Other·May 2, 2024

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 §72311 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. § 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 2/14/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about quality of care. As a result of the investigation, CDPH determined the facility failed to: 1. Ensure Resident 1 received adequate supervision to prevent accidents. 2. Ensure Resident 1’s care plan was carried out by properly monitoring Resident 1’s wander-guard (a device designed to activate alarms when a resident gets closer to entries and exit points). On 2/14/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility-reported incident (FRI) about quality of care. The facility failed to ensure Resident 1, who was a high risk for elopement, had severe impaired cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering), and was wearing a wander-guard, was provided with supervision and monitoring to prevent elopement. As a result, on 2/8/2024 at 2:35 a.m., Resident 1 was noticed missing from the facility. On the same day, at 8:00 a.m. Emergency Medical Services (EMS, paramedics) found Resident 1 on a street, transported him to General Acute Care Hospital 1 (GACH 1), where Resident 1 was diagnosed with hypothermia (abnormally low body temperature) and assessed as having abrasions (skin scrapes) above the right and left eyebrow, on the left forehead, right knee, and left posterior side of the forearm. A review of Resident 1’s Admission Record indicated the facility re-admitted Resident 1, a 45 years-old male, on 12/28/2023 with diagnoses that included hypertension (elevated blood pressure), type 2 diabetes mellitus (a disease in which blood glucose [blood sugar] levels are too high), depression, bipolar disorder (a mental illness that causes unusual shifts in mood, ranging from extreme highs to lows) and schizophrenia (a mental disorder in which a person interpret reality abnormally). A review of Resident 1’s Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 2/5/2024, indicated Resident 1’s cognition was severely impaired. A review of Resident 1’s Elopement Risk Form, dated 12/28/2023, indicated Resident 1 had one or more predisposing diseases present, was disoriented all the time, and took two or more medications that could place the resident at risk for elopement. A review of Resident 1’s Physician Order, originally dated 10/7/2023 and clarified on 1/18/2024, indicated use of the wander-guard device and for licensed nurses to check the presence and placement of Resident 1’s wander guard bracelet every shift and document one if present and two if absent. A review of Resident 1’s Care Plan for Resident 1’s wandering behavior, revised on 2/2024, indicated Resident 1 had sporadic wandering and the goal was for Resident 1 to be free of injuries and unplanned exits. The care plan interventions included providing a safe place to wander and away from safety hazards, use of wander-guard device including checking of wander-guard placement every shift due to episodes of trying to leave the facility and to monitor Resident 1’s wandering behavior. A review of Resident 1’s Situation Background Assessment Recommendation (SBAR – a tool used to communicate a resident’s condition among members of the health care team) Form, dated 2/8/2024, indicated that on 2/8/2024 at approximately 2:35 a.m., Registered Nurse 1 (RN 1) noted Resident 1 was not in his bed. RN 1 alerted the facility staff and searched the facility building, parking lot and surrounding streets. Resident 1 was not located in the facility. A review of Resident 1’s Nurses Notes, dated 2/8/2024 and timed at 8:00 a.m., indicated that at approximately 8:00 a.m., of 2/8/2024, Emergency Medical Services (EMS) notified the facility that they found Resident 1 (location not specified) and took him to GACH 1. A review of Resident 1’s GACH Emergency Department (ED) Notes, dated 2/8/2024, indicated Resident 1 was seen and evaluated at 9:04 a.m. after Resident 1 was found wandering along a street. Resident 1 was diagnosed with hypothermia, his temperature was 94.1 degrees Fahrenheit (ºF, normal body temperature ranges from 97°F to 99°F). Resident 1 was provided with external warming measures. The GACH ED Notes indicated Resident 1 was given intravenous fluids to hydrate him. A review of Resident 1’s Nurses Notes dated 2/8/2024 indicated Resident 1 returned to the facility from GACH 1 at 6:00 p.m. Resident 1 was wearing the wander-guard bracelet upon re-admission to the facility. Resident 1 had abrasions above the right and left eyebrow, on the left forehead, right knee, and left posterior side of the forearm. Resident 1’s physician ordered treatment to apply on the affected areas. On 2/14/2024 at 8:30 a.m., during an interview, the Director of Nursing (DON) stated that on 2/8/2024 at approximately 2:35 a.m., RN 1 noted Resident 1 was missing. The DON stated that nursing staff did not adequately monitor Resident 1 as evidenced by the fact they did not know when or how Resident 1 left the facility. The DON stated that Resident 1 could have been hit by a car or fallen and sustained some other injury while outside of the facility. During an interview on 2/15/2024 at 4:50 p.m., Resident 1 was unable to recall the elopement incident. A review of the facility’s policy and procedure titled, “Elopement/Against Medical Advice,” with an effective date of 2/15/2018, last reviewed 2/28/2023, indicated “…the facility has a responsibility to provide oversight and protect the rights, health and safety of each resident.” A review of the facility’s policy and procedure titled, “Wandering Resident” undated, indicated “It is the facility’s policy to identify residents who walk or wheel about and are a threat to leave the facility unattended due to their confusion… to ensure the resident’s safety.” As a result of the investigation, CDPH determined the facility failed to: 1. Ensure Resident 1 received adequate supervision to prevent accidents. 2. Ensure Resident 1’s care plan was carried out by properly monitoring Resident 1’s wander-guard. The facility failed to ensure Resident 1, who was a high risk for elopement, had severe impaired cognition, and was wearing a wander-guard bracelet, was provided with supervision, and monitoring to prevent elopement. As a result, on 2/8/2024 at 2:35 a.m., Resident 1 was noticed missing from the facility. On the same day at 8:00 a.m. EMS found Resident 1 on a street, transported him to GACH 1 where Resident 1 was diagnosed with hypothermia and assessed as having abrasions above the right and left eyebrow, on the left forehead, right knee, and left posterior side of the forearm. The above violations jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.