Other·October 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. § 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. The Department received a complaint on 8/10/21 regarding a resident (Resident 1) being observed running from the facility onto incoming traffic with a staff member running behind. On 8/11/21, an unannounced investigation was conducted at the facility. The facility failed to: 1. Ensure Resident 1, who exhibited high elopement (an act of leaving a safe area or safe premises unsupervised and undetected without permission) risk and wandering (aimlessly move about within the building or grounds without appreciation of their personal safety) behavior, was provided with close supervision (an intervention and a means of mitigating accident risk) to prevent elopement. 2. Implement appropriate interventions to closely supervise Resident 1 after being assessed as a high risk for elopement on admission (8/2/2021) and after the first episode of elopement on 8/10/2021 at 5 a.m. to prevent further elopements. 3. Re-assess Resident 1's risk for elopement after the resident eloped from the facility on 8/10/2021 at 5 a.m. and document the outcome of the re-assessment in the resident's medical records. As a result, Resident 1, who was preoccupied with leaving the facility, was not supervised and eloped from the facility twice within three hours (5 a.m. and 8:25 a.m.) on the same day (8/10/2021), left the facility without permission and ran into oncoming traffic on a high traffic street in front of the facility while being chased by the facility's staff, placing Resident 1 at risk for serious injury and/or death. During a review of Resident 1's general acute care hospital (GACH 1), records, prior to the resident's admission to the skilled nursing facility (SNF), dated 8/2/2021, GACH 1 records indicated Resident 1 was alert and oriented, had history of homelessness, alcohol abuse (the habitual misuse of alcohol), and cirrhosis (a late stage of fibrosis [scarring] of the liver caused by excessive alcohol consumption). During a review of Resident 1's Admission Record (Face Sheet), the face sheet indicated the resident, was a 40 year-old male, who was admitted to the facility on 8/2/2021. Resident 1's diagnoses included difficulty in walking, alcohol abuse, metabolic encephalopathy (an alteration of brain function, due to a chemical imbalance in the blood), and a lack of coordination. During a review of Resident 1’s History and Physical (H/P), dated 8/2/21, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 1's Elopement /Wandering Evaluation, dated 8/2/2021, the evaluation indicated Resident 1 was in the high-risk category for elopement. There was no updated evaluation after the resident eloped. During a review of Resident 1's care plans indicated there were no care plans created to address Resident 1's elopement and wandering behavior with preoccupation of leaving the facility until after the resident eloped twice on 8/10/2021 (at 5 a.m. and 8:25 a.m.). During a review of an email, dated 8/10/2021 and timed at 1:49 p.m., a complainant wrote Resident 1 was observed on 8/10/2021 at 8:25 a.m., running into oncoming traffic almost being struck by cars on a high traffic main street located in front of the facility, while being chased by numerous facility's staff members. During a review of Resident 1's late entry (L/E) Change of Condition (COC) evaluation, written by Licensed Vocational Nurse 2 (LVN 2), dated 8/10/2021 and timed at 3:26 p.m., the COC indicated Resident 1 was "exit seeking" on 8/10/2021 (no time specified). The COC indicated there were no changes observed for Resident 1's behavioral evaluation. The COC indicated Resident 1's assigned physician (Physician 1) was notified at 8 a.m. [sic] During a review of Resident 1's L/E Licensed Progress Notes (LPN) written by LVN 2, dated 8/11/2021 and timed at 3:39 p.m., the LPN indicated Resident 1 was observed exiting the facility, at an unspecific date and time, with staff behind him, monitoring him closely for safety. Resident 1 stopped and sat down on sidewalk. The LPN indicated the staff was able to talk Resident 1 into returning inside the facility. Resident 1 verbalized he wanted to go back to the place (school) he previously lived before coming to the facility. During a review of Resident 1's L/E LPN written by LVN 2, dated 8/11/2021 and timed at 3:43 p.m., for Resident 1's elopement that happened on 8/10/2021 indicated an order was received from Physician 1 (on 8/10/2021) to transfer Resident 1 to GACH 2 for a psychiatric evaluation (process of gathering information about a person with a psychiatric [specialist in the treatment of mental illness] service, with a purpose of making a diagnosis) and evaluation for substance abuse (type of substance was not identified). The LPN indicated the physician order was noted, carried out, and Resident 1 was notified of the new order. During an interview on 8/11/2021 at 2:57 p.m., LVN 1 stated he had to chase Resident 1 in the streets (on 8/10/2021 at 8:25 a.m.) because Resident 1 left the facility. LVN 1 stated he overheard the staff yelling Resident 1 was running away from the facility, and he (LVN 1) immediately went outside to help the other staff members chase Resident 1. LVN 1 stated he crossed the main street to get Resident 1, who stopped running, once he crossed the busy street, due to being tired. LVN 1 stated when he reached Resident 1, he was sitting on the street curb. During the interview on 8/11/2021 at 2:57 p.m., LVN 1 stated he asked Resident 1 why he ran away, and Resident 1 stated he did not want to be in the facility anymore. LVN 1 stated he then assisted Resident 1 back to the facility and notified the resident's assigned nurse, LVN 2, about Resident 1 eloping from the facility and wanting to leave the facility. LVN 1 stated he did not personally notify the Administrator (ADM) or the Director of Nursing (DON) of Resident 1's elopement because he notified LVN 2, the assigned nurse. LVN 1 stated he did not physically assess Resident 1 once he was returned to the facility. LVN 1 stated he should have assessed the resident and document in Resident 1's clinical record about the elopement. During an interview with LVN 2 on 8/11/2021 at 3:08 p.m., LVN 2 stated she was informed by LVN 1 that Resident 1 ran away from the facility (on 8/10/2021 at 8:25 a.m.). LVN 2 stated she was busy passing medication when Resident 1 ran away from the facility. LVN 2 stated LVN 1, along with other staff members, brought Resident 1 back to the facility. LVN 2 stated Resident 1 would wander around the facility frequently and stated she (LVN 2) was not monitoring Resident 1 for elopement. LVN 2 stated she did not physically assess Resident 1 after he eloped from the facility because he was fine and took all his morning medications. During the interview with LVN 2 on 8/11/2021 at 3:08 p.m., LVN 2 stated Resident 1 was transferred to GACH 2 on 8/10/2021 (no time specified) for a psychiatric evaluation and evaluation for substance abuse. LVN 2 stated she received an order for Resident 1 to have a psychiatric evaluation because the resident left the facility. LVN 2 acknowledged not documenting Resident 1's assessment after the elopement and documenting the physician order for the transfer to GACH 2. LVN 2 stated she did not document Resident 1's elopement because the resident was fine, but she did notify the ADM and DON. During an interview on 8/11/2021 at 3:46 p.m., LVN 3 stated she was passing the morning medications on 8/10/2021 (time not specified) during the day shift (7 a.m. to 3 p.m.), when she heard the receptionist mentioned Resident 1 ran away from the facility. LVN 3 stated Resident 1 wanders and pace back and forth in the facility's hallways. LVN 3 stated the staff should have closely monitored Resident 1, because he displayed behaviors of trying to leave the facility. LVN 3 stated during the change of shift (on the day shift [7 a.m. -3:30 p.m.]) huddle (communication), the nurses discussed the incident of Resident 1 eloping from the facility on 8/10/2021 and the DON was present. During an interview with the ADM and DON on 8/11/2021 at 5:27 p.m., the DON stated she was aware Resident 1 left the facility (on 8/10/2021 at 5 a.m. and 8:25 a.m.). The DON stated she arrived late for work on 8/10/2021 and was informed about Resident 1 leaving the facility. The DON stated she was informed by the (day shift) staff (not identified) Resident 1 needed fresh air and the DSD took Resident 1 outside, at the front of the facility. The DON stated the DSD had the Admissions Assistant (AA) relieve her while she (the DSD) went to the restroom and AA took over watching Resident 1. The DON stated Resident 1 was at the facility's front entrance outside near the busy street with AA when the resident started running away from the facility while AA called for help. The DON stated Resident 1 was ambulatory (able to walk unassisted), had "exit seeking" behavior and verbalized to the nursing staff on multiple occasions that he wanted to "go home" referring to the grounds of a school where he slept, while he was homeless. During the interview with the ADM and DON on 8/11/2021 at 5:27 p.m., the DON stated the nursing staff did not document or create a care plan of Resident 1's "exit seeking behavior" prior to Resident 1's elopement incidents. The DON stated the nurse (LVN 2) contacted Physician 1 on 8/10/2021 (time not specified) to notify him of Resident 1's "exit seeking" behavior which was considered a change of condition. The physician determined Resident 1 needed to be sent out due to his history of substance abuse and a need for a psychiatric evaluation. During the interview with the ADM and DON on 8/11/2021 at 5:27 p.m., the DON stated LVN 2 did not document Resident 1's elopement on 8/10/2021 and should have documented it at the time she received the order. The DON stated LVN 2 did not document the order for Resident 1's transfer or the details of the elopement because LVN 2 forgot. The DON stated LVN 2 documented Resident 1's transfer order (to GACH 2) more than 24 hours after receiving the physician order and after being interviewed by Surveyor 2 as a L/E. The DON stated it was not the facility's normal practice not to document residents' elopements, physician orders, and/or COCs with transfer details. During a subsequent interview with the ADM on 8/11/2021 at 5:46 p.m., in the presence of the DON, the ADM stated he was aware of Resident 1 leaving the facility on 8/10/2021(at 5 a.m. or 8:25 a.m.), as he arrived for work that morning and the staff were bringing Resident 1 back into the building. The ADM stated he had informal conversations with the staff about Resident 1 leaving the facility. During an interview on 8/13/2021 at 8:42 a.m., Resident 1, who is Spanish speaking only was interviewed and a translator used to interpret, stated he left the facility twice on 8/10/2021 at 5 a.m. and 8:25 a.m. because he did not want to be there. Resident 1 stated on those two occasions he left the facility, a staff member brought him back. Resident 1 stated the last time he left (on 8/10/2021 at 8:25 a.m.) he was sent out to the hospital on the same day because the facility's staff did not want him to try to leave again. Resident 1 stated he told the nursing staff he wanted to go back to where he used to sleep. During an interview with the Activities Director (AD) on 8/13/2021 at 11:19 a.m., the AD stated she arrived for work on 8/10/2021 on the day shift (7 a.m.-3:30 p.m. [no time specified]) and just as she was putting down her belongings, she overheard the AA ask for help and she looked up and saw Resident 1 running from the facility. AD stated she and LVN 1 chased after Resident 1. AD stated Resident 1 ran across the busy street in front of the facility and then the resident sat down on the other side of the street sidewalk after becoming tired. AD stated LVN 1, who was Spanish speaking, spoke with Resident 1 and kept him calm. During an interview with the DSD on 8/13/2021 at 11:25 a.m., the DSD stated Resident 1 wanted to go outside and get fresh air, so on 8/10/2021 (no time specified), she accompanied him to see how he was doing. DSD stated after a few minutes of being outside with Resident 1, she asked AA to relieve her and to stay with Resident 1 outside the facility. DSD stated she was not present to witness Resident 1 run away from the facility. DSD stated she saw staff bringing Resident 1 back to the facility and she notified the ADM and the DON. DSD stated it was the licensed nurses' responsibility to document any unusual occurrence by the end of their shift. During a review of the facility's P/P titled, "Elopement and Unsafe Wandering," dated 6/2018 indicated it was the facility's P/P to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Elopement is when a resident leaves the facility premises or a safe area without authorization and/or necessary supervision to do so. When the resident returns to the facility an assessment of the resident will be completed to determine if medical attention is required and provide interventions as indicated. Document relevant information in the resident's medical record. Notification to the appropriate state agency will be made within twenty-four (24) hours of the serious accident/incident. During a review of the facility's policy and procedure (P/P) titled, "Documentation and Charting," dated 5/2009 indicated it was the facility's P/P to provide documentation pertaining to accidents/incidents involving residents which should include where the accident/ incident took place, the date and time the incident occurred, name of witnesses and their account of the accident/incident, the resident's account of the accident/incident, the time the physician was notified as well as the time the physician responded, the disposition of the resident such as transferred to hospital, and all pertinent observations. The facility failed to: 1. Ensure Resident 1, who exhibited high elopement risk and wandering behavior, was provided with close supervision to prevent elopement. 2. Implement appropriate interventions to closely supervise Resident 1 after being assessed as a high risk for elopement on admission (8/2/2021) and after the first episode of elopement on 8/10/2021 at 5 a.m. to prevent further elopements. 3. Re-assess Resident 1's risk for elopement after the resident eloped from the facility on 8/10/2021 at 5 a.m. and document the outcome of the re-assessment in the resident's medical records. As a result, Resident 1, who was preoccupied with leaving the facility, was not supervised and eloped from the facility twice within three hours (5 a.m. and 8:25 a.m.) on the same day (8/10/2021), left the facility without permission and ran into oncoming traffic on a high traffic street in front of the facility while being chased by the facility's staff, placing Resident 1 at risk for serious injury and/or death. The above violations had a direct or immediate relationship to the health, safety, or security of Resident 1.