Other·June 27, 2024

CFR §483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices. 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 Nursing Service--General. (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. 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 5/13/2024, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility for an annual recertification survey. On 5/15/2024 at 7:45 a.m., the Administrator (ADM) notified the survey team that Resident 1 eloped (to leave unnoticed and unsupervised) from the facility. The facility failed to: 1. Implement its policy and procedure (P&P) titled, “Wandering and Elopements,” which indicated the facility will identify residents who were at risk of unsafe wandering. As a result, Resident 1 left the facility unsupervised, was at risk for worsening medical conditions, motor vehicle accidents and death, for several hours before he was found by local law enforcement and returned to the facility. A review of Resident 1’s admission record indicated Resident 1 was a 71-year-old male who was admitted to the facility on 4/3/2024, with diagnoses that included dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), type 2 diabetes (abnormal blood sugar), alcohol abuse (any alcohol use that puts your health or safety at risk or causes other alcohol-related problems), polyneuropathy (damage or disease affecting multiple nerves of the body, causing weakness, numbness, and burning pain), hypertension (high blood pressure), dysphagia (difficulty swallowing), unsteadiness on feet, seizures (a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations), and muscle weakness. A review of Resident 1’s History and Physical (H&P) dated 4/5/2024, indicated Resident 1’s capacity to understand and make decisions was not determined. A review of Resident 1’s Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 4/10/2024, indicated Resident 1 had no cognitive impairment (ability to think and reason). The MDS indicated Resident 1 required minimal assistance with eating, oral, and personal hygiene. The MDS indicated Resident 1 used a cane for mobility. During an interview on 5/15/2024 at 7:45 a.m. with the ADM, the ADM stated Resident 1 eloped during the night shift on 5/14/2024. The ADM stated on 5/15/2024 at 4:30 a.m., the charge nurse reported that Resident 1 was missing. The ADM stated that Resident 1 removed the locks and screen from his bedroom window and left through the window. The ADM stated Resident 1 made up his bed to look as if he was sleeping prior to eloping. The ADM stated that the incident was reported to local law enforcement and that the facility was actively searching for the resident. During an observation on 5/15/2024 at 8:38 a.m., in Resident 1’s room, Resident 1’s bed was observed with a rolled-up blanket that was covered by another blanket which appeared as though the resident was sleeping. During an interview on 5/15/2024 at 9:30 a.m., with the ADM, the ADM stated Resident 1 was found by local law enforcement at a nearby bar and was brought back to the facility. The ADM stated that Resident 1 was currently in his bedroom and did not appear to have any injuries. During a concurrent observation and interview on 5/15/2024 at 10:00 a.m., in Resident 1’s room, Resident 1 was observed sitting at the edge of his bed, fully dressed, awake and alert. Resident 1 stated that he left the facility because he was listening to the voices in his head. Resident 1 stated the voices told him to jump from one bed to another and then jump out of the window. Resident 1 stated he made his bed look like a person was lying in it, so the staff would not know what he did. Resident 1 stated he went out of the window so no one could see him leave the facility. Resident 1 stated he was adventurous and did not need to ask permission to leave the facility because he was old enough to do what he wanted. Resident 1 was asked how he managed to open the window. During an interview on 5/15/2024 at 10:28 a.m. with the Social Services Director (SSD), the SSD stated Resident 1 was a newly admitted resident. The SSD stated Resident 1 liked to walk around the facility but never attempted to leave. The SSD stated the elopement incident was a brand-new behavior for Resident 1. During an interview on 5/16/2024 at 7:37 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 5/15/2024 at approximately 4:30 a.m., a Certified Nursing Assistant (CNA) assigned to Resident 1 informed LVN 1 that the window screen was broken in Resident 1’s room. LVN 1 stated did not known Resident 1 wandered or tried to elope. LVN 1 stated CNAs rounded on residents every two hours. LVN 1 stated the CNAs were usually in the hallways to answer call lights and then walk around the facility to conduct their rounds. LVN 1 stated the last time he saw Resident 1 was on 5/15/2024, just before 3 a.m., walking to his room and talking to the CNAs. During a concurrent interview and record review on 5/15/2024 at 10:07 a.m. with Registered Nurse Supervisor (RN) 1, Resident 1’s progress notes and admission assessments were reviewed. RN 1 stated that Resident 1 was admitted on 4/3/2024, but the initial elopement assessment was not done until 5/15/2024 (after Resident 1’s elopement incident). RN 1 stated an initial elopement assessment should be done within 72 hours of admission. RN 1 stated an elopement assessment should have been done prior to 5/15/2024. RN 1 stated it was the responsibility of the admitting licensed nurse to complete the elopement assessment. RN 1 stated if the licensed nurse was unable to complete the assessment, then the elopement assessment should be endorsed to the next shift for completion. RN 1 stated if staff did not assess a resident for elopement, the resident could not be monitored as a high risk for elopement. RN 1 also stated if the resident was not assessed, the resident could elope and have an accident outside of the facility. During a concurrent interview and record review on 5/16/2024 at 10:26 a.m. with the Case Manager (CM), the facility P&P titled “Wandering and Elopements,” revised March 2019, was reviewed. The CM stated upon admission an elopement assessment should be done for all residents, within 72 hours of admission. The CM stated the elopement assessment was done to see if residents were at high or low risk for elopement. The CM stated even though Resident 1 had no behaviors that indicated he wanted to elope, an elopement assessment should have been done. The CM stated if staff did not know the elopement risk of a resident, staff would not know if the resident was at risk for elopement. The CM stated that the facility should follow the guidelines regarding their elopement policy. During an interview on 5/15/2024 at 1:03 a.m., with the ADM, the ADM stated it was the nurse’s job to look for behaviors to determine if residents were an elopement risk. The ADM stated the facility should have followed the facility’s P&P and should have performed an elopement assessment for all residents upon admission. A review of the facility’s P&P titled, “Wandering and Elopements,” revised March 2019, indicated, the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for the resident. The P&P indicated that if a resident is 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. The facility failed to: 1. Implement its P&P titled, “Wandering and Elopements,” which indicated the facility will identify residents who were at risk of unsafe wandering. On 5/15/2024 at 7:45 a.m., the ADM notified the survey team that Resident 1 eloped from the facility. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.