Health inspection·July 25, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,interview and record review, the facility failed to conduct hourly checks in the locked unit of Building 2 and also failed to ensure accurate documentation of hourly checks. This failure led to the elopement (leaving the facility without permission) of Resident 1. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (episodes of recurring delusions and hallucinations with a pattern of feeling suspicious or mistrustful of other people); Anxiety Disorder (excessive worrying); and Atrial Fibrillation (an irregular heartbeat) per the facility's admission record. Resident 1 was admitted to the facility under conservatorship due to no capacity to make decisions and no known family. A review of Resident 1's medical record (progress notes) was conducted on 6/28/23 at 9 A.M. The progress notes indicated Resident 1 was picked up by the transport van from the facility at 12:18 P.M. for a court appearance and returned to the facility at 4:55 P.M. At 9:15 P.M, the charge nurse (CN)1 reported that Resident 1 was not in his room; inside the building or the yard. An interview was conducted with the Director of Nursing (DON) on 6/28/23 at 9:00A.M. The DON stated, Resident 1 left (the facility) after return from the court date and was disappointed that the conservatorship was maintained. An interview was conducted with the Social Services Director (SSD) on 6/28/23 at 9:10 A.M. The SSD stated, I called all the hospitals, emergency rooms and other facilities and there were no admissions under Resident 1's name. An interview was conducted with the assistant Director of Nursing (ADON) on 6/28/23 at 10:30 A.M. The ADON stated, Residents have access from the building to the yard and can go in and out; the alarm must be switched on. An interview was conducted with the Administrator (Admn) on 6/28/23 at 10:40 A.M. The Admn stated,The door is not locked, but the alarm is turned on at 9:00 P.M. A review of the facility's document, titled, Building 2 One-Hour Rounds, dated 6/26/23, indicated Page 1 of 2 555140 555140 07/25/2023 Bradley Court 675 E Bradley El Cajon, CA 92021

F 0689 room [ROOM NUMBER] A, Resident 1,was in bed at 9 P.M. Level of Harm - Minimal harm or potential for actual harm A concurrent record review and interview was conducted with the ADON on 6/28/23 at 11:10 A.M. The ADON reviewed the hourly rounds document and stated, The Resident is marked being in bed at 9 P.M;but the closed circuit TV (CCTV) video shows the resident going over the fence at 8:39 P.M. Residents Affected - Some A concurrent record review and interview was conducted with the DON on 6/28/23 at 11:20 A.M. The DON reviewed the hourly rounds document. The DON stated, The document indicates Resident was in bed at 9 P.M. and the CCTV video shows the resident going over the fence at 8:39 P.M. That is not accurate documentation. An interview was conducted with the Admn on 6/28/23 at 1:10 P.M. The Admn stated, The 9 P.M. documentation cannot be accurate since the video shows the 8:40 P.M. The CCTV video was viewed by HFEN on 6/26/23 at 2:10 P.M. The video indicated Resident 1 walked from the building, across the yard to the fence and used the fence's chain links as a step and climbed over the fence and walked away. The video is date stamped 8:39:40. A concurrent record review and interview was conducted with certified nursing assistant (CNA)1 on 6/28/23 at 2:16 P.M. CNA 1 stated, I make rounds and residents start going to bed at 9 PM ; at 8:55 P.M. Resident 1 was in his bed. I turned on the alarm at 9 PM, then I saw he wasn't in bed. We searched the building and grounds, no sign of him. I told the CN (1) and searched again and called the police. The hourly rounds document was reviewed with CNA 1. CNA 1 stated, I saw the resident at 8:55 PM. CNA 1 was informed the CCTV video indicated the resident went over the fence at 8:39 P.M. CNA 1 stated, My watch must be wrong; I cannot state accurately he was in bed at 9 PM; I do my rounds a little early because there are so many residents, and I wrote 9PM . An interview was conducted on 6/28/23 at 2:49 P.M. with CNA 2. CNA2 stated, We did rounds and then I turned on the alarm at 9. I walked into the resident's room and he was not there. An interview was conducted with the CN1 on 6/28/23 at 3:01 P.M. CN1 stated, The last time I saw Resident 1 was 8-8:15 P.M. I asked the CNA's to check everyone was in bed at 9PM and I set the alarm. At 9:15 P.M., CNA's 1 and 2 said Resident 1 was not in his room. I searched inside and out and called the police. The fence had chicken-wire and it was bent down, and that's where he went over. An interview was conducted on 6/28/23 at 3:40 P.M. with the ADON. The ADON stated, No one monitors the door until 9 P.M., when the alarm is set. A review of Resident 1's care plan,dated 10/23/22, titled, At risk for Elopement related to involuntary placement, non-adherence to treatment, refusal to take medication, danger to self/community and self well-being indicated: do not open door when resident is close to the exit door. A review of the facility's policy, dated 5/12/23. titled, Elopement, indicated, Definitions: 1. A situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision, if necessary, would be considered an elopement. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. 555140 Page 2 of 2