Health inspection·April 5, 2022

REGULATION VIOLATION Title 42 of the Federal Code of Regulations 483.25 Quality of Care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. 483.25(d) Accidents. The facility must ensure that - 483.25(d)(1) The resident environment remains as free from accident hazards as is possible; and 483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity[YL1] and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e). 483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. Title 22 of the California Code of Regulations 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: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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. 72301. Required Services. (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. On July 2, 2021, at 11:35 AM, California Department of Public Health conducted an unannounced visit at the facility to investigate a complaint that a resident (Resident 1) had eloped (occurs when a patient who is incapable of adequately protecting himself departs a health care facility unsupervised and undetected from the facility under the category of death. Resident 1 had diagnoses that included dementia (loss of cognitive function, thinking, and remembering), and physician's orders for 1:1 monitoring (to ensure the safety of resident's who suffer from a cognitive impairment) and a care plan for wandering after he eloped from the facility on February 1, 2021. The facility failed to ensure one of nine residents (Resident 1) with a diagnosis of dementia and periods of forgetfulness was being properly monitored and supervised. The facility failed to: 1. Monitor and supervise Resident 1 on February 1, 2021, when he eloped without staff's knowledge. 2. Implement 1:1 monitoring and supervision of care per physician's orders after Resident 1 left the facility without staff's knowledge on February 1, 2021. 3. Assess and evaluate Resident 1 for risk of wandering/elopement upon change of condition dated February 16, 2021, indicating "Dementia-Increased Forgetfulness," as per the facility's policy and procedure. 4. Monitor and supervise Resident 1 on June 26, 2021, when he eloped and was hit by a car causing his death. 5. Ensure all door alarms were working to maintain an operable alarm system as per the facility's policy and procedure. As a result of these failures, Resident 1 eloped from the facility on June 26, 2021, and was involved in a motor vehicle accident resulting in his death. Findings: A review of Resident 1's face sheet (contains demographic and diagnosis) indicated Resident 1, a 69-year-old male, was admitted to the facility on August 13, 2020, with diagnoses that included anxiety disorder (any of various disorders in which anxiety is a predominant feature), confusion (disturbance of consciousness characterized by inability to engage in orderly thought or by lack of power to distinguish, choose, or act decisively), major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies), and dementia. A review of Resident 1's baseline care plan dated August 13, 2020, indicated a need for observation, assessment, and medical management for dementia, altered level of consciousness (decreased wakefulness, awareness, or alertness), and confusion. Interventions were as follows: Observe and review Resident 1 for any change of condition, complete assessment for elopement, identify risk factors and plan accordingly. A review of Resident 1's Wander-Elopement Risk Evaluation dated August 13, 2020, indicated Resident 1 had a risk factor of being cognitively impaired and a diagnosis of dementia A review of Resident 1's history and physical dated November 1, 2020, indicated diagnoses of dementia, anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs such as tension, sweating, and increased pulse rate; by doubt concerning the reality and nature of the threat; and by self-doubt about one's capacity to cope with it), and difficulty walking. A review of Resident 1's License Progress Notes dated February 1, 2021, indicated Resident 1 was last seen asleep during rounds at 5:20 AM by the Certified Nurse's Assistant 1 (CNA 1). The CNA 1 noted at 5:45 AM, Resident 1 was not in the room. The Licensed Progress Notes further indicated at 6:15 AM, Resident 1's brother called the facility to report Resident 1 made a call and was outside of the facility and wanted to go home. Law Enforcement was notified and at 6:30 AM, CNA 1 located Resident 1 wandering outside the facility and trying to go home. A review of Resident's 1 physician's order dated February 1, 2021, indicated, "May have 1:1 monitoring and discontinue if no episodes or verbalization of wandering." Review of this order indicated it was never discontinued. A review of the 72-Hour Registered Nurse (RN), Re-Assessment for Resident 1 dated February 1, 2021, indicated the following: (1) Type of Incident: Resident 1 wandering out of the facility; (2) Resident 1 verbalized with intention to go back home; and (3) Resident 1 stated, "I do not want a sitter at my bedside but, I still know I might faultier. Please remind me if I am leaving the facility, I need to notify the nurse." A review of Resident 1's Change of Condition (COC) dated February 1, 2021, indicated situation identified for: Resident wandered out of the facility. No documentation for 72-hour monitoring could be found following this COC. A review of Resident 1's care plans as follows: 1. Dated February 1, 2021, for wandering: Resident 1 was found outside the facility with interventions as follows: Redirect resident, provide reminder to resident, resident has restlessness and wandering at risk for falls. 2. Dated February 4, 2021, indicated "1:1 monitoring (a staff is assigned to be with the resident at all times) for 72 hours, continue or D/C, and transfer to a locked facility." During a telephone interview on January 26, 2022, at 11:19 AM with the DON, the DON stated there is no documentation required when conducting 1:1 monitoring for the residents. The DON confirmed the physician ordered for 1:1 monitoring for Resident 1 and it was not implemented. The DON was asked if Resident 1 had exit seeking behaviors and the DON stated, "He did not have any exit seeking behaviors." The DON stated, "When a resident continuously states they want to go home, that is not an exit seeking behavior." The DON further stated Resident 1 understood why he had to be in the facility and if he would go near an exit, staff would redirect him. During a telephone interview on January 26, 2022, at 11:36 AM with Licensed Vocational Nurse (LVN 4), LVN 4 stated, "When there is an order for 1:1 monitoring for any resident, it should be documented every hour and a care plan should be initiated." A review of Resident 1's Wander-Elopement Risk Evaluation form dated February 4, 2021 (four days after Resident 1 had wandered out of the facility without staff's knowledge) indicated Resident 1 was not at risk for wandering/elopement. During a concurrent interview and record review on July 2, 2021, at 3:57 PM with the Minimum Data Set (MDS) Nurse, the MDS Nurse stated, "I do not know why the Wander-Elopement Risk Evaluation form indicated Resident 1 was not at risk for eloping." The MDS Nurse stated after Resident 1's incident of wandering on February 1, 2021, Resident 1 should have been placed on 1:1 monitoring for 72 hours and updated as at risk for wandering. The MDS Nurse confirmed Resident 1 was not documented as an elopement risk even after he left the facility on February 1, 2021, without staff's knowledge. During an interview on July 6, 2021, at 3:50 PM with Resident 2, Resident 2 stated, "Resident 1 was my roommate during the month of February 2021, and he would wander around talking about wanting to go home." A review of Resident 1's Licensed Nurses Record (daily progress record) indicated the following: 1. Dated February 16, 2021, at 8:00 AM, increased forgetfulness and diagnosis of dementia. Physician was notified. 2. Dated June 6, 2021, indicated moderately impaired-decision poor/supervision required. Functional status all requires supervision. Dementia and generalized weakness. 3. Dated June 26, 2021, indicated moderately impaired-decision poor/supervision required. Functional status all requires supervision. Dementia and generalized weakness. A review of the Licensed Progress Notes dated June 26, 2021, at 8:30 PM, for Resident 1 indicated, Resident 1 was in his room watching television. A review of the License Progress Notes, dated June 26, 2021, at 10:40 PM, for Resident 1 indicated as follows: "Went and checked on [Resident 1] and noticed [Resident 1] was missing." License Progress Notes further indicated LVN 1 checked the facility inside, outside, called the DON, police, and emergency contact. During an interview on July 6, 2021, at 3:19 PM with CNA 3, CNA 3 stated, "The last time I saw [Resident 1] was on June 26, 2021, around 8:15 PM." CNA 3 said at 10:30 PM on June 26, 2021, he was going to do vital signs (checking temperature, respirations, pulse, blood pressure and pain) but Resident 1 was not in the room. He stated, "I believe [Resident 1] went out the front door because the door in the front lobby did not have an alarm." A review of Resident 1's Coroner's autopsy report dated July 1, 2021, indicated death occurred on June 26, 2021, at 9:53 PM, cause of death, "Multiple blunt force injuries, instantaneous due to motor vehicle accident." The autopsy report further indicated Resident 1 walked into the roadway and was struck by an approaching vehicle four in half miles away from the facility. During an interview on July 2, 2021, at 11:50 AM with the Receptionist, the Receptionist confirmed an alarm was placed on the front door of the facility about a week prior. During several observations on July 2, 2021, in the facility, not all alarms on the doors were activated while the alarms were being checked for resident's safety. During an interview on July 6, 2021, at 11:45 AM with Assistant Maintenance Director (AMD), AMD stated "There are three doors that alarms will not be triggered when opened." He stated if a resident goes out that door and no one hears the alarms, the resident can't get back in. The AMD further stated a few weeks ago they installed an alarm on the front door. During a concurrent interview and record review on July 2, 2021, at 4:53 PM with the MDS Nurse, Resident 1's Brief Interview for Mental Status (BIMS - a tool used to screen and identify the cognitive condition of residents) for Section C BIMS indicated a score of 5 (score of 0-7 indicates severely impaired cognition) on May 23, 2021, 5 on May 7, 2021, 5 on February 20, 2020, 5 on November 20, 2020, 14 (score of 13-15 indicates intact cognition) on November 20, 2020, and a 14 on May 23, 2021. Review of Resident 1's BIMS score dated May 7, 2021, indicated it was modified on June 30, 2021, from 5 to 15. The MDS Nurse confirmed Resident 1's MDS section C had modifications made to the score by the Director of Nursing (DON). The MDS Nurse stated having accurate assessments are important because having an inaccurate assessment can negatively impact the care Resident 1 would have received. During an interview on July 6, 2021, at 2:09 PM with the DON, the DON confirmed the BIMS score dated May 7, 2021, with score of 5 for Resident 1 was inaccurate and called it to the Social Worker's (SW) attention and she admitted that she made a mistake. The DON stated, "The modifications were not made until I talked to the SW in person, which was June 30, 2021." During a concurrent interview and record review with the DON on July 6, 2021, at 2:45 PM, facility's policy and procedure titled, "Policy and Procedure on Elopement" dated October 14, 2019, the DON stated it was her expectation that staff should do monitoring and checks every 1-2 hours. She stated, "It is everyone's responsibility to make sure the residents are checked and safe." The DON stated the policy was if they identify a resident that is at risk for wandering, they offer 1:1 staff monitoring, and the SW will evaluate resident within 72 hours for appropriate placement. A review of the facility's policy and procedure titled "Policy and Procedure on Elopement," dated October 14, 2019, indicated "Each resident will be provided with a safe place or residence." "Residents will be assessed and elevated for risk for wandering/elopement upon admission, quarterly, and change of condition." "Residents who are assessed and evaluated to be at high risk for wandering/elopement will be provided 1:1 monitoring, and Social Services Designee will evaluate resident within 72 hours for appropriate placement." A review of facility's policy and procedure titled "Routine Resident Checks," undated, indicated "Routine resident checks involve entering the resident's room and/or identifying elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns, and see if the resident is sleeping, needs toileting assistance, etc." A review of the facility's policy and procedure titled, "Alarm System," dated October 2014, indicated "Our facility always maintains an operable alarm system. Alarms on exit doors are tested weekly." The facility failed to: 1. Monitor and supervise Resident 1 on February 1, 2021, when he eloped without staff's knowledge. 2. Implement 1:1 monitoring and supervision of care per physician's orders after Resident 1 left the facility without staff's knowledge on February 1, 2021. 3. Assess and evaluate Resident 1 for risk of wandering/elopement upon change of condition dated February 16, 2021, indicating "Dementia-Increased Forgetfulness," as per the facility's policy and procedure. 4. Monitor and supervise Resident 1 on June 26, 2021, when he eloped and was hit by a car causing his death. 5. Ensure all door alarms were working to maintain an operable alarm system as per the facility's policy and procedure. These violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result, or substantial probability that death or serious physical harm would result, and was a dire