Health inspection·December 20, 2024

§483.25(d)(2) Accidents Each resident receives adequate supervision and assistance devices to prevent accidents. §72311(a)(1)(B)(C)(2)Nursing Service-General (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (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. §72523(a) 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 10/31/2024, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident (Resident 1) was reported missing from the facility. On 11/1/2024 the CDPH conducted an unannounced visit to investigate the FRI. Upon investigation the CDPH determined Resident 1, who was assessed at risk wandering (moving around inside the facility without awareness of personal safety, potentially putting themselves in harm's way) eloped (the act of leaving a facility unsupervised and without prior authorization) from the facility on 10/30/2024. The facility failed to: 1. Have a system in place to supervise and monitor Resident 1's whereabouts to prevent him from eloping from the facility. 2. Develop a care plan with interventions addressing Resident 1's risk for wandering, to ensure the resident's safety, and prevent him from eloping from the facility. 3. Ensure staff followed the facility's policy and procedure (P&P), titled "Wandering Residents - No Facility Wide Wandering Notification System" dated 11/2016, that indicated residents at risk for wandering shall have a care plan implemented with interventions appropriate to the resident to help prevent wandering out of the facility during the day. These deficient practices resulted in Resident 1 eloping from the facility on 10/30/2024 and was missing for over two hours before staff noticed he was gone. Resident 1 was placed at risk for exposure to harsh environmental conditions, including extremes in heat and/or cold, possible motor vehicle accidents, medical complications related to his diagnoses of diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar [b/s] control and poor wound healing), such as hyperglycemia (when b/s levels are too high [normal b/s levels range from 70 milligrams [mg]/deciliter [dl] a unit of measurement), hypoglycemia (when b/s levels are too low), and possible death. Resident 1 was eventually located on 11/6/2024 (eight days after he was found missing from the facility), in a towing yard, living in a van. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on 9/7/2024 with diagnoses including wedge compression fracture (a break or crack in the spine that usually occurs from too much pressure) of the thoracic vertebra (the 12 bones in the middle section of the spine between the neck and the bottom of the ribs), DM, and mild cognitive (ability to think and reason) impairment. The Face Sheet indicated Resident 1 prior to admission to the facility was unsheltered/homeless (when someone's primary night time residence is in a place that is not designed for sleeping such as a car). A review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/16/2024, indicated Resident 1's cognition (ability to think and reason) was mildly impaired. The MDS indicated Resident 1 had no functional limitations in range of motion ([ROM] the direction a joint can move to its full potential) to his upper or lower extremities (arms/legs) and he required moderate assistance (helper does less than half the effort) for showering and dressing the lower body and he required supervision for toileting hygiene. A review of Resident 1's Wandering Risk Scale Assessment dated 9/7/2024, indicated Resident 1 was at risk for wandering due to his diagnosis of cognitive impairment. A review of the Care Plan section of Resident 1's clinical records, indicated there was no care plan developed for Resident 1's risk for wandering, based on his Wandering Risk Scale Assessment conducted 9/7/2024. A review of Resident 1's Physician's Order dated 9/7/2024, indicated Resident 1 was to receive Regular Insulin (a short-acting injected medication, used to treat DM, that helps the body metabolize sugar) subcutaneously (administered under the skin) before meals and at bedtime per a sliding scale (pre-meal insulin dosage based on the b/s level before set intervals) as follows: For a b/s of 121 mg/dl -150 mg/dl give one unit of Regular Insulin For a b/s of 151 mg/dl - 200 mg/dl give two units of Regular Insulin For a b/s of 201 mg/dl - 250 mg/dl give three units of Regular Insulin For a b/s of 301 mg/dl - 350 mg/dl give six units of Regular Insulin For a b/s of 351 mg/dl - 400 mg/dl give eight units of Regular Insulin For a b/s greater than 400 mg/dl give eight units of Regular Insulin and call the Medical Doctor (MD). A review of Resident 1's Change in Condition (COC) Evaluation note dated 10/30/2024, indicated on 10/30/2024 at 4:30 p.m., Resident 1 could not be located by facility staff and a Code Orange was called. During an interview on 11/1/2024 at 12:23 p.m., Certified Nursing Assistant (CNA 1) stated on 10/30/2024, she worked a double shift beginning 7 a.m. to 3 p.m., and continued 3 p.m. to 11 p.m., but was only assigned to Resident 1 from 3 p.m. to 11 p.m. CNA 1 stated the last time she saw Resident 1 was in his room, lying in bed awake after lunch around 1 p.m. CNA 1 stated she did not see Resident 1 on her next shift when she started at 3 p.m. CNA 1 stated at 3:40 p.m., she spoke to Resident 1's roommate (Resident 4), who told her Resident 1 informed him (Resident 4) that Resident 1 was upset because his room was being deep cleaned (a cleaning process where all furniture is removed from the residents room). CNA 1 stated she believed Resident 1 left through the front exit because he liked to sit on the couch and hang out in the front lobby. CNA 1 stated Resident 1 was able to walk holding onto a wheelchair and pushing the wheelchair in front of him. CNA 1 stated she reported to the Assistant Director of Nursing (ADON) at 4:15 p.m., that Resident 1 was missing, and the ADON called a Code Orange at 4:45 p.m., but they were unable to locate Resident 1 after searching the facility. During an interview on 11/1/2024 at 3:02 p.m., CNA 2 stated on 10/30/2024 she was assigned to Resident 1 for the first time from 7 a.m. to 3 p.m. and was not told when she was given report that Resident 1 was a wandering risk. CNA 2 stated the last time she saw Resident 1 on 10/30/2024 was before lunch, around 11 a.m., in the front lobby near the front door of the facility. CNA 2 stated she normally made rounds three times on her eight-hour shift, between 7:30 a.m. to 8 a.m., 12:30 p.m. to 1 p.m. and at 2:45 p.m., before her shift ended at 3 p.m. CNA 2 stated on 10/30/2024 it was busier than usual, residents' rooms were being deep cleaned, including Resident 1's room, and she had to take residents to the facility's Halloween event after lunch. CNA 2 stated she was unable to stick to her normal routine and forgot to check on Resident 1. During an interview on 11/1/2024 at 3:30 p.m., the MDS Nurse (MDSN) 1 stated, the admitting nurse was responsible for creating an initial care plan for residents at risk for wandering, based on the resident's Wandering Risk Scale assessment, which was completed on admission. MDSN 1 stated the Wandering Risk Scale assessment was completed for all newly admitted residents and if a resident was determined to be at risk for wandering, a care plan should be created. MDSN 1 stated the nursing staff and MDS department does not specify on the care plan how often a resident who was at risk for wandering should be monitored. MDSN 1 stated in her professional opinion a resident with mild cognitive impairment should be monitored every 1 to 2 hours, and more frequently for a more confused resident. MDSN 1 stated nurses should have communicated that Resident 1 was at risk for wandering during their huddle ((meetings to discuss residents typically at the change of shift). During an interview on 11/5/2024 at 9:40 a.m., Registered Nurse (RN 1) stated during admission, if a wandering risk assessment indicated a resident was at risk for wandering, a care plan should be created with interventions to monitor the resident at least once every 2 hours. RN 1 stated even if the resident does not exhibit wandering behaviors but was mildly confused, the resident could have impaired judgement and should be monitored. RN 1 stated during huddle residents who need to be monitored closer due to wandering or confusion should be discussed amongst staff. During an interview on 11/5/2024 at 10:14 a.m., the Director of Staff Development (DSD) stated residents should be visually checked at a minimum of once every two hours and more as needed, which is determined by any licensed nurse. The DSD stated monitoring frequency for residents at risk for wandering was at the discretion of the licensed nurse who should communicate the frequency needed to monitor the resident to the CNAs during their huddle, then the licensed nurse should oversee the CNA to make sure the residents were being monitored. During an interview on 11/5/2024 at 10:59 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 1 was ambulatory (able to walk) and would often walk through the facility pushing his wheelchair daily. LVN 1 stated Resident 1 was not in his room most of the day on the day he eloped from the facility (10/30/2024) because his room was being deep cleaned from 10:15 a.m. to 3 p.m. LVN 1 stated she last saw Resident 1 before lunch when she attempted to take Resident 1's b/s, and she assumed he was at the facility's Halloween event. LVN 1 stated Resident 1 was not discussed in their huddle at the beginning of the shift on 10/30/2024, she was not aware Resident 1 was at risk for wandering, and she was not sure if Resident 1 had a care plan related to his at risk for wandering. LVN 1 stated, normally CNAs make rounds to monitor residents three times on an eight-hour shift but for residents at risk for wandering she instructed the CNAs to do rounds every 1 to 2 hours. During an interview on 11/5/2024 at 11:59 a.m., the ADON stated the purpose of completing a wandering risk assessment was to identify residents who were at risk for elopement, and the purpose of creating a care plan, based on the wandering risk assessment, was to ensure all staff were aware to monitor the resident. The ADON stated charge nurses were responsible to familiarize themselves with a resident's care plan and communicate those needs to the CNAs. The ADON stated residents who were at risk for wandering should be monitored once an hour or more. The ADON stated care plans should be clear and not left open for interpretation so goals could be measured to know if the goals were being met or not. During an interview on 11/6/2024 at 12:38 p.m., the Director of Quality Assurance (DOA) stated the last time she saw Resident 1 was in the facility's front lobby near the front door at 2 p.m., on 10/30/2024. The DOA stated a wandering risk assessment should be completed for all residents, and a care plan should be created if a resident was at risk for wandering, in order to document the care needed for a resident and implement it. The DOA stated a care plan should have been created for Resident 1's risk of wandering by the admitting nurse. The DOA stated Resident 1 should have been monitored at least four times during an eight-hour shift based on his mild cognitive impairment and ability to walk. During an interview on 11/6/2024 at 10:36 a.m., the DON stated per their policy when a resident was assessed as a wandering risk, a care plan should be created to make everyone aware of the resident's specific care needs. The DON stated for residents at risk for wandering, monitoring should be done at least six times during an eight-hour shift. The DON stated the reason why a wandering/elopement care plan was not created for Resident 1 was because he did not exhibit any actual wandering behaviors. The DON stated different frequencies of monitoring were dependent on the resident. During an interview on 11/6/2024 at 1:22 p.m., the DON stated the purpose of a care plan was to identify appropriate care for residents based on their needs and preferences. The DON stated a care plan should have been developed to address Resident 1's risk for wandering and documentation should have been completed to monitor Resident 1's location to prevent him from eloping from the facility and potentially getting hurt. The DON stated Resident 1 was diabetic and required insulin depending on his b/s levels and could suffer a medical emergency if he did not get his medication as prescribed. The DON stated Resident 1 was living in his van prior to admission to the facility and he voiced wanting to be discharged from the facility to go back to his van, but the physician stated it was unsafe for him to leave at that time. During an interview on 11/12/2024 at 1:14 p.m., Admission Nurse Assistant (ANA 1) stated she had been an ANA at the facility for six months and part of her duties included completing the wandering risk assessment for newly admitted residents. ANA 1 stated she was not instructed to complete a care plan for residents who were assessed at risk for wandering. ANA 1 stated her understanding was that wandering care plans were to be completed by the MDS department. A review of facility's P&P titled "Wandering Residents - No Facility Wide Wandering Notification System" dated 11/2016, indicated residents at risk for wandering shall have a care plan implemented with interventions appropriate to the resident to help prevent wandering out of the facility during the day. A review of facility P&P titled "Care Plans - Baseline and Summary" dated 10/2024, indicated a baseline care plan should be developed for each resident within 48 hours of admission to provide instructions for the provision of effective and person-centered care to each resident, striking a balance between conditions and risks affecting the residents' health and safety. A review of facility's P&P titled "Routine Resident Checks" dated 10/2024, indicated to ensure the safety and well-being of residents nursing staff shall make a routine resident check on each unit at least once per 8-hour shift, but frequency adjustments will be made according to individual needs. The facility failed to: 1. Have a system in place to supervise and monitor Resident 1's whereabouts to prevent him from eloping from the facility. 2. Develop a care plan with interventions addressing Resident 1's risk for wandering, to ensure the resident's safety, and prevent him from eloping from the facility. 3. Ensure staff followed the facility's P&P titled "Wandering Residents - No Facility Wide Wandering Notification System" dated 11/2016, that indicated residents at risk for wandering shall have a care plan implemented with interventions appropriate to the resident to help prevent wandering out of the facility during the day. These deficient practices resulted in Resident 1 eloping from the facility on 10/30/2024 and was missing for over two hours before staff noticed he was gone. Resident 1 was placed at risk for exposure to harsh environmental conditions, including extremes in heat and/or cold, possible motor vehicle accidents, medical complications related to his diagnoses of DM, such as hyperglycemia, hypoglycemia, and possible death. Resident 1 was eventually located on 11/6/2024 in a towing yard, living in a van. These violations, jointly, separately or in any combination, had direct o