Other·April 9, 2024

The following reflects the findings of the California Department of Public Health during the investigation of: Facility Reported Incident (FRI) CA00888720. Event ID: G77Q11 Representing the Department, HFEN # 44841 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)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. Title 22 of the California code of Regulations §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. FINDINGS: On March 8, 2024, at 2:30 PM, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding a patient elopement. Patient 1 had eloped from the facility on March 6, 2024, at approximately 1:30 PM. He was last seen by staff in his room at 10:00 AM. There was three and a half hours without adequate supervision which resulted in Patient 1 leaving a safe area without the facilitys awareness on March 6, 2024. He had not been found for more than 72 hours. During the time Patient 1 was missing from the facility, he was at risk for accidents, psychotic outburst (which might lead danger to self and/or others), heat exposure, hypothermia (prolonged exposure to the cold can lead to complete failure of your heart and respiratory system and eventually to death) , dehydration (a condition in which you lose so much body fluid that your body can't function normally) and/or other medical complications, including severe injury and even death which may occur as a result of being exposed to environmental elements, accident hazards, missed antipsychotic medications (drugs used to treat symptoms of psychosis (mental disorder characterized by a disconnection from reality) and being without readily available vital resources such as food, water, and shelter. The facility failed to: 1. To provide adequate supervision for Patient 1, who was identified to be a wanderer and elopement risk. 2. Implement "Wandering and Elopement" policy and procedure for Patient 1, along with a care plan will include strategies and interventions to maintain Patient 1's safety. 3. Implement Patient 1's individual care plan strategies for the intervention for "At risk for: elopement and wandering out of facility" by not addressing the specific monitoring needs and frequency necessary to effectively minimize the risk and prevent Patient 1 leaving a safe area without the facility's awareness. A review of Patient 1's clinical record titled, "Admission Record" (contains medical and demographic information) indicated Patient 1 was admitted to the facility on November 16, 2023, with diagnoses which included schizoaffective disorder (mental health disorder including schizophrenia [disorder that affects a person's ability to think, feel, and behave clearly] and mood disorder symptoms), altered mental status, and toxic encephalopathy (a degenerative neurological (nerve cell) (condition that can lead to memory loss, impaired or loss of vision, and altered mental status). During a review of Patient 1's clinical record from the hospital, dated November 3, 2023, it indicated, " ...Patient [Patient 1] was confused and not able to hold conversation get distracted and walking around ... lacks decision making capacity ... brought to ER [Emergency Room] for AMS [Altered Mental Status]. Patient stated he is from Chicago and walked to California and took for him 99 months to reach California..." During a review of Patient 1's History and Physical (H&P), dated November 17, 2023, it indicated, "Patient [Patient 1] is not able to make own decision ... consider psych eval (also known as Psychiatric diagnostic evaluations; used to determine a patient's mental state and guide recommendations for the best treatment...". During a review of Patient 1's psychiatric follow up/progress note, dated February 20, 2024, it indicated, " ... Pt [Patient 1] continue to endorse auditory hallucination [happen when you hear voices or noises that don't exist in reality] ... MSE [Mental State Examination] Memory impaired ... Insight [level of understanding] poor ... Judgment [ability to make decisions] poor ... Plan/Recommendation/Intervention. 1) Medication Recommendation: a. Continue Olanzapine [medication used to treat schizophrenia] ... schizoaffective/hallucinations. b. Increase Depakote [medication used as mood stabilizer], schizoaffective/mood lability ... 5. Continue to monitor for safety ..." During a review of Patient 1's Initial Elopement Assessment (a form to complete to determine if an individual requires necessary safety intervention. A score 0 18 used to determine the risk level patient for elopement), completed upon admission, dated November 16, 2023, it indicated Patient 1 had score of 9, which was moderate risk (refers to a situation where a resident, has a moderate likelihood or possibility of leaving the premises without authorization or supervision, wandering away from a controlled environment). A review of Patient 1's Social Service Notes, dated January 4, 2024, at 9:27 AM, indicated, " ...discuss resident [Patient 1] medication and referral to public guardianship per (Public Guardian 1 (PG 1)) ... Riverside County, Department of Public Social Services. The resident has no Public Guardian set at this time..." During a review of Patient 1's Physician's Order Sheet, dated January 10, 2024, it indicated Patient 1 had an order to receive "Zyprexa ... 10 MG [milligrams-a unit of measure] (Olanzapine) Give 10 mg by mouth every morning and at bedtime for schizoaffective..." A review of Patient 1's Physician's Order Sheet, dated February 20, 2024, indicated Patient 1 had an order to receive "Depakote ... Give 500 mg by mouth two times a day for schizophrenia disorder ..." During a review of Patient 1's Quarterly (completed in 3 months from the last elopement assessment) Elopement Reassessment, dated February 8, 2024, the elopement reassessment indicated Patient 1 had score of 7 (moderate risk). During a review of Patient 1's Minimum Data Set (MDS part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes), Section "GG" Functional Abilities and Goals, dated February 12, 2024, of the MDS indicated Patient 1 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient/resident completes activity. Assistance may be provided throughout the activity or intermittently) with mobility. During a review of Patient 1's undated Care plan for "Self care deficit: due to need assistance in ADL [activities of daily living]: Impaired cognitive[mental abilities], physical limitation/disability..." indicated the interventions included: "...Provide assistance if needed..." During a review of Patient 1's undated Care Plan for "At risk for elopement and wandering out the facility," it indicated the interventions included "Check resident's whereabout." The care plan did not specify supervision, monitoring and frequency required for Patient 1. A review of Patient 1's "Social Service Note," dated March 6, 2024, at 4:46 PM, indicated "IDT (Interdisciplinary team composed of staff from various disciplines) met to discuss ... resident [Patient 1] was missing from his room, per staff [LVN 1] the resident was last seen at before 10AM ... " During a concurrent interview and record review on March 8, 2024, at 3:30 PM with the Director of Nursing (DON) of the Facility's Notification Memo, sent to the San Bernardino District Office, dated March 7, 2024, written by the Administrator, indicated "I am reporting an unusual occurrence that occurred yesterday, March 6, 2024. Our resident [Patient 1] eloped from the facility. It was reported to me at approximately 1:30PM [on March 6, 2024] that Patient 1 could not be located in the facility ... The administrator directed the RN [Registered Nurse] Supervisor to notify the physician, conservator, and San Bernardino Police Department per policy ... Additional calls have been placed to the police and local hospitals today. Additional expanded searches were completed today of the neighborhoods, parks, and homeless encampments ..." The DON stated Patient 1 was last seen by staff [LVN 1] in the facility at 10:00 AM during the morning routine medication administration. Patient 1 was not identified as missing despite Patient 1 not being present during lunch time. (There was three and a half hours without adequate supervision and Patient 1 had been gone from the facility and had not been found for more than 72 hours.) During further interview with the DON, on March 8, 2024, at 3:45 PM, the DON stated Certified Nursing Assistant (CNA 1) was assigned to care for Patient 1 but failed to report to Licensed Vocational Nurse (LVN 1) that Patient 1 was not present for lunch when it was served between 12:15 12:30 PM. The DON further stated CNA 1 assumed Patient 1 was in the restroom. The DON stated CNA 1 should have checked Patient 1's restroom to confirm Patient 1's location and should have checked Patient 1 more frequently throughout the shift. During a follow up interview with the DON, on March 8, 2024, at 3:50 PM, the DON stated she was not aware that Patient 1 had a previous hospitalization record of walking a long distance, resulting in altered mental status and fracture, before being admitted to this facility. During a concurrent interview and record review on March 8, 2024, at 3:55 PM, with CNA 1 of the statement written by the Director of Staff Development (DSD) when the DSD interviewed CNA 1 on March 7, 2024, it indicated "CNA 1 said at 8:40 AM on 3/6/24 [March 6, 2024] she passed his breakfast tray, and she woke him [Patient 1] to eat. Then at lunch she delivered his lunch at 12:20 PM the bathroom door was shut but the light was on, so she assumed he is here. She knocked and then went out of the room. At 1:00 PM she went back to see if he was finished. She noticed he never ate his food [lunch meal], she searches the room and then asked her charge nurse [name of LVN 1] if she had seen him. After checking around there is no sign of [name of Patient 1] ...". CNA 1 stated she should have not assumed Patient 1's whereabouts. Furthermore, CNA 1 stated she should have checked Patient 1's restroom to make sure he was actually inside and should have checked on him more frequently, and not just during mealtimes. During an interview on March 8, 2024, at 4:00 PM, with the Social Services Director (SSD), the SSD stated she did not realize that she had not seen Patient 1 all morning until code yellow was announced [facility's code for missing resident] for Patient 1. The SSD further stated while searching Patient 1's room, she noticed that Patient 1's belongings were not in his room. During an interview on March 8, 2024, at 4:05 PM, with LVN 1, LVN 1 stated the last encounter she had with Patient 1 on March 6, 2024, was when she passed his routine morning medication between 9:45 AM to 10:00 AM. LVN 1 further stated, CNA 1 did not report to her when CNA 1 did not see Patient 1 visually when she left Patient 1's lunch tray in his room. LVN 1 stated she did not check on or look for Patient 1 from after the morning medication was passed at or around 10:00 AM to 1:30 PM which was after she learned that Patient 1 did not eat his lunch and was nowhere to be found. During a phone interview on March 8, 2024, at 4:15 PM, with the facility Receptionist, the Receptionist stated that on March 6, 2024, she had not seen Patient 1 all morning, but later discovered that Patient 1 had gone missing after the nurses went out the front door to search for him. During a concurrent interview and record review with the DON, on March 8, 2024, at 4:35 PM, the DON reviewed an undated facility document titled, "Certified Nursing Assistant Job Description" which indicated " ... Report to: Charge Nurse. Position Description: A nursing assistant responsible to providing routine nursing care accordance with establish policy and procedures and as may directed by the Charge Nurse, RN Supervisor, Director of Nurses or Administrator, to assure that the highest degree of quality care can be maintain at all times ... General Duties and Responsibility: General ... Make resident rounds at the beginning of each shift and every 2 hours thereafter to administer quality nursing care ...". The DON stated the facility did not follow the policy. During a concurrent interview and record review with the DON, on March 8, 2024, at 4:40 PM, the DON reviewed an undated facility document titled, "Charge Nurse Job Description" which indicated " ...Report to: Director of Nursing Services [DNS also known as Director of Nursing (DON)]. Position Description: The Charge Nurse is responsible for staff assignment and provides overall supervision of resident care activities ... General Duties and Responsibility: ... Supervision ... Make resident's round to review physical, medical an emotional status and to implement required nursing intervention ... Assure that nursing personal follow establish nursing procedures ..." The DON stated the facility did not follow the policy. During an interview with the Administrator (ADMIN), on March 8, 2024, at 8:20 PM, the ADMIN stated Patient 1 had diminished mental capacity due to his mental health status. The Admin further stated Patient 1 eloped from the facility on March 6, 2024, left with his belongings, and had not been found since. During a concurrent interview and record review with LVN 2, on March 8, 2024, at 8:30 PM, LVN 2 reviewed Patient 1's undated Care plan for " At risk for elopement and wandering out the facility" and stated that checking patient whereabouts meant checking maybe every 30 minutes to an hour. LVN 2 remained uncertain with the frequency of checking a patient's whereabouts for patients with risk of elopement and where to document the findings, as no specific direction/guidance was provided. During a concurrent interview and record review, with the DON, on March 8, 2024, at 8:45 PM, the DON reviewed Patient 1's undated Care Plan for "At risk for elopement and wandering out the facility," and acknowledged it did not specify the frequency on how often to check on Patient 1's whereabouts. The DON further stated the staff should do it every hour, and it should be documented to ensure the task was completed. The DON was unable to provide documentation to show that Patient 1's whereabouts were checked by the staff. During a review of the facility's policy and procedure (P&P) titled, "Wandering and Elopement," revised March 2019, the P&P indicated " ...The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for resident ... Policy interpretation and implementation. 1. If identified as at risk for wandering, elopement, or other safety issue, the resident's care plan will include strategies and intervention to maintain resident's safety ..." Conclusion: In violation of the above cited standards, the facility failed to: 1. To provide adequate supervision for Patient 1, who was identified to be a wanderer and elopement risk. 2. Implement "Wandering and Elopement" policy and procedure for Patient 1, along with a care plan will include strategies and interventions to maintain Patient 1's safety. 3. Implement Patient 1's individual care plan strategies for the intervention for "At risk for: elopement and wandering out of facility" by not addressing the specific monitoring needs and frequency necessary to effectively minimize the risk and prevent Patient 1 leaving a safe area without the facility's awareness. These violations, jointl