Other·February 17, 2023

42 CFR § 483.25(d) Accidents. 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. 42 CFR § 483.25 Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. 42 CFR § 483.21(b) Comprehensive Care Plans §483.21(b)(1) 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 § 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 12/30/2022, the California Department of Public Health (CDPH) received a facility reported incident (FRI), alleging a resident (Resident 1) eloped from the facility on 12/30/2022. The police were notified, and a search was conducted unsuccessfully. Resident 1 remained missing as of 2/16/2023. On 12/31/2022, the CDPH conducted an unannounced investigation at the facility. Resident 1 had a history of elopement with impaired cognitive (ability to think and reason) skills for daily decision making, with wandering behavior (walking around aimlessly without a fixed plan). On 12/29/2022, the resident became agitated and combative (eager to fight), striking out at staff and pacing anxiously while continuing to escalate (increase in extent) a hostile behavior. On 12/29/2022, Resident 1 was placed on 1:1 monitoring (one nurse to watch the resident for close monitoring) by the resident's psychiatrist per a verbal order, until Resident 1 transferred out to the hospital. On 12/30/2022, Resident 1 went missing and was last seen on 12/30/2022 at approximately 4 a.m. On 12/30/2022, at approximately 8:15 a.m. (over four hours after the resident was last seen), the facility's staff noticed Resident 1 was missing and called a Code Green (to alert staff of a missing resident). The facility conducted an official head count of all the residents at the facility and confirmed Resident 1 had eloped from the facility. The facility failed to: 1. Ensure the Director of Nursing (DON) transcribed a verbal order from the physician placing Resident 1 on 1:1 close monitoring after the resident became combative, striking a staff member and wanting to leave the facility. 2. Ensure the Licensed Vocational Nurse (LVN 3) assigned a staff member to conduct 1:1 monitoring of Resident 1 on the night shift of 12/29/2022, as ordered by the physician. 3. Ensure the nursing staff monitored Resident 1 at frequent intervals as documented in the resident's care plan titled, "Elopement/Wandering Risk." 4. Ensure the nursing staff provided 1:1 monitoring to Resident 1 to prevent complications as documented in the resident's care plan titled, "Resident on multiple medications." 5. Ensure the nursing staff implemented the facility's policy and procedure (P/P) titled, "Physician Orders and Telephone Orders," which indicated physician's order shall be obtained prior to the initiation of any treatment and telephone orders shall be noted and implemented promptly. These deficient practices resulted in Resident 1 eloping from the facility on 12/30/2022 and placed the resident at high risk for exposure to harsh environmental conditions including excessive cold and rain, at risk for injuries and medical complications including malnutrition, dehydration, respiratory problems due to the resident's diagnosis of chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems) and possible death. As of 2/16/2023 (over 45 days later), Resident 1's whereabouts remain unknown. During an interview with the DON on 12/31/2022 at 4:10 p.m., while in Resident 1's room, a concurrent observation indicated that Resident 1's room was located on the second floor of the facility, two rooms away from an exit door. This exit door led to an outside balcony with a cement wall approximately 2-3 feet in height. During this interview, the DON was asked how the staff ensure a resident does not get out from that exit door and climb over the wall. The DON stated, "One Certified Nursing Assistant (CNA) monitors the exit door because it is on the second floor and residents would not have a chance to get out from the exit." The DON stated Resident 1 was placed on 1:1 monitoring by CNA 1 on 12/29/2022 from 7 a.m. to 11 p.m. (worked two shifts) for the resident's behavior of striking at a CNA during a group activity. The DON stated Resident 1 was provided with 1:1 monitoring on 12/29/2022 until 11 p.m., as a nursing intervention. The DON stated Resident 1 did not have 1:1 monitoring on the nightshift on 12/29/2022 due to a shortage of staff. During an interview with CNA 1 on 12/31/2022 at 4:50 p.m., CNA 1 stated he worked on 12/29/2022 from 7 a.m. to 11 p.m. and was assigned to provide 1:1 monitoring to Resident 1. CNA 1 stated Resident 1 struck a staff member that morning (12/29/2022) and was placed on 1:1 observation until 11 p.m. on 12/29/2022. CNA 1 stated he came back to work on 12/30/2022 at 7 a.m. and during rounds with other staff noticed Resident 1 was not in his room. During an interview with Resident 2 (Resident 1's roommate) on 12/31/2022 at 5:05 p.m., Resident 2 stated he last saw Resident 1 at approximately 4 a.m. on 12/30/2022 when Resident 1 went to the bathroom. During a review of Resident 1's Admission Record (AR), the AR indicated Resident 1, a 61 year-old male, was originally admitted to the facility on 6/20/2019 and last readmitted on 12/20/2022 with diagnoses including paranoid schizophrenia (serious mental disorder in which reality is interpret abnormal and it impairs daily functioning), major depressive disorder (serious mood disorder; affects how a person feels, think, and handle daily activities, such as sleeping, eating, or working), bipolar disorder (a brain disorder; shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks), psychosis (effects the mind, where there has been some loss of contact with reality), muscle weakness with difficulty walking, hypertension, COPD, and blindness in the left eye. During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 12/27/2022, the MDS indicated Resident 1's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 1 required supervision for eating, bed mobility, transferring, walking, dressing, eating, toilet use, and personal hygiene. During a review of Resident 1's Elopement Risk Assessment (ERA), dated 12/20/2022, the ERA indicated Resident 1 was at risk for elopement. The ERA tool indicated the resident was always disoriented and had a prior history of elopement on 7/9/2019. During a review of Resident 1's Nurse Progress Note (NPN), completed by an unknown registered nurse (RN) during admission, dated 12/20/2022 and timed at 8:58 p.m., the NPN indicated Resident 1 was awake, disoriented, and unable to state his name or where he was. During a review of Resident 1's care plan, initiated on 12/21/2022 and titled, "Elopement/Wandering Risk," the care plan indicated Resident 1 was at risk for leaving a safe area without supervision and the goal indicated Resident 1 will have no elopement. The staff's intervention included to monitor the resident at frequent intervals. During a review of Resident 1's care plan initiated on 12/21/2022 and titled, "Altered behavior patterns related to bipolar disorder, depression and psychosis manifested by (M/B) inability to process internal stimuli causing anger interfering with the resident's daily living activities," the care plan indicated Resident 1 would have reduced episodes of manifested behavior daily. The staff's intervention included to provide reality awareness. During a review of Resident 1's care plan titled, "Resident on multiple medications" initiated on 12/21/2022, the care plan indicated the resident would be free of being an endangerment to self and others for three months. The staff's interventions included to provide 1:1 monitoring to prevent complications. During a review of Resident 1's Interact Assessment Form indicated a Change of Condition Evaluation (COCE), dated 12/29/2022 and timed at 5:20 p.m., the COCE indicated Resident 1 had aggressive behavior, struck-out at staff and the police and the resident's psychiatrist (Physician 1) were immediately notified. The COCE indicated Physician 1 was notified and a new order to transfer the resident to the hospital for a psychiatric evaluation ([P/E] an evaluation used to diagnose problems with memory, thought processes, and behaviors). During a review of Resident 1's physician order, dated 12/29/2022, the order indicated to transfer the resident to the hospital for aggressive behavior and danger to self. During a review of Resident 1's NPNs, from 12/20/2022 to 12/30/2022, the NPNs indicated there was no documented evidence staff monitored Resident 1 for elopement and wandering behaviors as indicated in the resident's care plan. During a review of Resident 1's NPN, dated 12/30/2022 and timed at 3:05 p.m., the NPN indicated Resident 1 was not in his room at the beginning of the shift (3 p.m.) on 12/30/2022 and a search was initiated. Staff were unable to locate the resident, so a Code Green was called, and all rooms were searched. According to the NPN, staff made the Administrator (ADM) and the DON aware and called the police at 9:23 a.m. on 12/30/2022. During a concurrent observation and interview with the Director of Staff Development (DSD) on 1/3/2023 at 2:15 p.m., the DSD stated the facility had six exit doors within the facility and all alarms were working. When the exit doors were opened the alarms activated loudly. The DSD stated there was one exit door in the facility, in the vicinity of Resident 1's room, which lead to a balcony with stairs to the ground floor which had a door that was locked with an alarm in place. During an interview with LVN 1 on 1/3/2023 at 2:45 p.m., LVN 1 stated he started his shift at 7 a.m. and the nurses informed him Resident 1 usually goes to breakfast at 7:30 a.m. LVN 1 stated the resident did not show up at 7:30 a.m. on 12/30/2022. LVN 1 stated at approximately 8:15 a.m. on 12/30/2022 the staff did a head count and could not find Resident 1. During a concurrent observation and interview with CNA 2 on 1/3/2023 at 3 p.m., CNA 2 stated she had taken care of Resident 1 many times. CNA 2 stated on the morning of 12/30/2022 (time unknown) while she was in the middle of caring for another resident, a Code Green was announced. CNA 2 stated on 12/30/2022 the facility was short-staffed. CNA 2 stated she did not know Resident 1 was at risk for elopement. During an interview with the ADM on 1/3/2023 at 4:25 p.m., the ADM stated the surveillance camera that monitors the facility was not working and he needed to get it repaired. The ADM stated, "[Resident 1] was a runner and I had heard the resident elopes all the time." The ADM stated, "The alarms in the facility are loud, so he probably did not use the doors, maybe hopped the fence." The ADM stated they were still looking for Resident 1. During a subsequent interview with LVN 1 (Resident 1's primary charge nurse) on 1/4/2023 at 10:31 a.m., LVN 1 stated he did not know the resident was an elopement risk. LVN 1 stated had he known Resident 1 was an elopement risk, he would have had someone watch the resident closely. During a telephone interview with Resident 1's Physician 1 on 1/9/2023 at 12:03 p.m., Physician 1 stated she was familiar with Resident 1 as he had been in and out of the hospital under her care. Physician 1 stated she had treated Resident 1 while in the hospital prior to admission to the facility due to his dual diagnosis of psychiatric illness and alcohol abuse with poor judgement. Physician 1 stated she was called on 12/29/2022, after Resident 1 hit a staff member and she told the DON to place the resident on 1:1 close monitoring (as a telephone order) until he was transferred to the hospital and to call the police. Physician 1 stated the DON did not transcribe her order and place the resident on continuous 1:1 monitoring as she ordered until the resident was transferred to the hospital. Physician 1 stated Resident 1 was an elopement risk and should have been monitored closely, as the resident was not ready for discharge. An interview with the DON was attempted on 1/9/2023 regarding Physician 1's telephone order, but the DON was not available, as she resigned from the facility on 1/4/2023, per the ADM. During a telephone interview on 1/5/2023 at 7:15 a.m., LVN 3 stated on 12/29/2022, Resident 1 was staying to himself (not social with others), while talking to himself, screaming at times; and punching in the air in an aggressive manner. LVN 3 stated Resident 1 hit a staff member on 12/29/2022 during the 3 p.m. to 11p.m. shift and it was the first time he was aware of the resident hitting anyone. LVN 3 stated Resident 1 was placed on 1:1 monitoring. LVN 3 stated Resident 1 was in bed when he came to work on 12/29/2022 at 11 p.m. LVN 3 stated the staff called the police, but the police could not take the resident because of his diagnosis and the hospital had no available beds. LVN 3 stated the staff placed Resident 1 on 1:1 monitoring, as a standing order (an instruction or prescribed procedure in force permanently or until changed or canceled), because he hit a nurse, and he was the elopement risk. LVN 3 stated the resident was monitored every two hours. LVN 3 stated, "I did not have a male CNA that night (12/29/2022 on 11 p.m. shift), that is why I did not put Resident 1 on 1:1 monitoring on the night shift." LVN 3 stated Resident 1 eloped after 4 a.m., because he saw Resident 1 around 4 a.m. on 12/30/2022. LVN 3 stated he did not check on Resident 1 at 6 a.m. on 12/30/2022 because he was busy passing out medications. LVN 3 stated Resident 1 had a history of eloping from facilities and should have been monitored closely. During a review of the facility's P/P, dated 1/2004 and titled, "Physician Orders and Telephone Orders," the P/P indicated Physician's orders shall be obtained prior to the initiation of any treatment from the person lawfully authorized to prescribe for and treat human illness. All orders must be specific and complete, and no standing orders will be accepted. The P/P indicated telephone orders shall be signed in a timely manner or at least by the next routine visit by the physician. Telephone orders shall be noted promptly, all orders must include the date and time received and must be noted by the professional staff taking the order (e.g., licensed nurse). The facility failed to: 1.Ensure the DON transcribed a verbal order from the physician placing Resident 1 on 1:1 close monitoring after the resident became combative, striking a staff member and wanting to leave the facility. 2. Ensure LVN 3 assigned a staff member to conduct 1:1 monitoring of Resident 1 on the night shift of 12/29/2022, as ordered by the physician. 3. Ensure the nursing staff monitored Resident 1 at frequent intervals as documented in the resident's care plan titled, "Elopement/Wandering Risk." 4. Ensure the nursing staff provided 1:1 monitoring to Resident 1 to prevent complications as docum