Health inspection·January 2, 2025

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.

F741 §483.40(a) Sufficient/Competent Staff?Behavioral Health Needs The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with §483.71. These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for: §483.40(a)(1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to §483.71. On 12/3/2024, at 10:00 AM the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a complaint regarding patient elopement. As a result, CDPH determined, the facility failed to provide sufficient nursing staff who have the knowledge, training, and skills sets to address behavioral healthcare needs for Patient 1, who was diagnosed with dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) and assessed at high risk for elopement, in accordance with the Patient ' s care plan, the facility ' s policy and procedure on "Behavioral Health Services, " "Dementia Care," and the Facility Assessment. The facility staff failed to intervene when Patient 1, who was visibly agitated and refused to come back inside the facility upon returning from an out-on-pass with the Family Member [FM] on 11/27/2024. Registered Nurse [RN] 1 failed to implement Patient 1 ' s care plan on "Behavioral "Problem." RN 1 did not address Patient 1 ' s agitated behavior and allowed Patient 1 to wander out of the facility and instructed the FM to follow the patient and for FM to call law enforcement. As a result of this deficient practice Patient 1 could not be found for two and half hours on 11/27/2024. On 11/27/2024, at around 8:10 PM, local law enforcement found Patient 1 and transferred to the general acute care hospital [GACH] and was placed on Code 5150 hold (the code allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour when evaluated to be a danger to others, or to himself or herself, or gravely disabled). A review of Patient 1 ' s Admission Record indicated the facility admitted Patient 1, who is a 75-year-old female patient, on 6/20/2024 with diagnoses that included encephalopathy (a general term for a group of brain disorders or diseases that cause brain dysfunction) and unsteadiness on feet. A review of Patient 1 ' s Elopement Risk Assessment (ERA), dated 6/21/2024, indicated Patient 1 had elopement risk total score of 12 which indicated Patient 1 had a history of elopement and was at high risk for elopement. The ERA indicated Patient 1 had wandering behavior and wandered aimlessly. The potential interventions for elopement indicated frequent monitoring-check every two hours, identification bracelet, and staff aware of patient ' s wander risk. A review of Patient 1 ' s Care Plan, dated 6/21/2024, the Care Plan indicated Patient 1 was at risk for elopement and the interventions were to assist in re-orientation to room/facility, monitor patient location with visual check, monitor behavior and mood patterns, anticipate patient needs based upon wandering behavior. A review of Patient 1' s History and Physical Examination (H&P), dated 6/22/2024, indicated Patient 1 had a diagnosis of dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) and Patient 1 does not have the capacity to understand and make decisions. A review of Patient 1' s Psychiatric Examination, dated 6/27/2024, indicated the patient’s chief complaint and psychiatric history was anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress). A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 9/24/2024, indicated Patient 1 required supervision or touching assistance for eating, and partial/moderate assistance with oral hygiene, toileting hygiene, shower/bathe self, and personal hygiene, and chair/bed-to-chair transfer. A review of Patient 's Care Plan, dated 10/8/2024, the Care Plan indicated Patient 1 has a behavior problem and the intervention was to intervene as necessary by approach/speak in a calm manner, divert attention, and remove from situation and take to alternate location as needed. A review of Patient 1' s Elopement Evaluation (EE), with effective date 11/26/2024 and timed at 12:18 PM, indicated Patient 1 had a history of elopement and was the risk for elopement and she had a pattern of wandering behavior. The EE indicated the intervention included notify staff of wandering and elopement risk and monitor location frequently. A review of Patient 1' s Change in Condition Evaluation (COC), dated 11/26/24 at 5:09 PM, the COC evaluation indicated Patient 1 attempted to leave the facility on 11/26/2024 [prior to the patient ' s out on pass with the family member on the same day]. A review of Patient 1 ' s Progress Notes (PN), dated 11/27/2024, was reviewed. The PN indicated the Family Member (FM) took Patient 1 home out on pass on 11/26/2024 at 6 PM [an hour prior to Patient 1 ' s attempt to elope the facility on 11/26/2024 timed at 5:09 PM] and planned to bring Patient 1 back to the facility after the holiday celebration, but Patient 1 was showing aggressive behavior at home. On 11/27/2024 at 6:30 PM, the FM came inside the facility and asked for help because she brought Patient 1 to the outside of the facility but Patient 1 refused to come inside and walked away. The PN indicated FM 1 did not want to force Patient 1 getting inside the facility. The facility staff followed up with the FM over the phone twice and asked about Patient 1 ' s whereabouts, then, the FM stated she did not know where Patient 1 was. The facility staff advised the FM to report to local police. On 11/27/2024 around 9:30 PM, Patient 1 was found by police. A review of the Police Report (PR), dated 11/27/2024, the PR indicated that on 11/27/2024, at approximately 8:10 PM assisted with a missing person report. The PR indicated Patient 1 walked away from the facility after she was dropped off by the FM. The PR indicated Patient 1 was located sitting on a bus bench, subsequently. The PR indicated that based on Patient 1 ' s conflicting statements and wanting to wander the streets of another city. Patient 1 was transported to the GACH and was placed on 5150 hold by the GACH. The PR indicated Patient 1 was gravely disabled and a danger to herself. A review of Patient 1 ' s Order Summary Report, for December 2024, the Order Summary Report indicated physician order dated 6/21/2024, to monitor the patient ' s whereabouts every two hours, visual check due to high risk for elopement. The Order Summary Report also indicated another physician order dated 11/26/204, that Patient 1 may go out on pass with the FM for 48 hours. During an interview on 12/3/2024 at 10:53 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to take care of Patient 1 regularly in the morning shift and she was familiar with Patient 1 ' s care. CNA 1 stated Patient 1 was confused, and she would get mad sometimes by yelling and screaming at the staff. CNA 1 stated she was not aware that Patient 1 was on the watch for elopement risk before the incident on 11/27/2024. During an interview on 12/3/2024 at 11:15 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Patient 1 was delusional (having a fixed false belief that is resistant to change, even when presented with evidence that it is not true) sometimes and she could be aggressive sometimes by yelling and screaming at the staff. LVN 1 stated the facility identified Patient 1 was at risk for elopement before [could not recall date]. LVN 1 stated Patient 1 tried to go out the facility without the staff ' s supervision two times before [unable to recall dates], but the facility staff caught the patient before she could go out the facility. During an interview on 12/3/2024 at 11:30 AM, with the Director of Nursing (DON), the DON stated the receptionist reported to her that Patient 1 was holding a bag and had the tendency of going out the facility on 11/26/2024 [prior to leaving out on pass with the FM], so the facility notified Patient 1 ' s physician and obtained an order to put a wander guard on the patient, and completed the COC. The DON stated Patient 1 was often out on pass with the family members and returns to the facility on the same day without any issue in the past. The DON stated Patient 1 did not have any history of an actual elopement from the facility, so the FM ' s request to take Patient 1 home for 48 hours for the holiday was approved even though it was the first time for Patient 1 to be out of the facility overnight. The DON stated the FM took Patient 1 home out on pass for 48 hours on 11/26/24 at 6 PM, but the FM decided to bring Patient 1 back to the facility on 11/27/2024, because Patient 1 was showing aggressive behavior, and she could not control the patient at home. The DON stated the FM informed the staff that Patient 1 did not want to come inside the facility and Registered Nurse (RN) 1 offered that the staff could grab Patient 1 and bring the patient inside, but the FM did not want to forcefully bring Patient 1 back to the facility. The DON stated since the FM refused the staff ' s help at that time [on 11/27/24] and allowed Patient 1 kept walking away, the facility had to respect the FM ' s choice and followed up with the FM by phone to check the whereabouts of Patient 1. The DON stated the facility did not send a staff to follow Patient 1 because the staff could not follow Patient 1 wherever she was going to walk to. The DON stated when RN 1 knew about Patient 1 was missing, the facility did not report to the police, instead, RN 1 advised the FM to report to the police to find Patient 1. During a telephone interview on 12/3/2024 at 12:52 PM, with RN 1, RN 1 stated on 11/27/2024 at 6:30 PM, the FM came inside the facility and said she brought Patient 1 back to the facility. The FM stated Patient 1 was still outside the facility, because the patient refused to come back inside the facility and walking away. RN 1 stated the FM said Patient 1 was acting out at home and yelling at the FM, and she could not control Patient 1 at home. RN 1 stated she did not see Patient 1 outside the facility lobby at that time. RN 1 stated she asked the FM if it was ok for the staff to grab Patient 1 and bring her in, but the FM did not want to force Patient 1 to go inside and wanted Patient 1 to be willing to go back to the facility. RN 1 stated she offered help, but the FM refused at that time. RN 1 stated she did not send any facility staff outside to check on Patient 1 because if Patient 1 would not listen to the FM, then, she would not listen to a facility staff who the patient was not familiar with. RN 1 stated she told the FM to follow Patient 1 and kept a visual on her, then, she called twice to follow up with the FM regarding the whereabouts of Patient 1. RN 1 stated 20 minutes later, she saw the FM was sitting in the car outside of the facility, and the FM said she did not know where Patient 1 was. RN 1 stated she advised the FM to report to the police. RN 1 stated Patient 1 was found around 9:30 PM. RN 1 stated Patient 1 was out on pass, the FM was responsible for the patient. RN 1 stated the facility would be responsible for Patient 1 until she was checked in back to the facility. RN 1 stated she was not sure or aware if Patient 1 was at risk for elopement. During a telephone interview on 12/3/2024 at 2:36 PM, with the FM, the FM stated on 11/27/2024 morning, Patient 1 was getting more difficult and agitated as the day progressed and she could not control Patient 1 at home anymore, so she decided to bring Patient 1 back to the facility. The FM stated Patient 1 had dementia and was showing the symptoms of early stage of dementia, but the aggressive behavior at home was new to her and she did not know how to handle Patient 1 safety at home. The FM stated she drove Patient 1 to the facility, but when Patient 1 was 10 feet away from the facility ' s lobby door, patient refused to go inside and started to walk away. The FM stated she tried to convinced Patient 1 but Patient 1 just kept walking further away. The FM stated she did not know what to do and went inside the facility to ask for help. The FM stated she could not get help from the facility staff at the front lobby until RN 1 came out and talked to her. The FM stated RN 1 asked if she agreed to have the staff to grab Patient 1, and she replied she did not want to force Patient 1 back to the facility and she did not know what to do. The FM stated RN 1 told her to follow Patient 1 and keep an eye on the patient. The FM stated she tried to follow Patient 1, but when Patient 1 saw her, Patient 1 turned around and walked away from her, so she decided to wait in the car, in hoping that Patient 1 would return on her own if Patient 1 did not see her following, but she did not see Patient 1 walked back to the facility. The FM stated when she told RN 1 that she did not know where Patient 1 was, RN 1 told her that she had to call the police herself. The FM stated she went inside the facility to ask for help because she did not know what to do when Patient 1 refused to go inside the facility and walked away. The FM stated she thought the facility staff would send someone outside to talk to Patient 1 and bring her in the facility calmly, but the facility did not send anyone outside to check on Patient 1. The FM stated she felt helpless at that time because she did not have the professional knowledge of dealing with a situation like this and she expected the facility staff to provide professional assistance to address Patient 1 ' s behavior and ensure the patient safety. During an interview on 12/3/2024 at 3:55 PM, with the DON, the DON stated the facility had the responsibility for Patient 1 ' s safety when the patient was outside the facility. The DON stated Patient 1 had a diagnosis of dementia and was showing signs and symptoms of distress when the FM tried to bring Patient 1 back to the facility. The DON stated the staff should addressed Patient 1 ' s distress and provide professional assistance to check on Patient 1 right away, bring her back to the facility, and call