Health inspection·May 18, 2023

The following reflects the findings of the California Department of Public Health during the investigation of: Entity Reported Incident (ERI) CA00825728 of Shandin Hills Behavior Therapy Center. Event ID: 47LB11 Representing the Department, HFEN # 44142 Citation B. Select the Violated Requirements(s): Title 42 of the Federal Code of Regulations §483.25(d) Accidents. The facility must ensure that – (2) Each resident receives adequate supervision and assistance devices to prevent accidents. §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. On February 8, 2023, at 2:10PM, an unannounced visit was conducted at the facility to investigate a Facility reported incident regarding Patient 1. Patient 1 was admitted to the facility on September 28, 2017, with the diagnoses of schizoaffective disorder unspecified (mental illness that affects moods and thoughts) and insomnia unspecified (difficulty in falling asleep). Patient 1 eloped (went missing) from the facility on February 6, 2023, at approximately 4:00 PM. Certified Nursing Assistant 2 (CNA) noticed Patient 1 was missing when CNA 2 made rounds on February 6, 2023, at 4:06 PM. Staff searched the premises, stores and parks. Facility did not find Patient 1. The facility failed to: 1. Provide supervision and monitoring for Patient 1 who had history of previous elopements attempts, when he eloped from the locked yard during a break. Patient 1 has not been located. 2. Implement the facility’s policies and procedures for patients at risk for wandering, to take precautions to ensure their safety Patient 1 was admitted to the facility on September 28, 2017, with the diagnoses of schizoaffective disorder unspecified (mental illness that affects moods and thoughts) and insomnia unspecified (difficulty in falling asleep). Patient 1 has fluctuating capacity to understand and make decisions.” During a review of Patient 1’s Minimum Data Set (MDS- an assessment of a Patients functional and health status), dated December 7, 2022, the MDS section “C” – Cognitive Patterns (section used to determine a patients cognitive functioning status) indicated the patient had a Brief Interview for Mental Status score (BIMS score – a score of 0-15 used to determine cognitive functioning) score of 15 (which means cognition is intact). During a review of Patient 1's " Doctor's Progress Notes," dated February 6, 2023, indicated Patient 1 had impulse control, insight, and judgment which were partially impaired. During a phone interview on February 8, 2023, at 12:11 PM, with the Administrator-in-training, regarding the elopement of Patient 1, he stated, “Patient 1 was outside in the yard with the staff for social event. When residents were outside, staff did not count the correct head count. Patent 1 was left outside, and he hid behind the old wending machines. He broke the latch of the back gate and took off.” The Administrator-in-training stated, the facility staff immediately searched the premises, nearby stores, and parks, but they did not find Patient 1. During an interview on, February 8, 2023, at 3:10 PM, with a Mental Health Counselor (MHC), she stated, [ Name of Certified Nursing Assistant (CNA 2)] made rounds and noted Patient 1 was missing. They searched on the unit, and in the yard, but did not find Resident 1. During an interview on, February 8, 2023, at 3:30 PM, with CNA1, she stated, when staff searched, Patient 1 was not on the unit. During an interview on February 8, 2023, at 4:21 PM, with the Program Director (PD), she stated, when Patient 1 first came to the facility, he tried to elope twice in first six months and never tried to elope again. During a telephone interview on, February 23, 2023, at 9:55 AM, with CNA 2, she stated, when she made rounds on February 6, 2023, at 4:06 PM, she did not see the Patient 1 on the unit. CNA 2 informed the charge nurse, and the charge nurse informed the Program Director and Administrator-in-training. CNA 2 went out in the car with another programmer, searched side streets and the grocery store. No one was able to locate Patient 1. During a concurrent interview and record review, with the PD, on February 8,2023, at 4:30 PM, of the facility's policy and procedure (P&P) titled, “Elopement of Resident [Patient],” effective date March 22, 2022, the P&P indicated, “Purpose: To provide a process for managing residents at risk for elopement. Policy: Resident [patient]will be evaluated for elopement risk upon admission, re-admission, and with a change in condition as part of clinical assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury…3. Unwitnessed Elopement: 3.1. Notify the supervisor that the patient is missing. 3.2 Supervisor will alert all staff of missing patient with an announcement to activate missing patient protocol…” The PD stated the policy was not followed. During a review of facility’s Policy titled, “Safety and Supervision of Residents [Patients],” revised date July 2017, the policy indicated, “Policy Statement: Our facility strives to make the environment as free form accident hazards as possible. Resident [patient] Safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy interpretation and Implementation… Systems Approach to Safety 1. The facility- oriented and resident [patient]-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. 2. 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 document titled, “Quality Assurance Performance Improvement” (QAPI)dated February 7, 2023, indicated, “A resident was able to leave the facility after the fresh air break in unit 2. The staff supervising the yard during break did not notice the resident was still out in the yard when they entered the facility. The staff supervising the yard did not have and account for the residents in the yard during break…” Conclusion: In violation of the above cited standards, the facility failed to: 1. To provide supervision and monitoring for Patient 1 who eloped from the locked yard during a break. Patient 1 has not been located. 2. Implement the facility’s policies and procedures for patients at risk for wandering, to take precautions to ensure their safety. These failures had a direct or immediate relationship to the health, safety or security of long-term health care facility patients.