Other·October 25, 2023

42 CFR §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. Free of Accident Hazards/Supervision/Devices 42 CFR §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 42 CFR §483.5 Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. California Code of Regulations, title 22, § 72311(a)(1) and(a)(2) (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, § 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. The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident number 848742 and complaint number 848874. On 7/18/2023 at 10:20 AM, an unannounced visit was conducted at the facility to investigate a facility reported incident and complaint regarding Resident 1's elopement. Resident 1 was 68 years old, admitted on 2/15/2022 with diagnoses of Metabolic Encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), Cerebral Infarction (disrupted blood flow to the brain), Dementia (memory loss), Mood Disturbance (mental disorder), and anxiety, Schizoaffective Disorder (Mental Disorder), Major Depressive Disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities), Muscle Weakness, and Difficulty Walking. Based on observation, interview, and record review, the facility failed to supervise and monitor one of three sampled residents (Resident 1) who was an at risk for elopement, when Resident 1 was outside of the facility during hot weather. This failure resulted in Resident 1 eloping (to leave a healthcare facility without permission, authorization, or supervision) and being admitted to the hospital for two days due to heat stroke (a heat-related illness, occurs when the body can no longer control its temperature and the body's temperature rises rapidly). Findings: During a review of the facility's "Risk Review Note (RRN-summary of investigation)," dated July 6, 2023, the "RRN" indicated, "[On 7/4/23] Resident [1] was observed by staff member to be sitting in the wheelchair in the front patio with another resident at approximately 4:10 p.m. Was noted to have left the premises at approximately 4:35 p.m. At approximately 5:10 p.m., fire department alerted staff he [Resident 1] was being transported to hospital after he was found in close by neighborhood." During an observation on 7/18/23 at 10:20 a.m., at the front patio of the facility, there was no fence and was open to the street, there were three random residents, propelling themselves via wheelchairs, and front wheel walker by the sidewalk of the facility. No staff were observed supervising the residents. During an interview on 7/18/23 at 10:25 a.m., with Director of Nursing (DON), DON stated, "He [Resident 1] was sitting outside, from there [Social Services Designee/Certified Nursing Assistant (CNA) 1] noticed he was not here. The cops [police] came and told us they were taking him [Resident 1] to the hospital, he was admitted to the hospital for two to three days for heat exhaustion. Police and fire department alerted staff at 5:10 p.m. The resident [1] was a couple of blocks away in a nearby neighborhood." During an observation on 7/18/23 at 11:17 a.m., in Resident 1's room, Resident 1 was sitting in a wheelchair beside his bed. Resident 1's speech was garbled (unclear/distorted). Unable to be interviewed and had a limited mobility due to right arm weakness and difficulty walking. During an interview on 7/20/23 at 2:32 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, "Around 4 p.m., he [Resident 1] went outside [at the front patio]. At 4:35 p.m., we noticed he [Resident 1] wasn't outside. At 4:45 p.m., we got notification that EMS [Emergency Medical Service-also known as ambulance or paramedic services, are emergency services that provide urgent pre-hospital treatment, and stabilization for serious illness and injuries and transport to hospital] called and EMS stated they were taking him to the hospital." During a review of Resident 1's "Minimum Data Set (MDS-assessment tool)," dated May 26, 2023, the "MDS" indicated, Resident 1's Brief Interview for Mental Status (BIMS) score was 7 (a score of 0-7 means severe cognitive impairment) out of a total possible score of 15. Resident 1's MDS section G (Functional Status) dated July 18, 2023, was reviewed. The MDS indicated, Resident 1 required extensive assistance (full staff support) with one to two persons physical assist with Activities of Daily Living (ADL's- including but not limited to Transfer, Dressing, Eating, Toilet use, and Bathing). During a review of Resident 1's "Progress Notes," dated July 18, 2023, the "Progress Notes" indicated, "Admission Date: 2/25/22. Diagnoses: Metabolic Encephalopathy [a problem in the brain caused by a chemical imbalance in the blood], Cerebral Infarction [lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off], Cognitive Communication Deficit [speech impairment], Dementia [memory loss], Unsteadiness on feet, Psychotic Disturbance [severe mental disorders that cause abnormal thinking and perceptions], Mood Disturbance [feelings of distress], Anxiety Disorder [excessive feelings of worry], Schizoaffective Disorder [mental disorder], and Difficulty in walking." During a concurrent interview and record review on 8/3/23 at 3:30 p.m., with DON, Resident 1's "Treatment Administration Record (TAR)," dated July 2023 was reviewed. The TAR indicated, on 7/4/23 at 4:00 p.m. hourly check, the resident was on the (outside) patio. DON stated, "At 4:35 p.m., family arrived, resident [1] was not in his room, and we started searching. At 5:10 p.m. the fire department [fire rescue service personnel] arrived and made the facility aware that resident [1] had been located and was being taken to the hospital." During an interview on 8/8/23 at 2:55 p.m. with SSD/CNA 1, SSD/CNA 1 stated she was assigned to monitor (check/watch) Resident 1 on 7/4/23 but did not witness him (Resident 1) leave the facility. SSD/CNA 1 stated, "I don't know what was the temperature that day [7/4/23], but it was hot that day." According to the Weather Channel (weather.com), on 7/4/23, [at the location of the facility] had a temperature, Record High of 112° F (Fahrenheit-temperature measurement), and noted when the heat index reaches above 97° F, it's dangerous, and it can cause sunstroke, muscle cramps and heat exhaustion. During an interview on 8/11/23, at 5:05 p.m., with DON, DON stated, "No hydration assessment was done [when Resident 1 was outside at the patio]. All departments [heads] participate in rounding however due to being a holiday [7/4/23], no management [department heads] was in the facility. Social Services Designee was his CNA [SSD/CNA 1] that day." During a review of Resident 1's "Care Plan," undated, the "Care Plan" indicated, "The resident is an elopement risk r/t [related to] history of attempts to leave the facility unattended, impaired safety awareness. Interventions: Distract resident from wandering, monitor for fatigue [exhaustion], provide structured activities." During a review of Resident 1's "EMS [Emergency Medical Service/Ambulance] Care Summary (ECS)," dated July 4, 2023, the "ECS" indicated, "at 5:13 p.m., [Resident 1's] blood pressure [pressure of circulating blood against the walls of blood vessels] was 160/100 [normal blood pressure is below 120/80]. Heart rate was 160 [normal heart rate is 60 to 100 beats per minute]. Temperature was 100.2 degrees [normal body temperature is 97.6 - 99.6 degrees] Fahrenheit [unit of measurement]." During a review of hospital records of Resident 1, the "Emergency Department Note (EDN)," dated July 4, 2023, the "EDN" indicated, "Ambulance offload time 7/4/2023 at 5:49 p.m. Vital signs are notable for Tachycardia [increased heart rate] of 142 beats per minute, febrile [elevated temperature] at 101.1 degrees Fahrenheit. Final Diagnosis: Heat Stroke and sunstroke [a severe heat illness that results in an elevated body temperature]. Altered Mental status [Confusion]. Disposition [plan]: admit to observation." During a review of hospital records of Resident 1, the "History and Physical Report (H&P)," dated July 4, 2023, the "H&P" indicated, "[Resident 1's] chief complaint was heat exposure, pt [Patient - Resident 1] was found outside sitting on wheelchair for unknown amount of time. GCS [Glasgow Coma Scale-a scale used to objectively describe the extent of impaired consciousness of trauma patients] of 9 [score of 9-12 means moderate impairment], pt [Patient - Resident 1] is nonverbal. PT [Patient - Resident 1] is Tachycardic [increased heart rate] in the 150's [normal heart rate is 60 - 100]. Assessment/Plan: Altered mental status [confusion], Heat Stroke." During a review of Resident 1's hospital records "Discharge Summary (DCS)", dated July 6, 2023, the "DCS" indicated, "Dates of service: 7/4/23 to 7/6/23 [stayed two days in the hospital]. Diagnosis: Heat Stroke." During a review of the facility's policy and procedure titled, "Safety and Supervision of Residents," dated 2017, the P&P indicated, "The care team shall target interventions to reduce individual risk related to hazards in the environment, including adequate supervision." During a review of the facility's policy and procedure (P&P) titled, "Resident Hydration and Prevention of Dehydration," dated 2017, the P&P indicated, "Nurses will assess for signs and symptoms of dehydration during daily care. Nurses' aides will provide and encourage intake of bedside, snack, and meal fluids." The facility failed to provide supervision for Resident 1 while outside the facility. This failure resulted in Resident 1 eloping which resulted in Resident 1 sustaining heat stroke related physical symptoms that required hospitalization. This violation presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and is a class A citation.