Health inspection·December 10, 2024

Facility: Del Rosa Villa Event ID: ZY6U11 CLASS B CITATION – PATIENT CARE REGULATORY VIOLATIONS: Title 42, CFR §483.25(d) 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, 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. California Code, Health, and Safety Code - HSC § 1424 (e)(1) Except as provided in paragraph (4) of subdivision (a) of Section 1424.5, 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 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 likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient is a class “B” violation. A class “B” citation is subject to a civil penalty in an amount not less than one hundred fifty dollars ($150) and not exceeding three thousand dollars ($3,000) for each citation. A class “B” citation shall specify the time within which the violation is required to be corrected. If the 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. Based on interview, and record review, the facility failed to prevent elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) for one of eight sampled patients (Patient 1) with a wander guard system (a wander guard system relies on three components: bracelets that patients wear, sensors that monitor doors and a technology platform that sends safety alerts in real time when a patient with a bracelet approaches a monitored door, the system alerts with an audible sound) who was at risk for elopement, did not have close monitoring of his whereabouts and eloped from the facility through a parking lot gate which automatically opened to vehicles entering and exiting from the facility’s parking lot. This failure had the potential to cause Patient 1 to suffer harm, injury, or possible death while being unsupervised outside of the facility from November 4, 2024, through November 8, 2024. During a review of Patient 1’s “admission Record” (a facility document containing demographic and medical information), the “admission Record” indicated Patient 1 is a 59 years old male, and was admitted to the facility on June 21, 2024, with diagnoses which included: encephalopathy (a group of conditions that cause brain dysfunction such as confusion, memory loss, and personality changes), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Patient 1’s “Elopement and Wandering Risk Observation/Assessment,” dated September 28, 2024, indicated, “Reason for the Evaluation, Instructions: Evaluate/Assess the [patient] status in the seven clinical areas listed below. If the total score is 10 or greater, the [patient] would be considered At Risk for Wandering or Elopement…” Patient 1’s score was 18. During a review of Patient 1’s care plan indicated, “Elopement: [Patient] is at risk for elopement/exit seeking/wandering related to: difficult to redirect, exit seeking behaviors, mood or behavior disorders, psychotropic/mood-altering medications, cognitive deficit-poor safety awareness, impulsivity, wander guard placed on [left] ankle, as per order. Date Initiated: [June 24, 2024], Revision on: [November 6, 2024]. Interventions: Monitor environment for hazards which may increase supervision requirements. Date Initiated: [June 24, 2024], Monitor whereabouts frequently. Date Initiated: [June 24, 2024], Provide redirection as needed. Date Initiated: [June 24, 2024]. Wander alarm as ordered. Date Initiated: [June 24, 2024].” During an interview with the Assistant Director of Nursing (ADON) on November 6, 2024, at 1:52 PM, the ADON stated Patient 1 was last observed at the facility on November 4, 2024, at approximately 9 PM and around 10:40 PM, a Certified Nursing Assistant (CNA 1) noticed Patient 1 was not in his room. The ADON stated a search of the facility, the surrounding parking lot area, and a five-mile radius in the community was conducted but Patient 1 was not located. The ADON stated Patient 1 was admitted on June 21, 2024, and had been assessed as an elopement risk and a wander guard bracelet was placed on his left ankle. The ADON stated the wander guard system was activated on all the facility’s exit doors and the automatic parking lot gate. The ADON stated when a patient with a wander guard bracelet passes through an exit door or the automatic parking lot gate, an alarm would sound. The ADON stated CNA 1 reported seeing Patient 1 in the outside smoking area around 9 PM and the smoking area was open to the parking lot area. The ADON stated Patient 1 could have walked freely to the automatic parking lot gate and walked through when a vehicle entered or exited because staff did not continuously monitor the automatic parking lot gate. The ADON stated Patient 1’s wander guard should have alarmed inside the facility if Patient 1 had walked through the automatic parking lot gate, but staff did not report hearing the alarm on November 4, 2024, between 9 PM and 10:40 PM. The ADON further stated Patient 1 could have cut off his wander guard, but the staff did not locate the remains of a wander guard during their search of the facility. During an interview with CNA 1 on November 7, 2024, at 1:10 PM, CNA 1 stated she brought Patient 1’s dinner tray to his room on November 4, 2024, around 6:30 PM. CNA 1 stated she checked on Patient 1 at approximately 9 PM and Patient 1 was sitting in the outside smoking area, “just sitting there, not smoking.” Around 10:40 PM she checked on Patient 1 again and stated, “I don't see him.” She searched for him in the facility and outside and then she informed the nurse Patient 1 was missing. CNA 1 stated Patient 1 liked to be alone and outside most of the time, and she did not hear the alarm for the automatic parking lot gate sound go off on November 4, 2024, between 9 PM and 10:40 PM. CNA 1 further stated she was surprised Patient 1 was sitting in the smoking area because his usual activity was to walk quickly around the parking lot area, which brought him close to the automatic parking lot gate. During an interview with Patient 1 on November 12, 2024, at 12:30 PM, Patient 1 stated he left the facility through the parking lot gate because he thought the facility was going to send him away to a mental health facility and he did not want to go and stated, “so I left.” Patient 1 further stated he decided to come back because the facility was not going to send him away anymore. During a review of the facility’s policy and procedure (P&P) titled, “Wandering and Elopements,” dated March 2019, indicated, “Policy Statement: The facility will identify [patients] who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for [patients]. Policy Interpretation and Implementation: 1. If identified as at risk for wandering, elopement, or other safety issues, the [patient’s] care plan will include strategies and interventions to maintain the [patient’s] safety.” Conclusion: In violation of the above cited standards, the facility failed to: 1. Provide supervision and monitoring for Patient 1 while in the parking lot area with an automatic gate which opened multiple times a day for vehicles to enter and exit the facility. 2. Implement the facility’s policies and procedures regarding elopement and wandering by not ensuring precautions were taken to ensure the patients safety. These violations, jointly, separately or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.