was back on my shift." Per LN 3, she and LN 4 did not make rounds together. LN 3 stated, "I assumed most likely he was around...he does walk around and was not an elopement risk." LN 3 stated she and LN 4 did not verify the leave of absence (LOA) binder if Resident 1 had signed out. LN 3 stated Resident 1 had meds and she did not give it since she thought Resident 1 was not in his bed. LN 3 stated there was no exit door alarm that went off during her shift. LN 3 further stated, "I assume he was asleep. To me, he was fine, he closed his room and I assume he was in his room, I should have not assumed, I learned that now. Should have I known that, we should have looked around to find him." On 7/11/24 at 1:15 P.M., a telephone interview with the security guard (SG) was conducted. SG stated on 6/27/24, he worked from 9 P.M. to 5 A.M. SG stated he last saw Resident 1 headed back to the building at around 9 P.M. Per SG, there was no code green that was called during his shift. On 7/11/24 at 3:21 P.M., a telephone interview with LN 4 was conducted. LN 4 stated he was familiar with Resident 1. Per LN 4, Resident 1 went in and out of the building any time of the day and sometimes snuck out. Per LN 4, during the change of shift on 6/27/24, he noticed Resident 1 was not in his bed and asked LN 3. Per LN 4, LN 3 told him Resident 1 signed out. LN 4 stated he did not find the LOA binder to verify if Resident 1 went OOP. LN 4 stated he lost track. LN 4 stated should LN 3 had not mentioned Resident 1 was on OOP, "We could have looked for him." LN 4 stated Resident 1 usually visited the area where he had the accident. LN 4 stated, "I passed by that area. I saw him there before." On 7/8/24 at 2:07 P.M., a joint review of Resident 1's clinical record and an interview with LN 1 was conducted. LN 1 stated Resident 1 regularly went OOP. Per LN 1, Resident 1's OOP form had incomplete documentation. LN 1 stated there were columns for residents and the LNs had to fill up which included the date, time out, scheduled return time, name of Responsible Party (RP), signature of RP, nurse initial, RP contact number, time returned, Signature of RP when returned and another column for the nurse initial. LN 1 stated and verified that Resident 1 went OOP on the following dates: - 6/13/24, Resident 1 left at 12:37 P.M., came back at 4:45 P.M. LN 1 stated the OOP form was incomplete missing the signature of RP when returned. - 6/13/24, LN 1 stated Resident 1 left again at 7 P.M. LN 1 stated there was no physician's order, and the OOP form was incomplete missing LN signature for the 7 P.M. OOP, RP signature when returned, time returned, and LN signature when Resident 1 came back after the 7 P.M. OOP. - 6/15/24, LN 1 stated Resident 1 left at 2:25 P.M., came back at 3:30 P.M. LN 1 stated there was no physician's order, and the OOP form was missing the RP signature when returned and LN signature when Resident 1 came back. - 6/16/24, LN 1 stated Resident 1 left at 11:26 A.M. LN 1 stated the OOP form was missing the scheduled return time, the nurse initial, the RP contact number, the signature of RP when returned and LN signature when Resident 1 came back. - 6/16/24, LN 1 stated Resident 1 left 4:58 P.M. LN 1 stated there was no physician's order for the 4:58 P.M. OOP and the OOP form was missing the scheduled return time, the RP contact number, the time returned, the signature of RP when returned and LN signature when Resident 1 came back. - 6/17/24, LN 1 stated there was no physician's order and the OOP form was missing the time out, the scheduled return time, RP signature when returned, time returned and the LNs signature when Resident 1 went out and came back to the facility. - 6/19/24, LN 1 stated Resident 1's OOP form had two entries. LN 1 stated the OOP form was missing the time out, the scheduled return time, the nurse initial, and the RP signature when returned. LN 1 stated she was the one who signed the resident back at 4 P.M. - 6/19/24, LN 1 stated Resident 1 left again at 5:26 P.M. LN 1 stated the OOP form was incomplete and missing the scheduled return time, the nurse initial, and the RP signature when returned. LN 1 stated she mistakenly signed the column for nurse initial. LN 1 stated there were no physician's order on both events. - 6/20/24, LN 1 stated the OOP form was incomplete and missing the time out, the scheduled return time, the nurse initial, and the RP signature when returned. LN 1 stated she was the one who signed the resident back but did not indicate the time. - 6/24/24, LN 1 stated the OOP form was incomplete and missing the time out, the scheduled return time, the nurse initial, and the RP signature when returned. LN 1 stated she was not sure whose signature was in the form if it was the RP or the LN. - 6/27/24, LN 1 stated Resident 1 left at 11:46 A.M., and was expected to return 3:45 P.M. LN 1 stated the OOP form was incomplete and missing the signature of RP, the RP contact number, the time returned and the RP signature when returned. LN 1 stated the po