Health inspection·November 25, 2024

42 CFR § 483.21 Comprehensive Care Plans The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at § 483.10(c)(2) and § 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under § 483.24, § 483.25, or § 483.40 22 CCR § 72311 (a) Nursing service shall include, but not be limited to, the following: (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 § 72523 (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 10/15/2024, the California Department of Public Health (CDPH) received a Facility-Reported Incident indicating Resident 1 was missing from the facility on 10/13/2024. On 10/16/2024, the CDPH conducted an unannounced visit of the facility to investigate the allegation. The facility failed to: 1. Implement its policy and procedure (P&P) titled "Wandering & Elopement," which indicated to implement immediate interventions to prevent further wandering/ elopement (the act of leaving a facility unsupervised and without prior authorization) by the resident. 2. Implement its P&P titled, "Care Planning," by failing to ensure Resident 1's care plan was person-centered to meet the resident's needs. 3. Specify the type of supervision (refers to an intervention and means of mitigating risk of accidents or elopement and frequency [i.e. one nurse to one resident observation] is determined by the resident's assessed needs) Resident 1 needed after he eloped from the facility on 6/19/2024 and 8/24/2024. 4. Specify how often Resident 1 would be monitored (watched), daily. As a result, Resident 1 eloped from the facility and was placed at risk for medical complications, such as hypertensive crisis (dangerously high blood pressure), diabetic coma (loss of consciousness due to uncontrolled blood sugar), stroke (loss of blood flow to a part of the brain), behavioral crisis (inability to control oneself, becoming a danger to themselves or others), embolism (blockage of blood flow in the body), sepsis (a life-threatening blood infection), malnourishment (lack of food), motor vehicle accident, and death. Resident 1 was found on 10/21/2024 (6 days later) at a General Acute Care Hospital (GACH). Resident 1 was a 61-year-old male, originally admitted to the facility on 11/21/2018, with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), COPD, diabetes mellitus (DM-abnormal blood sugar levels), heart failure (a heart disorder which causes the heart not to pump the blood efficiently), chronic (long-term) atrial fibrillation (A-fib, irregular heart beat that increases risk of blood clots), and hypertension (HTN-high blood pressure). Resident 1 had a conservator (a judge-appointed person to act or make decisions for the resident). A review of Resident 1's care plan titled, "Noted with repetitive pacing behaviors; no actual destination or purpose," dated 11/14/2023, indicated staff will monitor Resident 1's behavior every shift, record and notify the physician if behavioral episodes increased, provide visual checks and frequent monitoring of behavior, remind the resident not to leave the facility unassisted and encourage him to be involved in activities of choice. A review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool) dated 3/22/2024, indicated Resident 1 had intact cognition (ability to think and reason). The MDS indicated Resident 1 did not experience hallucinations (thinking or feeling that something is real, when it is not) or delusions (beliefs that are firmly held and do not align with reality). The MDS indicated Resident 1 was independent with sitting to standing, lying to sitting position, and walking 10 feet. The MDS indicated Resident 1 required supervision with transfer to and from the toilet and with walking 50 feet (a unit of measurement) with two turns and walking 150 feet. A review of Resident 1's "Elopement Evaluation," dated 5/19/2024, did not indicate Resident 1 was at risk for elopement or had elopement attempts. A review of Resident 1's Change in Condition (COC) Evaluation form, dated 6/19/2024 at 6:33 a.m., indicated on 6/19/2024, at night (time not indicated), Resident 1 "walked out of the premises with his travelling bag." The COC also indicated Resident 1 was observed walking back and forth the hallway with a travelling bag, stating "the facility cannot tell me when and where to smoke, so I walked out the building." The COC indicated the police was notified and 10 minutes later, Resident 1 returned to the building. A review of Resident 1's "Elopement Evaluation," dated 6/19/2024 at 7:33 a.m., (post elopement), indicated Resident 1 had a history of, or an attempted elopement while at home. The report indicated Resident 1 had a history of leaving the facility without informing staff. The report indicated Resident 1 verbally expressed the desire to go home, packed his belongings and stayed near an exit door. The evaluation report also indicated Resident 1's wandering behavior was likely to affect his safety or wellbeing and that of others. The evaluation's clinical suggestions section indicated staff will apply an identification (ID) bracelet on Resident 1, monitor the resident's location frequently, use visual barriers such as stop signs, ribbons, and tapes, and notify staff of Resident 1's wandering and elopement risk. A review of Resident 1's care plan titled, "Resident left facility this morning without notifying staff," dated 6/19/2024, indicated interventions for staff to monitor Resident 1 for wandering behavior and provide diversional activities frequently. A review of Resident 1's Interdisciplinary Team (IDT-group of healthcare professionals, including the resident/ resident representative, working together to provide residents with needed care) meeting notes dated 6/19/2024, indicated Resident 1 stated he eloped so he can smoke cigarettes at his preferred times. The IDT meeting notes indicated Resident 1 was reminded of the facility's rules. The IDT meeting notes indicated Resident 1 was offered smoking cessation assistance but refused. A review of Resident 1's "Elopement Evaluation," dated 8/24/2024 (after the second elopement on 8/24/2024), indicated Resident 1 had a history of elopement and attempts to leave the facility. The evaluation indicated Resident 1 verbally expressed a desire to go home, packed his belongings, or stayed near an exit door. The evaluation indicated Resident 1's wandering behavior occurred in a pattern. The clinical suggestions section was left blank with no suggestions on how staff would care for Resident 1 to prevent him from eloping. A review of Resident 1's care plan titled, "Resident left the facility on 8/24/2024 without notifying staff," dated 8/26/2024, indicated interventions for staff to distract Resident 1 from wandering by offering the resident pleasant diversions, structured activities, food, conversation, television, book resident prefers. A review of Resident 1's care plan titled, "Noted with repetitive pacing behaviors," dated 8/26/2024, indicated interventions for staff to monitor Resident 1's location routinely, monitor the resident for wandering behavior, and provide diversional activities. The care plan indicated the staff will monitor Resident 1's triggers for eloping and de-escalate (calm down) the behaviors. A review of Resident 1's physician order dated 8/26/2024, indicated to apply a wander guard bracelet (a wearable device to help track residents who are at risk of wandering) to alert staff if Resident 1 attempted to leave the facility. The physician's order indicated to check the wander guard bracelet's placement at the left wrist every shift, monitor the number of attempts to leave the facility every shift, weekly check of wander guard bracelet to ensure it is functioning properly every day shift every 7 days. A review of Resident 1's IDT meeting notes dated 8/26/2024, indicated on 8/24/2024, at 12:30 a.m., Resident 1 eloped from the facility. The IDT notes indicated by 1:15 a.m., Resident 1 was accompanied back to the facility by a staff member. The notes indicated Resident 1 was educated on the dangers and risk of going out alone, and a wander guard was offered to Resident 1 to remind him not to leave the facility unattended. A review of Resident 1's COC Evaluation form dated 8/30/2024, indicated Resident 1 left the facility on 8/24/2024 at around 5:45 a.m., through the front door. The COC indicated the door alarm turned on and two (2) staff members went after Resident 1 and brought Resident 1 back inside the facility. A review of Resident 1's physician orders for the month of October 2024 indicated the following: 1. Advair Diskus Aerosol Powder Breath Activated 250 50 microgram (mcg- unit of measurement)/ Fluticasone-Salmeterol 1 inhalation orally two times a day for chronic obstructive pulmonary disease (COPD- lung disease). 2. Aspirin Tablet Chewable 81 milligram (mg - a unit of measurement) 1 tablet by mouth daily for cerebral vascular accident (CVA- stroke) prophylaxis (PPX- prevention). 3. Coreg Tablet 6.25 mg 1 tablet by mouth two times a day for hypertension (HTN- high blood pressure). 4. Digoxin (medication for Atrial-fibrillation ([A-fib] irregular heart rate) oral tablet 125 micrograms (mcg- a unit of measurement) 1 tablet by mouth in the morning. 5. Insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) glargine (long-acting medication for DM) 100 units (measurement for insulin)/milliliter (mL- a unit of measurement) inject 8 units subcutaneously (under the skin) at bedtime for DM 6. Insulin lispro (fast-acting medication for DM) 100 units/mL injected as per sliding scale (dose adjusted based on current blood sugar) subcutaneously before meals and at bedtime for DM 7. Glyburide (medication for DM) tablet 5 mg by mouth in the morning for DM 8. Tiotropium bromide monohydrate (medication for COPD) 1 capsule inhale orally one time per day for COPD 9. Risperidone (medication for schizophrenia) tablet 2 mg by mouth two times per day for schizophrenia manifested by (m/b) auditory hallucinations (hearing sounds that are not real) 10. Benztropine mesylate (medication for movement disorders) 1 mg by mouth two times per day for extrapyramidal symptoms (EPS - uncontrollable movements due to antipsychotic medications) During a concurrent interview and record review on 10/16/2024 at 8:03 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's care plans dated 11/14/2023, 6/19/2024, and 10/15/2024, Elopement Evaluations dated 6/19/2024 and 8/26/2024, Physician Orders dated 8/26/2024 were reviewed. LVN 1 stated the Elopement Evaluation dated 6/19/2024 and 8/26/2024 indicated Resident 1 was at risk of eloping due to Resident 1's past attempts and successful elopements. LVN 1 stated Resident 1's Elopement Evaluations indicated Resident 1 eloped from the facility two times (on 6/19/2024 and 8/24/2024), prior to the third elopement on 10/13/2024. LVN 1 stated Resident 1's care plan dated 11/14/2023 indicated the staff will visually monitor Resident 1's location, Resident 1's behavior, and remind Resident 1 not to leave the facility unassisted. LVN 1 stated staff did not monitor Resident 1's location or wandering behavior. LVN 1 stated the visual checks were not performed or documented in Resident 1's clinical record. LVN 1 stated the interventions in Resident 1's care plan dated 6/19/2024 which indicated staff will monitor Resident 1's wandering behavior and location, were not documented in Resident 1's clinical record. LVN 1 stated Resident 1's care plan regarding elopement was not individualized and not specific to Resident 1's needs. LVN 1 stated Resident 1's physician's order dated 8/26/2024 indicated to apply a wanderguard bracelet on 8/26/2024. LVN 1 stated the wanderguard was not incorporated (added) to the care plan until 10/15/2024, after Resident 1 had eloped 10/13/2024 (third elopement). During an interview on 10/16/2024 at 10:50 a.m. with the Director of Nursing (DON), the DON stated the intervention on Resident 1's care plan to monitor for location routinely was vague (unclear) and not measurable. The DON stated the care plan's interventions should have been specific on the type of supervision Resident 1 needed and how often the staff had to monitor Resident 1. The DON stated the facility did not know where or when Resident 1 left the facility, or where Resident 1 was, after last seen on 10/13/2024 at 5:30 am. During an interview on 10/16/2024 at 12:37 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 was last seen in the facility on 10/13/2024 at 5:30 a.m. and was discovered missing on 10/13/2024 at 7:30 a.m. CNA 1 stated Resident 1's assigned staff were supposed to always monitor the resident's whereabouts and during the change of shift. CNA 1 stated on 10/13/2024 at 7:00 am, during the change of shift, staff did not monitor Resident 1's whereabouts. CNA 1 stated Resident 1 had eloped because staff was not monitoring his (Resident 1) location. During a concurrent interview and record review on 10/16/2024 at 2:18 p.m. with Registered Nurse (RN 2), Resident 1's physician orders for October 2024 and MAR for October 2024 were reviewed. RN 2 stated Resident 1 had no physician order to monitor his (Resident 1) location or his wandering behaviors. RN 2 stated the facility did not monitor Resident 1's location or wandering behaviors, which could have been the reason why the facility did not know where Resident 1 was. RN 2 stated there was no documentation in Resident 1's MAR indicating the resident's location. RN 2 stated Resident 1 eloped again because staff was not monitoring him. RN 2 stated Resident 1's elopement placed Resident 1's safety in danger. RN 2 stated, because Resident 1 eloped, Resident 1 missed the following daily medications: 1. Digoxin 2. Carvedilol 3. Aspirin 4. Insulin 5. Insulin lispro 6. Glyburide 7. Tiotropium bromide 8. Advair Diskus Aerosol 9. Risperidone 10. Benztropine RN 2 stated without receiving his (Resident 1) daily medications, Resident 1 was at risk for hypertensive crisis, diabetic coma, stroke, behavioral crisis, embolism. RN 2 stated Resident 1 could get struck by vehicles, possibly injured himself, resulting to hospitalization and death. During a concurrent interview and record review on 10/15/2024 at 4:47 p.m. with RN 3, Resident 1's care plan titled, "Resident left the facility without notifying staff or having escort," dated 8/24/2024, was reviewed. RN 3 stated the care plan interventions included to monitor for fatigue and weight loss, offer diversions, and monitor the resident's location routinely. RN 3 stated, the interventions were not individualized according to Resident 1's needs, who attempted to elope many times. RN 3 stated the intervention should have been specified to monitor the resident's location every hour. RN 3 stated the interventions listed on the care plan did not have a physician's order, therefore, the monitoring of location routinely was not conducted and documented in Resident 1's MAR. A review of the facility's undated policy and procedure (P&P) titled "Wandering & Elopement," indicated its purpose was to enhance safety of residents in the facility. The P&P indicated the license nurse in collaboration with the IDT, should assess residents upon identification of significant chan