Health inspection·December 11, 2024

The following reflects the findings of the California Department of Public Health during the investigation of complaint number CA00929040. A Class AA citation was written. REGULATORY VIOLATIONS: Title 42 Code of Federal Regulations §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. Code of Federal Regulations: Title, 22, 72311. Nursing Service--General. (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. Title 22, Section 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 11/6/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint regarding resident safety and death. As a result of the investigation, CDPH determined that the facility to: 1. Ensure that Resident 1, who had a history of elopement, was identified as at risk for elopement per facility policy and procedures "Wandering and Elopements", reviewed 1/25/24. 2. Implement Resident 1's care plan titled, "The resident has impaired cognitive function or impaired thought processes related to (r/t) psychotropic (drugs that affect the mind, emotions, and behaviors) drug use Acute Metabolic Encephalopathy" and "Acute Confusion d/t [due to] medical condition" dated 9/30/24, to Monitor/document/report PRN (whenever necessary) any changes in cognitive (of, relating to, being, or involving conscious intellectual activity (such as thinking, reasoning, or remembering) function when Resident 1 exhibited periods of confusion on 11/4/2024. 3. Monitor and supervise Resident 1 when Certified Nursing Assistant (CNA 3) observed Resident 1 on 11/5/24 at around 1 pm close to the elevator. Resident 1 was wearing a double gown (one on front and one on the back) with a sweater and had a black bag with some belongings. 4. Have a system in place to supervise and monitor Resident 1's whereabouts to prevent him from eloping from the facility according to the Wandering and Elopement policy and procedures (P&P) that indicated, "The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents." 5. To assess and notify Resident 1's physician of the change of condition on 11/4/2024 of the aggressiveness and confusion exhibited by Resident 1. As a result, Resident 1 eloped from the facility on 11/5/24 and was subsequently found by police deceased (dead) in a park two days later (11/7/24). A review of Resident 1's admission record indicated the 79 year old male was admitted to the facility on 9/29/2024 with diagnoses that included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking), metabolic encephalopathy (a problem with how the brain works caused by a chemical imbalance in the blood), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and acute (sudden) kidney failure. A review of Resident 1's elopement evaluation dated 9/30/2024 at 12:25 pm, indicated the resident was not a risk for elopement. The note indicated the resident did not have a history of elopement or an attempted elopement while at home. A review of Resident 1's history and physical (H&P- physician's examination of a resident, in which the physician obtains a thorough medical history from the resident or resident representative, performs a physical examination, and then documents the findings) dated 10/1/2024, indicated the resident had the capacity for medical decision making. The same H&P further indicated Resident 1 had a history of paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and had been recently hospitalized "for acute on chronic psychiatric decompensation (a period when the person's mental state becomes unbalanced, and symptoms return) and aggressive behavior towards others". The H&P indicated the resident was to have a psychiatric consult (a meeting with a psychiatrist to evaluate a patient's mental health and create a treatment plan). A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/5/2024, indicated Resident 1 had mild cognitive (ability to think, read, learn, remember, reason, express thoughts, and make decisions) impairment. The MDS indicated the resident was able to recall words after "cueing". A review of Resident 1's care plan titled "The resident has impaired cognitive function or impaired thought processes related to (r/t) psychotropic (drugs that affect the mind, emotions, and behaviors) drug use Acute Metabolic Encephalopathy" and "Acute Confusion d/t [due to] medical condition" dated 9/30/24, indicated three goals marked as "overdue" "the resident will be able to communicate basic needs on a daily basis through review date (OVERDUE)", "The resident will develop skills to cope with cognitive decline and maintain safety by review date (OVERDUE)", "The resident will improve current level of cognitive function through the review date (OVERDUE)". The listed interventions included "Cue, reorient and supervise as needed", "Discuss concerns about confusion, disease process, NH (nursing home) placement with resident/family/caregivers", and "Monitor/document/report PRN (whenever necessary) any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of conscious, mental status." A review of Resident 1's health status note dated 10/5/2024 at 10:39 pm, indicated the resident was found trying to smoke in the room. A review of Resident 1's multidisciplinary care conference note dated 10/6/2024, indicated the resident was admitted to the facility on 9/29/2024 and was noted to have "some memory problem, with episodes of inconsistency, requires assistance with mobility and self-care..." A review of Resident 1's Health Status note dated 10/7/2024 at 7:11 pm, indicated "Resident is on monitor for unscheduled smoke times inside bathroom." A review of Resident 1's Situation, Background, Assessment, and Recommendation (SBAR - a structured communication tool) form dated 10/7/2024 at 12 am, indicated "resident smoked inside the (resident's) room unscheduled, redirection, explanation, education given to comply (not to smoke in) facility room and to smoke in the patio with schedule time..." The SBAR indicated the primary care physician was notified and the facility staff were "awaiting" a call back for recommendations. A review of Resident 1's Nutrition/Dietary note dated 10/24/2024 at 4:21 pm, indicated the resident required feeding supervision/assistance with all meals. A review of Resident 1's health status note dated 11/4/2024 at 6:44 am, indicated "Resident refused to be change. Resident alert and awake with period of confusion. Noted resident agitated and verbally aggressive." The note did not indicate Resident 1's physician was notified of Resident 1's refusal to be changed, confusion, or verbally "aggressive" behavior. A review of Resident 1's health status note dated 11/5/2024 at 5:45 pm, indicated at 2 pm on 11/5/2024 Licensed Vocational Nurse 2 (LVN 2) saw Resident 1 walking in the hallway towards the patio. The note indicated at 2:45 pm LVN 2 noted the "resident was not in room and could not be found." The note indicated at 2:50 pm a "code green" [facility code for elopement] was initiated, facility and surrounding area searched, and the resident was not found. The note indicated the resident's family was not notified until 4:50 pm, the Nurse Practitioner (NP) at 5:08pm, and 911 was not called to assist in finding the resident until 5:11 pm. A review of Resident 1's health status note dated 11/5/2024 at 7 pm, indicated Resident 1's physician "notified that resident was not found during search of the facility and surrounding area, and left without notifying staff. Per MD, discharge AMA as resident is AOx4 [alert and oriented to person, place, time, situation] and is able to and has the capacity to make his own decisions as stated on MD's recent H&P. order read back and verified with MD." The detailed view of the progress note revealed the note was created on 11/6/2024 at 2:51 pm (the day after the resident had eloped from the facility). A review of Resident 1's physician's orders dated 11/6/2024 at 2:41 pm, indicated an order was received to "Discharge AMA 11/5/24." During an interview on 11/7/24 at 11:29 am with Registered Nurse Supervisor 2 (RNS 2), RNS 2 stated no one saw Resident 1 leave on 11/5/24, and they had initiated a code green (at 2:30 pm) to look for the resident, called the police, the doctor the resident's family, and Adult Protective Services (APS). The last time the RNS 2 saw the resident was in the hallway around 2 p.m. walking to the smoking patio area. During a telephone interview on 11/7/24 at 12:37 pm LVN 2 stated Resident 1 had behaviors of wandering around and going outside, he would disappear without anyone knowing. He would go outside and come back, a couple of times she had seen the Resident at the corner coffee shop. LVN 2 further stated his leaving was considered an elopement because he did not tell anyone, and they started the elopement procedures to look for him inside and outside of the building. LVN 2 stated it happened late in her shift, and the last time she saw the resident was around 2 pm walking in the hallway, the resident was wearing a gown and did not know if the resident would know how to call his family or get back to the facility. A review of Resident 1's "Alert Note" dated 11/7/2024 at 1:11 pm, indicated "Received a call from [MD] approximately 1300 [1pm] informing the facility that he received a call from law enforcement to inform him [Resident 1] was found dead at the park today (11/7/2024)". During an interview on 11/8/24 at 3:15 pm, Activities Assistant (AA) 1 stated Resident 1 was forgetful often forgetting the smoking times and asking when the smoking times were. Facility staff would have to remind him frequently, and the resident would often refuse to take a shower or be changed. He would need a lot of encouragement. During an interview on 11/12/24 at 12:25 pm, Certified Nursing Assistant (CNA) 3 stated the last time he saw Resident 1 on 11/5/24 was around 1 pm when he saw him close to the elevator, he was wearing a double gown (one on front and one on the back) with a sweater. CNA 3 stated he (Resident 1) had a black bag with some belongings. CNA 3 stated he (Resident 1) left some clothing and other items at his bedside. CNA 3 stated Resident 1 was an avid smoker and would need assistance with changing his incontinence brief (a type of underwear designed for people who have lost bladder or bowel control) and showers. Sometimes he (Resident 1) would refuse and would need some negotiation to get him to change and shower. The resident would need frequent reorientation because he was forgetful. During a telephone interview on 11/14/24 at 12:02 pm, the Medical Doctor (MD) 1 stated the police had called him on 11/7/24 and informed him Resident 1 had been found deceased in a park. MD 1 further stated the facility had texted him on 11/5/24 at 6 pm the resident took some cash and left the facility without notifying anyone, which would be considered an elopement. MD 1 further stated no one notified him about the aggressive behaviors and confusion the day before on 11/4/24. MD 1 also explained for someone with a diagnosis of metabolic encephalopathy that would affect the cognition (thought, reasoning, understanding) it is a broad term which is like a spectrum the way it would affect someone could make them act aggressively or could make them non-verbal obtunded (diminished responsiveness to stimuli, dulled or reduced level of alertness). A review of the facility's P&P titled, "Wandering and Elopement," with review date 1/25/24 indicated "The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents....If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety." A review of the facility's P&P titled "Discharging a Resident without a Physician's Approval" with a reviewed 1/25/24, indicated: "3. If the resident or representative (sponsor) insists upon being discharged without the approval of the Attending Physician, the resident and/or representative (sponsor) must sign a Release of Responsibility form. Should either party refuse to sign the release. such refusal must be documented in the resident's medical record and witnessed by two staff members." The policy indicated "The Director of Nursing Services, or Charge Nurse, shall inform the resident, and/or representative (sponsor) of the potential hazards involved in the early discharge of the resident and shall request that the resident remain in the facility until such time as the isolation/precautionary period has ended. The facility failed to: 1. Ensure that Resident 1, who had a history of elopement, was identified as at risk for elopement per facility policy and procedures "Wandering and Elopements", reviewed 1/25/24 2. Implement Resident 1's care plan titled, "The resident has impaired cognitive function or impaired thought processes related to (r/t) psychotropic drug use Acute Metabolic Encephalopathy" and "Acute Confusion d/t medical condition" dated 9/30/24, to Monitor/document/report PRN any changes in cognitive function when Resident 1 exhibited periods of confusion on 11/4/2024. 3. Monitor and supervise Resident 1 when CNA 3 observed Resident 1 on 11/5/24 at around 1 pm close to the elevator. Resident 1 was wearing a double gown with a sweater and had a black bag with some belongings. 4. Have a system in place to supervise and monitor Resident 1's whereabouts to prevent him from eloping from the facility according to the Wandering and elopement P&P that indicated, "The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents." 5. Assess and notify Resident 1's physician of the change of condition on 11/4/2024 of the aggressiveness and confusion exhibited by Resident 1. As a result, Resident 1 eloped from the facility on 11/5/24 and was subsequently found by police deceased (dead) in a park two days later (11/7/24). These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability tha