Health inspection·November 9, 2023

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(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. 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. On 9/28/2023 the California Department of Public Health (CDPH) received a complaint regarding a resident (Resident 1), who went missing from the facility on 9/27/2023 at 1:15 p.m. The Complaint indicated Resident 1 had a monitoring device on that was broken/not working and Resident 1’s room had a door inside the room that lead to the outside of the building. Resident 1 had a history of leaving the facility. On 9/28/2023 at 2 p.m., the CDPH conducted an unannounced visit to the facility to investigate the complaint. The CDPH determined, Resident 1, who had a history of wandering (moving aimlessly around the facility without awareness of personal safety) and a history of elopement (when a resident who is not capable of protecting or caring from themselves leaves the facility unsupervised and undetected) from the facility was not supervised and/or monitored (ongoing observation and assessment) to prevent Resident 1 from leaving the facility without staff knowledge and/or permission. The facility failed to: 1. Ensure there was a system in place to prevent Resident 1’s elopement from the facility, when the facility’s wander guard sensor (alarm to signal if a resident at risk for elopement tries to exit the facility) was disabled on 9/19/2023 due to the facility’s front door being under construction. 2. Ensure the facility’s staff followed Resident 1’s Care Plan indicating Resident 1 would not attempt to leave the facility and to monitor the nature and circumstances (triggers) of attempted elopement during specific activities, involvement of others with resident, and patterns of behavior. 3. Follow the facility’s policy and procedure (P&P), titled, “Safety and Supervision” to consider the hazards identified in the environment, individual resident risk and the resident’s assessed needs. 4. Follow the facility’s P&P, titled, “Unusual Occurrence Reporting” to report unusual occurrences or other reportable events which affect the health, safety, or welfare of the resident within 24 hours of such incident. These deficient practices resulted in Resident 1 eloping from the facility on 9/27/2023 at approximately 11:15 a.m., Resident 1 was missing from the facility for 8 hours and had the potential to sustain injury, harm, and death. A review of Resident 1’s Admission Record (Face Sheet), indicated Resident 1 a 72 year old female was initially admitted to the facility on 9/16/2018 and readmitted on 6/15/2021, with diagnoses of dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and anxiety disorder (extreme and persistent fear and/or worry). A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/13/2023, indicated Resident 1’s cognition was intact, and Resident 1 required extensive one-person physical assist for bed mobility, transfers, walking in her room and the corridors and locomotion on/off the unit. A review of Resident 1’s Change of Condition (COC1), dated 1/5/2022, indicated on 1/5/2022 at approximately 12 p.m., Resident 1 could not be located in the facility. A review of Resident 1’s Progress Notes, dated 1/5/2022 and timed at 2:36 p.m., indicated on 1/5/2022 at approximately 2:50 p.m., Resident 1 was located by the police and was returned to the facility. A review of Resident 1’s Care Plan, dated 1/5/2022, indicated Resident 1 was at risk for elopement related to one or more attempts by Resident 1 to leave the facility and Resident 1’s impaired decision due to dementia and schizophrenia. The Care Plan goals indicated Resident 1 would not attempt to leave the facility without an escort. The Care Plan interventions indicated for Resident 1 to have a wander guard due to poor safety awareness, check for placement and function of the wander guard every shift, monitor the nature and circumstances (triggers) of attempted elopement during specific activities, involvement of others and patterns of behavior. A review of Resident 1’s Physician’s Orders, dated 12/27/2022, indicated a wander guard elopement device due to poor safety awareness. A review of Resident 1’s Progress Notes, dated 9/27/2023 and timed at 3:31p.m., indicated on 9/27/2023 at approximately 11:15 a.m., Resident 1 could not be located in the facility. A review of Resident 1's Progress Notes dated 9/27/2023 and timed at 7:07 p.m., indicated Resident 1 was located by the police department (no location was noted, where the resident was found) and would be returned to the facility escorted by the Administrator (ADM) and Director of Nursing (DON). During an interview on 9/28/2023, at 2:45 p.m., Resident 1 stated she went out yesterday (9/27/2023) to her parent’s house but did not remember how she got there or how she got back to the facility. During an interview on 9/28/2023, at 3 p.m., Certified Nurse Assistant 1 (CNA 1), stated Resident 1’s daily routine was to walk around the facility with her bags and to say, “my dad is coming to pick me up.” CNA 1 stated, Resident 1 has a wander guard bracelet on her left hand but the sensor on the front door was removed on 9/19/2023. CNA 1 stated the morning of 9/27/2023, Resident 1 said she was waiting for her father to pick her up and was seen walking into the front entrance lobby. CNA 1 stated she redirected Resident 1 onto the patio where she remained until 10 a.m. CNA 1 stated when she checked on Resident 1 at 11 a.m., she could not locate Resident 1. CNA 1 stated Resident 1 had previously eloped from the facility and must be closely monitored. CNA 1 stated the front lobby was very busy that morning. Resident 1 could have walked out of the front door entrance because the wander guard alarm had been deactivated and there would have been no alarm sound as Resident 1 exited the facility. CNA 1 stated Resident 1 was at risk injury and or death. During an interview on 9/29/2023 at 1:37 p.m., the Receptionist (R1), stated she is a CNA at the facility, but she was working as the receptionist during the time Resident 1 eloped from the facility (9/27/2023). R1 stated, she knew Resident 1 had a history of eloping from the facility before and needed a lot of redirection to keep her safe. R1 stated, Resident 1 must be monitored closely because the wander guard sensor was removed on the front door. R1 stated the morning of 9/27/2023 the front lobby was very hectic, and she (R1) was assisting many visitors and answering phone calls. R1 stated she should have asked for a partner to sit at the front desk to ensure Resident 1 did not walk out of the front door. During an interview on 10/3/2023, at 11 a.m., the DON stated, when the wander guard sensor was removed from the front door of the facility, on 9/19/2023, Resident 1 was at an even higher risk for elopement. The DON stated the staff should have monitored Resident 1’s whereabouts more closely since the wander guard was not available at the front door. The DON stated Resident 1 could have been hit by a car, assaulted, hospitalized, or killed during the time of her elopement. The DON stated the facility did not report the incident to CDPH until 9/29/2023 (two days after Resident 1 was found after being missing) because Resident 1 returned to the facility without any injuries. The DON acknowledged, that an elopement was considered an unusual occurrence and the facility should have reported when Resident 1 eloped. The DON stated at the time Resident 1 eloped from the facility, she was not aware of the facility’s policy. A review of the facility’s P&P, titled, “Unusual Occurrence Reporting,” revised 12/2007 indicated as required by Federal or State regulations our facility reports unusual occurrences or other reportable events which affect the health, safety or welfare of our residents, employees, or visitors. Unusual occurrences shall be reported via telephone to the appropriate agencies as required by current laws and regulations within twenty-four (24) hours of such incident or as otherwise required by Federal and State regulations. A review of the facility’s P&P, titled, “Safety and Supervision,” dated 7/2017, indicated the facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk, resident supervision is the core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident’s assessed needs and identified hazards in the environment, the type and frequency of resident supervision may vary among residents and over time for the same resident. These risk factors and environment hazards include unsafe wandering. The facility failed to: 1. Ensure there was a system in place to prevent Resident 1’s elopement from the facility, when the facility’s wander guard sensor was disabled on 9/19/2023 due to the facility’s front door was under construction. 2. Ensure the facility’s staff followed Resident 1’s Care Plan indicating Resident 1 would not attempt to leave the facility and monitor the nature and circumstances (triggers) of attempted elopement during specific activities, involvement of others with resident, and patterns of behavior. 3. Follow the facility’s P&P, titled, “Safety and Supervision” to consider the hazards identified in the environment, individual resident risk and the resident’s assessed needs. 4. Follow the facility’s P&P, titled, “Unusual Occurrence Reporting” to report unusual occurrences or other reportable events which affect the health, safety, or welfare of the resident within 24 hours of such incident. These deficient practices resulted in Resident 1 eloping from the facility on 9/27/2023 at approximately 11:15 a.m., Resident 1 was missing from the facility for 8 hours and had the potential to sustain injury, harm, and death. These violations, jointly, separately or in any combination, had direct or immediate relationship to safety, or security of residents.