Other·December 31, 2024

California Nursing and Rehabilitation Center Class B Citation California Code of Regulation Title 22, Section 72311 (a)(1)(C)(2) -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. California Code of Regulation Title 22, Section 72523(a) – 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. Code of Federal Regulation Title 42, §483.25(d)(1)(2) Accidents. §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. On November 15, 18, and 19, 2024, unannounced visits were conducted to investigate a complaint related to quality of care. It was determined by the California Department of Public Health (CDPH) that the facility failed to: 1. Provide adequate supervision to Patient 1, who was identified as at risk for elopement (when a resident leaves a healthcare facility without permission or when they are unable to make safe decisions on their own) and had multiple prior attempts to elope, in accordance with the facility policy and procedure. 2. Review, evaluate, and update the care plan to address Patient 1's multiple attempts to elope. Patient 1 attempted to elope on August 19 and 23, September 4 and 19, October 27, and November 2 and 15, 2024. These failures resulted in Patient 1 to successfully elope on November 18, 2024. Patient 1 was found by law enforcement wandering in a stranger's backyard covered in feces (poo), was disoriented, and was admitted to the general acute care hospital (GACH) thereafter. On November 18, 2024, at 12 p.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the following: a. Patient 1 eloped from the facility on November 18, 2024, during the night (11 p.m. to 7 a.m.) shift and had not returned yet. According to the information he received, Patient 1 opened the front door of the facility at 2 a.m. A certified nursing assistant (CNA) tried to stop him, but he started running. The CNA tried to follow him for 30 minutes outside the facility, but it got too dark, so the CNA returned to the facility. b. Patient 1 had an ankle monitor due to being on probation, and a WanderGuard (bracelet worn by the patient that triggers alarms on doors to alert staff if a Patient leaves a safe area) as well. The patient had a history of leaving the facility and staff had been able to bring him back to the facility. c. Patients are assessed for elopement risk upon admission, after each incident of elopement and quarterly. When a patient is identified as at risk for elopement, they get an order for WanderGuard from the physician, place the patient’s information in the elopement binder, initiate a care plan, and notify the staff as well. d. Patient at risk for eloping may also be placed on close monitoring like a 1:1 (a medical intervention where a patient is constantly observed by a staff member). A 1:1 is initiated after a patient tries to elope from the facility and if the patient is at high risk for elopement. LVN 1 stated the 1:1 ends depending on how the patient is doing. During a concurrent review of Patient 1's medical record conducted with LVN 1, the record indicated Patient 1 was admitted to the facility on May 15, 2024, with diagnoses which included dementia (loss of cognitive functioning, such as thinking, remembering, and reasoning, that interferes with daily life). Patient 1's "Elopement Assessment" dated August 23, 2024, indicated Patient 1 was identified as at risk for elopement. The care plan indicated Patient 1 had multiple attempts to leave the facility on August 19 and 23, September 4 and 19, October 27, and November 2 and 15, 2024. LVN 1 stated Patient 1 should have been placed on a 1:1 and frequent visual checks. A review of Patient 1’s care plan titled, "Resident had an episode of non-compliance and attempted to leave facility on 10/27/24 (October 27, 2024)," initiated on October 27, 2024, indicated Patient 1 refused WanderGuard. On November 18, 2024, at 2:10 p.m., during an interview with Certified Nurse Assistant (CNA) 1, CNA 1 stated Patient 1 was independent with most activities of daily living (ADL) and had a WanderGuard on. She stated on November 15, 2024, as they were passing out breakfast trays, she heard "Code Pink" announced which meant a resident eloped, and that she knew it was Patient 1. CNA 1 stated LVN 3 followed Patient 1 up to the gasoline station and brought him back to the facility. CNA 1 stated the patient was not placed on a 1:1. They just kept a close eye on him, and all staff checked the doors. On November 18, 2024, at 3:29 p.m., during an interview, LVN 2 stated the following: a. Patients identified as at risk for elopement are frequently checked visually, the facility has alarms installed on all exit doors and they provide a WanderGuard to the patients. b. She was the charge nurse for the night shift (11 p.m. to 7 a.m.) when Patient 1 eloped on November 18, 2024, around 2 a.m. Patient 1 had frequently eloped from the facility, and the staff conducted visual checks on him every 30 minutes. c. On November 18, 2024, Patient 1 was pacing throughout the hallways. She gave him Ativan (a medication that treats anxiety-a mental illness) and approximately 15 minutes later a CNA saw Patient 1 leave through the emergency exit door. The CNA followed him but was not able to bring him back to the facility. The CNA returned to the facility and took her car to continue searching for the patient, but he could not be located. d. Patient 1 was not on a 1:1 and he continued to pace around the facility. There were no other interventions initiated for Patient 1 to prevent elopement, and when he was pacing around the facility a 1:1 was indicated. She would have placed Patient 1 on a 1:1 if there was enough staff. During a review of Patient 1's medical record on November 18, 2024, Patient 1's "History and Physical" dated May 6, 2024, indicated Patient 1 can make needs known but cannot make medical decisions. Patient 1’s care plan titled, "The resident (patient) has a behavior problem attempted to leave the facility," initiated on July 9, 2024, and revised on November 18, 2024, indicated Patient 1 had an actual attempt to leave the facility on August 19, 2024, and he eloped on November 18, 2024. The care plan had interventions initiated on July 9, 2024, which included, "...Administer medications as ordered. Monitor/document for side effects and effectiveness...Anticipate and meet The (sic) resident's needs...Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately..." The care plan also had interventions initiated on August 20, 2024, which included, "...Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes...Provide a program of activities that is of interest and accommodates residents (sic) status..." The care plan titled, "Risk for Wandering / Elopement Identified," with an initiated date of August 19, 2024, indicated Patient 1 had three episodes of elopement on August 19, 2024, and an episode of elopement on September 4, 2024. The care plan had interventions initiated on September 4, 2024, which included, "...Clearly identify Resident ' s room & bathroom...Engage Resident in purposeful activity...Identify if there is a certain time of day wandering / elopement attempts occur...Implement scheduled hydration, if not contraindicated...schedule time for regular walks / appropriate activity..." The care plan titled, "Resident had an episode of non-compliance and attempted to leave the facility on 10/27/2024...11/2/2024..." initiated on October 27, 2024, and revised on November 18, 2024, had interventions initiated on October 27, 2024, which included, "...Anticipate and meet needs...Apply wanderguard (sic) for increase safety, resident refused wanderguard (sic)...For monitoring of behavior per protocol...IDT (Interdisciplinary Team- a group of healthcare professionals from different disciplines who work together to provide care) with parole officer for safe discharge...Psychiatric evaluation..." The care plan had interventions initiated on October 28, 2024, which included, "...Redirect resident as necessary..." The care plan also had interventions initiated on November 2, 2024, which included, "...Lorazepam (Ativan) Tablet 0.5 mg Give 1 tablet by mouth every 8 hours as needed for restlessness for 14 Days and re-assess...Notify family per protocol...Notify MD (medical doctor) for recommendations..." A review of Patient 1's "Physician Note" titled, "Psychiatry" dated October 29, 2024, indicated Patient 1 "...presents significant risk to self, due to impaired judgment and attempts to leave facility without safety awareness. Requires close supervision..." A review of Patient 1's "Progress Notes" indicated the following: a. November 15, 2024, Patient 1 eloped from the facility in the morning using emergency side door and was brought back to the facility by staff. The Administrator (ADM), Patient 1's doctor and family were made aware. b. November 18, 2024, at 2:13 a.m., staff heard a door alarm and ran to the doors. CNA 1 followed Patient 1 but was unable to redirect him back to the facility. Staff drove around the perimeter of the facility but was unable to locate the resident. The ADM and police department were notified. Patient 1's doctor and family were notified. There was no documented revision on Patient 1's care plans or post elopement Interdisciplinary Team (IDT) meetings from November 15 to November 18, 2024, to address why Patient 1 continued to make elopement attempts, or new interventions implemented to reduce his risk for elopement. During an interview and concurrent record review with Registered Nurse (RN) 1, on November 19, 2024, at 11:59 a.m., RN 1 stated patients who are at risk for elopement and exhibit exit seeking behaviors are provided with a WanderGuard and a 1:1. RN 1 further stated a 1:1 is also recommended for a patient who had eloped and returned to the facility. A review of Patient 1's care plan was conducted with RN 1. RN 1 stated there were no updates to Patient 1's elopement care plans after November 2, 2024, and the plans were ineffective because Patient 1 successfully eloped on November 18, 2024. On November 19, 2024, at 2:27 p.m., during an interview with the Director of Nursing (DON), she stated Patient 1 had made multiple attempts to elope, was always redirected back to the facility by staff, was checked on frequently, monitored every 30-minutes, had a psychiatry evaluation with (name of psychiatrist), and the family, doctors, and parole officers were notified. The DON further stated the facility was not the appropriate place for Patient 1. In addition, she stated Patient 1 needed a locked unit. On November 19, 2024, at 6:30 p.m., during a concurrent interview and record review of Patient 1's care plans and progress notes for the period of November 15 to November 18, 2024, with the DON, the DON stated there were no revisions on the care plans titled, "The resident has a behavior problem attempted to leave the facility," initiated on July 9, 2024, and revised on November 18, 2024, "Risk for Wandering / Elopement Identified," with an initiated date of August 19, 2024, and "Resident had an episode of non-compliance and attempted to leave the facility on 10/27/2024...11/2/2024..." initiated on October 27, 2024, and revised on November 18, 2024. The DON also stated there was no IDT meeting conducted on November 15, 2024, after Patient 1 had made attempts to elope. On November 19, 2024, at 7:08 p.m., during an interview, the ADM stated the expectation for staff and the IDT was to find other interventions to prevent Patient 1 from eloping from the facility, but it was challenging. The ADM stated the facility tried to manage Patient 1 the best they could. A review of Patient 1's GACH records titled, "ED (Emergency Department) Note - Physician," dated November 19, 2024, indicated Patient 1 was admitted to the GACH on November 18, 2024, at approximately 8:50 p.m., and was placed on a 5150 hold. The police found Patient 1 wandering in a stranger's backyard covered in feces (poo) and was disoriented. On November 29, 2024, at 2:09 p.m., during a telephone interview with the DON, the DON stated prior to Patient 1 eloping on November 18th, he was being monitored for elopement every shift. The DON stated he was not placed on 30-minute monitoring because his elopement attempts were considered his behavior. A review of the facility's policy and procedure titled, "Resident Safety," dated April 15, 2021, indicated "...During the comprehensive assessment period the interdisciplinary team (IDT) members will assess the Resident ' s safety risk (e.g. ...wandering, elopement...) as well as any other Resident specific safety risks... After a risk evaluation is completed, a Resident-centered care plan will be developed to mitigate safety risk factors..." A review of the facility's policy and procedure titled, “Wandering and Elopement," dated February 10, 2023 indicated "...The resident ' s risk for elopement and preventative interventions will be documented in the resident ' s medical records and will be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly and upon change in condition...The IDT will develop a plan of care considering the individual risk factors of the resident...upon return the Licensed Nurse will implement immediate interventions to prevent further elopement of the resident and update the plan of care...The Interdisciplinary Team as part of the investigation will conduct a post elopement meeting to determine if alternative prevention measures can be put in place (activities, rehab, etc.)..." It was determined by CDPH that the facility failed to: 1. Provide adequate supervision to Patient 1, who was identified as at risk for elopement and had multiple prior attempts to elope in accordance with the facility policy and procedure. 2. Review, evaluate, and update the care plan to address Patient 1's multiple attempts to elope. Patient 1 attempted to elope on August 19 and 23, September 4 and 19, October 27, and November 2 and 15, 2024. These failures resulted in Patient 1 to successfully eloped from the facility on November 18, 2024. Patient 1 was found by law enforcement wandering in a stranger's backyard covered in feces (poo), was disoriented, and was admitted to the GACH, thereafter. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.