Other·May 5, 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 facility reported incident (FRI) on 12/28/2020 indicating a resident (Resident 1) eloped (to leave unnoticed) from the facility. On 12/29/2020, an unannounced investigation was conducted at the facility. The facility failed to: 1. Provide adequate supervision to Resident 1. 2. Implement the facility’s policy and procedure titled, “Residents Safety Monitoring,” which indicated staff were to have visual observation of the resident. As a result, Resident 1, who was identified as an elopement risk, eloped on 12/24/2021 and was homeless under the influence of drugs for 30 days, and later admitted to a general acute care hospital (GACH) and placed on a 5150 (involuntary 72-hour hold/ stay for psychiatric evaluation) hold. During a review of Resident 1's Admission Record indicated Resident 1, was a 33 year-old male, who was initially admitted to the facility on 10/5/2021, and last readmitted on 1/25/2021 with diagnoses that included schizoaffective disorder (a mental health disorder characterized by altered sense of reality in thought and beliefs, and mood swings of feeling extremely happy and sad), alcohol abuse, homelessness, cannabis use (a common street and recreational drug that comes from the marijuana plant) and other stimulant (chemical or substance that affects one’s behavior, mind, and body) dependence. During a review of Resident 1's care plan titled, “At risk for AWOL (absence without leave) related to schizoaffective disorder, initiated on 10/14/2020, the care plan indicated the goal was to minimize Resident’1s risk for AWOL daily for 90 days. The staff’s interventions included to assess for elopement upon admission, quarterly, and PRN (as needed) using an elopement assessment tool, and proceed with AWOL policy and procedure should AWOL occur. During a review of Resident 1’s GACH records, dated 1/23/2021, the records indicated Resident 1 informed staff at the hospital he was homeless and a substance abuse user. The records indicated Resident 1 was admitted to the GACH and placed on a 5150 hold. During a review of the facility’s final investigation report, dated 12/24/2020 through 12/30/2021, the investigation report indicated Resident 1’s whereabouts could not be identified during safety rounds at approximately 7 p.m. on 12/24/2021. The report indicated the facility activated code “Dr. Search” and an immediate search of the premises and outer perimeter of the facility was conducted to no avail. The report indicated the facility activated the Reddinet emergency alert system (a web based medical communication system that facilitates information exchange among hospitals, EMS, paramedics, law enforcement and other healthcare system professionals to alert or notify incident) to communicate the resident’s missing person status. During a concurrent observation and interview with the Director of Nursing (DON) on 12/29/2020 at 2:16 p.m., the DON stated the video surveillance monitoring was accessed and monitored by the administrator. Visual monitors were observed on each station showing all areas of the facility including hallways and patios. During an interview with the Director of Staff Development (DSD) on 12/29/2020 at 3:34 p.m., the DSD stated there were missing monitoring logs for the south-back patio on 12/23/2020. During an interview with Certified Nurse Assistant 1 (CNA 1) on 12/29/2020 at 4:30 p.m., CNA 1 stated Resident 1 was in the patio on the day he eloped and all the doors were locked. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 12/29/2020 at 4:35 p.m., LVN 1 stated Resident 1 went through the ceiling in the patio. During an interview with Registered Nurse 1 (RN 1) on 12/29/2020 at 4:39 p.m., RN 1 stated all residents were monitored for safety and staff should always know where their assigned residents were and if they were safe. During an interview and concurrent review of the facility’s surveillance video footage with the Administrator (ADM) on 12/29/2020 at 5:05 p.m. the ADM stated, “Resident 1 used a table in the patio to climb up, pushed the fence on the ceiling and eloped.” During an interview with the Program Manager/Director (PM) on 2/18/2021 at 10:50 a.m., the PM stated Resident 1 was on “line of sight” monitoring. The PM stated Resident 1 pushed the metal fence in the patio and got away. The PM stated staff should be monitoring all residents when they are in the patio. During an observation and concurrent interview with Resident 1, on 2/18/2021 at 1:10 p.m., Resident 1 was observed standing in front of his room. Resident 1 stated, "I was not happy staying in the room for almost two months because of the COVID-19 (a highly contagious respiratory disease caused by a virus) situation, so I just left.” During an interview on 2/18/2021 at 1:30 p.m. with LVN 2, LVN 2 stated when a resident was at high risk for elopement, they needed close supervision. During a review of the facility's policy and procedure (P/P) titled, “Residents Safety Monitoring,” the P/P indicated the facility closely monitors the status of residents who are at risk for unsafe behavior, to observe for a significant change in their behavior or their physical or mental condition. The P/P indicated direct care staff shall be assigned by the Licensed Nurse to do safety check rounds every fifteen minutes for safety. The policy indicated safety checks would be conducted every fifteen minutes and documented by the person conducting rounds, and at the end of the twenty four hour period the rounds sheet would be placed in the rounds binder daily. The facility failed to: 1. Provide adequate supervision to Resident 1. 2. Implement the facility’s policy and procedure titled, “Residents Safety Monitoring,” which indicated staff were to have visual observation of the resident. As a result, Resident 1, who was identified at risk for elopement, eloped on 12/24/2021 and was homeless under the influence of drugs for 30 days, and later admitted to a general acute care hospital (GACH) and placed on a 5150 (involuntary 72-hour hold/ stay for psychiatric evaluation) hold. The above violation had a direct relationship to the health, safety, or security of Resident 1.