Other·January 28, 2022

22 CCR §72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. 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. On 11/9/2021, the California Department of Public Health (the Department) conducted an unannounced visit to the facility to investigate an allegation of resident safety. The facility failed to implement its policy on Reporting Unusual Occurrences by not notifying the Department when, on 11/5/2021, Resident 2 did not return the same day after signing out on pass. As a result, Resident 2 did not return after signing out on pass for more than 24 hours jeopardizing the Resident 2’s safety. A review of Resident 2's Admission Record, indicated Resident 2, a 58 years old male, was admitted to the facility on 10/21/2021 with diagnoses including Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), alcohol abuse, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) and nicotine dependence (is an addiction to tobacco products caused by the drug nicotine [a toxic colorless or yellowish oily liquid that is the chief active constituent of tobacco]). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care-planning tool) dated 10/28/2021, indicated Resident 2 required supervision with bed mobility and eating. Resident 2 required limited assistance with activities of daily living (ADLs, such as transfer, walking, dressing, toilet use and personal hygiene). A review of Resident 2’s Progress Note dated 11/5/2021 timed at 3:25 p.m. [late entry], indicated Resident 2 went out on pass and should return before midnight per medical director (MD). A review of Resident 2’s Progress Note dated 11/5/2021 at 7:23 p.m., indicated, "Resident went with the other resident to go out on pass this morning has not come back as staff reported." During an interview with the MDS Registered Nurse 1 (MDS/RN 1), on 11/9/2021, at 11:52 p.m., the MDS/RN 1 stated, "Two residents were out on pass and did not come back, at 12 p.m. midnight" During an interview with the Administrator on 11/9/2021, at 12:02 p.m., the Administrator stated, "We have a lot of homeless people here, they are very awake and alert." The Administrator further stated, no incident report or investigation report was completed when Resident 2 did not return to the facility after signing out on pass on 11/5/2021. The Administrator further acknowledged and stated the Department should have been notified when Resident 2 did not return to the facility after 24 hours. During an interview with the Director of Nursing (DON), on 11/12/2021 at 1:11 p.m., the DON stated Resident 2 did not have a physician's order to go out on pass. Resident 2 had not returned to the facility as of 11/22/2021. DON further stated the Department was not notified that Resident 2 went out on pass on 11/5/2021 at 2:00 p.m. and did not return. A review of the facility's policy and procedure, titled "Wandering and Elopement," dated July 2017, indicated, "The facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement...The facility staff member who finds that a resident is missing will alert facility staff., The Charge Nurse will call CODE...and organ organize a search. Facility Staff will search areas of the Facility, including common area, bathrooms, showers, outside areas, etc. If the resident cannot be located, the Charge Nurse will notify, Administrator/designee, Director of Nursing Services/designee iii. Attending Physician, The Administrator/designee will continue to work with law enforcement and the responsible party until the resident is located; The Licensed Nurse most familiar with the incident will document in the resident's medical record how the elopement occurred, the facility will make necessary reports to state agencies in compliance." A review of the facility's policy and procedure titled, "Unusual Occurrence Reporting: Operational Manual-Administrative Policies," dated August 1, 2012, indicated, "The Administrator is notified of all events that require a report to a state or federal agency. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility will retain a copy of the confirmation letter. the facility conducts and documents timely and through investigation into all unusual occurrences and takes corrective action as appropriate. The investigation and documentation include but is not limited to...Interviews of residents and staff; Review of facility records; and/or...Audits of service/system; Reportable Events will be documented on Reportable Events Log, The Facility maintains copies of incident reports of any unusual occurrences for at least one (1) year, the facility will provide addition information to the local health officer or the Department of Public Health as requested. However, this did not happen." The facility failed to implement its policy on Reporting Unusual Occurrences by not notifying the Department when, on 11/5/2021, Resident 2 did not return the same day after signing out on pass. As a result, Resident 2 did not return after signing out on pass for more than 24 hours jeopardizing the Resident 2’s safety. The above violation had a direct relationship to the health, safety, and security of Resident 2.