Health inspection·February 20, 2025

The following reflects the findings of the California Department of Public Health during the investigation of Complaint #: CA00937990 Survey Event ID: Q88D11 Representing the Department, HFEN #50925 State Citation B was written Code of Federal Regulations, Title 42, Section §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. California Code of Regulations, Title 22, Section 72311. Nursing Service--General. (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. California Code of Regulations, Title 22, Section 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 1/22/25, the department conducted an unannounced visit to investigate a complaint regarding an elopement incident. The department determined the facility failed to ensure Resident 1's elopement (the act of leaving a facility unsupervised and without prior authorization) prevention were implemented when: 1. Resident 1 had exit seeking behaviors on 11/19/25 but orders for a wander guard device (an alarm that alerts the facility when a wandering resident tries to leave the facility unattended) and monitoring for wandering behavior were not initiated according to Resident 1's care plan, and an elopement risk assessment was not completed; 2. Resident 1's wander guard was not working when the elopement happened on 12/15/24; and, 3. Resident 1's charting for monitoring wander guard placement (where the device is on the body) was not consistently documented for the months of December 2024 and January 2025. These failures led to Resident 1's elopement which resulted in a head injury in the facility's parking lot, and a visit to a hospital where Resident 1 received eight stitches for the cut on the forehead. 1. Resident 1 was admitted to the facility with diagnoses which included dementia (a progressive state of decline in mental abilities), generalized muscle weakness, and history of falling. During a concurrent interview and record review with Licensed Nurse (LN) 2 on 1/22/25, at 9:50 a.m., Resident 1's exit seeking care plan was reviewed. LN 2 confirmed that Resident 1 had a care plan for exit seeking behavior due to wandering aimlessly that was initiated on 11/19/24. LN 2 stated that if a resident had wandering behavior the resident's doctor should be notified and an order for a wander guard would be obtained. LN 2 stated when an order was in place for a wander guard it would pop up (in the resident's medical record) for each nurse to check if the wander guard was in place on the resident and was active. LN 2 confirmed that Resident 1 did not have an order for wander guard placement when the wandering behavior started on 11/19/24. During a concurrent interview and record review with LN 3, on 1/22/25, at 10:28 a.m., Resident 1's exit seeking care plan and the facility's high risk for elopement binder kept at the receptionist's desk were reviewed. LN 3 stated Resident 1 was sitting in her wheelchair telling staff that she wanted to go home and was trying to look for exits on 11/19/24. LN 3 confirmed that the care plan initiated on 11/19/24 for the exit seeking behavior included frequent monitoring and placement of a wander guard device under the "interventions." LN 3 confirmed that there should have been an order obtained for the wander guard when the change in behavior happened on 11/19/24. LN 3 stated it would have been important to have an order for the wander guard and monitoring in place when the behavior started on 11/19/24. LN 3 stated that if a resident had an order in place for a wander guard the nurse would check for placement of the device on the resident and the expiration date every shift. LN 3 stated that Resident 1 was especially at risk of elopement due to her dementia. LN 3 stated at the time of Resident 1's elopement (on 12/15/24) there was not a receptionist sitting at the front desk like there usually was. The facility's high risk for elopement binder kept at the receptionist's desk was reviewed with LN 3. The binder revealed a face sheet (personal information about the resident) and photo for Resident 1. LN 3 stated the binder was to notify reception staff about residents who were at risk of eloping. A review of Resident 1 ' s exit seeking care plan, initiated on 11/19/24, indicated " ...Focus ...[Resident 1] exit seeking behavior r/t [related to] [Resident 1] wanders aimlessly ...Goal ...[Resident 1] will not leave facility unattended through the review date ...Interventions ...Monitor location every ...1 hr [hour] Document wandering behavior and attempted diversional interventions in behavior log ...WANDER ALERT [wander guard] ..." During a concurrent interview and record review with the Director of Nursing (DON), on 1/22/25, at 3:32 p.m., Resident 1's medical record was reviewed. The DON stated it was her expectation that if a resident was determined to have wandering behavior, then an elopement risk assessment should have been initiated and orders should have been obtained for wander guard placement and behavior monitoring (for exit seeking). The DON confirmed that there was no elopement risk assessment, and no orders for both the wander guard placement and behavior monitoring when Resident 1's wandering behavior started on 11/19/24. During an interview with Resident 1's doctor (MD), on 1/23/25, at 3:44 p.m., the MD stated that he recalled the change of condition initiated in November 2024 due to Resident 1 verbalizing wanting to go home but did not clearly remember if the facility's staff requested an order for the wander guard at the time. The MD stated that it was his expectation for the facility to initiate interventions including obtaining the order for the wander guard and elopement behavior monitoring if exit seeking behaviors were present. 2. During a concurrent observation and interview with Resident 1, on 1/22/25, at 9:13 a.m., Resident 1 stated that she was heading out to the parking lot in her wheelchair (on 12/15/24) and the wheel hit the curb, and she fell out of the wheelchair and hit her forehead. Resident 1 motioned to the right side of her forehead. Resident 1 stated she was feeling alright now but was still a little sore. Resident 1 was observed with a healed scar on the right side of the forehead. During an interview with CNA 2, on 1/22/25, at 9:15 a.m., CNA 2 stated that the current wander guard was placed on Resident 1 on 12/16/24, but previously Resident 1 had a wander guard that was not working. CNA 2 stated that he worked on the day of the elopement (12/15/24) and everyone was busy that morning. CNA 2 stated that Resident 1 fell in the parking lot and was sent out to the hospital on the same day. CNA 2 stated that the nurses were the ones who document in the resident's chart for the presence of the wander guard and the CNA also "checks" if the wander guard was on. CNA 2 stated that it was important to ensure that the wander guard was functional because of the risk of elopement that could cause accidents or harm to residents. During an interview with LN 4 on 1/22/25, at 2:27 p.m., LN 4 stated that she was the nurse assigned to Resident 1 when the elopement happened on 12/15/24. LN 4 stated that Resident 1 verbalized a lot about needing to leave the facility and would like to sit by the nurse's station. LN 4 stated that Resident 1 had a wander guard on before the elopement incident. LN 4 stated that she was passing medications at the end of the hallway when the elopement happened at about 9:20 AM, when the housekeeping staff came running to LN 4 yelling and stating that Resident 1 was bleeding. LN 4 stated that Resident 1 was seen by housekeeping staff who was driving through the facility's parking lot when Resident 1 fell off the wheelchair. LN 4 stated that Resident 1 was already sitting on her bottom when she arrived and saw that Resident 1 had a deep gash to her right forehead with lots of bleeding. LN 4 stated that she cut off Resident 1 ' s wander guard before the paramedics came and transported Resident 1 to the hospital. LN 4 stated that Resident 1 received stitches at the hospital and came back the same day around 5 p.m. LN 4 stated that she immediately called the DON and had read the expiration date on the wander guard, which was expired, dated September 2022. LN 4 stated that she tested the wander guard by the door and the alarm did not go off. LN 4 stated that Resident 1 did not have an order in place for the wander guard before the elopement but Resident 1 had the wander guard in place. LN 4 stated that the wander guard was for resident's safety. LN 4 stated it was important for the wander guard to be in place, functioning, and not expired to avoid any accidents. LN 4 stated Resident 1 had been seen by staff 5-10 minutes prior to the incident and if there was an order in place for a wander guard and an order for monitoring, then staff would have been checking the wander guard's functionality, and the incident may have been prevented. A review of Resident 1's discharge document titled "Discharge Instructions Document," dated 12/15/24, indicated, " ...You were seen today for a fall and a laceration of the forehead ...I put 8 stitches in your forehead for the cut ..." A review of Resident 1's physician order, dated 12/16/24, indicated, " ...Wander guard placement secondary to: (Elopement/exit seeking behavior). Monitor for placement every shift ..." During an interview with the Director of Nursing (DON), on 1/22/25, at 3:32 p.m., the DON stated that Resident 1 had a wander guard on at the time of the elopement and that the nurse told her that the wander guard did not go off. The DON stated that the Maintenance person mainly checked the wander guard devices, but the nurses also checked for the functionality as well. The DON confirmed that Resident 1 had a care plan in place that was started on 11/19/24 that included the wander guard as an intervention. The DON stated that the risk of the wander guard not working was resident elopement. The DON stated that the resident's safety was important and that the staff were expected to follow interventions to prevent elopement. The DON confirmed that the LN should have obtained orders for a wander guard, behavior monitoring, and completed an elopement screening when Resident 1's behavior of wanting to the leave the facility was determined on 11/19/24. The DON stated that this incident could have been prevented if orders were in place to ensure staff were monitoring Resident 1's wander guard placement and exit seeking behaviors. 3. During an interview with LN 1, on 1/22/25, at 9:23 a.m., LN 1 stated that the nurse was responsible for checking the wander guard placement and expiration date of the device every shift. During a concurrent interview and record review with LN 2 on 1/22/25, at 9:50 a.m., LN 2 stated that the nurses were charting for wander guard placement in the electronic medical record under a section for devices. LN 2 stated that if there was an order in place, it would pop up for each nurse to check if the wander guard was in place and active. A review of Resident 1's monthly report to monitor for wander guard placement every shift with a start date of 12/16/24, indicated the following dates without any documentation: 12/17/24 evening and night shift, 12/19/24 day shift, 12/20/24, 12/21/24 and 12/22/24 day and evening shifts, 12/23/24, 12/24/24 day shift, and 12/25/24 day and night shifts, 12/26/24 and 12/27/24 day and evening shifts, 12/28/24 day, evening and night shifts, and 12/29/24 day shift. The monthly report for the month of January 2025, indicated the following dates without any documentation: 1/1/25 and 1/2/25 day and evening shift, 1/3/25 day shift, 1/4/25 day and night shift, 1/5/25 and 1/6/25 day shift, 1/10/25 day and evening shift, 1/13/25, 1/14/25, 1/15/25, 1/17/25, 1/19/25, 1/20/25 and 1/21/25 day shifts. During a concurrent interview and record review with the DON, on 1/22/25, at 3:32 p.m., Resident 1's monthly report on monitoring for wander guard placement for December 2024 and January 2025 was reviewed. The DON confirmed that there were several days on both months that did not have documentation. The DON stated that her expectation was for staff to have monitored and charted according to the order to make sure that all orders were being followed and completely documented. During an interview on 1/22/25, at 1:21 p.m., the Administrator (ADM) stated that he could not determine where the November and December 2024 logs were which showed the wander guard devices functionality were being checked by the maintenance department. During an interview with Resident 1's doctor (MD) on 1/23/25, at 3:44 p.m., the MD stated that he was notified of the elopement but was not aware that the wander guard was not working on 12/15/24. The MD stated that if the wander guard was checked and if it was working, an alarm would go off and the facility staff would have acted on it promptly. The MD stated that the facility should have monitored Resident 1 due to the wandering behavior and made sure that the wander guard was in place and functional. The MD further stated that the facility should look after resident's safety and should be proactive to prevent accidents. A review of the facility document titled "Wander Management Transmitters User Guide," dated 11/18, indicated, " ...Each transmitter is stamped with a warranty expiration date. This date indicates the date that...warranty on that transmitter expires. If the warranty period has expired, discard the transmitter immediately ...WARNING: Using a transmitter beyond the printed expiration date can result in system failure and/or elopement ...Visual Inspection ...1. Verify that the warranty expiration date that is stamped on the transmitter is not expired ...Weekly Testing ..." Therefore, the department determined the facility failed to ensure Resident 1's elopement preventions were implemented when the functionality of the wander guard was not checked per manufacturer's instruction, and an order for wander guard was not obtained from the MD. These failures led to Resident 1's elopement which resulted in a head injury in the facility's parking lot, and a visit to a hospital where Resident 1 received eight stitches for the cut in her forehead. This violation had a direct or immediate relationship to the health, safety, or security of Resident 1.