Health inspection·December 11, 2024

California Code of Regulations, Title 22 Section § 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. Code of Federal Regulations, Title 42 F689 §483.25(d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. On 11/15/2024, at 11:30 AM the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding patient elopement [an individual's behavior of leaving an area without permission or supervision]. As a result, CDPH determined, the facility failed to provide adequate monitoring and supervision to ensure Patient 1 who had severely impaired cognition (ability to think and reason) and was assessed at risk for elopement and with diagnosis of dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) did not elope from the facility on 11/14/2024. This deficient practice had resulted in Patient 1, eloping from the facility on 11/14/2024. Patient 1 had the potential for fall, injury or being struck by motor vehicles. Patient 1 also had the potential to be exposed to extreme weather and malnutrition (lack of proper nutrition). Patient 1 was located by the local law enforcement on 11/24/24, 10 days later. However, Patient 1 remained in the custody of local law enforcement. A review of Patient 1’s Admission Record indicated the facility admitted Patient 1, who is a 64-year-old, male patient, on 10/23/2024 with diagnoses that included dementia and heart failure (a condition that the heart isn’t pumping as well as it should). A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 11/4/2024, indicated Patient 1 had severely impaired cognition and memory. The MDS indicated Patient 1 required supervision or touching assistance for eating, chair/bed-to-chair transfer, walk 50 feet with two turns and walking 10 feet on uneven surfaces, and partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self, and personal hygiene. The MDS also indicated Patient 1 had wander/elopement alarm. A review of Patient 1’s Elopement Evaluation, dated 10/30/2024, indicated Patient 1 was at high risk for elopement. The Elopement Evaluation indicated Patient 1 had a history of elopement or attempted leaving the facility without informing staff. The Evaluation further indicated Patient 1 verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. In addition, the Evaluation indicated Patient 1 wanders, with a pattern of wandering behavior, goal-directed with specific destination in mind. The Evaluation indicated Patient 1’s wandering behavior likely to affect the safety or well-being of self/others; and Patient 1 has been recently admitted and is not accepting the situation. A review of Patient 1’s Order Summary Report, dated 10/31/2024, indicated the physician order Patient 1 may have wander guard due to elopement risk score at six (high risk), starting on 10/30/2024. A review of Patient 1’s Care Plan, dated 10/30/2024, the Care Plan indicated the goal was the patient would not leave facility unattended, and the patient’s safety would be maintained. The Care Plan indicated to identify if there is a certain time of day wandering/elopement attempts occur. A review of the facility record titled “Patient 1’s with Wanderguard,” dated 11/11/2024, indicated Patient 1 was on the list of Resident’s with Wanderguard. A review of the Facility’s Elopement Binder indicated Patient 1’s picture and information were in the Elopement Binder. During an interview on 11/15/2024 at 11:52 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Patient 1 always asked if he lived in the facility, and he remembered the place where he used to live. LVN 1 stated Patient 1 was high risk for elopement, and the facility put a wander guard on his wrist, and she checked his wander guard around 6:50 AM on 11/14/2024 which was working. LVN 1 stated the last time she saw Patient 1 was between 12 PM and 12:15 PM when she was passing medications to other patients. LVN 1 stated Patient 1 walked passing the medication cart and got some juice from her. LVN 1 stated it was between 12:50 PM and 1 PM, the Treatment Nurse (TXN) came to the nursing station and asked if someone saw Patient 1, then, everyone started to look for the resident and Code 10 (a code activated when a patient is missing) was called. During an interview on 11/15/2024 at 12:24 PM, with the Receptionist, the Receptionist stated his responsibility was stay at the front desk in the lobby to monitor the patients in the lobby. The Receptionist stated Patient 1 hangs out in the lobby and the activity room which the door was facing the lobby, and Patient 1 has said he wanted to leave the facility. The receptionist stated Patient 1 always held a plastic bag packed with his belongs and trying to go out. The Receptionist stated he reported Patient 1’s behavior to the nurses, and the nurses put a wander guard on his wrist. The Receptionist stated it was around 12:30 PM on 11/14/2024, he needed to use the restroom, then, he checked with an activity staff who was supervising the dining room during lunch time and the nursing supervisor at the nursing station who was assisting a patient, but they were busy at that time, so he decided to leave his post and go to the restroom without making sure someone was monitoring the lobby. The receptionist stated he saw Patient 1 sitting inside the activity room, holding his plastic bag, and looking outside before he left his post. The Receptionist stated he returned to his post 40 seconds later and the wander guard alarm by the lobby entrance was not beeping and he did not notice Patient 1 had eloped. The Receptionist stated he was unsure if Patient 1 was wearing the wander guard. The Receptionist stated the facility did not pre-assign other staff to cover his post when he was on break, and he could not find coverage for his break sometimes because everyone was busy with their own work. The Receptionist stated he should find someone to monitor the lobby before he left his post yesterday to prevent Patient 1 from leaving the facility without supervision. During a concurrent observation and interview on 11/15/2024 at 1:45 PM, with the Administrator (ADM), the facility’s video footage of the surveillance camera at the lobby was reviewed. The ADM stated the Receptionist left his post and disappeared from the footage at 12:31:07 PM on 11/14/2024, shortly after, Patient 1, who was holding a plastic bag came out from the Activity Room, walked towards the lobby and the entrance door. Patient 1 left the facility at 12:31:23 PM on 11/14/2024 without staff’s supervision. The ADM stated the Receptionist returned his post at 12:32:15 PM on 11/14/2024. The ADM stated there was no staff monitoring the lobby area during the time Patient 1 eloped and there should be a staff at the front desk to always monitor the lobby. During an interview on 11/15/2024 at 1:55 PM, with Patient 2, Patient 2 stated Patient 1 always said that he did not like to stay at the facility, and he wanted to leave. Patient 2 stated he was looking for Patient 1 before lunch and he could not find him on 11/14/2024. During an interview on 11/15/2024 at 2 PM, with the Assistant Director of Nursing (ADON), the ADON stated the Receptionist was supposed to find coverage before he left the post to ensure patient’s safety, and she did not know why the Receptionist did not ask someone to cover the reception area/lobby. During an interview on 11/15/2024 at 2:46 PM, with the Director of Nursing (DON), the DON stated Patient 1’s elopement on 11/14/2024 was because the Receptionist left the reception area/lobby without making sure someone was monitoring the lobby area. The DON stated the Receptionist must find someone to cover the reception area/lobby and have staff available to help with coverage to ensure patients’ safety. The DON stated the facility did not provide adequate supervision to ensure Patient 1’s safety. During a follow up telephone interview on 11/26/2024 at 2:08 PM, with the ADM, the ADM stated that local law enforcement called and informed him that Patient 1 was located and placed under police custody. The ADM stated that local law enforcement informed him it was not clear if Patient 1 would return to the facility at this time. A review of the facility’s policy and procedure (P&P) titled, “Receptionist,” dated 10/2003, indicated the receptionist promotes a safe environment for residents, visitors, and staff at all times. A review of the facility’s P&P titled, “Safety and Supervision of Residents,” dated 7/2017, indicated “Resident supervision is a core component of the systems approach to safety.” A review of the facility’s P&P titled, “Nursing-Wandering and Elopement,” dated 6/2018, indicated the facility to enhance the safety of the residents, reinforce proper procedures for leaving the facility for residents assessed to be at risk for elopement, and provide extra monitoring on the residents’ whereabouts. The facility failed to provide adequate monitoring and supervision to ensure Patient 1 who had severely impaired cognition and was assessed at risk for elopement and with diagnosis of dementia did not elope from the facility on 11/14/2024. The above violation had resulted in Patient 1, eloping from the facility on 11/14/2024. Patient 1 had the potential for fall and injury from being struck by motor vehicles. Patient 1 also had the potential to be exposed to extreme weather and malnutrition. Patient 1 was located by the local law enforcement on 11/24/24. Patient 1 remained in the custody of local law enforcement. This violation had a direct or immediate relationship to the health, safety, or security of Patient 1.