Other·April 28, 2021

F689 §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. Title 22 § 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. Title 22 § 75339 - Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, deaths from unnatural cause or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or, in areas not having an organized fire service, to the State Fire Marshal. On 2/1/2021 an unannounced visit was made to the facility to investigate a complaint about resident’s safety. The facility, which is locked (entrance and exit doors are locked with a keypad and buzzer system to prevent confused residents from eloping [leaving the facility, when doing so may present an imminent threat to the residents health or safety because of legal status or because the person has been deemed too ill or impaired to make a reasoned decision to leave), failed to ensure: 1. Resident 1, who was identified as a high risk for elopement and had previously eloped, was provided with the necessary supervision and safe environment to prevent further elopement and injuries per facility’s policy. 2. Resident 1’s elopement, in two separate occasions, was reported to the State Agency (the Department) as unusual occurrence as per facility’ policy. As a result: 1. On 1/29/2021, at 11 p.m., Resident 1 successfully eloped and sustained a fall with injuries. Resident 1 was treated at General Acute Care Hospital 1 (GACH 1), where the resident was identified with a laceration (deep cut or tear in the skin) near his left eye that required sutures (a thread-like material used to join together the open parts of a wound). Upon Resident 1's return to the facility, Resident 1 was noted with swelling and bruising on his left hand and an x-ray result showed a fracture (break of a bone) of the fourth finger (ring finger) on his left hand which required a splint (a piece of medical equipment used to keep an injured body part from moving and to protect it from any further damage). This finger injury was attributed to have occurred during the time he eloped. 2. The Department learned about the two elopements during a complaint investigation. The lack on notification of the unusual occurrence delayed the investigation by the Department and place the resident at risk for further elopement episodes. A review of Resident 1's Admission Record indicated the resident was admitted on 2/5/2020 with diagnoses including unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 11/14/2020, indicated the resident's cognition (ability to think, understand and reason) was severely impaired. Resident 1 was unable to make decisions. Resident 1 was not steady while walking and did not require the use of mobility devices. A review of Resident 1’s Elopement Risk Assessment, dated 11/14/2020 indicated the resident was disoriented, forgetful, did not understand surroundings, did not understand what was being said, and was a high risk for wandering (moving about without a definite destination or purpose and can be dangerous when the person goes in areas with unsafe conditions). A review of Resident 1’s Situation, Background, Appearance, and Review (SBAR) Communication Form - Change of Condition Progress Note (used to facilitate prompt and appropriate communication between the healthcare team about a resident's condition), dated 1/24/2021, indicated Resident 1 left the facility without notifying the staff. A review of Resident 1’s SBAR Communication Form - Change of Condition Progress Note, indicated Resident 1 was missing as of 11 p.m. on 1/29/2021. Staff was unable to locate Resident 1. At 11:30 p.m. on 1/29/2021, GACH 1 called and notified the facility Resident 1 was at the Emergency Room (ER) for a fall and would be transferred to General Acute Care Hospital 2 (GACH 2). A review of Resident 1's GACH 1's ER notes dated 1/30/2021, indicated Resident 1 had two centimeters (cm, a unit of measure) left eyebrow laceration that extended down to the fascia (connective tissue). Resident 1 underwent a left eyebrow laceration repair in which sutures (stitches) were used to close the laceration. A review of Resident 1's GACH 2's Computer Tomography (an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body) of the head, dated 1/30/2021 indicated a left supraorbital scalp hematoma (over the eye collection of blood). A review of Resident 1's Progress Notes dated 1/30/2021, timed at 4:50 p.m. indicated Resident 1 returned to the facility with swelling of the left hand. Resident 1 was re-admitted to the facility with non-pitting edema (swelling that does not indent when pressure is applied) on the left hand , generalized facial swelling, a swollen left eye with discoloration, scabs (a dry, rough protective crust that forms over a wound during healing) around the left eyebrow, a scab on the left lower cheek and a scab on the right mid-abdominal (stomach) area. A review of Resident 1's Progress Notes dated 2/1/2021, timed at 12:40 p.m. indicated the physician ordered for x-rays of the left hand. A review of Resident 1's x-ray result dated 2/1/2021 indicated fracture of the fourth proximal (close to the palm of the hand) phalanx (small bone of the ring finger). A review of Resident 1's SBAR Communication form dated 2/1/2021, timed at 10:03 p.m. indicated the physician was informed of the Resident 1's ring finger fracture and ordered a splint to Resident 1's left hand. On 2/1/2021, at 2:15 p.m., during an interview, the DON stated Resident 1 had a total of two elopement episodes at the facility. DON states that each time, Resident 1 was able to make it passed the locked doors and outside of the facility. Resident 1's room had an alarmed sliding door that led to the patio. The DON stated that the alarm is triggered when the doors are opened, and the alarm turns off when the doors are closed. When asked why the staff did not respond to the alarm once the sliding door was opened, DON stated Resident 1 must have quickly closed the sliding door to his room to silence the alarm. DON stated that the patio leads to the business office which leads to the lobby and the main entrance/exit door. The DON stated Resident 1 must have quickly closed the sliding door to his room to silence the alarm, and then was able to break the lock of the business office as evidenced by the broken doorknob, and was able to leave through the front door, on both occasions. On 2/1/2021 at 4:15 p.m., during an interview, the Administrator stated he did not know he had to report the elopement episodes since Resident 1 was found within a 24-hour period. When asked if the elopements were unusual occurrences, the Administrator stated, “yes.” On 4/2/2021, at 10:20 a.m., during an interview, the DON stated when Resident 1 opened the sliding door, the alarm was triggered and should have been heard by the staff. The DON stated the alarm probably only rang briefly because Resident 1 was able to close the sliding door right away, but the staff should have provided supervision and checked on the alarm sound, no matter how brief. The DON stated residents are not supposed to be able to elope from the locked facility and the point of the facility being locked is to ensure that wanderers and elopements risks residents are provided with enough supervision to stay safely inside the facility. A review of the facility's policy and procedure titled, "Elopement," revised on 8/1/2016 , indicated the facility will enhance the safety of the residents by identifying the residents at risk for elopement and minimizing any possible injury as a result of elopement. A review of the facility's policy and procedure titled "Elopement," revised on 8/1/16, indicated that in response to resident elopement, the facility will make necessary reports to state agencies. A review of the facility's policy and procedure titled "Unusual Occurrence Reporting," revised on 10/1/17, indicated the facility will follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences. The facility, which is locked, failed to ensure: 1. Resident 1, who was identified as a high risk for elopement and had previously eloped, was provided with the necessary supervision and safe environment to prevent further elopement and injuries per facility’s policy. 2. Resident 1’s elopement, in two separate occasions, was reported to the State Agency (the Department) as unusual occurrence as per facility’ policy. As a result: 1. On 1/29/2021, at 11 p.m., Resident 1 successfully eloped and sustained a fall with injuries. Resident 1 was treated at GACH 1, where the resident was identified with a laceration (deep cut or tear in the skin) near his left eye that required sutures. Upon Resident 1's return to the facility, Resident 1 was noted with swelling and bruising on his left hand and an x-ray result showed a fracture of the fourth finger on his left hand which required a splint. This finger injury was attributed to have occurred during the time he eloped. 2. The Department learned about the two elopements during a complaint investigation. The lack on notification of the unusual occurrence delayed the investigation by the Department and place the resident at risk for further elopement episodes. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 1.