Health inspection·September 12, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety for 1 of 3 sampled residents (Resident 1), when he eloped from the facility unaccompanied and when the Licensed Nurses (LNs) failed to check and document the wanderguard (a door alarming device placed on the ankle) placement consistently every shift as per the care plan. This failure placed Resident 1's life in danger when he left the facility unaccompanied and walked over a mile on a busy street to his friend's house. Findings: According to Resident 1's 'admission Record,' he was recently admitted to the facility with multiple diagnoses which included cardiomyopathy (a disease that affects the heart muscle and may lead to heart failure), difficulties walking and muscle weakness. Resident 1 scored 8 out of 15 in a Brief Interview for Mental Status (BIMS, tests memory and recall) contained in his admission Minimum Data Set (MDS, an assessment tool). A score of 8 indicated he had severe cognitive impairment. The resident was discharged on 9/7/23 in the morning. A review of Resident 1's 'Progress Notes,' dated 8/19/23 concurrently with the Director of Nursing (DON), indicated the resident had verbalized he wanted to leave the facility and walk 20 miles to another county, and he was observed seeking exit doors. The nurse had obtained an order to place a wanderguard to alert staff when he attempted to exit by alarming the exit door. Resident 1's 'Care Plan' initiated on 8/19/23, indicated he had adjustments issues manifested by exit seeking behaviors. The care plan had one of the interventions documented as placement of a wanderguard and checking placement and function of the device as ordered. The care plan had no intervention for staff to supervise the resident for safety. A review of Resident 1's ' Medication Administration Record (MARs)' documentation for checking the wanderguard placement on his right ankle every shift by licensed nurses for the period 8/19/23 through 9/6/23, reflected missed checks for multiple shifts as follows: Day shifts on 8/22, 8/23, 8/31, 9/1, 9/4 and 9/5; evening shifts on 9/1 and 9/2; and night shifts on 8/28, 8/29, 8/31 and 9/3. This represented 12 shifts when the wanderguard placement was not checked and documented by the LNs. A review of Resident 1's progress note, dated 9/2/23, indicated Resident 1 attempted to elope at 3 p.m. The resident went missing the second time at 4:20 p.m. and was brought back to the facility by Page 1 of 2 555049 555049 09/12/2023 Lodi Nursing & Rehabilitation 1334 S. Ham Lane Lodi, CA 95242

F 0689 a friend at 7:25 p.m. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent record review with LN 1 who was assigned to Resident 1 on 9/2/23, at 3 p.m., she stated the first time the resident went outside the door she managed to convince him to come back. LN 1 stated she was giving medications in the hallway when she saw Resident 1's wheelchair at the main entrance door. LN 1 stated she did not hear the alarm sound when the resident eloped. LN 1 stated the resident was brought back to the facility at 7:25 p.m. by a friend who reported he had walked to his house from a nearby store located about a mile or more from the facility. LN 1 stated Resident 1 did not have the wanderguard when he returned to the facility, and he may have removed it before he eloped. LN 1 stated she should have placed the resident on frequent checks by staff after the first attempt to elope. Residents Affected - Few In an interview conducted on 9/7/23, at 3:15 p.m., with a Certified Nursing Assistant (CNA 1) who was assigned to Resident 1 on 9/2/23, she stated she did not hear the front door alarm sound at 3 p.m., when the resident attempted to elope the very first time, when he eloped after 4 p.m., and when he returned to the facility that evening. CNA 1 stated she was busy helping another resident at the time the resident eloped. CNA 1 stated she should have checked on the resident more frequently, but she was covering for another CNA who had taken a lunch break. The DON was interviewed on 9/7/23, at 3:43 p.m., and he stated he should have expected the LNs to place Resident 1 on every 30 minutes checks by staff to ensure safety after he attempted to leave the facility on 9/2/23 at 3 p.m. The DON stated the nurses should have documented the wanderguard placement every shift as per the risk for elopement care plan. A review of the facility's policy and procedure titled 'ELOPEMENT' and dated 2/2013, indicated the purpose of the policy was, To protect residents from injury who wander and/or attempt to elope from the facility.' The policy directed staff to update care plan and implement immediate intervention to prevent further wandering or elopement following an elopement incident. The policy further directed staff to document interventions in the resident's medical record. 555049 Page 2 of 2