Health inspection·January 27, 2022

§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. §72521. Administrative Policies and Procedures. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. On 11/05/21, at 1:04 p.m., the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a complaint regarding quality of care and resident safety. The facility failed to provide adequate supervision and assistance to Resident 1 on 11/03/2021 when after going to a 3 p.m. pain management appointment (at an outside clinic) via private transportation arranged by the facility, was not picked up, at 4:50 p.m. as scheduled, to return to the facility. As a result, Resident 1 walked back to the facility, using her walker, for 1.4 miles and arriving after midnight, at 12:44 a.m., placing Resident 1 at a high risk of accidents and injuries. A review of Resident 1's Admission Record indicated the facility admitted the resident a 87-year-old female on 12/15/2018, with diagnoses including paroxysmal atrial fibrillation (an irregular heart rate that commonly causes poor blood flow), major depressive disorder (a mental health disorder characterized by persistently depressed mood), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), chronic kidney disease (disease of the kidneys leading to kidney failure); muscle weakness (lack of strength in the muscles); hypertension (a condition in which the force of blood against the artery walls is too high), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 10/21/2021, indicated Resident 1 had moderate cognitive impairment (a condition in which a person experiences a decline in mental abilities [memory and thinking skills]), required supervision with bed mobility (movement to and from lying position) and locomotion (movement to and returns from off-unit locations). Resident 1 required limited assistance with one-person physical assist with transfers, dressing, toilet use and personal hygiene. Resident 1 utilized a walker for mobility, was not steady moving from seated to standing position, walking, turning around, and moving on and off toilet. Resident 1 experienced occasional moderate pain. During an interview with Resident 1, on 11/5/2021 at 1:35 p.m., Resident 1 stated, “I went to an appointment and Access didn’t show up. I was supposed to be picked up by Access from 4:40 p.m., to quarter to 6, so I walked down Wilshire to Lincoln and from Lincoln to the facility.” A review of the facility's documentation titled "Wednesday 11/03/2021 Appointments: Today's Scheduled Appointments" indicated Resident 1, 2:10 p.m. pick up time for 3:00 p.m. appointment with pain management. Return pick up time 4:50 p.m. with private van transportation. A review of Resident 1's Progress Notes dated 11/04/2021 at 4:33 a.m. indicated Resident 1 went out at 2:30 p.m., via transportation, for a 3:00 p.m. pain management appointment on 11/03/2021 and did not returned until 12:44 a.m. on 11/04/2021. A review of an online mapping on Google indicated that the pain management center was 1.4 miles from the Skilled Nursing Facility (SNF). A review of Resident 1's Progress Notes dated 11/04/2021 at 4:33 a.m. indicated the resident stated “when I finished my appointment, I went out front to wait for pick up at 4:30 p.m. and waited until about 5:45 p.m. and since nobody was around, I walked with my walker… I would stop and take breaks…” During an interview on 11/05/2021 at 4:25 p.m., the Administrator and Director of Nursing (DON) stated if the resident does not return, the facility usually calls the transportation company 15 to 20 minutes after the scheduled time to return to the facility. A review of the facility's policy and procedures titled, “Unusual Occurrence Reporting,” revised on 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. Our facility will report the following events to appropriate agencies: Allegations of abuse, neglect and misappropriation of resident property…and Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. A review of the facility's policy and procedures titled, “Elopements,” revised on 12/2007, “Staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. If an employee discovers that a resident is missing from the facility, he/she shall: If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident’s legal representative (sponsor), the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.).” The facility failed to provide adequate supervision and assistance to Resident 1 on 11/03/2021 when after going to a 3 p.m. pain management appointment (at an outside clinic) via private transportation arranged by the facility, was not picked up, at 4:50 p.m. as scheduled, to return to the facility. As a result, Resident 1 walked back to the facility, using her walker, for 1.4 miles and arriving after midnight, at 12:44 a.m., placing Resident 1 at a high risk of accidents and injuries. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1.