Other·April 25, 2023

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. 42 CFR §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 CFR §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. On 3/20/2023, the California Department of Public Health (CDPH) received a facility reported incident (FRI) on 3/20/2023 indicating Resident 1 eloped from the facility. On 3/20/2023, the CDPH conducted an unannounced visit at the facility. The facility failed to: 1. 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, unnoticed, and/or prior to their scheduled discharge) from the facility on 3/18/2023. As a result Resident 1 left the facility unsupervised and was exposed to harsh environmental conditions including cold weather and rain, had a potential of being hit by a car, and had a potential for medical complications including malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), dehydration (a harmful reduction in the amount of water in the body), and death. Resident 1 had still not been found as of 3/29/2023. Resident 1 was 77-year-old male admitted to the facility on 2/16/2023 with diagnosis including Alzheimer's disease (a progressive mental deterioration that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety (intense, excessive, and persistent worry and fear about everyday situations), cognitive communication deficit (impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), dysphagia (difficulty swallowing), cognitive communication deficit, protein -calorie malnutrition (low energy intake, weight loss, loss of subcutaneous fat [a type of fat that's stored under the skin], loss of muscle mass, fluid accumulation, and decreased hand grip strength), and Chronic Obstructive Pulmonary Disease ([COPD] a group of lung diseases that blocks airflow and make it difficult to breathe). During a review of Resident 1's general acute care hospital (GACH) Psychiatric Initial Evaluation (Psych Eval), dated 2/10/2023, the GACH Psych Eval indicated Resident 1 was admitted to the GACH on 2/10/2023 with psychosis (a severe mental disorder in which thought, and emotions are so impaired that contact is lost with external reality). and suicidal ideation ([SI] when someone thinks about killing themselves) by overdosing on medication. During a review of Resident 1's GACH History and Physical (H&P), dated 2/10/2023, the H&P indicated Resident 1 was placed on AWOL (absent without leave)/Assaultive/Suicidal Precautions. During a review of Resident 1's, H&P from the facility, dated 2/16/2023, the H&P indicated Resident 1 could make his needs known but could not make medical decisions. During a review of Resident 1's MDS, dated 2/23/2023, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required limited assistance (staff provided non-weight-bearing assistance) activities of daily living (ADLs) such as transferring, walking, and moving in the unit. The MDS indicated Resident 1 required extensive assistance (staff provided weight bearing support) for dressing and toilet use. The MDS also indicated Resident 1 used a wheelchair for movement. The MDS indicated Resident 1 used an antipsychotic (medication primarily used to manage psychosis [mental disorder characterized by a disconnection from reality], particularly in schizophrenia) for seven out of the seven days of the week. During a review of Resident 1's physician's order dated 2/16/2023, the physician's order indicated Risperdal (medication used to treat certain mental/mood disorders such as schizophrenia), 1 milligram ([mg] unit of measurement), two times daily (BID), and Neurontin (medication used to relieve nerve pain) 200 mg, 1 capsule three times daily (TID) for polyneuropathy (a condition in which a person's peripheral nerves are damaged). During a review of Resident 1's Elopement Risk Evaluation dated 2/16/2023, the evaluation indicated Resident 1 was at moderate risk for elopement and required care planning for elopement. Resident 1's history of elopement from a previous facility and diagnosis of Alzheimer's disease, were not considered during the elopement risk assessment to place the resident at high risk for elopement. During a review of Resident 1's care plan, titled "Elopement Risk," dated 2/16/2023, the interventions indicated staff will encourage Resident 1 to notify the nurse if he had to leave the facility for any reason, assess/record/report to the doctor (MD) risk factors for potential elopement like wandering, repeated requests to leave facility, statements such as "I am leaving and I wanna go home," attempt to leave the facility, elopement attempts from previous facility or hospital. The care plan intervention also indicated staff would observe Resident 1's location with visual checks, at least every two hours. During a review of Resident 1's Change in Condition (COC), Assessment dated 3/18/2023 and timed 6:30 a.m., the COC indicated Licensed Vocational Nurse (LVN) 1 noticed that on 3/18/2023 at 6:30 a.m., Resident 1 was not in his bed when LVN 1 was doing rounds. The COC indicated LVN 1 looked around the facility and gathered incoming staff to drive around the neighborhood to look for Resident 1 but did not find the resident. During an interview on 3/20/2023 at 2:14 p.m., with LVN 2, LVN 2 stated Resident 1 was alert and aware but had episodes of confusion and during those episodes of confusion, Resident 1 would say he had to go to work. LVN 2 stated she performed visual checks on Resident 1's location at least every 2 hours during her shift but did not document anywhere in the resident's medical record that visual checks were done. LVN 2 stated, it was important to document all care given, to indicate it was done. During an interview on 3/20/2023 at 3:13 p.m., with the Director of Nursing (DON), the DON stated there were two security guards during the day in charge of monitoring residents. The DON stated at night, the nursing staff were supposed to monitor exit doors of the facility during rounds to prevent residents from leaving the facility unsupervised. The DON stated staff was to perform visual checks on Resident 1 at least every two hours and document on the resident's chart. The DON stated unfortunately, staff did not document. During an interview on 3/20/2023 at 3:45 p.m., with LVN 1, LVN 1 stated Resident 1 had dementia, was confused, and had sundowning syndrome (a state of confusion that can cause restlessness, agitation, irritability occurring in the late afternoon and lasting into the night). After dinner, Resident 1 would get up from his wheelchair and state he had to go to work. LVN 1 stated on 3/18/2023 at 6:30 a.m., she noticed Resident 1 was no longer in his room. while she (LVN 1) was doing her final rounds. She was looking for Resident 1 and noticed his wheelchair and his cane were missing. LVN 1 stated she did not remember the last time she performed visual checks on Resident 1. LVN 1 stated she did not document Resident 1's whereabouts in the resident's medical record. LVN 1 stated she did not hear the door alarms that night. LVN 1 stated if the alarm on the doors were on, it would have sounded, if Resident 1 went through the doors. During an interview with the Administrator (Admin) on 3/21/2023 at 9:59 a.m., the Admin stated the facility's security footage was not available because the recordings reset every Sunday. The Admin stated he forgot to review the recordings before it reset. The Admin stated on 3/20/2023, he called the previous facility where Resident 1 resided prior to hospitalization and was told Resident 1 would repeatedly sign himself out and not come back to that facility. The Admin stated the facility was unaware of Resident 1's previous behavior because the facility did not call Resident 1's previous facility to inquire. During a concurrent interview and record review on 3/21/2023 at 12:27 p.m., with the DON, Resident 1's "Elopement Risk Evaluation" dated 2/16/2023 was reviewed. The DON stated Resident 1 was admitted to the GACH for suicide ideation ([SI] when a person thinks about killing him/herself) and feelings of hopelessness on 2/9/2023. The DON stated an elopement risk evaluation was done for the resident on 2/16/2023 and a care plan written. The DON stated staff was supposed to perform visual checks on Resident 1 but were not required to document routine visual checks. The DON stated on weekends, the entrance to the facility was through the main entrance, ambulance entrance, and hallway exit. The DON stated the three main entrances/exits had alarms on the door. The DON also stated the facility did not know how Resident 1 eloped from the facility on 3/18/2023, because the wires of the facility's security cameras were damaged by the rain and did not work well. The DON stated there is a likelihood Resident 1 had not been medicated since eloping from the facility on 3/18/2023 because the resident had still not been located. During an interview on 3/21/2023 at 1:44 p.m., with the MS, the MS stated Resident 1's room window can be opened from the resident's room. The MS stated Resident 1 could push the window open and get out through the window to the alley. During an interview on 3/21/2023 at 2:16 p.m., with LVN 2, LVN 2 stated Resident 1 would say he had to go to work. LVN 2 stated she did not document Resident 1's statement and did not report it to the MD. LVN 2 stated Resident 1 had a history of suicidal ideation and should have been monitored or supervised more often than just every two hours, per the resident's elopement risk care plan, to prevent the resident from eloping. LVN 2 stated staff should have monitored Resident 1 every two hours because the resident stated he wanted to go to work. During a concurrent interview and record review on 3/21/2023 at 4:30 p.m., with LVN 1, Resident 1's Elopement Risk care plan dated 2/16/2023, was reviewed. LVN 1 stated the care plan interventions indicated to document and report to the MD risk factors for wandering, such as Resident 1 stating he needed to go to work. LVN 1 stated she did not document Resident 1 saying that he had to go to work and did not report to the MD because she redirected Resident 1 successfully. LVN 1 stated that when Resident 1 stated he wanted to go to work, she should have educated the resident on the risk of leaving the facility. LVN 1 stated Resident 1 had Alzheimer's and was at risk for elopement. LVN 1 stated she was not concerned about the resident leaving the facility at the time because Resident 1 was redirectable. LVN 1 also stated Resident 1's Elopement Risk Evaluation was inaccurate because it scored the resident as a 15 instead of an 18 or more, considering Resident 1's diagnoses of Alzheimer's and statement "I want to go to work." During a telephone interview on 3/23/2023 at 10:45 a.m., with CNA 1, CNA 1 stated the last time she saw Resident 1 was on 3/18/2023 at 6 a.m., while she was doing her hourly rounds. Resident 1 was in his room in his wheelchair. CNA 1 stated she did not document anywhere when she saw Resident 1 because the charge nurse did not tell her to document Resident 1's visual checks. CNA 1 stated she did not hear any alarms go off during that shift. CNA 1 stated the alarm was very loud and if it went off, everyone would have heard it. CNA 1 stated Resident 1 would talk about missing his wife and that his daughter was coming to see him. During a record review of the Accuweather forecast report for Los Angeles area from 3/18/2023 to 3/24/2023 Los Angeles, CA Monthly Weather | AccuWeather, the temperature was in the low 60's-degree Fahrenheit ([°F] unit of measurement) to high 50's °F. It also indicated some days were, rainy, cloudy and with thunderstorms. During a record review of https://crimegrade.org/murder-90043, the Los Angeles city's overall crime grade for violent crimes for zip code 90043, where the facility was located, was an F grade (meaning most dangerous). During a review of the facility's P&P titled "Elopement Risk Assessment," undated, the P&P indicated interventions for elopement include notification of physician for changes in behavior, such as increasing insistence or attempts to leave and environmental controls such as a functional alarm system for egresses. The facility failed to: 1. 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, unnoticed, and/or prior to their scheduled discharge) from the facility on 3/18/2023. As a result Resident 1 left the facility unsupervised and was exposed to harsh environmental conditions including cold weather and rain, had a potential of being hit by a car, and had a potential for medical complications including malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat), dehydration (a harmful reduction in the amount of water in the body), and death. Resident 1 had still not been found as of 3/29/2023. This violation presented a direct or immediate relationship to the health, safety, security, or welfare of Resident 1.