Other·May 13, 2021

F689 §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. § 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. The Department received a complaint on 3/15/2021 indicating a resident (Resident 1) reported to the hospital emergency room staff that she had been physically abused by a male staff member at the facility. Resident 1 stated she left the facility against medical advice (AMA) and wandered the streets for approximately five (5) days. On 3/16/2021, an unannounced complaint investigation was conducted at the facility. The facility failed to: 1. Ensure Resident 1, who had a documented history of depression (characterized by persistent feelings of sadness and hopelessness) with attempts to harm self, was adequately supervised to prevent the resident from leaving the facility unsupervised. 2. Provide adequate supervision to prevent Resident 1 from leaving the facility unsupervised. 3. Report Resident 1’s elopement (to leave unnoticed) to the Department of Public Health (DPH). 4. Adhere to its policy and procedure (P/P) regarding resident Elopement and notifying the local police department and reporting an unusual occurrence of Resident 1 eloping to the Department within 24 hours. As a result, Resident 1, who was wheelchair bound (unable to walk due to illness; relying on a wheelchair for mobility to move around) and had multiple medical conditions that required medications for treatment, left out the facility’s front door unnoticed and unsupervised. Resident 1 went missing for seven (7) days and was without significant medications, was found almost 6 miles away from the facility and once found required a transfer to a general acute care hospital (GACH) for evaluation, care, and treatment. Resident 1 was diagnosed with a cerebral vascular accident ([CVA (a stroke)] blockage in the blood vessels supplying blood to the brain) requiring an admission on the telemetry unit (a specialized unit that monitors and records resident’s heart beats and patterns) for close monitoring and was hospitalized for six (6) days. This non-compliance resulted in a delay in the DPH conducting an investigation, and placed Resident 1 at risk for harm. During a review of Resident 1’s History and Physical (H/P), dated 6/23/2020, the H/P indicated Resident 1 had the capacity to understand and make decisions. The H/P indicated Resident 1 had a history of depression (persistent feelings of sadness and hopelessness) and attempted to harm herself in the past. During a review of Resident 1’s Admission Record (face sheet), the face sheet indicated Resident 1, was a 52-year-old female, who was initially admitted to the facility on 1/23/2019 and last re-admitted on 8/4/2020. Resident 1’s diagnoses included, but not limited to epilepsy (abnormal brain activity with the absence of body jerking), abnormalities of gait (walk) and mobility, hemiplegia (the loss of the ability to move and sometimes to feel anything on one side) following a cerebral infarct (blockage in the blood vessels supplying blood to the brain) of the dominant (main) right side, diabetes mellitus (high sugar levels in the blood) and hypertension (high blood pressure). During a review of Resident 1’s recapitulated (a summary) physician’s orders, for the month of 3/2021, the orders indicated to administer Resident 1 the following medications: 1. Glipizide (medication used to lower blood sugar) 5 milligrams ([mg] a unit of measurement) by mouth daily for diabetes mellitus (health condition that affects how your body turns food into energy. Most of the food eaten is broken down into sugar (also called glucose) and released into your bloodstream). 2. Lexapro (an antidepressant [reduce feelings of hopelessness and sadness] medication) 10 mg by mouth daily for depression manifested by persistent feelings of hopelessness and helplessness. 3. Aspirin (blood thinning medication) enteric coated 81 mg by mouth daily for CVA. 4. Depakote (medication used to prevent seizure [a brief episode of uncontrolled body jerking and loss of mental awareness]) 500 mg by mouth twice a day for seizure (a sudden, uncontrolled electrical disturbance in the brain, it can cause changes in your behavior, movements or feelings). 5. Metformin Hydrochloride (medication used to lower blood sugar) 1, 000 mg orally twice a day for diabetes mellitus. 6. Basaglar (a medication used to treat high blood sugar levels) 14 units subcutaneously (beneath the skin) at bedtime diabetes mellitus. 7. Fasting blood sugar (BS) checks before breakfast and dinner and administer Regular Insulin (a medication used to treat high blood sugar level) Injection 100 units/milliliter (mL) as per sliding scale (often used for periods of insulin adjustment depending on the blood sugar level), before meals and at bedtime subcutaneously. Notify the physician if BS is below 60 or above 400 The summary also indicated Resident 1 may go out on pass ([OOP] allowed to leave the facility for brief periods during the day) with a responsible party/person. During a review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 1/22/2021, the MDS indicated Resident 1's cognition (thought process) was intact and required limited assistance of a one-person physical assist for transfers and activities of daily living ([ADLs] routine activities that people do every day). The MDS indicated Resident 1 had an impairment on one side of the upper and lower extremities and was dependent of a wheelchair for mobility. During a review of Resident 1’s care plan, dated 1/22/2021 and titled, “Potential for bleeding, bruising, skin tear secondary to aspirin therapy for CVA, the care plan indicated for the staff to monitor Resident 1 for bleeding episode. During a review of Resident 1’s care plan, dated 1/22/2021 and titled, “Impaired physical mobility related to loss of balance and coordination secondary to CVA and right hemiplegia,” the care plan indicated for the staff to assess Resident 1’s degree of weakness in upper and lower extremities, assist Resident 1 in performing movements or task and to begin with the task that require small range of movements and encourage control. During a review of Resident 1’s care plan, dated 1/22/2021 and titled, “Fall risk prevention and management, resident at risk for fall related to limited mobility, poor balance, decreased endurance, medications, unsteady gait and a history of falls,” the care plan indicated for the staff to provide an environment that supports minimized hazards over which the facility has control, monitor for side effects of medications and report side effects to the physician. During a review of Resident 1’s care plan, dated 1/22/2021 and titled, “Language barrier, primary language is Spanish, at risk for difficulty making needs known,” the care plan indicated for the staff to utilize family members and translators as necessary, encourage use of non-verbal communication techniques, provide education to Resident 1, responsible party and staff regarding special needs. During a review of Resident 1’s “Fall Risk Assessment,” dated 1/22/2021, the assessment indicated Resident 1 had a score of 35 (without a range provided) and was at a high risk for falls. During a review of Resident 1’s “Medication Administration Record (MAR),” for the month of 3/2021 dated from 3/1/2021 through 3/31/2021, the MAR indicated for the staff to monitor and tally (total) Resident 1’s behavior of hopelessness and helplessness by hashmarks (a form of counting). The MAR indicated from 3/1/2021 through 3/5/2021 (four days), Resident 1 had a total of 21 episodes of feeling hopelessness and helplessness. During a review of Resident 1’s nurse’s note (NN), dated 3/6/2021 and timed between the hours of 3 p.m. to 11 p.m., the NN indicated Resident 1 was OOP in her wheelchair, but did not indicate with whom. The NN indicated Resident 1 was observed by staff at 4:30 p.m., on the same day, propelling backwards in her wheelchair towards a room near the main entrance of the facility. The NN indicated at 5 p.m. on the same day, Resident 1 was not observed in her room when the dinner trays were being served. The NN indicated the facility’s staff conducted an internal and external search for Resident 1 but Resident 1 was not located and was missing from the facility. The NN indicated at 6:15 p.m., the same day, Resident 1’s family member (FM 1) was called to check if FM 1 had taken Resident 1 OOP. The NN indicated at 7:45 p.m., the same day, the police arrived at the facility and was made aware that Resident 1 was self-responsible and was missing and a police report was obtained. The NN indicated at 8:30 p.m. and at 10:30 p.m., the same day, the staff conducted a search around facility’s perimeter and community looking for Resident 1, but the staff were not able to locate Resident 1. During a review of Resident 1’s Social Services note, dated 3/8/2021 and timed at 2:17 p.m., the note indicated Resident 1 left the facility on 3/6/2021 between the time of 4:30 p.m. and 4:50 p.m. According to the note, FM 1 stated someone probably assisted Resident 1 out of the facility because Resident 1 was heavy (262 pounds) and hard to push and Resident 1 could not get far propelling herself in the wheelchair. During a review of the facility’s Discharge Against Medical Advice (AMA) form, dated 3/13/3021 (seven days after Resident 1 left from the facility [eloped]) and timed at 2:45 p.m., the AMA form indicated Resident 1 refused to sign. During a review of the facility’s investigative report, dated 3/13/2021 and timed at 3 p.m., the report indicated FM 2 found Resident 1 and could not take care of her so, she went to the facility and attempted to drop off Resident 1 at the facility. According to the report, FM 2 stated she received an anonymous call indicating Resident 1 was seen at a supermarket, almost 6 miles away from the facility. FM 2 requested for the facility to readmit Resident 1 but was instructed by the staff to take Resident 1 to the nearest hospital for an evaluation. According to the note, FM 2 stated she should “sue” the facility because the facility did not take care of Resident 1 and the resident was not supposed to be on the street unsupervised. During a review of Resident 1’s Social Services note, dated 3/16/2021 and timed at 12:44 p.m., the note indicated Resident 1 was hospitalized and reported being physically assaulted by one of the facility’s staff. According to the note, Resident 1 stated she left the facility because the glass door opened by itself, no one would believe it, wheeled herself onto the street and a man put her into his car, gave her five dollars and drove her to the bus stop. According to the note, Resident 1 stated she caught a bus in the area, received food from some friends, and was at a church 5.5 miles away from the facility and was found near the church by FM 2. During an interview on 3/16/2021 at 1:18 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 could not walk, was wheelchair dependent, was self-responsible, could make her own decisions and had been missing from the facility for one week. During an interview on 3/16/2021 at 3:20 p.m., the DON stated the facility did not have a surveillance camera (used for close monitoring). The DON stated Resident 1 left out of the front (main entrance) door of the facility. During a concurrent observation and interview on 3/17/2021 at 3:45 p.m., Resident 1 was lying in a bed at the GACH with her right arm contracted (tightening of muscles that prevents normal movement) with tremors (unintentional trembling or shaking) of the left hand, an intravenous line ([IV] into the vein) in her left hand and had a telemetry monitor (a device that records heart beats and patterns) attached. Resident 1 stated a week prior she left from the main entrance of the facility at approximately 3 p.m. Resident 1 stated she had asked a stranger walking by her on the street for the time and then met a man who helped her by giving her five dollars and pushed her to the bus stop (approximately 0.4 miles away from the facility). Resident 1 stated she rode the bus for approximately 12.5 miles from the facility, then took another bus where she exited the bus at the supermarket. Resident 1 stated she slept sitting upright in her wheelchair by a bus stop near the supermarket and some people gave her food to eat. Resident 1 stated she began feeling sick because she was a diabetic and did not have any of her prescribed diabetic medications. Resident 1 stated she was found by her family, after her family (FM 2) heard about a woman who resembled her (Resident 1) was sleeping on the streets. Resident 1 stated FM 2 found her, brought her back to the facility but the facility instructed FM 2 to transport her to the GACH. During an interview on 3/18/2021 at 9:15 a.m., LVN 1 stated when someone enters and exits through the facility’s main entrance door the alarm would sound, but the sound would stop once the door was closed. During an interview on 3/18/2021 at 9:55 a.m., Certified Nursing Assistant 1 (CNA 1) stated the facility’s main door only alarm if a wander guard (a device that alarms when residents attempt to elope or wander from a safe environment) was near the door. CNA 1 stated the facility’s main door had no alarm. During a concurrent observation of the facility’s main entrance and interview on 3/18/2021 at 9:58 a.m., a buzzing sound was heard when the door of the facility’s main entrance was opened, and the buzzing sound was not heard when the door was closed. The Maintenance Supervisor (MS) stated the only alarm on the door of the main entrance was a wander guard alarm. During an observation on 3/18/2021 at 10:04 a.m., the buzzing sound from the facility’s main front door could be heard while standing by the DON’s office, which was at the rear of the facility. During an interview on 3/18/2021 at 12:51 p.m., the Administrator stated he did not report Resident 1 missing to the Department in a timely manner because Resident 1 was self-responsible and Resident 1’s physician indicated that she could make decisions on her own. The Administrator was informed Resident 1 had a physician’s order which indicated the resident could go out on pass (OOP) with a responsible person, the Administrator stated he was not aware of the physician’s order. During a review of Resident 1’s GACH H/P, dated 3/13/2021 and timed at 4:09 p.m., the H/P indicated Resident 1 was transported by ambulance to the Emergency Department and stated she was hit in the head by the facility’s staff. The H/P indicated Resident 1’s blood pressure was 214/82 millimeters of mercury [mmHg], (normal reference range [NRR] 139/79- 90/60 mm/hg), a white blood cell ([WBC] part of the body’s immune system; helps fight infections) count of 12.3 x10³ per microliter (uL) (normal reference range [NRR] = 4.50 -10.00 x10³) and a glucose level of 208 mg/dL (normal reference range [NRR] for blood glucose level is 70 and 130 mg/dL). The GACH H/P indicated Resident 1’s computerized tomography ([CT scan] combines a series of X-ray images taken from different angles and uses a computer for processing the images; more-detailed than x-rays) of the brain indicated Resident 1 had a new CVA. Resident 1 was discharged to another facility on 3/19/2021. During a review of the facility's revised P/P, dated 1/11/2016 and titled, “Out on Pass,” indicated a responsible person is considered to be a person who is over the age of 18 and could call for medical assistance if required, and when indicated, a person who has received education with regard to the administration of medications indicated by the resident’s specific needs. During a review of the facility’s undated P/P titled, Wandering and Elopement,” the P/P indicated the definition for elopement was a resident who does not have capacity and leaves the facility unaccompanied. The P/P indic