Other·October 8, 2021

The following reflects the findings of the California Department of Public Health during the investigation of Complaint Number 740116 and Facility Reported Incident Number 740329. Representing the Department: 38993, HFEN State Citation B was written. Health & Safety §1424 (4) A class "B" citation is subject to a civil penalty in an amount not less than one hundred dollars ($100) and not exceeding two thousand dollars ($2,000) for each and every citation. Class "B" violations are violations that the state department determines have a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents, other than class "AA" or "A" violations. Unless otherwise determined by the state department to be a class "A" violation pursuant to this chapter and rules and regulations adopted pursuant thereto, any violation of a patient's rights as set forth in Sections 72527 and 73523 of Title 22 of the California Code of Regulations , that is determined by the state department to cause, or under circumstances to be likely to cause, significant humiliation, indignity, anxiety, or other emotional trauma to a patient is a class "B" violation. A class "B" citation shall specify the time within which the violation is required to be corrected. If the state department establishes that a violation occurred, the licensee shall have the burden of proving that the licensee did what might reasonably be expected of a long-term health care facility licensee, acting under similar circumstances, to comply with the regulation. If the licensee sustains this burden, then the citation shall be dismissed. On 6/17/21, an unannounced visit was made to the facility to investigate a complaint and a facility reported incident regarding the elopement (leaving a health care facility unsupervised and undetected when doing so may present an imminent threat to resident's health or safety) of Resident 1. The facility failed to ensure Resident 1's safety when staff failed to provide supervision and were unaware Resident 1 had exited the facility through an unalarmed door. This failure resulted in Resident 1 being located a block away from the facility by local law enforcement and transferred to the acute hospital. Resident 1 was a 70-year-old female who was admitted to the facility on 12/19/2019. Diagnoses included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder, single episode, unspecified (persistently depressed mood and long-term loss of pleasure or interest in life). During a review of the "Report of Suspected Dependent Adult/Elder Abuse" (SOC 341), dated 6/17/21, the SOC 341 indicated, "Public Guardian received a call from (Tulare) County Crisis on 6/14 stating that [Resident 1] was in the ER [emergency room]. [Resident 1] was placed on a 5150 [allows a person with a mental illness to be involuntarily detained for a 72-hour psychiatric hospitalization] hold at approximately 11:30 p.m. on 6/13 after the Police Department received reports of her wheeling herself in traffic from 10-11 pm. . .I contacted [facility] at 8:30 am on 6/14 and spoke with SW [social worker] who stated she was not aware that [Resident 1] has eloped from the facility. . .I received a call from Administrator who reported she was attempting to speak with the night shift to get more details but at this time they were not aware of when she left the facility. They believe that [Resident 1] left through a side door. All doors have a buzzer to alert staff. The facility will be installing louder buzzers." During a review of Resident 1's hospital "Encounter Form" (details of visit to medical facility), dated 6/13/21, the Encounter Form indicated, "Enc [encounter] Start Date Time 6/13/21 Time 22:52 [10:52 PM]." During a review of Resident 1's hospital "Emergency Documentation," dated 6/13/21, at 23:14 [11:14 PM], the Emergency Documentation indicated, BIBA [brought in by ambulance] for 5150 per VPD [Visalia Police Department, local law enforcement]. Pt [patient] unable to care for herself." During a review of Resident 1's "Elopement Risk Assessment," dated 3/16/21, at 4:20 PM, the Elopement Risk Assessment indicated, "Diagnoses. . .Dementia [loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life] in oth [other] diseases classd [classified] elswhr [elsewhere] w/o [with out] behavrl [behavioral] dis [disturbance]. . .Bipolar disorder [psychiatric illness], unspecified. . .Major depressive disorder, single episode, unspecified. . .Anxiety disorder, unspecified. . .Moderate intellectual disabilities. . .Behaviors. . .Anger regarding facility placement. . .packing belonging. . .verbal statements about leaving. . .Contributing factors. . .Anxiety Disorder. . .Psychiatric Diagnosis. . .Evaluation Based on Assessment, does resident present an elopement risk? Yes. . ." During a review of Resident 1's facility "Progress Notes," dated 6/15/21, at 1:48 PM, the Progress Notes indicated, "IDT [Interdisciplinary Team-professionals that plan, coordinate and deliver personalized care] team met to discuss the current plan of care for resident. . .staff was notified by Public Guardian, that resident was in the acute [hospital], picked up by VPD/American Ambulance. . .per acute report, no injuries admitted back to facility, on 6/14/21, @ [at] 1730 [5:30 PM]." During an interview on 6/17/21, at 4:43 PM, with Administrator, Administrator stated, on 6/14/21, at 8:30 AM, Social Service Director (SSD) received a phone call from Public Guardian informing the facility Resident 1 was found by local law enforcement and taken to the acute care hospital on the night of 6/13/21. Administrator stated, the facility called the hospital and verified that Resident 1 had arrived via ambulance in the emergency room on 6/13/21 at approximately 11:30 PM. Administrator stated, during the facility's investigation it was discovered Resident 1 was last seen by a staff member on 6/13/21 between 9-10 PM. Administrator stated, staff were expected to do rounds (visually check on resident) at least every two hours and should have set eyes on each resident. During an interview on 6/17/21, at 6:45 PM, SSD stated, on 6/14/21, at approximately 8:20-8:30 AM, she received a phone call from Public Guardian stating Resident 1 had been found on 6/13/21 by local law enforcement and transported to the acute hospital by ambulance. During an interview on 6/17/21, at 5:11 PM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated, Resident 1 liked to go to the front of the building to the dining room and the small dining room/activity room that lead to the smoke area. CNA 2 stated, Resident 1 would stay there sometimes all night. CNA 2 stated, staff were responsible to check on each of the residents every one to two hours to make sure they are where they are supposed to be. During an interview on 6/17/21, at 5:28 PM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, she worked the AM shift (6:30 AM-3 PM) on 6/14/21 and was assigned to Resident 1. LVN 3 stated, when doing rounds with the off going shift (at approximately 6:30 AM) Resident 1 was not in her room and LVN 1 had told her that Resident 1 was wandering around the facility. LVN 3 stated, at approximately 7:45 AM she went to administer medications to Resident 1 and Resident 1 was not in her room, so she skipped Resident 1 and went to find her at the end of her medication pass (at approximately 8:20 AM). While looking for Resident 1 she was notified of Resident 1's elopement. During an interview on 6/17/21, at 5:57 PM, with CNA 3, CNA 3 stated, Resident 1 stayed in the hallway most of the time and only went to her room to use the bathroom. CNA 3 stated, the staff are expected to set eyes on the residents at least every two hours to ensure they are where they are supposed to be. During an interview on 6/17/21, at 6:01 PM, with Director of Nursing (DON), DON stated, all the facility doors had alarms except the dining room door. DON stated, Resident 1 left through the door in the dining room. During an interview on 6/17/21, at 6:03 PM, with LVN 4, LVN 4 stated, Resident 1 slept in her wheelchair and would go up front and hide, to avoid care. LVN 4 stated, Resident 1 exited the facility through an unalarmed door in the dining room that provided access from facility grounds. LVN 4 stated, staff are expected to check on the residents every 2 hours. During an interview on 6/21/21, at 8:55 PM, with LVN 2, LVN 2 stated, she was working the night Resident 1 eloped. LVN 2 stated, Resident 1 preferred to stay in the front hallway and only went to her room to use the bathroom. LVN 2 stated, she did not see Resident 1 during her shift. LVN 2 stated, the residents are supposed to be checked on every two hours and as needed. During an interview on 6/21/21, at 9:25 AM, with LVN 1, LVN 1 stated, she started her shift at 6:30 PM and was assigned to Resident 1 the night she eloped. LVN 1 stated, she last saw Resident 1 between 6 PM and 9 PM and no one reported Resident 1 was missing. LVN 1 stated, Resident 1 liked to sleep in the front of the facility in her wheelchair and she would normally not see Resident 1 through the night. LVN 1 stated, Resident 1 left the facility through the dining room door that provided access to the alley. LVN 1 stated, the dining room doors did not have alarms on them. During an interview on 6/21/21, at 1:40 PM, with CNA 4, CNA 4 stated, he last saw Resident 1 between 10:25 PM and 10:30 PM on the night she eloped from the facility. CNA 4 stated, staff are supposed to visually put eyes on the residents every two hours. During a review of the facility's policy and procedure (P&P) titled "Routine Resident Checks" dated 7/13, the P&P indicated, "Staff shall make routine resident checks to help maintain resident safety and well-being. . .2. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify and change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc. . .4. The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. . ." In violation of the above cited, the facility failed to ensure Resident 1's safety when staff failed to provide supervision and were unaware Resident 1 had exited the facility through an unalarmed door. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.