Health inspection·August 2, 2024

42 CFR §483.25 Free of Accident Hazards/Supervision/Devices 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. 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: (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. (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 § 72521 Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (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. 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 6/18/2024 at 8 a.m., the California Department of Public Health (CDPH) received a facility reported incident indicating Resident 1 was missing from the facility on 6/16/2024 around 5:35 pm. On 6/20/2024 at 10:20 a.m., the CDPH made an unannounced visit to the facility to investigate the incident. The facility failed to: Ensure Resident 1 was provided with supervision according to its policy and procedure (P&P) titled "Resident Elopement" which indicated the facility will provide a safe environment and preventive measures for elopement with the aim to monitor and document residents at risk for elopement. As a result, Resident 1 left the facility unsupervised on 6/16/2024. Resident 1 sustained redness on the left knee and a bump to the left eyebrow. A review of Resident 1's Face Sheet indicated Resident 1 was a 79-year-old female, originally admitted to the facility on 5/17/2024 and readmitted on 6/17/2024. Resident 1's diagnosis included dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), anxiety disorder (persistent and excessive worry that interferes with daily activities), hypertension (when the pressure in your blood vessels is too high), and osteoarthritis (a progressive joint disease, in which the tissues in the joint break down over time). A review of Resident 1's physician's order dated 5/17/2024, indicated a to apply wander guard (a device used for residents with wandering behavior that alarm when a resident attempts to leave the facility unsupervised) to right wrist for elopement precautions. The physician’s order indicated to monitor for proper placement and battery function every shift. A review of Resident 1's care plan, titled "At risk for elopement and wandering out of the facility due to dementia," dated 5/18/2024, indicated to apply wander guard bracelet on right wrist and to check Resident 1’s where abouts (frequency not specified). A review of Resident 1's Elopement Risk Assessment, dated 5/19/2024, indicated Resident 1 was at risk of wandering and elopement. A review of Resident 1's History and Physical (H&P), dated 5/20/2024, indicated Resident 1 did not have the capacity for medical decision making due to dementia. A review of Resident 1's Minimum Data Set ([MDS]- a standardized assessment and care screening tool), dated 5/23/2024, indicated Resident 1 was able to comprehend most conversation. The MDS indicated Resident 1 required supervision or touching assistance from staff for activities of daily living (ADLs) such as showering, dressing, putting on and off footwear, and needed set up assistance for personal hygiene, oral hygiene and eating. A review of Resident 2’s progress notes dated 6/16/2024 at 5:35 p.m. indicated an unidentified Certified Nurse Assistant (CNA) reported to the Charge Nurse at 5:35 p.m. Resident 1 could not be found inside the facility. The notes indicated, the Charge Nurse last saw Resident 1 at the Nurses’ Station 2. During an interview on 6/20/2024 at 12:10 p.m., CNA 2 stated "Resident 1 was not in the bed when I started 3 p.m. to 11p.m. shift.” CNA 2 stated, "I have not heard an alarm went off from the wander guard." During an interview on 6/20/2024 at 1:15 p.m., Licensed Vocational Nurse (LVN) 3 stated Resident 1 was noticed missing on 6/16/2024 at 5:30 p.m. LVN 3 stated Resident 1 was a high risk for wandering. LVN 3 stated Resident 1 should have the wander guard placed on her (Resident 1) wrist. LVN 3 stated when Resident 1 got closer to an exit door, the alarm would have sounded. LVN 3 stated on 6/16/2024, she did not hear an alarm sound. LVN 3 stated, it was important to check and supervise residents at risk for elopement for safety issues, and so residents will be kept safe. During an interview on 6/20/2024 at 3:22 p.m., the Director of Nursing (DON) stated, whenever residents were assessed at high risk for elopement, an order to apply wander guard was obtained from the physician and should have been applied to the resident. The DON stated, if Resident 1 had wander guard on, the alarm should have sounded when Resident 1 got close to the door on 6/16/2024. The DON stated, there was no coverage (for receptionist) at the front entrance door on 6/16/2024 at 5:30 p.m. The DON stated, receptionist and office staff left the facility at 4:30 p.m. and the front door should have been locked. The DON stated, when Resident 1 went missing on 6/16/2024, there was no staff or receptionist at the front door. The DON stated Resident 1 was brought back to the facility by the Police on 6/16/2024 at 6:40 p.m. with redness on the left knee, a bump to the left eyebrow and was provided treatment. A review of the facility's undated P&P titled "Safety Supervision of Residents," indicated resident supervision is a core component of the system’s approach to safety. The P&P indicated, the type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P indicated, certain resident risk factors and environmental hazards should be addressed in the dedicated P&P, including unsafe wandering. A review of the facility's undated P&P titled, "Resident Elopement" indicated, the facility will provide a safe environment and preventive measures for elopement with the aim to monitor and document residents at risk for elopement. The facility failed to: Ensure Resident 1 was provided with supervision according to its P&P titled "Resident Elopement" which indicated the facility will provide a safe environment and preventive measures for elopement with the aim to monitor and document residents at risk for elopement. As a result, Resident 1 left the facility unsupervised on 6/16/2024. Resident 1 sustained redness on the left knee and a bump to the left eyebrow. This violation had a direct or immediate relationship to the health, safety, or security of the resident.