Health inspection·July 2, 2021

§72311, Nursing Services – General (a)Nursing service shall include, but not be limited to, the following: (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. 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. On 9/9/2020, an unannounced visit was conducted at the facility to investigate a complaint about quality of care. The facility failed to provide Resident 1, who was at risk for wandering (going about from place to place) and elopement (an unauthorized absence of an admitted resident from the boundaries of a facility without staff knowledge), with a safe environment and monitoring by: 1. Leaving a ladder unattended and within Resident 1’s reach contrary to the facility's policy on Maintenance and Plant Operations. 2. Having the doorknob and the sliding door in the dining room area easy to be unlocked. 3. Certified Nursing Assistant 1 (CNA 1) not monitoring Resident 1's whereabouts at the beginning and throughout the shift and made rounds every two hours as indicated in the CNA Job Description. 4. Licensed Vocational Nurse 1 (LVN 1) not monitoring Resident 1's whereabouts at the beginning and throughout the shift contrary to the facility's policy on Monitoring Residents. 5. Not implementing the policy on Monitoring Residents as indicated in the plan of care. As a result, on 9/4/2020, during the night shift (11 p.m. to 7 a.m.) before 3:05 a.m. Resident 1 eloped by using the ladder to go to the roof and jumped to the outside of the facility. Resident 1 remained unfound as of 6/1/2021. A review of Resident 1's Admission Record indicated an admission to the facility dated 6/20/2019 with diagnoses including weakness, dysphagia (difficulty swallowing), toxic encephalopathy (alteration of mental status due to medications or toxic chemicals), cognitive communication deficit, (a disorder resulting in difficulty in communicating due to injury to the brain that controls the ability to think), and major depressive disorder (a mental disorder resulting in a prolonged loss of interest in normally enjoyable activities, low mood, low energy and pain without a clear cause). A review of Resident 1's Physician's Order dated 6/20/2019, indicated to admit the resident to the secured facility. A review of Resident 1's Wandering Assessment form dated 6/20/2019 indicated a score of 13, a high risk of wandering (a score of 10 or higher indicated high risk). A Review of Resident 1's Care Plan dated 6/20/2019 indicated Resident 1 was at risk for falls and needed frequent visual monitoring during ADL care and medication rounds and activities. A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 6/25/2019, indicated the resident had severe impaired cognition (mental action of acquiring knowledge and understanding through thought and the senses) and needed supervision with bed mobility, transfers, and walking. A review of Resident 1's Multidisciplinary Progress Record dated 9/4/2020 and timed at 3:05 a.m., documented by Licensed Vocational Nurse 1 (LVN 1), indicated Resident 1 was not found and at 4 a.m., after searching inside and outside the facility and the resident was not found, LVN 1 notified the police department and supervision. On 9/9/2020 at 9:21 a.m., during an interview with Director of Nurses (DON) and concurrent review of the facility's investigation, DON stated the investigation concluded that on 9/4/2020, before 3:05 a.m., Resident 1 dragged a ladder, left by maintenance in the dining room, through another resident's room, and onto the patio (Patio # 1) and with the ladder, the resident was able to gain access to the roof and probably jumped to the ground outside of the facility. DON stated on 9/4/2020, there were torn brushes on one area in the front of the facility, and they believe it was there where the resident jumped from the roof. On 9/9/2020 at 9:46 a.m., during an interview, Maintenance Supervisor (MS) stated that on 9/3/2020, he was making some repairs in the dining room and used a ladder. Since he did not complete the repairs, he left the ladder in the dining room overnight. MS stated the ladder was very heavy to be moved. The MS stated the ladder was normally kept hanging on hooks, on a wall in the back alley. On 9/9/2020 at 10:25 a.m., during an interview, LVN 1 stated, on the night shift starting at 11 p.m., on 9/3/2020 and ending on 9/4/2020 at 9 a.m., he did not making rounds, at the beginning of the shift, to observe all residents and ensure they were all accounted for because the CNAs would report if there was a problem. LVN 1 stated he did not see Resident 1 the entire night. On 9/9/2020 at 10:45 a.m., during an interview, the Director of Staff Development (DSD) stated staff are trained to make rounds at least every two hours but recommended checking on residents every 30 minutes to ensure safety. On 3/5/2021 at 9:20 a.m., during a concurrent observation and interview with the DON, multiple rooms around Patio 1 had sliding doors that could be easily opened by the residents to go to the patio. The sliding doors had a lock but could be easily unlocked from inside the room and from the outside (patio). DON stated if residents opened the doors and got access to the patio, there was no risk of elopement because there is not access to outside the facility, unless climbing over a wall onto the roof. DON stated on 9/4/2020, before 3:05 a.m., Resident 1 possibly went to Patio 1 through any of the rooms with sliding doors, went into the dining room, dragged the ladder, placed it upright on Patio 1, and climbed to the roof. DON stated Resident 1 possibly jumped from the roof at the front of the facility, where there were freshly torn branches. On 3/5/2021 at 10:45 a.m., during an interview with DSD and a concurrent review of the census list for 9/3/2020 and 9/4/2020, DSD stated during the night shift (11 p.m. to 7 a.m.) there are always two LVNs scheduled to work, but on the night of 9/3/2020, one LVN called in sick and no replacement was found. DSD stated the total resident census, per census list on the night 9/4/2020 was 69 residents. On 3/5/2021 at 11 a.m., during an observation of the dining room and concurrent interviews with DON and DSD, the two sliding doors could be easily unlocked from Patio #2. DON and DSD concurred the sliding doors could be unlocked from Patio #2. On 3/5/2021 at 11:40 a.m., during an interview, Administrator stated Resident 1 went missing on 9/4/2020 and had not been found. On 3/5/2021 at 12:20 p.m., during an interview, DON stated on 9/4/2020, they found the ladder in Patio 1. DON also stated that nobody physically saw Resident 1 between the hours of 11:30 p.m. and 3 a.m. A review of facility's undated policy and procedure titled "Maintenance and Plant Operations" indicated that tools should be properly store in the supply room when not in use. It also indicated never leave tools unattended or place them in the path of travel of residents or other staff members. It also indicated to inspect all doorknobs, door handles, and hinges at least monthly. A review of facility's policy and procedures "Certified Nursing Assistant Job Description" dated 8/23/2011, indicated one of the CNA's duties and responsibilities was making actual resident rounds and providing care. A review of facility's undated policy and procedures titled, "Monitoring Residents" indicated residents are monitored in accordance with the plan of care and at a minimum, included in the regular monitoring of charge nurses during endorsements of care to nurses' aides (CNAs). A review of facility's undated policy and procedures titled "Secured Unit" indicated placement in the secured unit will be for the resident's safety and for closer observation by facility staff. The facility failed to provide Resident 1, who was at risk for wandering (going about from place to place) and elopement (an unauthorized absence of an admitted resident from the boundaries of a facility without staff knowledge), with a safe environment and monitoring by: 1. Leaving a ladder unattended and within Resident 1’s reach contrary to the facility's policy on Maintenance and Plant Operations. 2. Having the doorknob and the sliding door in the dining room area easy to be unlocked. 3. Certified Nursing Assistant 1 (CNA 1) not monitoring Resident 1's whereabouts at the beginning and throughout the shift and made rounds every two hours as indicated in the CNA Job Description. 4. Licensed Vocational Nurse 1 (LVN 1) not monitoring Resident 1's whereabouts at the beginning and throughout the shift contrary to the facility's policy on Monitoring Residents. 5. Not implementing the policy on Monitoring Residents as indicated in the plan of care. As a result, on 9/4/2020, during the night shift (11 p.m. to 7 a.m.) before 3:05 a.m. Resident 1 eloped by using the ladder to go to the roof and jumped to the outside of the facility. Resident 1 remained unfound as of 6/1/2021. The above violations jointly or separately had a direct or immediate relationship to the health, safety, or security of Resident 1.