Health inspection·July 23, 2021

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. 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. The Department received a complaint on 4/26/21 indicating a resident (Resident 1) had complaints of not being able to see and the facility’s social services representatives refusing to help replace the resident’s glasses. The complainant alleged Resident 1, who has dementia, was found outside the facility last month by a staff member and was not notified, and the facility allows the resident to sign out whenever he wants but cannot care for himself. On 4/30/21, an unannounced visit was conducted at the facility. The facility failed to provide adequate supervision to prevent Resident 1, who had a documented history of suicidal ideation (thoughts of taking one owns life) with a plan to commit suicide by verbalizing a desire to overdose, depression (characterized by persistent feelings of sadness and hopelessness) with an attempt to harm self, from eloping (leaving a facility, unsupervised, undetected and without authorization or permission) from the facility. As a result, Resident 1 left the facility unsupervised and was located across the street from the facility near a busy traffic intersection. During a review of Resident 1's general acute care hospital (GACH) history and physical (H/P), prior to admission to the facility, dated 1/3/2021, the H/P indicated Resident 1 was on a 5150 hold (an involuntary hold of a person with a mental health disorder who is a danger to themselves and others) for being a danger to others, sexually inappropriate, increased aggressive (ready to attack or confront) behavior, yelling, screaming and threatening others with physical harm towards staff at a prior SNF. The GACH's H/P indicated Resident 1 had suicidal ideation (thoughts of taking one owns life) with the intent to overdose, and homicidal (having thoughts to kill someone) ideation with the intent to be aggressive and threaten others with physical harm. During a review of Resident 1's facility's Admission Record (Face Sheet), the Face Sheet indicated Resident 1, was a 78 year-old male, who was admitted to the facility on 1/14/2021 with diagnoses that included Type 2 diabetes mellitus (continuous high sugar levels in the blood), major depressive disorder (mental illness characterized by persistent feelings of sadness and hopelessness), paranoid schizophrenia (false beliefs that some individuals are plotting against self), dementia with behavioral disturbance (a condition characterized by a group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning) and lack of coordination (inability to maintain balance). During a review of Resident 1's social services summary (SS) note, dated 1/14/2021, the SS note indicated Resident 1 was admitted from a GACH and was hospitalized on a 5150 hold (an involuntary hold of a person with a mental health disorder who is a danger to themselves and others) for being a danger to others, sexually inappropriate, increased aggressive (ready to attack or confront) behavior, yelling, screaming and threatening others with physical harm. During a review of Resident 1's Elopement (leaving a facility, unsupervised, undetected and without authorization or permission) Risk Assessment (ERA), dated 1/14/2021, the ERA indicated Resident 1 had a total of four marked questions. According to the ERA, two or more responses of "Yes" for questions three (3) through eight (8) indicated at risk for wandering (walk around slowly without a clear purpose or direction) and Resident 1 should be placed on Wander Risk precautions. According to the ERA, the staff's interventions for Resident 1 included a personal safety alarm/Wanderguard ([WG] a device that alarms when residents attempt to elope or wander from a safe environment) and frequent monitoring. During a review of Resident 1's admission orders, dated on 1/14/2021, the orders indicated Resident 1 did not have an order for a safety device. During a review of Resident 1's care plan, dated 1/14/2021 and titled, "Behavior problem: wandering and sexually inappropriate, verbal abuse by yelling, screaming related to paranoid schizophrenia, the care plan indicated under the section for wandering and sexually inappropriate was not marked/identified by the staff. The staff's interventions included for the staff to address Resident 1's wandering behavior by walking with the resident, redirect from inappropriate areas, engage in diversional (change in use or purpose of activity) or behavior activity, investigate and monitor Resident 1 for needing psychological (the mental and emotional mood of a person)/psychiatric (mental illness and disorders) support and provide services as ordered by the physician. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/25/2021, the MDS indicated Resident 1's cognition (thought process) was intact with fluctuating (changing) disorganized (uncontrolled) thoughts and required limited assistance of a one-person physical assist for transfers and activities of daily living ([ADLs] routine activities, such as eating, bathing, dressing, toileting, transferring and walking). During a review of Resident 1's H/P, dated 2/4/2021, the H/P indicated Resident had a fluctuating capacity to understand and make decisions. During a review of Resident 1's daily skilled nursing notes (DSNN), dated 3/10/2021, 3/11/2021 and 3/12/2021, the DSNN did not indicate Resident 1 had eloped from the facility. During a review of Resident 1's recapitulated (summary) physician's orders, for the months of 3/2021, 4/2021, 5/2021 and 6/2021, the orders indicated Resident 1 did not have an order for a safety device (personal safety alarm), as per the ERA. During a review of Resident 1's psychologist (a clinical professional trained in mental health) evaluation, dated 3/31/2021, the psychologist evaluation indicated the staff stated Resident 1 did not have any changes in his behavior and there were no new reports of psychological (a person's mental and emotional mood) behaviors exhibited by Resident 1. During a review of Resident 1's nurses' note (NN), dated from 1/14/2021 through 4/28/2021, there was no documented evidence of Resident 1 eloping or attempting to elope from the facility. During an interview on 4/30/2021 at 2 p.m., Resident 1 stated he has been a resident in the facility since 1/2021 and on 3/10/2021 he woke up that morning, put his clothes on, and left out of the facility's main front door. Resident 1 stated he was two blocks away from the facility when a male staff from the facility came and took him back to the facility. Resident 1 stated there were no staff sitting at the desk, located at the front main entrance, of the facility on the morning he left the facility. During a concurrent observation and interview, of the facility's entrance doors, on 4/30/2021 at 3:40 p.m., the Director of Nursing (DON) stated the facility only had one WG alarm system which was on Station 3, located at the entrance of the facility. The DON was asked how would the facility ensure residents who were at risk for eloping would not exit from the main entrance of the facility, the DON stated residents would not exit from the main entrance of the facility because there was nursing staff always at the nursing station. The DON was asked if the staff sat at the main entrance at all hours of the day and night, the DON stated, "No, and the main entrance of the facility was always locked from the outside on a continuous basis. The DON was told the main entrance of the facility was unlocked upon entrance that morning. An alarm device was observed, in the presence of the DON and the Maintenance Supervisor, on the left side of the main entrance door that indicated "WG.” The DON stated the device was not a Wander guard alarm. The MS stated the device was a WG alarm. The DON was asked how did she ensure residents would not elope from the main entrance of the facility, the DON stated residents would not exit from the main entrance because the door was locked from the outside but not locked from the inside. A resident was observed with a WG bracelet that walked to the door of the main entrance, but the WG alarm did not activate. The DON stated the resident's WG battery should be changed and the WG alarm works on the facility's door at Station 3. During concurrent interviews and record reviews of Resident 1's elopement risk assessment on 4/30/2021 at 5:16 p.m. and 5:22 p.m., the DON stated Resident 1 was an elopement risk. The DON was asked how the residents at risk for eloping were monitored, the DON stated the staff observed the residents. The DON was asked for the staff's documentation of the monitoring, but the DON could not provide evidence of the staff's documentation on monitoring the residents who were at risk for eloping. During a telephone interview on 5/3/2021, Resident 1's Family Member 1 (FM 1) stated on 3/10/2021, she received a call from one of the staff at the facility that Resident 1 eloped from the facility. FM 1 stated the staff indicated Resident 1 was found across the street from the facility at the traffic light on a busy intersection. During a concurrent interview and review of Resident 1's records, on 6/9/2021 at 10:20 a.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 eloped from the facility and was observed across the street from the facility. LVN 1 stated he could not recall the date when Resident 1 eloped, but LVN 1 stated he had arrived at the facility at approximately 6:30 a.m., when he observed Resident 1 as being confused and requested to go to the store. LVN 1 was asked if he documented Resident 1's elopement, LVN 1 stated he did not observe any documentation regarding Resident 1's elopement in the resident's records. LVN 1 stated he did not provide care for Resident 1 on that day. During a telephone interview on 6/9/2021 at 10:44 a.m., LVN 2 stated he worked from 11 p.m. to 7 a.m. on the morning Resident 1 eloped. LVN 2 stated he heard staff shouting, "He is going out," and he observed Resident 1 across the street from the facility. LVN 2 stated he observed LVN 1 escorting Resident 1 back to the facility. LVN 2 stated he did not document Resident 1's elopement because he did not provide care for Resident and 1 and he was getting off from his shift. During an interview on 6/9/2021 at 11:48 a.m., the DON stated the staff failed to inform her of Resident 1's elopement. The DON stated LVN 1 knew about Resident 1's elopement but failed to inform her and the Administrator. The DON stated Resident 1 does not currently have a WG bracelet and was not being monitored by the staff. The DON was asked what was in place to prevent residents from eloping from the facility and what was done after a resident eloped from the facility. The DON did not provide a response. The DON was asked if the staff provided visual checks on Resident 1, the DON stated, "No." During a telephone interview on 6/9/2021 at 12:32 p.m., Resident 1's Nurse Practitioner ([NP] a nurse with additional education and training in a specialty area), stated he was not made aware that Resident 1 eloped from the facility. During a review of the facility's undated policy and procedure (P/P), titled, "Elopements and Wandering Residents," the P/P indicated the facility ensured residents who exhibit wandering behavior and/or are at risk for elopement, received adequate supervision to prevent accidents, and receive care accordance to their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The P/P indicated alarms are not a replacement for necessary supervision, the staff are to be vigilant in responding to alarms in a timely manner. The P/P indicated residents were assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the Interdisciplinary care plan team ([IDT] a group of professionals working toward a resident's goals), adequate supervision would be provided to help prevent accidents or elopements, charge nurses and unit managers would monitor the implementation of interventions, response to interventions and document accordingly. The facility failed to provide adequate supervision to prevent Resident 1, who had a documented history of suicidal ideation with a plan to commit suicide by verbalizing a desire to overdose, depression with an attempt to harm self, from eloping from the facility. As a result, Resident 1 left the facility unsupervised and was located across the street from the facility near a busy traffic intersection.