Health inspection·January 16, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review, the facility failed to implement care plan intervention for one of seven sampled residents (Resident 1), when the facility did not provide continuous monitoring as indicated in Residnt1 ' s care plan and Resident 1 eloped (left the health care facility unsupervised and undetected) from the facility on 9/23/23. This failure resulted in Resident 1 leaving the facility unsupervised and had a potential for accident which could lead to serious injury. Findings: During a review of Resident 1 ' s admission Record (AR-a document with personal identifiable and medical information), dated 11/2/23, the AR indicated, Resident 1 was admitted in the facility on 4/25/23, with diagnosis which included dementia (loss of cognitive functioning- thinking, remembering, and reasoning — to such an extent that it interferes with a person's daily life and activities ), depression (constant feeling of sadness and loss of interest, which stops you doing your normal activities), anxiety (a feeling of fear, dread, and uneasiness) and muscle weakness. During an interview on 11/2/23 at 3:38 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated if a resident has a sitter, then the sitter must be with the resident the entire time. During an interview on 11/2/23 at 4:16 p.m. with Licensed Vocational Nurse Infection Control (LVN/IC), LVN/IC stated, Resident 1 was initially on every 15-minute observation due to Resident 1 ' s history of wandering but was changed to 1:1 (continuous observation provided by healthcare worker) due to history of elopements. LVN/IC stated CNAs are not supposed leave the resident they are watching if the resident was on a 1:1. LVN/IC stated there should not be a lapse in monitoring. LVN/IC stated it ' s important that they keep constant supervision so resident cannot get away. LVN/IC stated Resident 1 had history of wandering and had noticed trying to leave the facility. During an interview on 11/2/23 at 5:20 p.m. with Administrator (ADM), the ADM stated, Resident 1 was on 1:1 at the time of the elopement on 9/23/23. ADM stated if CNAs are assigned to watch a resident on 1:1, they (CNAs) cannot leave the resident unattended. The ADM stated this was important, so the resident would not elope. ADM stated when a resident is on 1:1 it meant the staff knew exactly what the resident was doing or where they were. ADM stated it was important to constantly watch Resident 1, You don ' t want the resident to elope. During an interview on 11/2/23 at 5:25 p.m. with the DON, the DON stated, Resident 1 was able to elope because at the time of the incident, even though the Resident 1 was on 1:1, a code blue (patient Page 1 of 2 555920 555920 01/16/2024 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few requiring resuscitation or needs immediate medical attention) happened and a lot of the staff helped with the code blue. DON stated the CNA who was monitoring resident 1 left Resident 1 unsupervised, and he was able to leave the facility unsupervised. The DON stated the CNA should have stayed with Resident 1. DON stated the expectations were not to leave the resident alone at any time when Resident is on 1:1. During a phone interview on 1/3/24 at 1:33 p.m. with the DON, the DON stated, the resident will always have somebody with him since he was on 1:1. During a concurrent record review and interview on 1/3/23 at 1345 p.m., with DON, facility ' s 1:1 CNA/STAFF watch or Q15 Monitor Sheet (MS), dated 9/23/23 was reviewed. There were missing documentation of the resident ' s whereabouts starting from 7am to 10 a.m. The DON stated, There was a code blue, and everyone went to help, he (resident) was already awake during the code blue. During a concurrent record review and interview on 1/3/23 at 1400 p.m. of the resident ' s Care Plans (CP) undated, the CP indicated, .is high risk for elopement r/t to cognitive status .Resident will be on 1:1 continues and while awake. Resident has a sitter schedule every day. The DON stated, the 1:1 intervention was added on 9/25/23 by the MDS/DSD for the undated CP. The DON stated, the CP was initiated on 4/27/23, the date does not show when printed. During a review of the facility ' s policy and procedure (P&P) titled, Elopement and Wandering Residents, dated 2023, the PP indicated, .Policy: this facility ensures that resident who exhibit wandering behavior and or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Staff are to be vigilant in responding to alarms in a timely manner .adequate supervision will be provided to help prevent accidents or elopements . During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents dated 7/2017, the P&P indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .monitoring the effectiveness of interventions shall include the following: a. ensuring that interventions are implemented correctly and consistently .Systems Approach to Safety .2. Resident supervision is a core component of the systems approach to safety The type and frequency of resident supervision is determined by the individual resident ' s assessed needs .Resident Risks and Environmental Hazards .e. unsafe wandering . 555920 Page 2 of 2