Health inspection·October 31, 2024

§ 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. § 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. F689 Free of Accident Hazards/Supervision/Devices §483.25 (d) Accidents. (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 9/17/2024 at 9:20 AM, an unannounced visit was conducted at the facility to investigate a Facility Report Incidents (FRI) regarding patient safety related to wandering behavior (walking or going to places aimlessly) and elopement (the act of leaving a facility premises or a safe area without notifying anyone) that involved Patient 1. As a result of the investigation the California Department of Public Health (CDPH) determined the facility failed to prevent and respond to the elopement of Patient 1, who had severely impaired cognition (a condition that significantly impacts a person's ability to learn, remember, think, and communicate, making it difficult or impossible for them to live independently) by failing to implement the facility’s policy and procedures by:  1. Not assessing and identifying Patient 1 as at risk for unsafe wandering and elopement when the facility observed the patient wandering to other patient’s room and front lobby as indicated in the facility’s policy and procedure titled "Wandering and Elopement."   2. Not providing adequate supervision to ensure Patient 1 who had fluctuating capacity to understand and make decisions, with diagnoses including, schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior) , HIV (Human Immunodeficiency Virus), dysphagia (difficulty swallowing) and lack of coordination was properly assessed for risk of wandering and elopement as indicated in the facility’s policy and procedure titled "Nursing- Wandering and Elopement."   3. Not conducting a thorough investigation on how Patient 1 eloped and exited the facility to prevent other patients at risk of elopement from eloping in the exit areas as indicated in the facility’s policy and procedure titled "Accidents and Incidents- Investigating and Reporting."    4. Not developing a care plan to ensure Patient 1 received interventions, monitoring, and supervision to prevent elopement and wandering to other patient’s rooms as indicated in the facility’s policy and procedure titled "Nursing- Wandering and Elopement."   5. Not implementing the CODE Green (a code called out in the facility’s paging system [microphone announce a message] to alert staffs and visitors that a patient is missing or eloped) immediately when the patient was found missing as indicated in the facility’s policy and procedure titled "Use of Wander Guard"(Wander Guard-a set of equipment, consisting of a watch-like device worn by a person and a door alarm that is set off once the watch-like device gets in close proximity to the door alarm; used for the purpose of preventing a person from exiting an area)  and "Nursing Wandering and Elopement."   As a result of these failures, on 9/16/2024 at around 1:15 PM, Patient 1 eloped which potentially exposed the patient to extreme weather, medical complications, malnutrition, and death. Patient 1 missed her daily medications, including psychoactive medication (medications that affects mood and behavior) and antiviral medication (medications that treat viral infection). On 9/22/2024 at 9:10 AM Patient 1 readmitted back by the facility after she was brought back by the family member (six days after the patient eloped) to the facility after being found by the police in the street walking alone. Patient 1 was assessed with multiple skin discoloration with a new diagnosis of Urinary Tract Infection (UTI- an infection of the urinary tract) on 9/22/2024. A review of Patient 1’s Admission Record indicated a 61 year old, female patient, originally admitted to the facility on 8/21/2019, and readmitted on 5/1/2024, with diagnoses that included lack of coordination, schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and dysphagia (difficulty swallowing).     A review of Patient 1’s History and Physical (H&P), dated 5/3/2024, indicated the patient has fluctuating capacity to understand and make decisions. The H&P also indicated Patient 1 has a diagnosis of HIV (Human immunodeficiency virus is a virus that attacks the body's immune system, specifically white blood).     A review of Patient 1’s Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 6/17/2024, indicated the patient has severe cognitive impairment. The MDS indicated Patient 1 can walk 150 with supervision (helper provides verbal cues and/or touching assistance). The MDS also indicated Patient 1 does not use any mobility devices such as a cane, walker, or wheelchair and did not exhibit wandering behavior.     A review of Patient 1’s "Change in Condition Evaluation" form, dated 9/16/2024, timed at 4:07 PM, conducted with the Director of Nursing (DON), indicated on 9/16/2024 at 1PM, Certified Nursing Assistant (CNA) "was doing rounds and she noticed that [Patient 1] is not in her room. She looked if the patient is in the front which she always frequented but nowhere to be found."     A review of Patient 1’s "Order Summary Report" dated 9/17/2024, included the following orders:     -Olanzapine (medication that affects mood and behavior) tablet 15 MG (milligrams – a unit of measurement) to give 2 tablets orally (by mouth) at bedtime for Schizophrenia [manifested by] delusions [as evidenced by] believing her food has been poisoned     -Tivacay (Dolutegravir Sodium-medication used to treat HIV virus) oral tablet 50 MG to be given one tablet by mouth one time a day for HIV.     A review of Patient 1’s Progress Notes from 6/3/2024 to 9/17/2024, indicated no documented evidence that staff implemented interventions to monitor, supervise Patient 1 with wandering behavior of going into other patient’s room.     A review of Patient 1’s plan of care indicated no documented evidence that the facility developed a plan of care and implemented interventions to monitor, supervise and prevent Patient 1 from wandering or eloping from the facility after the facility observed Patient 1 wander to other patient’s room and wanders to the front lobby near the exit door that leads to a busy street.     During an interview on 9/17/2024 at 11:15 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Patient 1 usually sits in the front lobby, by the front exit. CNA 1 stated Patient 1 can walk by herself independently. CNA 1 stated the last time she saw Patient 1 was on 9/16/2024 at around 12 PM when Patient 1 was eating lunch inside of the patient’s room.     During an interview on 9/17/2024 at 11:32 AM with Receptionist (RP) 1, RP 1 stated Patient 1 was sitting by the front entrance in the lobby at around 11 AM to 11:30 AM on 9/16/2024 but did not notice Patient 1 leave the facility.     During an interview on 9/17/2024 at 11:49 AM with RP 2, RP 2 stated he last saw Patient 1 sitting in the front lobby near the facility’s entrance door at around 11 to 11:30 AM on 9/17/2024. RP 2 stated he did not see where Patient 1 went after 11:30 AM "because it became busy, and visitors started coming in."     During an interview on 9/17/2024 at 12:08 PM with CNA 1, CNA 1 stated she noticed Patient 1 was missing at 1:15 PM because she could not find Patient 1 in her room and the front entrance. CNA 1 stated she reported to Licensed Vocational Nurse (LVN) 1 that Patient 1 was missing at around 1:20 PM.     During an interview on 9/17/2024 at 12:10 PM, with LVN 1, LVN 1 stated she knows it was the usual routine of Patient 1 to sit on the chair by the front entrance of the facility. LVN 1 stated she was notified by CNA 1 at around 1:15 PM to 1:30 P.M on 9/16/2024 that Patient 1 was missing.  LVN 1 stated she informed CNA 1, CNA 2, and CNA 3 to look for Patient 1. LVN 1 stated she immediately checked the rooms, starting from rooms in her station LVN 1 stated after checking the rooms in her station’s rooms, she checked the rooms in 2 other stations and the front lobby. LVN 1 stated when she could not find the patient, she informed the Director of Nursing (DON) at around 2PM on 9/16/2024.     During an interview on 9/17/2024 at 12:12 PM, LVN 1 and CNA 1 both stated they "panicked" and forgot to announce the "Code Green" into the facility’s paging system. LVN 1 stated announcing "code green" a code used to alert all facility staff that a patient is missing or has eloped.   During an interview on 9/17/2024 at 12:28 PM with the DON, the DON stated LVN 1 reported to her that Patient 1 was missing at around 2PM. DON stated her initial response was to go out of the facility to look for the patient. The DON stated she and LVN 1 drove around the facility’s area and came back at around 3PM but did not find Patient 1. DON stated when she came back into the facility, and she informed the Administrator (ADM) that Patient 1 was missing, and reported the patient was missing to the police department. DON stated, "Code Green" was never announced on the facility’s paging system because she and the other staffs "panicked." The DON stated announcing "Code Green" was used by the facility to help spread information to all staff that a patient has gone missing and to potentially help in preventing the patient from going out and far from the facility’s premises.     During an interview on 9/17/2024 at 1:13 PM with CNA 2, CNA 2 stated he was verbally informed by LVN 1 that Patient 1 was missing at around 1:15 PM on 9/16/2024. CNA 2 stated Patient 1 usually wanders to other patient’s room and bathrooms, on 9/16/2024 at 1:15 PM when she looked for the patient, she did not find the patient in the facility.     During an interview on 9/17/2024 at 1:27 PM with CNA 3, CNA 3 stated she was informed by LVN 1 that Patient 1 was missing at around 1:30 PM. CNA 3 stated Patient 1 walks around the facility without any help from the staff. CNA 3 stated Patient 1 goes to other patients’ rooms but when she looked for the patient on 9/1/6/2024, she did not find the patient in the facility.     During an interview on 9/17/2024 at 1:58 PM with CNA 1, CNA 1 stated Patient 1 can walk without any need for assistance or devices. CNA 1 stated Patient 1 was not under any supervision or monitoring because "she is quiet and just walks slowly."     During an interview on 9/17/2024 at 1:59 PM with LVN 1, LVN 1 stated Patient 1 was not under any supervision and monitoring for wandering and elopement. LVN 1 stated Patient 1 was not one of the three patients listed in the elopement binder to be at risk for elopement in the facility. LVN 1 stated patients that are at risk for elopement are listed in the elopement binder.     During an interview on 9/17/2024 at 2:52 PM with Registered Nurse (RN) 1, RN 1 stated the facility has an elopement binder labeled, "Elopement Risk Patients" which has a list of patient's names that are at risk for elopement. RN 1 stated patients are added into the list based on the assessment of the patient by the nurse using the "Elopement Evaluation" form. RN 1 stated if the patient was assessed to have any risk factor, then the patient must be added into the list. RN 1 stated a patient who was at risk for elopement must have interventions put in place to prevent an elopement such as monitoring the patient’s whereabouts and supervision.      During a concurrent interview and record review on 9/17/2024 at 3PM with RN 1, Patient 1’s "Elopement Evaluation" form, dated 6/17/2024 and 9/16/2024 were reviewed. RN 1 stated the following questions were incorrectly answered "No" instead of answering "Yes."     a. Has the patient verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door.   b. Does the patient wander.   c. Is the wandering behavior a pattern, goal-directed (an action taken with the specific intention of achieving a desired outcome).   d. Is the wandering behavior likely to affect the privacy of others.    e. "Score value or 1 or higher indicate Risk of Elopement."     During a follow up interview on 9/17/2024 at 3:05 PM with RN 1, RN 1 stated the questions should have been answered "yes" and the score should be greater than one because Patient 1 frequently stays in the front lobby, walks around the facility, and even wanders to other patients’ rooms. RN 1 stated if the form was answered correctly, Patient 1 could have been assessed as a high risk for elopement and put on the list for patients at risk for elopement. RN 1 stated Patient 1 should have been monitored to prevent elopement.     During another concurrent interview and record review on 9/17/2024 at 3:06 PM with RN 1, Patient 1’s "Elopement Evaluation" form, dated 9/16/2024, was reviewed. RN 1 stated she did identify Patient 1 as at risk for wandering and elopement because she followed the answers in the previous "Elopement Evaluation" form dated 6/17/2024 that indicated Patient 1 as not at risk for wandering and elopement. RN 1 stated because she evaluated the patient as not at risk for elopement, the staffs would not know that the patient was at risk for elopement.     During an interview on 9/18/2024 at 10:01 AM with Director of Staff Development (DSD), DSD stated patients who wander around the facility aimlessly and have psychiatric (mental, behavioral, and emotional disorders) medical diagnosis like Patient 1 are at risk for elopement. DSD added patients with psychiatric illness like Patient 1 have "tendency to go out if the doors are left open" which can jeopardize the safety of the patient and other patients who have behavior of wandering if they are not monitored or supervised.      During a concurrent interview and observation on 9/18/2024 at 2:14 PM with CNA 5, Room B and Room C were checked. CNA 5 stated Room B and Room C both have sliding doors that opens wide enough for a person to walk out to and leave the facility. CNA 5 stated any patient could go out of the sliding doors that leads to the back side of the building and elope.      During a concurrent interview and observation on 9/18/2024 at 2:30 PM with DON, Room B and Room C were checked. DON stated Room B was next to Patient 1’s room and Patient 1 could have eloped through the sliding doors. DON stated there were no alarms after a patient has passed through the sliding doors that could have alerted staff that a patient was eloping. DON stated there are no locks to the gate outside the sliding doors that could prevent any patient from leaving the facility. DON stated the sliding doors of Room B and Room C were not supposed to open wide enough for a person to be able to walk out.     During an interview on 9/18/2024 at 2:40 PM with Maintenance Supervisor (MS), MS stated the area outside the sliding doors of Room C and Room D do not have any alarms, sensors, or cameras that could notify staff if a patient was outside. MS stated the facility does not lock the gate outside of the sliding doors.     A review of Patient 2’s Admission Record indicated the patient was originally admitted on 6/4/2010, readmitted on 10/11/2021, with diagnoses that included spondylosis (abnormal wear on the cartilage [flexible