Health inspection·February 29, 2024

§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. Nursing Service - 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. 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 1/16/2024, the California Department of Public Health made an unannounced visit to the facility to investigate of a complaint and a facility-reported incident about quality-of-care/treatment. The facility failed to maintain an environment free from accident hazards and monitor Resident 1, who was at risk for elopement (resident who leaves the facility without staff noticing) and was wearing a wander guard bracelet (monitoring device that triggers an alarm when the resident gets close to a door), by not preventing Resident 1 from eloping. On 1/13/2024 around 3:15 p.m., Resident 1 was noticed missing from the facility and staff did not hear an alarm going off. As a result, on the same day (1/13/2024) by 5 p.m., Resident 1 was found by the police and paramedics transferred the resident to General Acute Care Hospital 1 (GACH 1), where he was diagnosed with a right rib fracture (broken bone). A review of Resident 1's Admission Record indicated the facility admitted the resident on 12/1/2023 with diagnoses that included muscle weakness, anxiety disorder, dementia (the loss of cognitive functioning to such extent that it interfered with a person's daily life and activities), and history of falling. A review of Resident 1's Internal Medicine Initial Evaluation, dated 11/27/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's Elopement Screening, dated 12/1/2023, indicated the resident had a history of elopement and had exit-seeking behavior or expression of wanting to go home. A review of Resident 1's Morse Fall Risk Screen, dated 12/1/2023, indicated the resident's score was 60. A total score of 45 or more indicated high fall risk. The Gait section of the Morse Fall Risk Screen indicated Resident 1's gait was impaired and Resident 1's steps were short, may shuffle, and the resident was unable to walk without assistance. A review of Resident 1's Physical Therapy (PT) Evaluation and Plan of Treatment, dated 12/2/2023, indicated the treatment diagnoses of muscle weakness. The Functional Assessment, Gait section indicated Resident 1 required total dependence on level surfaces. A review of Resident 1's Care Plan on depressive symptoms, initiated on 12/3/2023, indicated interventions that included to always maintain a safe and secured environment. A review of Resident 1's Physician Orders, dated 12/5/2023, indicated the physician ordered the following: 1. Wander guard placement and monitor for placement every shift; 2. Wander guard battery replacement every seven days; 3. Wander guard placement secured every shift. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/7/2023, indicated the resident's cognitive skills for daily decision making was severely impaired. Resident 1 was dependent on staff in performing activities such as sit to stand, chair to chair transfer, toilet transfer, and picking up objects. Resident 1 used a walker and a wheelchair as mobility devices. The MDS indicated Resident 1 needed supervision or touching assistance with walking. A review of Resident 1's Care Plan on falls, initiated on 12/11/2023, indicated the resident was high risk for falls and injury. The care plan interventions indicated that Resident 1 wore a wander guard. A review of Resident 1's Care Plan on anxiety, initiated on 12/11/2023, indicated the resident was taking anti-anxiety medications that could increase the resident's risk of confusion, loss of balance, and increased risk of falls. The care plan interventions indicated to monitor Resident 1 for safety. A review of Resident 1's Progress Notes, dated 1/13/2024, indicated that the resident was wearing a wander guard on the ankle. The progress notes indicated that Resident 1 continuously requested to go home and constant reassurance from the staff was provided. The progress notes indicated that between 2 p.m. to 3 p.m., Resident 1 was propelling self in the hallways. The progress notes indicated that around 3:15 p.m., Resident 1 could not be found, and the wander guard system did not alarm. Resident 1's family was notified. At 5 p.m., the Police Department informed the facility that Resident 1 was found and was sent to the hospital. A review of Resident 1’s GACH 1 Progress Notes indicated the resident was admitted on 1/13/2024 and discharged on 1/14/2024. The progress notes indicated the diagnoses during GACH 1 visit that included ground-level fall and right rib fracture. A review of Resident 1's GACH 1 General Radiology report, chest x-ray, dated 1/13/2024, indicated acute appearing mildly displaced fracture of the right ninth rib. On 1/16/2024 at 3:15 p.m., during a concurrent observation and interview, the Maintenance Supervisor (MS) stated that the wander guards were checked every week on every door in the facility. The MS stated that he checked all the wander guards and door alarms after Resident 1 eloped and all were in working condition. The MS stated that he checked Resident 1's wander guard after the resident returned from GACH 1 and it was in working condition. Also observed that the facility patio had two gates with exit to the facility's front and side parking lot. The MS stated that the two gates from the patio can only be opened from inside. During an observation, the exit door alarm pad labeled #14 located inside the staff lounge did not alarm but the red emergency alarm box was activated. The MS stated that the red emergency alarm box needed a key to stop the alarm. The MS stated that he did not know there was a wander guard alarm in the staff lounge. Also observed exit door alarm labeled #11 located inside the PT room that had a low volume alarm and the red emergency alarm box did not alarm. The MS stated that the emergency alarm box was turned off. The MS stated that he does not check the exit door alarms in the PT room because the residents do not have access to the room at night. On 1/16/2024 at 3:35 p.m., during a concurrent observation and interview, the exit door inside the dining room did not alarm and did not have the red emergency alarm box. The MS opened the dining room door, went outside to the patio, went back inside, and closed the door then the alarm was activated with a loud sound. The MS stated the wander guard may or may not have worked during the day the resident left the facility. The MS stated that it should alarm to prevent residents from going out unsupervised. On 1/16/2024 at 4:42 p.m., during an observation, the facility's back parking lot had access to the main street. There were few cars passing by on that street. On 1/16/2024 at 5:05 p.m., during an interview, the Administrator (ADM) stated that the monitoring alarm system was shared with the adjacent building. The ADM stated that facility staff should respond to the door that alarmed. The ADM stated that the wander guard alarm could only be turned off at the alarm pad located at the door using a number code. On 1/16/2024 at 7:30 p.m., during an interview with the Director of Nursing (DON) and concurrent review of Resident 1’s care plans and assessments, the DON stated that Resident 1 was assessed for elopement behavior and a wander guard was attached to the resident. The DON stated nursing should have provided Resident 1 with more supervision and more activities to keep Resident 1 engaged to decrease the wandering behavior. The DON also stated that after assessing Resident 1 as at risk for elopement, a care plan was needed to be develop, however, the DON was not able to provide documented evidence that an individualized care plan for Resident 1’s elopement risk was developed with strategies and interventions to maintain Resident 1's safety, as per facility’s policy. The DON stated the facility failed to provide more monitoring for Resident 1 to prevent Resident 1 from leaving the facility. The DON stated that Resident 1 had the potential for accidents on the street, a serious injury, or even death because the resident was not cognitively intact and did not have a stable gait. The DON was unable to provide documentation that the wander guard bracelet battery was changed every seven days. A review of the current facility-provided policy and procedure titled, "Wandering and Elopements," dated 1/26/2023, indicated the facility will identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy indicated that a resident identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the current facility-provided policy and procedure titled, "Elopement," dated 1/26/2023, indicated the purpose to enhance the safety of residents in the facility, to help identify residents who were at risk for elopement, and to minimize possible injury as a result from elopement. The prevention section of the policy indicated the facility shall safeguard exit doors with devices such as audible alarms, if possible, to alarm staff whenever a resident attempt to leave the premises unsupervised. The facility failed to maintain an environment free from accident hazards and monitor Resident 1, who was at risk for elopement and was wearing a wander guard bracelet, by not preventing Resident 1 from eloping. On 1/13/2024 around 3:15 p.m., Resident 1 was noticed missing from the facility and staff did not hear an alarm going off. As a result, on the same day (1/13/2024) by 5 p.m., Resident 1 was found by the police and paramedics transferred the resident to GACH 1, where he was diagnosed with a right rib fracture. 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.