Health inspection·August 16, 2024

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. §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On 6/28/2024, the California Department of Public Health (CDPH), received a facility reported incident (FRI) indicating Resident 1 eloped (left the health care facility unsupervised and undetected) on 6/27/2024 and was found on 6/28/2024 the next morning. On 7/10/2024 at 10:45 AM, the CDPH made an unannounced visit to investigate the incident. The facility failed to: Ensure Resident 1 was supervised the facility’s exit doors were safeguarded with audible devices, to alert staff when a resident attempted to leave the facility, in accordance with its policy and procedure (P&P) titled, “Elopement”. As a result, Resident 1 eloped from the facility on 6/27/2024 and was found by the police on 6/28/2024 around 9:30 AM. A review of Resident 1’s Admission Record indicated Resident 1 was an 81-year-old female, originally admitted to the facility on 12/30/2022 and readmitted on 6/22/2023. Resident 1’s diagnoses included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and toxic encephalopathy (brain dysfunction caused by exposure to toxic substances). A review of Resident 1’s History and Physical (H&P) dated 6/27/2023 indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 6/12/2024, indicated Resident 1 had severe cognitive impairment (ability to reason, understand, remember, judge, and learn). A review of Resident 1’s Elopement Screening, dated 6/12/2024, indicated Resident 1 was at risk for wandering and elopement. A review of Resident 1’s care plan addressing the resident’s “Risk for wandering or elopement related to recent elopement, dementia, ambulatory (able to walk)” dated 6/24/2024, indicated interventions included staff to call the attention of the resident and redirect when seen going towards the exit door, frequent checks of the resident’s whereabouts and to implement measures to provide safety for the resident. During an interview on 7/10/2024 at 4:15 PM, Licensed Vocational Nurse (LVN) 1, stated he was notified Resident 1 was missing by a staff member and began to search for the resident. LVN 1 stated he did not hear an alarm go off on any of the doors that lead outside of the facility during the shift. LVN 1 stated Resident 1 did not have any devices on her to notify the staff if she attempted to leave the facility unsupervised. LVN 1 stated if the facility’s exit door alarm was on, it would have alerted the staff when Resident 1 eloped. During an interview on 7/11/2024 at 12:33 PM, RN 1 stated the last time she saw Resident 1 on 6/27/2024 was around 10:30 PM. RN 1 stated Resident 1 was in bed and awake. RN 1 stated around 11:00 PM, a nurse from the next shift stated Resident 1 was not in the room. RN 1 stated she did not hear a door alarm go off during her shift. RN 1 stated it was very possible for Resident 1 to have left through the front door undetected because there was no alarm on the front door that night. During an interview on 7/11/2024 at 3:15 PM, the Director of Nursing (DON) stated Resident 1 could have left undetected because there was no alarm installed on the front door. A review of the facility’s undated P&P titled, “Elopement”, indicated the facility shall safeguard exit doors with devices such as audible alarms, to alert staff whenever a resident attempted to leave the facility unsupervised. Ensure Resident 1 was supervised the facility’s exit doors were safeguarded with audible devices, to alert staff when a resident attempted to leave the facility, in accordance with its policy and procedure (P&P) titled, “Elopement”. Ensure Resident 1 was supervised the facility’s exit doors were safeguarded with audible devices, to alert staff when a resident attempted to leave the facility, in accordance with its policy and procedure (P&P) titled, “Elopement”. As a result, Resident 1 eloped from the facility on 6/27/2024 and was found by the police on 6/28/2024 around 9:30 AM. This violation had a direct or immediate relationship to the health, safety, or security of residents.