Health inspection·August 16, 2024

CFR §483.25 Quality of Care (d) Accidents. The facility must insure that (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: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72523(a) Patient Care Policies and Procedure. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 7/3/2024, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident (Resident 1) eloped (an unauthorized departure of a patient from an around-the-clock care setting without the facility's knowledge and supervision) from the facility on 7/3/2024. On 7/4/2024, CDPH made an unannounced visit to the facility to investigate the FRI. Upon investigation CDPH determined the facility failed to ensure Resident 1 did not elope. The facility failed to: 1. Implement Resident 1’s care plan to ensure Resident 1 was wearing his Wander guard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time). 2. Have a system in place to alert staff when facility lobby Doors 1 and Door 2 were opened, to prevent residents from leaving the facility without staff supervision. As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including Olanzapine (medication to treat schizophrenia [a disorder mental health that affects a person's ability to think, feel, and behave clearly]) 15 milligrams (mg) twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024, ten days after the elopement, and subsequently transferred to a general acute care facility (GACH) for further evaluation. At the GACH, Resident 1 was admitted with diagnoses including acute psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), severe anemia (not enough red blood cells in the body), and Resident 1 received a blood transfusion (process of transferring blood products). According to psychiatric (medical practitioner specializing in diagnosis and treatment of mental illness with medication) consult, Resident 1 was supervised by a sitter (a healthcare worker who will provide continuous supervision to a resident) for safety because he was agitated and aggressive and was placed on a 5150 hold (72-hour involuntary hold for observation due to patient being a danger to self or others). The psychiatric consult indicated Resident 1 required inpatient hospitalization for further stabilization of behavioral symptoms. Resident 1, a 54-year-old male, was admitted to the facility on 6/11/2024 with diagnoses including paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia, type 2 diabetes (problem in the way the body regulates and uses sugar as fuel), and hypertension (when the force of blood pushing against the walls of blood vessels is too high). A review of Resident 1’s Admission Initial Assessment, dated 6/11/2024, indicated Resident 1 was a high risk for elopement because Resident 1 was independently mobile and had a history of elopement. A review of Resident 1’s Psychiatric Evaluation, dated 6/12/2024, indicated Resident 1’s judgement and insight (ability to predict consequences of behavior and decisions) were moderately impaired. The evaluation indicated Resident 1 was disheveled (untidy), very disorganized and was a poor historian. The evaluation indicated Resident 1 had delusions (altered reality that is persistently held despite evidence or agreement to the contrary) and auditory hallucinations (when the person hears voices or noises that don't exist in reality). The evaluation indicated Resident 1 was diagnosed with psychosis. A review or Resident 1’s History and Physical (H&P), dated 6/13/2024, indicated Resident 1 was unable to communicate/ make decisions for self. A review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 6/15/2024, indicated Resident 1 had severe cognitive (ability to learn, remember, understand, and make decision) impairment for daily decision making. The MDS indicated Resident 1 needed set up assistance with eating, supervision (helper provides verbal cues) with oral hygiene, upper body dressing, personal hygiene, and needed partial assistance (helper less than half the effort to complete the task) with toilet hygiene, and lower body dressing. A review of Resident 1’s Weekly Summary, dated 6/30/2024 at 2:38 a.m., indicated Resident 1 was alert and confused. A review of Resident 1’s Order Summary Report, active orders dated 7/5/2024, indicated the following orders, starting on 6/11/2024: a. May have wander guard to the left hand to alert staff of resident trying to leave the facility unassisted. b. Check wander guard placement every shift. c. Monitor Resident 1 for episodes of wandering behavior (a behavioral problem of disorientation and difficulty relating to the environment with aimless or purposeful motor activity that causes a social problem such as getting lost, leaving a safe environment, or intruding in inappropriate places) around hallway and patio every shift. d. Check for wander guard function every Sunday during 7-3 p.m. shift. e. Olanzapine 15 mg one tablet orally two times a day for schizophrenia. A review of Resident 1’s untitled care plan, initiated on 6/17/2024 indicated Resident 1 was at risk for elopement related to cognitive impairment, and mood and behavioral symptoms. The care plan goal indicated Resident 1 will not leave the facility unsupervised. Care plan interventions included: a. May have wander guard on left hand to alert staff if resident was trying to leave the facility unassisted. b. Check wander guard function every Sunday during day shift. c. Check wander guard placement on the left hand every shift d. Monitor Resident 1 for wandering behavior every shift around the hallway and patio. e. Frequent rounds by staff f. Remind resident that he needs to remain in the facility unless family of staff member was with them. A review of Resident 1’s Monitoring side effects/Behaviors/black box (added to the labeling of drugs when serious adverse reactions or special problems occur) warnings, for 7/2024, indicated: a. Starting 6/11/2024, check wander guard placement every shift. On 7/2/2024 night shift, Resident 1 was absent from the facility without medications on 7/2/2024 night shift. b. Staring on 6/11/2024, monitor Resident 1 for episodes of wandering behavior, around hallway and patio every shift. On 7/1/2024, Resident 1 was observed wandering four times. On 7/2/2024, Resident 1 was observed wandering four times. A review of a document titled Situation Background Assessment, Recommendation (SBAR) Communication Form, dated 7/3/2024 at 1:45 a.m., for Resident 1, indicated the following: a. At 11:00 p.m., Resident 1 was seen lying in bed comfortably watching television in no apparent distress. b. At 12:00 midnight Resident 1 was sitting at the edge of the bed watching television. c. At approximately 1:15 a.m., Certified nurse assistant (CNA) noticed Resident 1 was not in the resident’s room or restroom and made charge nurse aware. d. At 1:20 a.m. staff searched for Resident 1 in the facility. Resident 1’s wander guard was noted fully stretched on the floor. e. At 1:36 a.m., police were notified of Resident 1’s elopement. f. At 1:52 a.m. Sheriffs arrived. g. At 2:13 a.m. the Sheriff was made aware Resident 1 was alert and oriented times 2 with episodes of confusion and diagnosis of paranoid schizophrenia. A review of Resident 1 GACH Emergency Department Physician note dated 7/13/2024 at 7:17 p.m., indicated facility staff found Resident 1 wandering around the streets and was brought in by ambulance to the GACH for further evaluation. The note indicated Resident 1 had acute (sudden onset) psychosis, severe anemia, and type 2 diabetes. Resident 1 received a blood transfusion for anemia. A review of GACH Psychiatric consult dated 7/14/2024, indicated Resident 1 was agitated and aggressive in the Emergency room and Resident 1 was placed with a sitter for safety on a 5150 hold. The consult indicated Resident 1 required inpatient hospitalization for further stabilization of symptoms. During a concurrent observation and interview on 7/4/2024 at 9:50 a.m., with Registered Nurse Supervisor (RNS), the left side of the double doors to Door 1 (lobby) did not trigger an alarm when opened. RNS stated the alarm should trigger whenever either door was opened. RNS stated the alarm not triggering was not safe for residents. During a continued observation and interview on 7/4/2024 at 9:50 a.m., with RNS, it was noted that Resident 1’s room was right by the front door that exits to the parking lot (Door 2). Door 2 was also noted with two unsecure (can be opened without a key or a code) latches. The RNS stated that Door 2 does not alarm when opened and at night no one was monitoring the residents exiting Door 2. The RNS stated since Resident 1 removed his wander guard he probably just opened the latches and exited. RNS stated Door 2 not being secure was not safe because if residents can remove the wonder guard bracelet and open the latches, they can leave at night undetected. During an interview on 7/4/2024 at 12:15 p.m., the Maintenance Supervisor (MS) stated the alarm for Door 1 had been deactivated and the MS just activated it right now. The MS stated Resident 1 could have eloped through Door 1 because the alarm would not have been triggered to notify staff that he was leaving. During an interview on 7/4/2024 at 2:00 p.m., Licensed Vocational Nurse (LVN1) stated, at approximately 1 a.m., CNA 4 reported to her that Resident 1 was not in his room or the restroom. After a search was conducted in the facility, the Sheriff was notified, and three sheriffs also searched on the premises to no avail. During an interview on 7/4/2024 at 3:55 p.m., the Administrator (ADM) 3:55 p.m., stated Door 2 was not adequate for the resident’s safety because it did not have an alarm to notify staff if residents opened it. The ADM stated the Door 1 alarm should have been triggered when opened. During an observation and interview on 7/5/2024 at 10:28 a.m., with MS, at Door 1, the alarms on the door was observed to have the code or password clearly labeled on the alarms. The MS stated the codes were labeled there so anyone who can read can disarm it if needed; that makes the door alarms unsecure because anyone can punch the code and can exit undetected. MS stated Resident 1 might have exited from here (Door 1) or Door 2. During a concurrent interview and record review with LVN 1, on 7/5/2024 at 10:53 a.m., Resident 1’s medical record was reviewed. Resident 1’s Elopement assessment on admission, dated 6/11/2024, indicated Resident 1 was a high risk for elopement. Resident 1’s SBAR, dated 7/3/2024, was reviewed, and the SBAR indicated the stretched out and damaged wander guard was observed on the floor, indicating Resident 1 had pulled the wander guard off and threw it on the floor. LVN 1 stated Resident 1 should have had the wander guard on. LVN 1 stated Resident 1 should not have been able to leave the facility undetected because it was not safe. During an interview on 7/5/2024 at 4:00 p.m., the ADM stated the facility exit doors should be secure and high elopement risk residents should be monitored. The ADM stated to prevent further elopements, in-services (staff training/education) were completed. The ADM stated the facility will install magnetic door locks to Doors 1 and 2. The ADM stated until the locks were installed facility staff will be assigned to monitor the door area around the clock to ensure no residents eloped. The ADM stated this will be a systematic change that will be immediately implemented. A review of the facility’s policy and procedure (P&P) titled Behavioral Assessment, Intervention and Monitoring, revised 3/2019, indicated the facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessment and plan of care. Residents will have minimal complications associated with the management of altered or impaired behavior. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. A review of the facility’s P&P titled Care plans, Comprehensive Person-Centered care plan policy, revised 12/2016, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. The facility failed to: 1. Implement Resident 1’s care plan to ensure Resident 1 was wearing his Wander guard. 2. Have a system in place to alert staff when facility lobby Doors 1 and Door 2 were opened, to prevent residents from leaving the facility without staff supervision. As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including Olanzapine 15 mg twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024, ten days after the elopement, and subsequently transferred to a GACH for further evaluation. At the GACH, Resident 1 was admitted with diagnoses including acute psychosis, severe anemia and Resident 1 received a blood transfusion. According to psychiatric consult, Resident 1 was given a sitter for safety because he was agitated and aggressive and placed on a 5150 hold. The consult indicated Resident 1 required inpatient hospitalization for further stabilization of behavioral symptoms. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.