Other·October 12, 2023

REGULATION VIOLATION: Title 42, 483.25(d)(1)(2) Accidents The facility must ensure that: (1) The patient environment remains as free of accidents hazards as is possible; and (2) Each patient receives adequate supervision and assistance devices to prevent accidents. Title 22, 72311(a)(2) 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. Title 22, 72523(a) 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. Based on interview, and record review, the facility failed to provide routine supervision and monitoring for one patient (Patient 1) and failed to implement interventions developed to help prevent an elopement (unauthorized and unsupervised exit from the facility) when: 1. On August 1, 2023, staff were unaware Patient 1 (a confused patient with cognitive deficit and required assistance with walking) had eloped from the facility. In addition, it was not identified Patient 1 was missing from the facility despite Patient 1 not being present during the evening meal and that Patient 1 required direct 1:1 [one to one] staff assistance during mealtime. This failure resulted in Patient 1 subsequently being found (by non-facility staff) in a neighboring backyard unresponsive, on the ground, and covered with vomit. Patient 1 required hospitalization and intubation (a tube placed through the airway to help the resident breath when they are unable to breath on their own). This also had the potential to result in death to Patient 1 due to exposure of the (outdoor) elements and without vital resources such as food, water, and shelter. 2. The facility's front door alarm was not armed to audibly alert staff (as specified in the facility's policy and procedure for elopement prevention) and staff did not provide supervision of the facility's main entrance and exit while the alarm was unarmed. This failure resulted in staff not to be alerted to the unauthorized exit of Patient 1 from the facility and therefore, did not provide staff an opportunity to prevent Patient 1's elopement by responding to the area in a timely manner to divert Patient 1 back into the facility. A review of Patient 1's clinical record titled, "Admission Record" (contains medical and demographic information) dated August 2, 2023, indicated Patient 1 was admitted to the facility on July 27, 2023, with diagnoses which included Craniotomy (surgical opening in the skull), altered mental status, unsteady gait (walking uncoordinated), Epilepsy (Neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions), anxiety disorder (feelings of fear and/or worry that interfere with daily activities), and restlessness and agitation. During a review of Patient 1's Minimum Data Set (MDS), Section "C" - Cognitive Patterns (section used to determine a patient cognitive functioning status) dated, July 31, 2023, the MDS indicated Patient 1 had a Brief Interview for Mental Status (BIMS a score 0-15 used to determine cognitive functioning) score of 3 (severe impairment). Section "G" Functional Status" for eating indicated, "...2 (Limited Assistance...staff provide guided maneuvering of limbs or other non-weight-bearing assistance...one-person physical assist.) During a review of Patient 1's History and Physical (H&P) dated July 28, 2023, the H&P indicated Patient 1 did not have the capacity to understand and make decisions. During a review of Patient 1's care plan (an individualized plan of care) dated July 28, 2023, the care plan indicated, "At risk for re-hospitalization r/t [related to] hx [history of] altered mental status, [confusion] HTN [elevated blood pressure], alcohol dependence [When the person can't stop drinking alcohol] craniotomy [surgery of the skull]...interventions...Turn and reposition every 2 hours and PRN [as needed] for circulation and comfort." During a review of Patient 1's physician orders, dated July 27, 2023, the order indicated, "one to one feeding assistance..." During a review of Patient 1's care plan dated July 28, 2023, the care plan indicated, "The resident has limited physical mobility r/t weakness/unsteadiness of feet...interventions...Provide supportive care, assistance with mobility as needed..." During an interview on August 4, 2023, at 12:28 PM with the Administrator (ADMIN), the ADMIN stated Patient 1 eloped from the facility on August 1, 2023, and was last seen by staff in the facility at 3:15 PM. The ADMIN further stated the facility staff were unaware Patient 1 was missing until around 7:15 PM (four hours later) on August 1, 2023, when Patient 1's family called the facility to notify them Patient 1 was in the hospital. During an interview on August 4, 2023, at 3:23 PM with the Director of Nursing (DON), the DON stated Certified Nurse Assistant 1 (CNA 1) was assigned to care for Patient 1 but failed to report to License Vocational Nurse (LVN 1) Patient 1 was not present for and did not eat his dinner when it was served at 5:00 PM. The DON further stated CNA 1 did not look for Patient 1 to determine the whereabouts of Patient 1. The DON stated the CNA should have checked on Patient 1 more frequently throughout the shift. During an interview on August 7, 2023, at 4:22 PM with CNA 1, CNA 1 stated that she was not aware Patient 1 required 1:1 (one on one) assistance with eating his meals and that CNA 2 delivered Patient 1's meal tray to his room at approximately 5:00 PM on August 1, 2023. CNA 1 further stated she picked up Patient 1's dinner tray at approximately 8:30 PM and it was untouched, but she (CNA 1) did not look for Patient 1 and did not assist Patient 1 during dinner mealtime. During an interview on August 8, 2023, at 3:04 PM, with CNA 2, CNA 2 stated she delivered Patient 1's dinner tray to his room on August 1, 2023. CNA 2 stated when she delivered the tray, she noticed Patient 1 was not in his room. CNA 2 further stated she asked Patient 1's roommate where Patient 1 was at, and the roommate informed her that Patient 1 was in therapy. CNA 2 stated she left the meal tray inside Patient 1's room but never looked for or checked on Patient 1. CNA 2 stated Receptionist 2 (R2) came to Patient 1's room looking for Patient 1, and the tray was still in the room, untouched. CNA 2 stated CNA 1 should have provided Patient 1 assistance with his meal. During a review of the facility's job description for "Certified Nurse Assistant" dated 2003, the job description indicated, "The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan as may be directed by your supervisors ..., ensure that residents who are unable to call for help are checked frequently..., check each resident routinely to ensure that his / her personal needs are being met in accordance with his/her wishes..., serve food trays. Assist with feeding as indicated (i.e., cutting, foods, feeding assist in the dining room supervision, etc.) ... immediately notify the nurse supervisor/charge nurse of any Resident leaving/missing from the facility." During a review of CNA 1's "Counseling/Disciplinary Notice" dated, August 1, 2023, the document indicated, "Failure to do rounds adequately to ensure the safety of your patients." During an interview on August 7, 2023, at 3:06 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated it was her first time working with Patient 1 and she did not see Patient 1 from the beginning of her shift around 3:00 PM, because she got busy with her assignment. LVN 1 further stated, CNA 1 did not report to her Patient 1 did not eat his dinner. LVN 1 stated she did not check on or look for Patient 1. During a review of the facility's job description for "Licensed Vocational Nurse" dated 2003, the job description indicated, "The primary purpose of your job position is to provide direct nursing care to the residents and to supervise the day-to-day nursing activities performed by nursing assistants..., make daily rounds of your unit / shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards"..., make periodic checks to ensure the prescribed treatment are being properly administered by certified nursing assistants and to evaluate the resident's physical and emotional status..., ensure that residents who are unable to call for help are checked frequently..." During a review of LVN 1's "Counseling / disciplinary notice," dated, August 1, 2023, signed by LVN 1, the document indicated, "...Failure to be accountable for your patients to ensure their safety." During an interview on August 7, 2023, at 3:47 PM with Receptionist 2 (R2), R2 stated that on August 1, 2023, around 7:15 PM she received a phone call from Patient 1's family member to inform the facility Patient 1 was admitted to the hospital. Patient 1's family wanted to speak to the facility's Registered Nurse 1 (RN 1). During an interview on August 7, 2023, at 4:45 PM with RN 1, RN 1 stated on August 1, 2023, around 7:15 PM, Patient 1's family called to inform the facility Patient 1 was missing from the facility and Patient 1 was admitted to the Emergency Department. RN 1 stated she looked around the facility for Patient 1, but she was not able to find him. RN 1 further stated the ADMIN checked the surveillance camera located by the main entrance and noticed Patient 1 walked out of the facility at approximately 3:30 PM. RN 1 stated she knew Patient 1 needed full assistance with meals. RN 1 stated she did not check if Patient 1 received assistance with his meals. During a review of the "RN" job description dated 2003, the job description indicated, "The primary purpose of your job position is to supervise the day-to-day nursing activities of the facility during your tour of duty..., ensure that all nursing service personal are in compliance with their respective job description..., make daily rounds of the nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standard. Report findings to the Director..." During a review of Patient 1's care plan dated July 28, 2023, the care plan indicated, "... has impaired cognitive function or impaired thought process related to head injury/craniotomy...Interventions...Cue, reorient and supervise as needed." During a review of Patient 1's care plan dated July 28, 2023, the care plan indicated, "...is at risk for falls related to poor safety awareness...Interventions... needs a safe environment." During a review of Patient 1's care plan dated July 28, 2023, the care plan indicated, "...has risk for re-hospitalization related to history of altered mental status, HTN, Alcohol dependence, craniotomy...interventions...Diet as ordered and assist with meals as needed." During a review of Patient 1's hospital medical records dated, August 1, 2023, at 6:08 PM, the records indicated, "68-year-old male who presents with a GCS [Glasgow Coma Scale used to describe the extent of impaired consciousness] of "3" [the lowest possible score, unresponsive] after he was found outside someone's yard. Patient also noted to be hypotensive [low blood pressure] and have emesis [vomit] on his clothes. He was intubated in the Emergency Department." 2.During an interview on August 4, 2023, at 12:28 PM with ADMIN, the ADMIN stated Patient 1 eloped from the facility on August 1, 2023, and was last seen by staff in the facility at 3:15 PM. The ADMIN further stated Patient 1 eloped from the facility after the main entrance door alarm was disarmed by the receptionist (R1). A review of Patient 1's clinical record title, "Interdisciplinary" (IDT - team composed of staff from various disciplines) dated August 2, 2023, at 4:50 PM, indicated "per charge nurses, (pt) patient was seen last approx. [approximately] August 1, 2023, at 3:15 PM. Patient was seen in walking from his room to the hallway without helmet. Patient was redirected and encourage to wear his helmet for safety. Patient went back to the room and put on his helmet.... patient [Pt] has a medical history and not limited to altered. mental status, unsteadiness of feet, seizure, HTN (elevated blood pressure) alcohol dependence, (is the body's inability to stop drinking). Craniotomy (Surgery into the skull)..., RN supervisor received a call from the hospital, stating that resident was found at someone's backyard unresponsive and was brought to [the admitting hospital] for further evaluation..., recommendations:..., all exit door alarm must be functional..., front door alarm will remain armed at all times..., if at any time, the alarm goes off, receptionist / designee needs to be reset alarm immediately to remain functional." During an interview on August 7, 2023, at 2:30 PM, with ADMIN, the ADMIN stated the facility had a protocol which indicated the door alarm was to be kept "ON" at all times to prevent elopement of their residents [Patients]. The ADMIN further stated it was an error committed by the staff to disarm the main entrance door alarm. During an interview on August 8, 2023, at 8:53 AM with R1 via telephone, R1 stated on August 1, 2023, at 3:00 PM, she disarmed the main entrance alarm because she was working by herself, and it was hard for her to answer the phone calls. R1 stated it was hard to be in two places at the same time, and when Patient 1 eloped from the facility she was probably busy doing something because she missed it. She further stated she was aware that main entrance alarm should be "ON" at all times to alert the staff if someone was leaving through the front door. During a review of the facility's policy and procedure (P&P) titled, "Elopement and Wandering Resident's" dated, December 19, 2022, the policy indicated "1. The facility is equipped with door locks / alarms to help avoid elopements.", "2. Alarm are not replacement for necessary supervision, Staff are to be vigilant in responding to alarms in a timely manner...d. Adequate supervision will be provided to help prevent accidents or elopements..." During a review of the facility's P&P, titled "Accidents and Supervision" dated, December 19, 2022, the P&P indicated, "The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard and risk (s)..., 3. Implementing interventions to reduce hazard (s) and (risk)..., 4. Monitoring for effectiveness and modifying interventions when necessary..., 5. Supervision-Supervision is an intervention and means of mitigating accident risk. The Facility will provide adequate supervision to prevent accidents. Adequacy of supervision: A. Defined by type and frequency..., B. based on the individual resident's assessed needs and identified hazards in the resident environment." Conclusion: In violation of the above-cited standards, the facility failed to: 1. Provide routine supervision and monitoring for Patient 1; and 2. Implement interventions developed to help prevent an elopement. These failures resulted in Patient 1 subsequently leaving the facility unsupervised and being found (by non-facility staff) in a neighboring backyard unresponsive, on the ground, and covered with vomit. Patient 1 required hospitalization and intubation This also had the potential to result in death to Patient 1 due to exposure of the (outdoor) elements and without vital resources such as food, water, and shelter. These violations, jointly, separately, or in any combination, presented either imminent danger that death or serious physical harm would result.