Health inspection·May 9, 2025

The following reflects the findings of the California Department of Public Health during the investigation of: Complaint Number: CA00955802 Event ID: EEOL11 Representing the Department, HFEN # 42706 State Citation Class A was written. REGULATION VIOLATIONS: Title 42 of the Federal Code of Regulations §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. Title 22, CCR §72311(a) (1) (A) 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 the admission of the patient and be completed within seven days after admission. Title 22 CCR §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. On April 8, 2025, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint about quality of care. The facility failed to ensure services and care are in accordance with the comprehensive assessment, plan of care and facility’s policies by not providing supervision and a safe environment for Resident 1 who had wandering behavior (a common behavior in patients with dementia [a group of thinking and social symptoms that interfere with daily functioning] and occurs when the person roams around and become lost or confused about location causing a great risk for the person). The facility failed to: 1. Follow the facility’s policy by not providing continuous one-on-one supervision (continuous monitoring of residents by staff for safety reasons. This may involve staff members always staying within arm’s reach). 2. Follow the physician’s order by not applying wander guard (wander management system designed to help protect residents, particularly those with memory impairment, from elopement) to the patient. 3. Follow facility’s policy of completing a wander/elopement (refers to a patient’s leaving the facility without permission or staff knowledge) assessment risk to a patient upon admission to the facility; and 4. Develop and implement a care plan for elopement. These failures resulted in Patient 1’s elopement on April 7, 2025 when he wandered over two miles away from the facility and was found deceased by local law enforcement approximately three hours later. During a review of Patient 1’s “Admission Record" (contains demographic and medical information), it indicated a 71 year old male Patient was admitted to the facility on April 4, 2025, with diagnoses which included dementia (gradual decline in memory, thinking and other cognitive functions) with agitation (a state of being restless, anxious, or stirred up, like feeling overly excited or tense). During a review Patient 1’s "Internal Medicine Admission History and Physical Note" from the General Acute Care Hospital (GACH), with a date of service of March 19, 2025, it indicated Patient 1 ...with dementia, recently released from jail, here for placement due to lack of caregivers, unable to care for self ..." During a review of patient 1’s "History of Present Illness (HPI)" from the GACH, with a date of service of March 19, 2025, it indicated Patient 1 has a history of major cognitive disorder (mental health conditions that primarily affect cognitive abilities like memory, learning, and problem solving) and was sent to the emergency department due to concerns of dementia. Patient 1 upon evaluation did not understand why he had to come to the emergency department and repeatedly stated, " I'm here because you know I was from there and then there's other people over there." Further evaluation suggested Patient 1 believed he was a 17-year-old from the 15th century. Social Worker (SW) contacted Patient 1’s niece, and she shared that Patient 1 was previously residing in a skilled nursing facility (SNF is a place where people received medical care and rehabilitation after a hospital stay or injury) but had run away and ended up in jail for a parole violation. During a review of patient 1‘s "Notice of Admission" from the GACH, dated April 4, 2025, there was a remark at the very top of the document, which indicated "…needs a wander guard." During a review of patient 1’s "Order Summary Report", which includes active orders as of April 5, 2025, it indicated "Apply wanderguard [wander guard] to prevent resident [patient] from going out of the facility unassisted. Monitor presence of wanderguard [wander guard] every shift every shift." During a review of patient 1’s Nursing Progress Notes, dated April 5, 2025, at 5:44 PM, documented by Licensed Vocational Nurse (LVN) 1, it indicated "Apply wanderguard [wander guard] to prevent resident [patient] from going out of the facility unassisted. Monitor presence of wanderguard [wander guard] every shift every shift wander guard not available" During a review of patient 1’s Nursing Progress Notes, dated April 7, 2025, at 9:29 AM, documented by LVN 2, it indicated "On rounds resident [patient] was found to be out of bed and absent from facility grounds. Resident [Patient] was last seen at 0900 (9:00 AM). SB PD [San Bernardino Police Department] notified. Voicemail left with PO [Parole Officer] …." During a review of patient 1’s Nursing Progress Notes, dated April 7, 2025, at 9:54 AM, documented by Registered Nurse (RN 1), it indicated "Called 911 at 9:30AM informed of patient missing, last seen at 9AM ...." During a review of patient 1’s Nursing Progress Notes, dated April 7, 2025, at 6:38 PM, documented by Registered Nurse Supervisor (RN Supervisor), it indicated, “I spoke with [Name of the police investigator] police investigator on the case. To get more information from admission and diagnosis hx [history]. The coroner case number is Coroner case [case number].” During a review of patient 1’s Nursing Progress Notes, dated April 8, 2025, at 9:34 AM, documented by Director of Social Services (SW), it indicated, “Social services called [Name of responsible party] to follow up. She [responsible party] verbalized that the police found him deceased at a bus stop. Social services expressed condolences and will follow up as needed.” During a review of patient 1’s Wander/Elopement Assessment Risk Evaluation (form to complete to determine if an individual requires necessary safety intervention.), dated April 7, 2025, it indicated Patient 1 was not at risk for elopement or wandering. The form was completed the same day the patient eloped, and three days after he was admitted to the facility. During an interview on April 8, 2025, at 3:45 PM, with the Director of Nursing (DON), the DON stated the nursing staff attempted to apply the "wander guard" to patients during his admission on April 4, 2025. The DON further stated the "wander guard" was not working properly so the facility initiated one on one (1:1) monitoring by assigning a Certified Nursing Assistant (CNA) to monitor Patient 1. Upon request, the DON was unable to provide documented evidence to show the one-on-one monitoring was provided to patient 1. The DON confirmed the "wander guard" was never used on patient 1. During an interview on April 9, 2025, at 12:50 PM, with the DON, a request was made to interview the CNA who was assigned to supervise Patient 1 prior to his departure from the facility without staff noticing. The DON stated no one was assigned to patient 1 at the time. The DON further stated the night supervisor was responsible for monitoring Patient 1 and left around 8:00 AM. After this point, no one else had been assigned to monitor Patient 1, and that is when Patient 1 left. During a concurrent interview and record review on April 9, 2025, at 1:10 PM, with the DON, the facility's undated document titled, "Order Listing Report" was reviewed. The "Order Listing Report" indicated there were eight (8) patients who were at risk of elopement. The DON confirmed the list of these 8 patients assessed and identified by the facility to be at risk for elopement. During a telephone interview on April 9, 2025, at 2:37 PM, with a cadet in the Police Department [name of police department], the cadet stated he is only able to disclose limited information over the telephone regarding Patient 1’s case, the records indicate Patient 1 was reported missing on April 7, 2025, at 9:27 AM, and was found deceased by a responding police officer at 12:48 PM, roughly 3 hours after reported missing at [address where Patient found]which is about 2.5 miles away from the facility. The cadet indicated that if more detailed information is needed, a request should be made by mail or online. However, obtaining the requested information may take a significant amount of time. During a review of the facility's policy and procedure (P&P) titled, "Safety and Supervision of Patients" dated July 2017, the P&P indicted, " ...Resident [Patient] supervision is a core component of the systems approach to safety. The type and frequency of resident [patient] supervision is determined by the individual resident's assessed needs and identified hazards in the environment …” During a review of the facility's policy and procedure for Elopement and Wandering, dated February 29, 2024, it indicated " ... A Wander/Elopement assessment will be completed on all residents [patients] upon admission to the facility ..." Conclusion: In violation of the above cited standards, the facility failed to: 1. To follow the facility’s policy by not providing continuous one-on-one supervision (continuous monitoring of residents by a staff for safety reasons. This may involve staff members always staying within arm’s reach). 2. To follow the physician’s order by not applying wander guard (wander management system designed to help protect residents, particularly those with memory impairment, from elopement) to the patient. 3.To follow facility’s policy of not completing a wander/elopement assessment risk to a patient upon admission to the facility. 4. Develop and implement a care plan for elopement. These violations, jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and constitutes a Class “A” violation.