Other·October 11, 2023

42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms. 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 §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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 8/21/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident about neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress), quality of care and treatment, and resident safety. The facility failed to protect Resident 1 from neglect failed to maintain an environment free from hazards, and placed Resident 1 at high risk of accidents, harm, and death by not preventing Resident 1 from eloping (resident who leaves the facility without staff noticing and when doing so may present an imminent threat to the resident's health or safety because the resident has been deemed too ill or impaired to make a reasoned decision to leave). For Resident 1, who was assessed as high risk for elopement, was wearing a wander-guard bracelet (a device designed to activate exit door alarms when a resident gets closer to entries and exit points), had previous elopement attempts, had episodes of taking (stealing) staff’s personal items, and had an assigned one-to-one (1:1) sitter (one staff always remains with one resident to prevent elopement), the facility failed to: 1. Ensure Certified Nursing Assistant 1 (CNA 1), Resident 1’s assigned one-to-one sitter, did not leave Resident 1 unsupervised (out of sight) in a restroom with two exit doors. 2. Ensure CNA 1 followed the facility’s policy and procedures (P&P) to call a Code Grey (code used in the facility to alert all staff that a resident is missing) when first discovering Resident 1 missing. 3. Ensure Certified Nursing Assistant 2 (CNA 2) did not turn off the Nursing Station 2 door equipped with a wander-guard alarm, when it was activated by Resident 1 exiting through the door, without first identifying the cause of the alarm. 4. Ensure Licensed Vocational Nurse 1 (LVN 1) did not leave her personal car key unattended on top of computer and easily accessible to Resident 1. As a result, on 8/20/2023, at 6:20 p.m., during a severe storm with continued heavy rains, high winds, and flooded roads, Resident 1 drove away in LVN 1’s car. Resident 1 was found by the police the following day, on 8/21/2023 at approximately 5:09 p.m., in a park after Resident 1 had contacted Family Member 2 (FM 2). A review of Resident 1’s Admission Record indicated the facility admitted the resident, a 63-year-old female, on 8/9/2023 with diagnoses that included epilepsy (chronic disorder that causes recurrent seizures [abnormal electrical activity in the brain]), subdural hemorrhage (bleeding in the area between the brain and the skull), and unspecified psychosis (conditions that affect the mind, in which people have trouble distinguishing between what is real and what is not). A review of Resident 1’s Minimum Data Set (MDS – an assessment and care screening tool) dated 8/18/2023, indicated the resident was able to make herself understood and understand others and required supervision with walking and toilet use. The MDS further indicated Resident 1 required the daily use of wander-guard alarm. A review of Resident 1’s Elopement Risk form, dated 8/10/2023, indicated that Resident 1 was at risk for elopement, had history of elopement and / or attempted elopement while at home, attempted to leave the facility, and verbally expressed her desire to go home, packed belongings to go home and / or stayed near an exit door. Resident 1 had wandering behavior (walking around without any clear purpose or direction). A review of the Physician’ Orders for Resident 1 indicated the following: a) Apply wander-guard to left wrist to alert staff of resident’s whereabouts, dated 8/9/2023. b) Monitor wander-guard if functioning properly every shift, dated 8/9/2023. c) Check placement of wander-guard bracelet every shift, dated 8/9/2023. d) One-to-one sitter every shift for 30 days, dated 8/11/2023. A review of Resident 1’s Care Plan titled, “The Resident is an elopement risk/wanderer (a resident who walks around without any clear purpose or direction) related to history of homelessness,” initiated 8/10/2023, indicated a goal that the resident would not leave the facility unattended, and safety would be maintained. The care plan interventions included to provide a one-to-one sitter, monitor Resident 1’s location, distract the resident from wandering by offering pleasant diversions, and the use of a wander-guard device. A review of Resident 1’s Situation Background Assessment Recommendation form (SBAR – a tool used to communicate a resident’s condition among members of the health care team)) dated 8/10/2023 timed at 5:08 p.m. indicated Resident 1 was noted wandering into rooms and taking belongings. A review of Resident 1’s Care Plan titled, “Patient taking other people’s belongings” initiated 8/11/2023, indicated a goal that the resident would remain safe and respect other people’s belongings. The care plan intervention included to provide a one-to-one sitter and resident will be re-oriented when observed attempting to take belongings. A review of Resident 1’s Nursing Progress Notes dated 8/11/2023 and timed at 11:56 p.m. indicated Resident 1 wandered around the facility and had tendency to collect other resident’s stuff and hide them in her room. Further review of Resident 1’s Nursing Progress Notes indicated: - On 8/13/2023 at 10:56 p.m. Resident 1 was identified as a high risk for elopement due to continuously attempting to leave the facility to go to the store. - On 8/14/2023 at 3:30 p.m. Resident 1 observed wandering in the hallway. - On 8/15/2023 at 4:39 a.m. Resident 1 observed wandering in the hallway. - On 8/16/2023 at 4:52 a.m. Resident 1 observed wandering in the hallway. - On 8/17/2023 at 4:14 p.m. Resident 1 observed wandering throughout the shift. - On 8/18/2023 at 7:32 a.m. Resident 1 took another resident’s phone, was found, and was returned. A review of the Social Services Progress Notes for Resident 1 dated 8/14/2023 timed at 2:34 p.m. indicated Resident 1 was able to walk, had confusion and was at risk for elopement. The note further indicated that Resident 1 walked around the facility and took other resident’s and staff’s belongings. A review of Resident 1’s SBAR form dated 8/20/2023 timed at 7:35 p.m. indicated Resident 1 was taken to the restroom by CNA 1. While CNA 1 was waiting for Resident 1 outside the restroom, CNA 1 heard the wander-guard alarm go off, CNA 1 ran to the door where the alarm was heard, however, CNA 1 was unable to catch Resident 1. During an interview on 8/21/2023 at 12:40 p.m., the Administrator (ADM) stated she was notified on 8/20/2023 after 6:00 p.m. that Resident 1 had eloped from the facility. The ADM stated CNA 1 had taken Resident 1 into a “Jack and Jill” layout restroom (a restroom that has two doors and is accessible from two bedrooms) and the resident exited the adjoining room’s restroom door leading to a sliding door exiting to an enclosed patio. From the enclosed patio, Resident 1 then re-entered the facility in possession of LVN 1’s personal vehicle keys (left unattended behind the computer) and exited through the Nursing Station 2 exit door leading to the back of the facility parking lot. Resident 1 eloped driving LVN 1’s vehicle. During an interview on 8/21/2023 at 1:54 p.m., CNA 1 stated she was the assigned one-to-one sitter for Resident 1 on 8/20/2023 evening shift (3:00 p.m. to 11:00 p.m.). CNA 1 stated Resident 1 liked to grab everything and had a behavior of going back and forth from the dining room, activities room, and restroom. CNA 1 stated on 8/20/2023 at approximately 6:15 p.m. she assisted Resident 1 to the restroom. CNA 1 stated she was unable to see Resident 1 because Resident 1 closed the restroom door. CNA 1 stated she did not notify anyone that Resident 1 was out of sight. CNA 1 stated at approximately 6:20 p.m., she heard the facility wander-guard alarm at Nursing Station 2 exit door leading to the back of the parking lot. CNA 1 stated she then ran to the activated alarm at Nursing Station 2 and saw Resident 1 in the parking lot but chose not to follow Resident 1 out the same door but instead, she walked to the front lobby exit door and exited to the front of the parking lot in hopes of catching Resident 1. CNA 1 stated at approximately 6:30 p.m. a black vehicle exited the facility parking lot, but she did not see who was driving because it was raining very hard. CNA 1 stated she was later made aware Resident 1 had driven away from the facility in LVN 1’s vehicle. CNA 1 stated she did not know when and how Resident 1 obtained LVN 1’s vehicle keys. During an interview on 8/21/2023 at 2:55 p.m., LVN 1 stated on 8/20/2023 evening shift she was assigned to Resident 1. LVN 1 stated Resident 1 needed a one-to-one sitter to ensure supervision was always provided because Resident 1 verbalized she wanted to go out and had attempted to leave the facility. LVN 1 stated Resident 1 had a behavior of taking things from others. LVN 1 stated on 8/20/2023 at approximately 6:45 p.m. CNA 1 notified her that Resident 1 eloped. LVN 1 stated she then called a Code Grey. LVN 1 stated it was her routine practice to leave her car key behind the computer in the nursing station. LVN 1 confirmed the car key was visible to anyone walking by the nursing station. During an interview on 8/21/2023 at 12: 50 p.m., the Director of Nursing (DON) stated that on 8/20/2023, after the Code Grey was called, staff went outside the building, and it was at that point that LVN 1 realized her vehicle and vehicle key were missing. During a follow-up interview on 8/22/2023 at 10:29 a.m., the DON stated CNA 1 should have immediately sought assistance when Resident 1 was out of sight and CNA 1 could have intervened and prevented Resident 1 from getting into the vehicle had CNA 1 followed Resident 1 out the exit door that alarmed. The DON stated staff was responsible to secure personal belongings including vehicle keys in a place not accessible to the residents. On 8/22/2023 at 11:39 a.m., during a concurrent interview with the DON and a review of the facility’s P&P on Abuse, Neglect and Exploitation, the DON stated the facility had the responsibility to provide the needed care and services to ensure Resident 1’s safety. The DON stated Resident 1 potentially could have had a car accident and caused harm to herself and / or others. The DON stated that not providing the needed services to a resident is considered neglect. During an interview on 8/22/2023 at 3:45 p.m., CNA 2 stated on 8/20/2023 sometime after 5:30 p.m., but unsure of exact time, he heard Station 2 exit door wander-guard alarm activate. CNA 2 stated he then went to the exit door, opened the alarming door twice and did not see anyone. CNA 2 stated he leaned out the door and it was raining hard. CNA 2 stated he turned off the wander-guard alarm without determining why it was activated. CNA 2 stated about five minutes later he heard the Code Grey announced. On 8/23/2023 at 8:32 a.m., during an interview, the Director of Staff Development (DSD) stated the facility’s process was that when the wander-guard alarm was activated all staff that heard the alarm should run towards the alarming door and determine why the alarm was activated. The DSD stated CNA 2 did not determine what activated the wander-guard alarm before turning the wander-guard alarm off. The DSD stated Resident 1’s elopement was preventable. On 8/23/2023 at 9:30 a.m., during a concurrent interview with the DON and a review of the facility’s P&P on Elopement, the DON concurred the DSD’s statement on Code Grey process. The DON stated CNA 1 took it upon herself to search for Resident 1 instead of calling a Code Grey which resulted in Resident 1 eloping using LVN 1’s vehicle. During a follow-up interview on 8/24/2023 at 9:50 a.m., CNA 1 stated on 8/20/2023 she was aware Resident 1’s restroom had two door (one restroom for two adjoining rooms). CNA 1 stated the restroom layout made it difficult to have eyes on Resident 1. CNA 1 stated she could not monitor all the exit points from the restroom and did not ask for assistance to monitor the adjoining room’s restroom door. CNA 1 also stated a Code Grey could be called by anyone in the facility and she should have called it in less than a minute from when the resident went missing on 8/20/2023. During an interview on 8/25/2023 at 9:33 a.m., the Social Services Director (SSD) stated on 8/15/2023 during the “stand up” (a daily, short meeting of department heads) meeting, staff was notified to ensure all staff’s personal belongings were secured due to Resident 1’s behavior of taking things. On 8/25/2023 at 11:45 a.m., during a concurrent interview with the DON and a review of the facility’s P&P on Elopement and P&P on Neglect, the DON stated the alarms were to help avoid elopements. The DON stated CNA 1 acted negligently by not following the facility’s “code grey” protocol upon discovering Resident 1 was missing. The DON stated CNA 2 had the responsibility to determine what activated the alarm. The DON stated CNA 2 acted negligently by turning off the wander-guard alarm without determining what activated the alarm. The DON stated Resident 1’s elopement was preventable.  A review of the facility’s P&P titled, “Elopement,” last reviewed 12/19/2022 indicated the facility must ensure that residents who exhibit wandering behavior and or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. The facility is equipped with door locks/alarms to help avoid elopements. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Interventions to increase staff awareness of the resident’s risk, modify the resident’s behavior, or to minimize risks associated with hazards will be added to the resident’s care plan and communicated to appropriate staff. Adequate supervision will be provided to help prevent accidents or elopements. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g., internal alert code). The designated facility staff will look for the resident. A review of the facility’s P&P titled, “Abuse, Neglect and Exploitation,” last reviewed 9/2/2022 indicated it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect. “Neglect” means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will provide ongoing oversight and supervision of staff to assure that its policies are implemented as written. New Employees and existing staf