Health inspection·June 27, 2024

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. 72311 Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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. 72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (12) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs. Findings: On 1/26/2024, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Patient 1 was missing from the facility. The facility failed to assess level of supervision required for safety for Patient 1, who was cognitively impaired, for elopement (when a patient leaves the premises or safe area without the facility's knowledge and supervision) risk when he attempted to leave the facility and fell at the facility's back gate (South Gate) on 6/5/2023. In addition, the facility staff did not follow the facility expectation as directed to visualize the patient every two hours. Patient 1 eloped and fell approximately one mile from the facility, and was missing for approximately 9 hours, on 1/24/2024. These failures resulted in a two-centimeter forehead laceration that required five sutures for Patient 1. Review of Patient 1's clinical record indicated Patient 1 was admitted to the facility on 3/27/2020, with diagnoses that included dementia (the loss of cognitive function-thinking, remembering, and reasoning, which interferes with a person's daily life) and paranoid schizophrenia (serious mental illness that causes disorganized thinking). A review of Patient 1's Minimum Data Set (MDS- assessment tool that measures health status in nursing home residents), dated 12/10/2023, indicated Patient 1 had a BIMS (Brief Interview for Mental Status- a tool to measure and track a resident's cognitive decline or improvement) score of 9 out of 15 (a score of 8 to 12 suggests moderate cognitive decline). A review of the Physician Order, dated 9/29/2023, indicated Patient 1 may go out of the facility on pass with a responsible party. During an interview with the Facility Administrator (FM) on 1/26/2024 at 10 AM, the FM stated the facility's staff did not know Patient 1's whereabouts on 1/24/2024 after 9:12 AM until he was returned to the facility via ambulance from the hospital at 6:40 PM. (Patient 1 was missing for approximately 9 hours). During a concurrent observation and interview on 1/26/2024 at 10:19 AM, in the facility's Activity Room, Patient 1 was observed with a bandage on his forehead, dark purple discoloration on the skin under both eyes, and an abrasion/scab along the entire length of his nose. Patient 1 was ambulatory with a walker. He had on a red color-coded ID badge. Patient 1 was alert and oriented. Patient 1 stated he walked to the nearby shopping center (approximately a one mile walk from the facility), tripped, and fell on his face in the parking lot, on 1/24/2024. He stated he was taken by ambulance to the hospital for his injuries. Patient 1 stated that he did not notify staff that he was leaving the campus, and he did not sign out when he left. Patient 1 further stated he attempted to go to the same shopping center a few months ago (on 6/5/2023) but he could not control his walker going downhill and fell by the facility's back gate. A review of Patient 1's Nursing Note, dated 6/5/2023, indicated the facility's Security Officer called at 8:50 AM to report that Patient 1 fell on the pavement at the facility's 'South Gate'. Patient 1 sustained a forehead abrasion, and skin tears on his left elbow and right fourth finger. Patient 1 stated, "I tripped from my walker, and I lost my balance." A review of the Interdisciplinary Team (IDT) Meeting Note for Patient 1's fall on 6/5/2023, indicated Patient 1 was alert and oriented to person and place, with intermittent confusion and forgetfulness. Patient 1 was found by nursing staff on the pavement outside of the South Gate (back gate). Per the patient, he wanted to go to the store to buy reading glasses, but had difficulty maneuvering his walker going downhill, lost his balance and fell on the pavement. During a concurrent interview and record review with the Standards Compliance Coordinator (SCC) on 2/14 2024 at 5:32 PM, the facility's Security Video Surveillance Record, dated 1/24/2024, indicated Patient 1's physical locations as follows: At 9:07 AM - walking through the facility's lobby past the Pharmacy. At 9:10 AM - walking on campus towards the South Gate (leads to public roads, not manned, and left opened during the day). At 9:12 AM - walking toward the South Gate, and then he walked out of camera view. The SCC stated Patient 1 left the facility's campus unsupervised on 1/24/2024 at 9:12 AM. A review of the acute care hospital's Emergency Department (ED) Record, dated 1/24/2024 at 10:40 AM, indicated Patient 1 fell down face forward and sustained a two-centimeter forehead laceration that required five sutures. During a concurrent interview and record review with the Certified Nurse Assistant (CNA 1), on 3/6/2024 at 2:55 PM, the "AM Shift Resident Monitoring Sheet," dated 1/24/2024, included documentation of Patient 1's physical locations as follows: At 7 AM -documented as "[in] Room." At 9 AM -documented as "[in] Room." At 11 AM -documented as "Around/out of POD [common area]." CNA 1 stated she did not look for Patient 1 on 1/24/2024 at 11 AM because she knew his routine. She stated that he usually went to the Canteen to buy ice cream, and then he would go back to the POD. CNA 1 stated that when she went to deliver Patient 1's lunch on 1/24/2024 at around 12:15 PM, he was not in his room, but his walker was there. CNA 1 stated she looked for him but could not find him, so she notified the nurse. During an interview with the Registered Nurse (RN 1) on 6/5/2024 at 3:20 PM, RN 1 stated she expected CNA 1 to visualize Patient 1 when she monitored and documented his whereabouts. RN 1 stated it was unacceptable to document "Around/out of POD," without actual visualization of the resident. CNA 1 should have looked for Patient 1 at 11 AM on 1/24/2024. During an interview with the Director of Nursing (DON) on 6/5/2024 at 10 AM, the DON stated CNAs were directed to observe and document the residents' whereabouts every two hours, as a "Best practice." The DON further stated it was unacceptable for CNA 1 to document Patient 1's location without direct visualization on 1/24/2024 at 11 AM. A review of Patient 1's Safety/Fall Risk Care Plan (CP), initiated on admission, included "Red ID badge," initiated on 3/27/2020, with no end date. The CP was updated after Patient 1's elopement and fall with injuries on 6/5/2023. The interventions included to monitor the patient's whereabouts frequently, to remind the patient for safety precautions, and to not go off the campus without a responsible party. During an interview with the Director of Nursing (DON) on 2/23/2024 at 11:58 AM, the DON stated that after Patient 1 left the facility's campus without staff knowledge on 6/5/2023, the IDT Team agreed that Patient 1 was still able to travel safely throughout the campus and should continue to have Green ID badge privileges. She stated there was no documented assessment, rather a discussion among IDT members. A review of the medical record revealed there was no documented evidence of a physician order or an assessment for Green ID badge privileges for Patient 1. During a follow-up interview on 2/23/2024 at 1 PM, with the DON, the DON stated they did not develop policies and procedures to prevent elopements because they were an unlocked facility, and patients had the right to leave the facility. The DON also stated an Elopement Risk Assessment was not conducted for Patient 1, after the incident on 6/5/2023, when he attempted to go to the store by himself. A review of Patient 1's medical record, failed to show documented evidence that an Elopement Risk assessment was completed after Patient 1 attempted to elope on 6/5/2023, to prevent the elopement and fall with injuries on 1/24/2024. A review of the facility Policy and Procedure, "Campus Access Identification of Residents (Facility patients)," dated 5/30/2023, included the purpose of identification (ID) badge color codes was to communicate to staff the primary care provider recommended safety protocols for all patients. Green was for patients deemed able to safely travel throughout the campus without assistance, and Red was for patients with Physician recommendations to limit unsupervised travel within Building A and the sidewalks around Building A (facility's campus). A review of the facility Policy and Procedure, "Elder Abuse, Prevention and Reporting," dated 6/6/2022, included Neglect- the failure of the facility to provide services to the Patient necessary to avoid physical harm, and to identify, correct and intervene in situations in which neglect is more likely to occur... The facility's failure to assess level of supervision required for safety for Patient 1, who was cognitively impaired, for elopement (when a patient leaves the premises or safe area without the facility's knowledge and supervision) risk when he attempted to leave the facility and fell at the facility's back gate (South Gate) on 6/5/2023. In addition, the facility staff did not follow the facility expectation as directed to visualize the patient every two hours. Patient 1 eloped and fell approximately one mile from the facility, and was missing for approximately 9 hours, on 1/24/2024. These failures resulted in a two-centimeter forehead laceration that required five sutures for Patient 1. These violations jointly or separately or in any combination had a direct or immediate relationship to the health, safety, or security of patients.