Health inspection·October 16, 2024

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. §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. §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. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time limited. (C) Reviewing, evaluating, and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (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 9/9/2024, the California Department of Public Health (CDPH) received a facility reported incident indicating a resident (Resident 1) went absent without leave (AWOL - a resident’s absence from the facility without permission) on 9/8/2024 around 9:30 a.m. and was still missing. On 9/10/2024, the CDPH conducted an unannounced visit at the facility. The facility failed to: 1. Assess Resident 1’s elopement (to leave unnoticed) risk after the resident attempted to elope from the facility on 4/30/2024 and 5/23/2024 and was assessed on the Minimum Data Set (MDS, resident assessment and care-screening tool) as having wandering behaviors (when a person leaves a safe area or caregiver, which can be a risk to their safety, also called elopement), per the care plan. 2. Follow its policy and procedures (P&P) titled “Interdisciplinary Team Conference (IDT, group of different disciplines working together towards a common goal for a resident)” and “Elopement Wandering Resident” by not holding an IDT meeting to ensure the resident’s safety, after Resident 1’s elopement attempts on 4/30/2024 and 5/23/2024. As a result, Resident 1 eloped from the facility on 9/8/2024. Resident 1 was found on 9/20/2024 by law enforcement and taken to a general acute care hospital (GACH) for evaluation. Resident 1, was a 48 year-old male, initially admitted to the facility on 2/21/2024 and readmitted on 9/6/2024 diagnoses including schizoaffective disorder (a mental health condition that was marked by symptoms, such as hallucinations (seeing, hearing, smelling, tasting, or feeling something that appears to be real but doesn't actually exist), delusions (when a person cannot tell what was real from what was imaginary), and mood disorder (a mental health condition that primarily affects the feelings and moods experienced by an individual) symptoms, bipolar type (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), hypertension (high blood pressure), major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), dysphagia (difficulty swallowing), and chronic obstructive pulmonary disease (COPD - a common lung disease that makes it difficult to breathe and worsens over time). A review of Resident 1’s History and Physical (H&P) dated 5/24/2024, indicated Resident 1 was guarded (cautious) and needed assistance with instrumental activities of daily living (IADLs, complex activities that allow an individual to live independently in a community such as managing medications, paying bills, and cooking meals) and was independent with activities of daily living (ADLs, self-care activities performed daily such as dressing, toileting hygiene, and bathing). A review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 8/26/2024, indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1’s ability to make decisions regarding daily life was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 1 was independent with eating and required set-up and clean-up assistance for toileting and personal hygiene. The MDS indicated Resident 1 had behaviors of hallucinations, delusions and wandering that occurred one to three days per week. The MDS indicated Resident 1 did not use wander and/or elopement alarm (an alarm used to help prevent people from leaving a safe area or caregiver, worn on the wrist or ankle) or other alarms. A review of Resident 1's care plan titled, “Wandering,” dated 4/18/2024, indicated Resident 1 was at risk for wandering and injury. The care plan indicated the goal was for Resident 1 to wander safely within appropriate areas and have no falls or injury for three months. The care plan indicated staff were to monitor Resident 1’s whereabouts, assess the resident’s risk for elopement and maintain a safe and hazard free environment. A review of Resident 1’s Situation, Background, Assessment, Recommendation (SBAR – a written communication tool that helps provide essential, concise information, usually during crucial situations), dated 4/30/2024 at 2:30 p.m., indicated on 4/30/2024 Resident 1 had an attempted AWOL. The SBAR indicated Resident 1 was found walking on the street outside of the facility and transported back to the facility. A review of Resident 1’s care plan titled, “Wandering,” revised 4/30/2024, indicated interventions to include increase Gabapentin (medication used to treat for seizures [sudden, uncontrolled burst of electrical activity in the brain], nerve pain, and can also be used to relieve anxiety) 300 milligrams (MG – a unit of measure), Ativan (medication used to treat anxiety) 1 MG every eight hours as needed for 14 days due to agitation (a condition in which a person was unable to relax and be still). The care plan did not indicate any non-pharmacological (a treatment or intervention that does not use medication) interventions to prevent Resident 1’s wandering behaviors. A review of Resident 1’s care plan titled, “Wandering” dated 5/21/2024, indicated Resident 1 was at risk for wandering, actual wandering, a had a history of elopement and exit seeking behavior. The care plan indicated interventions such as monitoring Resident 1’s whereabouts, assess the resident’s risk for elopement, ensure the resident had an identification band, monitor toileting needs, redirecting, cueing as appropriate and maintain a safe and hazard free environment. A review of Resident 1’s SBAR, dated 5/23/2024 at 2 p.m., indicated on 5/23/2024 Resident 1 had an attempted AWOL. The SBAR indicated Resident 1 attempted to leave over the fence of the outside patio and was brought back inside the facility by staff. A review of Resident 1’s care plan titled, “Wandering” revised 5/23/2024, indicated interventions including a psychiatric consult as ordered, as needed and document effectiveness. A review of Resident 1’s care plan titled, “Inappropriate Behavior,” dated 8/31/2024, indicated Resident 1 had acute wandering, related to increased agitation. The care plan indicated Resident 1 will not injure himself or others daily for three months. The care plan interventions included staff will provide a safe, calm quiet environment/approach, establish daily routine based on input of the resident, assist the resident for ability to control behavior and express needs, and refer to a mental health specialist and review medications monthly. A review of Resident 1’s SBAR, dated 8/31/2024 at 3:30 p.m., indicated Resident 1 was exhibiting increased agitation, was sexually inappropriate, delusional, pacing hallways, had exit seeking behaviors (wandering into unfamiliar places to find a way out) and increased risk for elopement. The SBAR indicated Resident 1’s family member (FM 1) and Physician and were notified and the Physician ordered for Resident 1 to be transferred to a general acute care hospital (GACH). A review of Resident 1’s Physician and Telephone Orders dated 8/31/2024 at 3:30 p.m., indicated to transfer Resident 1 to a GACH for psychiatry evaluation. A review of Resident 1’s Licensed Personnel Progress Notes dated 9/6/2024 at 1:25 p.m., indicated Resident 1 was readmitted to the facility from the GACH. A review of Resident 1’s care plan titled, “AWOL,” dated 9/6/2024, indicated Resident 1 would have no episodes of leaving the facility every day for 90 days. The care plan interventions indicated to alert all staff that resident was an AWOL risk, frequent visual checks at least every 2 hours, to assess the resident’s safety and whereabouts, redirect resident when close to the fence, redirect away from the fence, and the yard monitor (staff assigned to observe and frequently check resident’s whereabouts when outside) would closely watch Resident 1 when on the patio. A review of Resident 1’s SBAR dated 9/8/2024 at 9:20 a.m., indicated a Certified Nursing Assistant (CNA 3) reported he was unable to find Resident 1. The SBAR indicated Resident 1 left the facility AWOL. The SBAR indicated staff searched inside and the surrounding areas outside of the facility but was unable to locate Resident 1. The SBAR indicated FM 1 and the police were notified. A review of Resident 1’s Social Services Progress Note, dated 9/9/2024, indicated Resident 1 left the facility AWOL. The progress note indicated Resident 1 broke the window, climbed out and walked out of the back fence. During an observation on 9/10/2024 at 10:31 a.m., Resident 1’s room was observed at the far end of the hallway, away from the nursing station and next to a locked exit door leading to the smoking patio. There were no other residents observed residing in the room. During an interview on 9/10/2024 at 10:47 a.m., the Infection Preventionist (IP) Nurse stated the staff needed to be in-serviced of AWOL risks for Resident 1. The IP stated frequent visual checks and hourly visual checks should have been done for Resident 1. The IP stated that someone must not have been following the protocol which led to Resident 1’s elopement. During an interview on 9/10/2024 at 11:52 a.m., CNA 2 stated about three months ago he (CNA 2) observed Resident 1 outside in the yard, standing by a bush. CNA 2 stated Resident 1 suddenly ran and jumped over the fence. CNA 2 stated the gate of the fence was locked and he called the Director of Staffing Development (DSD) to assist. CNA 2 stated the DSD got in his vehicle to look for Resident 1. CNA 2 stated the DSD found Resident 1 in the surrounding neighborhood and brought the resident back to the facility. CNA 2 stated staff were expected to do frequent visual checks on Resident 1 and know the resident’s whereabouts while in the yard. During an interview on 9/10/2024 at 12:55 p.m., FM 1 stated Resident 1 had a history of AWOL which was why he was placed in a locked facility. During an interview on 9/10/2024 at 2:24 p.m. the Director of Staff Development (DSD) stated Resident 1’s biggest risk was going AWOL. The DSD stated he could not recall the date, but he searched for Resident 1 after he eloped when he was first admitted to the facility. The DSD stated he found Resident 1 and bring him back to the facility in his (DSD) car. The DSD stated Resident 1 came to the facility with a history of exit seeking behaviors. The DSD stated Resident 1 attempted to leave the yard on several occasions and jumped the fence twice (unable to recall the dates). The DSD stated a yellow tape was placed across the area where Resident 1 jumped the fence to prevent him from going over the fence. The DSD stated on 9/8/2024 at approximately 9:20 a.m., Resident 1 broke the window in his room and went out of the window. The DSD stated nobody heard the window break. The DSD stated Resident 1’s window led to an area of the facility that was not used or monitored by staff. The DSD stated Resident 1’s room should have been in an area where the window faced the patio and staff could see when the resident attempted to leave through the window. The DSD stated the trouble with Resident 1 being out was alarming because he cut himself and the facility had not received a call from any of the hospitals indicated the resident was there. During a telephone interview on 9/10/2024 at 3:32 p.m., CNA 3 stated he was assigned to Resident 1 on 9/8/2024. CNA 3 stated Resident 1 received his medications around 7:30 a.m., began walking around the facility. CNA 3 stated Resident 1 went on a smoke break out on the patio at 9 a.m. CNA 3 stated he (CNA 3) went on break, returned at 9:15 a.m. and went to Resident 1’s room. CNA 3 stated he got to Resident 1’s room about 9:18 a.m. and Resident 1 was not there. CNA 3 stated, CNA 5 reported that she had just seen Resident 1 at 9:20 a.m. walking down the hallway. CNA 3 stated Resident 2, who was in the room next to Resident 1’s room, came out of the room and told CNA 3 that he saw blood in the bathroom he shared with Resident 1, at about 9:21 a.m. CNA 3 stated he went to Resident 1’s room and observed small drops of blood on the bathroom floor, bathroom sink and on Resident 1’s bed. CNA 3 stated he ran out of the room to try and locate Resident 1. CNA 3 stated when he could not find Resident 1, he notified the charge nurse and went back to Resident 1’s room. CNA 3 stated when he noticed the broken window. CNA 3 stated he went to his car and searched throughout the neighborhood. CNA 3 stated Resident 1 was nowhere to be found so he returned to the facility. CNA 3 stated when he arrived back to the facility, the police department was there. During a concurrent interview and record review on 9/11/2024 at 9:38 a.m., with the Director of Nursing (DON), Resident 1’s care plans titled, “Wandering” dated 4/8/2024 and 5/21/2024, “Inappropriate Behavior”, dated 8/31/2024 and “AWOL” dated 9/6/2024 and the facility’s Policy and Procedures (P&P) titled “Interdisciplinary Team Conference (IDT), undated, and “Elopement Wandering Resident” undated, were reviewed. The DON stated if a resident eloped and was found, an SBAR or Change of Condition (COC) was supposed to be done on the resident. The DON stated an IDT meeting was only done for residents that eloped and were not found. The DON stated Resident 1’s care plan should have had better interventions to meet the resident’s specific needs. The DON stated the facility was a locked facility, and all residents were considered high risk for elopement, but the elopement and wandering care plans for the Resident 1 did not reflect an individualized care plan for his elopement behaviors. The DON stated the facility did not put residents on 1:1 monitoring (close supervision, to keep the resident within sight at all times to reduce the risk