Health inspection·November 22, 2023

F689 42 CFR §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 §43.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §72311. Nursing Service - General. (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 10/5/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident about a missing resident. The facility failed to ensure Resident 1, who did not have the capacity to understand and make decisions, who had wandering (going about from place to place, walking without purpose) behavior, and was assessed at risk for fall and elopement (a form of unsupervised wandering that leads to the resident leaving the facility without notice or permission and doing so may present an imminent threat to the resident's health or safety) was supervised and free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress). The facility failed to: 1. Ensure staff provided Resident 1 with supervision and monitoring to meet Resident 1’s care needs. 2. Implement Resident 1's care plan wandering or elopement to provide 1 on 1 (1:1, supervision of the resident always) supervision. 3. Develop comprehensive policies and procedures (P&P) on supervision of residents with wandering behavior and elopement risk to prevent Resident 1 to leave the facility unnoticed by staff. 4. Develop P&P on the wander guard system (a monitoring bracelet or anklet placed on a resident at risk of elopement which alarm the exit door equipped with the wander alarm system once the resident goes close and / or through the exit door). Staff did not hear a door alarm which should have been triggered when Resident 1, who was wearing a wander guard on his left wrist, left the facility through the door near the kitchen which led to the visitor's parking lot at the back of the facility. 5. Implement its P&P on the security and surveillance cameras (video cameras that record images in or outside a building) to monitor the video surveillance cameras for the safety and benefit of its residents. As a result, on 10/4/2023 after 6 a.m., Resident 1 eloped from the facility. Resident 1, who was last seen at 6 a.m. on 10/4/2023, remained missing three days until 10/7/2023, when he was evaluated at General Acute Care Hospital 1 (GACH 1) Emergency Room (ER) and subsequently transferred back to the facility on 10/8/2023. Resident 1 was at risk for exposure to environmental elements including extreme temperatures and increased probability of encountering an accident that could have led to serious injury, serious harm, serious impairment, including the possibility of death. Resident 1 was also at risk for a negative outcome on his health because of not receiving his daily needed medications, food, and hydration. Due to Resident 1's impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual lost in the streets and unable to find refuge, food and drinks, Resident 1 may have psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for yourself). A review of Resident 1's Admission Record indicated the facility admitted the 56-year old male resident on 5/25/2022 with diagnoses including traumatic subdural hemorrhage (when a blood vessel near the surface of the brain bursts and blood builds up between the brain and the brain's tough outer lining) without loss of consciousness (the state of being awake and aware of one’s surroundings), fracture of other specified skull and facial bones/right side (a break in the bone on right side of the head), gastrostomy, and cocaine abuse. A review of Resident 1's “Hospitalist Visit Progress Notes,” dated 6/2/2022, indicated resident did not have the capacity to understand and make decisions. A review of the Physician's orders for Resident 1, dated 6/30/202, indicated to apply the resident a wander guard (bracelet) every shift due to high risk of elopement to alert staff. A review of Resident 1's Care Plan, revised on 12/20/2022, for the resident’s risk for wandering or elopement related to cognitive status, unfamiliarity with new environment, unaware of safety needs, and attempting to open exit doors. Resident 1's care plan goal was to minimize episodes of wandering and possible injuries. The interventions included applying a wander guard bracelet as ordered and identifying certain times of day wandering / elopement attempts occurred. A review of Resident 1's Care Plan, on 12/20/2022, for the resident’s attempts to open exit doors, had a goal for Resident 1 to will remain safe and not having episodes of trying to open exit doors. The interventions included providing 1:1 supervision. A review of Resident 1's Care Plan, revised on 4/11/2023, for the resident’s fall risk secondary to history of falling, limited mobility, poor balance, lack of awareness, cognitive, communication, hearing and vision deficit, and impulsive behavior. The care plan goal was to provide Resident 1 a safe environment that minimized complications associated with falls. A record review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-planning tool), dated 8/3/2023, indicated Resident 1 had moderately impaired cognition, required supervision with locomotion. A review of Resident 1's Elopement Evaluation, dated 8/3/2023, indicated Resident 1 scored 4 out of 4.2 total points. Score value of 1 or higher indicated risk for elopement. A review of Resident 1's Change in Condition Evaluation, dated 10/4/2023 at 7 a.m., indicated staff were unable to locate Resident 1 within the facility or the surrounding outdoor areas. On 10/5/2023 at 4:25 p.m., during an interview, the administrator (ADM) stated the facility's security camera footages only recorded for 24-hour period. After 24 hours, the cameras will start recording over the previous videos and not allowing review after one day. The ADM was asked to show video footages within 24 hours. However, after multiple attempts, the ADM was unable to access the recordings of same-day video footages. When the ADM was asked if video footages were reviewed on 10/4/2023, after staff noticed Resident 1 was missing, and the ADM stated they did not because sometimes the cameras do not work. On 10/6/2023 at 6:32 a.m., during an observation, the facility's entrance double doors labeled “#8” leading to the back entrance / exit for staff and visitor parking lot was observed with one door propped open. There was no alarm sounding and there was no staff present in the area. On 10/6/2023 at 7:03 a.m., during an interview, Certified Nurse Assistant 3 (CNA 3) stated CNA 3 worked during the 11 p.m. to 7 a.m. shift when Resident 1 was noted missing (10/4/2023). CNA 3 stated CNA 3 was not assigned to care for Resident 1, but worked in the same area where Resident 1's room was located. CNA 3 stated CNA 3 did not hear any door alarm going off or licensed nurses calling through the overhead paging system a Code Yellow (an alarm code used for missing residents). On 10/6/2023 at 7:30 a.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated LVN 4 worked during the 11 p.m. to 7 a.m. shift when Resident 1 was noted missing (10/4/2023), and was assigned to Resident 1. LVN 4 stated the last time seeing Resident 1 was at the start of the shift on 10/3/2023 at 11 p.m. LVN 4 stated the entrance / exit # 8 was not equipped with the wander alarm system. LVN 4 stated Resident 1 walked outside into the streets by himself and was subjected to hot temperatures during the day and cold temperatures at night. On 10/6/2023 at 8:02 a.m., during an interview, Registered Nurse 1 (RN 1) stated RN 1 worked during the 11 p.m. to 7 a.m. shift when Resident 1 was noted missing (10/4/2023). RN 1 stated RN 1 did not know which door Resident 1 used to exit the facility. RN 1 stated Resident 1 was at risk of dehydration (loss of water in the body) and at risk of dizziness and falling injuring his head and body. On 10/6/2023 at 6:32 a.m. and at 8:59 a.m., the facility's entrance double doors labeled “#8” leading to the back entrance / exit for staff and visitor parking lot was observed with one door propped open. There was no alarm sounding and there was no staff present in the area. On 10/6/2023 at 3:45 p.m., during an interview, the Director of Nursing (DON) stated the facility did not have P&P on the use of wander guard to guide staff on monitoring for the use of wander guard and functionality. On 10/7/2023 at 7:07 a.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated CNA 1 worked during the 11 p.m. to 7 a.m. shift when Resident 1 was noted missing (10/4/2023) and was assigned to Resident 1. CNA 1 stated CNA 1 did not hear any door alarms when Resident 1 left the facility. On 10/7/2023 at 10:44 a.m., during an interview, Licensed Vocational Nurse 7 (LVN 7) stated licensed nurses check if residents are wearing a wander guard bracelet and the maintenance department checks for their functionality. On 10/7/2023 at 11:50 a.m., during an interview, the ADM stated she was the only staff monitoring the surveillance camera monitor located in her office. A review of Resident 1's Change in Condition (COC) Evaluation, dated 10/8/2023, indicated Resident 1 was readmitted at 9 a.m., from GACH 1 accompanied by his Significant Other (SO). The COC Evaluation indicated Resident 1 had fallen two to three days ago and had an abrasion on his right knee and multiple abrasions on his right elbow. On 10/8/2023 at 11:49 a.m., during an observation, Resident 1 was lying in bed covered with a blanket with his SO at the bedside. At the time of the observation, during an interview, SO stated Resident 1 left the facility after having a disagreement with another resident. SO stated Resident 1 was walking outside with no food, water, and no medications for a couple of days and something bad could have happened to him. SO stated Resident 1 was found with the same clothes he was wearing the last time he was seen in the facility with white dust all over his body. SO stated Resident 1 was found in the afternoon of 10/7/2023 and was sent to GACH 1 ER. On 10/9/2023 at 11:01 a.m., during an interview, the Director of Staff Development (DSD) stated DSD saw Resident 1 on 10/4/2023 at 6 a.m. On 10/9/2023 at 1:49 p.m., during an interview, Resident 1 stated that, on 10/4/2023, Resident 1 exited from the exit door near the kitchen going out to the visitor parking lot. Resident 1 stated nobody was there, he opened the door, left the building, and rode a bus. A review of the current facility-provided policy and procedure titled, "Abuse-Prevention, Screening, & Training Program," with last revised date of 7/2018, indicated the purpose, "To address the health, safety, welfare, dignity, and respect of residents by preventing abuse, neglect, misappropriation of resident property, exploitation, and mistreatment including freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat medical symptoms." The policy also defined neglect as, "Failure to provide goods and services necessary to attain or maintain physical, mental, and psychosocial well-being and avoid physical harm, pain, mental anguish, or emotional distress." A review of the facility’s P&P titled, "Resident Safety," with last revised date of 4/15/2021, indicated the purpose, "To provide a safe and hazard free environment." The policy also stated that the Interdisciplinary Team (IDT - team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions, and share resources and responsibilities) will establish a person-centered observation or monitoring systems for the Resident to address the identified risk factors identified. A review of the facility’s P&P titled, "Wandering & Elopement," with last revised date of 7/2017, indicated the purpose, "To enhance the safety of residents of the facility." The policy's procedures include, "Facility staff will reinforce proper procedures for leaving the Facility for resident assessed to be at risk of elopement." The procedures also indicated, "The Licensed Nurse most familiar with the incident will document in the resident ' s medical record how the elopement occurred." A review of the facility’s P&P titled, "Security Camera Installation," with last revision date of 9/25/2020, indicated the purpose, "To provide guidance for the Facility Security Committee to install, use and monitor video surveillance and security cameras ("Security Cameras") in the Facility in a professional, ethical, and lawful manner, and when necessary for the safety and benefit of the Facility, its residents, and its staff." The procedure(s) stated, "Retention and Access to Recordings, A.) 24 - hour destruction: any recording should be automatically deleted\overwritten after 24 hours, unless requested by law enforcement approves a longer retention. B.) Retention of security recordings for longer than 24 hours: if there is a reason to maintain recordings for longer than 24 hours, such as a security incident; the recordings should be transferred to secure storage (such as encrypted drive)." The facility failed to ensure Resident 1, who did not have the capacity to understand and make decisions, who had wandering behavior, and was assessed at risk for fall and elopement was supervised and free from neglect. The facility failed to: 1. Ensure staff provided Resident 1 with supervision and monitoring to meet Resident 1’s care needs. 2. Implement Resident 1's care plan wandering or elopement to provide 1:1 supervision. 3. Develop comprehensive P&P on supervision of residents with wandering behavior and elopement risk to prevent Resident 1 to leave the facility unnoticed by staff. 4. Develop P&P on the wander guard. Staff did not notice a door alarm which should have been triggered by Resident 1, who was wearing a wander guard on his left wrist, through the door near the kitchen which led to the visitor's parking lot at the back of the facility. 5. Implement its P&P on the security and surveillance cameras to monitor the video surveillance cameras for the safety and benefit of its residents. As a result, on 10/4/2023 after 6 a.m., Resident 1 eloped from the facility. Resident 1, who was last seen at 6 a.m. on 10/4/2023, remained missing three days until 10/7/2023, when he was evaluated at GACH 1 ER and subsequently transferred back to the facility on 10/8/2023. Resident 1 was at risk for exposure to environmental elements i