Health inspection·April 19, 2024

42 CFR § 483.25 (d) Accidents The facility must ensure that- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §72311 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. 22 CCR §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. The California Department of Public Health (CDPH) received an entity reported incident (ERI) on 2/23/2024, indicating Resident 1 eloped from the facility. On 3/4/2024, at 9 a.m., CDPH conducted an unannounced investigation at the facility. The facility failed to: 1.Implement its policy and procedure (P&P) titled “Wandering and Elopements,” which indicated the facility will identify residents who was at risk of unsafe wandering. 2. Implement its P&P titled, “Wander Guard Alarm Policy,” indicated the wander guard alarm system was an essential tool for ensuring residents at the facility are always safe and secure at all times, the wander-guard system should be enabled 24 hours each day, and all personnel are to monitor residents who are on a wander guard to prevent them from leaving the facility without prior approval/authorization. 3. Implement its P&P titled, “Wandering and Elopement,” indicated the facility will identify residents at risk for elopement upon admission and when there is a change in condition to minimize the risk of elopement. 4. Perform visual checks, at least every two hours for Resident 1, to prevent the resident from eloping (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised or unnoticed prior to their scheduled discharge) from the facility on 2/22/2024. As a result, Resident 1, left the facility unsupervised, fell on the streets, and sustained a 2-centimeter ([cm] unit of measurement) laceration (skin tear) to his forehead, and a right frontal subarachnoid hemorrhage (bleeding in the space that surrounds the brain), and was transported to the General Acute Care Hospital (GACH) for further evaluation and treatment. A review of Resident 1’s admission record indicated Resident 1 was an 88-year-old male, admitted to the facility on 2/3/2024. Resident 1’s diagnoses included repeated falls (more than two falls in a six-month period), difficulty in walking (inability to walk properly due to abnormal and uncontrollable walking patterns), Hemiplegia (muscle weakness on one side of the body that can affect the arms, legs, and facial muscles), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 1’s history and physical (H&P), dated 2/3/3034, indicated Resident 1could not make own decisions, but can make needs known. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/9/2024, indicated Resident 1’s cognitive (the ability to think and process information) skills for daily decisions making was severely impaired. The MDS indicated Resident 1 required a cane/crutch and wheelchair for walking. The MDS indicated Resident 1 required moderate assistance in functional abilities with activities of daily living (ADLs). A review of Resident 1’s Admission Skin Re-Assessment, dated 2/25/2024, indicated Resident 1 had abrasions (the surface layers of the skin has been broken) on the forehead, bridge of nose, and above the upper lip. The Admission Skin Re-Assessment indicated Resident 1 had a left buttock pressure injury. A review of Resident 1’s Change of Condition (COC), dated 2/7/2024, indicated Resident 1 wandered aimlessly and attempted to get out of the facility unattended. A review of Resident 1’s Care Plan titled, “Elopement” dated 2/13/2024, indicated Resident 1 was an elopement risk/wanderer related to a history of attempts to leave the facility unattended. The care plan interventions indicated staff will monitor Resident 1’s location at least every 2 hours or as needed, and document wandering behavior. During a concurrent interview and record review on 3/4/24 at 12:01 p.m., with the Administrator (ADM) and the Director of Nursing (DON), the facility’s video camera footage was reviewed. Resident 1 was observed pushing a wheelchair pass the east nursing station where two nursing staff was sitting. Resident 1 was observed exiting the facility at 6:12 p.m., at the east door. At 6:13 p.m., the Licensed Vocational Nurse (LVN1) was observed going to the east door to shut the alarm off. At 6:14 p.m. the LVN 1 was observed opening and shutting the east door without looking in both directions, to see if anyone was outside. LVN 1 was observed with the Receptionist going back to the door at 6:16 p.m., again without checking to see if anyone was outside. During an interview on 3/4/2024 at 12:45p.m. with the ADM, the ADM stated the outside video showed it took Resident 1 “40 seconds” to get around the corner from line of sight. The ADM stated, Resident 1 was a wanderer, and a wander guard (a device used to keep track of residents) was placed on his wrist prior to the elopement date. During an interview on 3/4/2024 at 1:40p.m. with LVN 1, LVN 1 stated, she worked as a desk nurse the evening Resident 1 left the facility unsupervised, and the last time she saw Resident 1 was around dinner time. LVN 1 stated she was sitting at the East station when she heard the alarms, and waited one or two minutes before she got up to check the door. LVN 1 stated she opened the door and looked in both directions. LVN 1 stated, she should have gotten up to check the alarm right away. During an interview on 3/4/2024 2:00 p.m. with DON, the DON stated the Fire department dispatch called the facility on 2/22/2024 at 7:30 p.m., to inform the facility that that Resident 1 was found on the street, with facial abrasions with bleeding and taken to a GACH facility. A review of the Los Angeles Paramedic Record dated 2/22/2024 indicated Resident 1 was found down on 2/22/2024 in the street at 7:23 p.m. with major injuries, trauma to the head from a fall. Resident 1 was then transferred to a GACH facility. A review of Resident 1’s GACH records, dated 2/22/2024, indicated Resident 1 was diagnosed with a right frontal subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding space). A review of Resident 1’s GACH records, dated 2/23/2024, indicated Resident 1 received a computerized tomography scan ([CT] combines data from several X-rays to produce a detailed image of structures of the body) of the head, and a CT angiography of the head (an image of the blood vessels in the head). The CT scan and CT angiography revealed a traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or penetrating head injury) on 2/23/2024. A review of Resident 1’s GACH records, dated 2/23/2024, indicated Resident 1 was transferred and admitted to a second GACH facility for higher level of care (a hospital capable of providing diagnostic, interventional or tertiary care beyond the capacity of the hospital from which a patient originates) due to developed acute encephalopathy (confusion, memory loss and coma in severe cases). Resident 1 was admitted to the Neurology Unit (an intensive care unit devoted to the care of patients with immediately life-threatening neurological problems) for close monitoring. The GACH records indicated Resident 1 was found unresponsive on the Neurology Unit (not reacting or able to react in a normal way when touched or spoken to) and in Supraventricular Tachycardia ([SVT] an irregularly fast or erratic heartbeat) which was spontaneously (happening or done in a natural, often sudden way) resolved and Resident 1 regained consciousness (awake and aware of one's surroundings) in the GACH facility. A review of Resident 1’s GACH records dated 2/24/2024, indicated Resident 1 was started on Keppra 500mg (medication used for seizures) in the GACH after suffering a traumatic brain injury during a fall when Resident 1 elopement from the facility. A review of the facility’s P&P titled, “Wandering and Elopements”, dated 3/2019, indicated, “The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment. for resident” and “If a resident is missing, initiate the elopement/missing resident emergency procedure. The P&P indicated if the resident is not located, notify the administrator and the director of nursing services, the resident’s legal representative, the attending physician, and law enforcement officials… A review of the facility’s undated P&P titled, “Wander Guard Alarm Policy”, indicated “The wander guard alarm system is an essential tool for ensuring residents at the facility are safe and secure at all times, all exit doors in the hallway are equipped with an alarm system to notify staff when wander guard residents attempt to leave the facility without notification. The P&P indicated to ensure these residents are provided with the highest level of safety and security, while at the same time respecting the rights of other residents from unnecessary disruptions due to a wander guard alarm being triggered, the facility has instituted the following: The wander guard alarm system be enabled 24 hours each day. Under no condition is the wander-guard system to be deactivated (turned off) during this time. All personnel are to monitor residents who are on a wander guard to prevent them from leaving the facility without prior approval/authorization. A review of the facility’s P&P titled, “Wandering and Elopement”, dated 1/31/2023 indicated the facility will identify residents at risk for elopement upon admission and when there is a change in condition to minimize the risk of elopement and to enhance the safety of residents in the facility. The facility failed to: 1.Implement its P&P titled “Wandering and Elopements,” which indicated the facility will identify residents who was at risk of unsafe wandering. 2. Implement its P&P titled, “Wander Guard Alarm Policy,” indicated the wander guard alarm system was an essential tool for ensuring residents at the facility are always safe and secure, wander-guard system be enabled 24 hours each day, and all personnel are to monitor residents who are on a wander guard to prevent them from leaving the facility without prior approval/authorization. 3. Implement its P&P titled, “Wandering and Elopement,” indicated the facility will identify residents at risk for elopement upon admission and when there is a change in condition to minimize the risk of elopement. 4. Perform visual checks, at least every two hours for Resident 1, to prevent the resident from eloping (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised or unnoticed prior to their scheduled discharge) from the facility on 2/22/2024. As a result, Resident 1 left the facility unsupervised, fell and sustained a 2-centimeter laceration to his forehead, and a right frontal subarachnoid hemorrhage, and was transported to the GACH for further evaluation and treatment. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.