Health inspection·November 30, 2022

F656 § 483.21(b) Comprehensive Care Plans (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. § 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 10/10/2022, the Department of Public Health (Department) received a facility reported incident (FRI) indicating a resident (Resident 1) left the facility without any staff members. The FRI indicated at approximately 6:30 p.m., on 10/10/2022, a nurse heard the door alarm in the front lobby. The nurses checked all sides of the building but did not see anyone. The nurses did a resident head count and found that Resident 1 was missing. A search team was formed and searched a square mile block. On 10/13/2022, the Department conducted an unannounced visit at the facility to investigate. The facility failed to: 1. Supervise and prevent the elopement (when a resident who is not capable of protecting or caring for themselves leaves the facility without authorization) for Resident 1 who was cognitively impaired (decreased ability to think and reason), had displayed behaviors of wandering (walking around aimlessly without a fixed plan), and had previously attempted to elope on 10/2/2022. 2. Develop and implement a resident-centered care plan and ensure Resident 1 had a detailed monitoring plan to address the resident’s wandering and a prior elopement attempt. As a result, on 10/10/2022, the facility’s staff conducted a count for all residents when the facility’s security alarm sounded, and Resident 1 was identified as missing from the facility. Resident 1 eloped from the facility on 10/10/2022 at approximately 6:30 p.m. which placed Resident 1 at high risk for exposure to harsh environmental conditions including excessive heat during the day or cold during the night, at risk for being hit by a car, and at risk for medical complications including malnutrition (lack of proper nutrients [molecules in food that are needed for growth and energy]), dehydration (not enough water in the body), stroke (blockage of blood to the brain), heat stroke (body is overheating) and possible death. Resident 1 was found on 10/26/2022 at approximately 2:30 p.m., sixteen days later, by the facility’s Physical Therapist Assistant (PTA) 1. According to PTA 1, Resident 1 was located on a sidewalk, 11 miles away from the facility with blood on his shirt and pants due to the resident’s stoma having no colostomy bag pouch. Resident 1 was then transferred to a general acute care hospital (GACH) for evaluation via 911 where he was diagnosed with acute behavioral disorder and acute kidney injury related to dehydration.During a review of Resident 1’s Admission Record, the admission record indicated Resident 1, was a 64-year-old male, who was admitted to the facility on 3/13/2022. Resident 1’s diagnoses included schizophrenia (serious mental disorder in which people interpret reality abnormally that impairs daily functioning), type 2 diabetes (body does not regulate glucose [sugar] properly), essential hypertension (high blood pressure), attention to colostomy (surgical opening of the colon [stoma] through the abdomen the opening has a pouch to collect stools), and cataract (a condition in which the lens of the eye becomes cloudy making it difficult to see). During a review of Resident 1’s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/16/2022, the MDS indicated Resident 1’s cognition was severely impaired. The MDS indicated Resident 1 required supervision with eating, bed mobility, transfer, and required one person assistance for dressing, toilet use, and personal hygiene. During a review of Resident 1's Admission and Data Tool, Elopement Risk Assessment, dated 3/14/2022, the tool indicated Resident 1 was at risk for elopement. The tool indicated “Resident 1 paced, wandered, tried to leave through the door, and to find family or friend.” The tool indicated Resident 1 was independent and mobile. During a record review of Resident 1's care plan titled, “Using psychotropic (drugs that affect mental state) medication chlorpromazine and olanzapine (medications for schizophrenia),” initiated on 3/14/2022, the care plan indicated to monitor and record occurrences of target behavior symptoms and specify if pacing or wandering. During a review of Resident 1's medical records and care plans, the care plans indicated there was no documented evidence a plan of care for elopement was initiated on 3/14/2022, after Resident 1 was noted to have high risk behavior for elopement as identified on the elopement risk assessment tool completed upon admission (Dated 3/14/22). During a review of Nurses Progress Note dated 8/23/2022 at 6:31 p.m., the note indicated Resident 1 was paranoid (characterized by suspiciousness) throughout the day and was noted with rapid audible tangential (a person constantly digresses to random, irrelevant ideas and topics) speech thinking that his medications were “rat poison.” The note indicated Resident 1 was “wandering in and out” from the smoking patio telling passersby that he "likes the poison." The note indicated staff stated this was Resident 1's normal behavior. During a review of Resident 1's medical records and care plans, the care plans indicated there was no documented evidence that a plan of care for elopement was initiated on 8/23/2022 after Resident 1 was noted to be independently mobile and wandering in and out of the patio with behaviors indicative of a risk for elopement. During a review of Resident 1’s “Los Angeles County Superior Court Conservatorship Re-evaluation Physician’s Declaration” (when a court appoints someone to manage financial and personal affairs) document, executed on 8/2/2022 and signed by two (2) physicians, the document indicated Resident 1 was evaluated on 7/19/2022 and diagnosed with schizoaffective (a combination of symptoms of schizophrenia and mood disorder), bipolar type (mental disorder). The document indicated the following for Resident 1: 1. Presents with a history of delusional (distorted reality) thoughts agitation, disorganized thoughts, mood swings.” 2. “Poor decision making, and lack of appropriate judgement place him at risk for not meeting his basic needs." 3. Displays a history of challenges with compliance with declining medications or hygienic needs. 4. Does not have the capacity of knowingly and intelligently accepting or refusing prescribed medication. 5. Does not have the capacity to complete an affidavit of voter registration and vote. 6. Does not have the privilege of possessing a license to operate a motor vehicle. 7. Possession of a firearm or other deadly weapon by the resident presents a danger to his/her safety or to another person. During a review of Resident 1's Change of Condition Evaluation dated 10/2/2022 at 5:09 p.m., the evaluation indicated the "resident (Resident 1) attempted to leave the facility, open up the door and stood there." During a review of Resident 1's Nurses Progress Note dated 10/2/2022 at 5:34 p.m., the note indicated Resident 1 was alert and oriented to self, mostly sat in the lobby throughout the shift and was "back and forth to the patio." The note indicated Resident 1 attempted to leave the facility and when asked by staff “why”, the resident made a “nonsense remark." During a review of Resident 1's Elopement Risk Evaluation dated 10/3/2022 at 11:07 a.m., the elopement risk evaluation indicated Resident 1 was not identified as at risk for elopement. There was no documented evidence a plan of care for elopement was initiated after Resident 1’s elopement attempt on 10/2/2022. During a review of Resident 1's medical records, there was no documented evidence an elopement care plan was initiated addressing the resident's post elopement attempt on 10/2/2022. During a review of Resident 1's Progress Notes dated from 10/5/2022 to 10/10/2022, the progress notes indicated there was no documented evidence Resident 1 was being monitored by staff for elopement and wandering behaviors. During a review of Resident 1's Nurses Progress Note dated 10/10/2022 at 6:31 p.m., the note indicated Resident 1 was observed with some confusion. The note indicated at 5:50 p.m. on 10/10/2022, the front door alarm was heard, and no residents were visualized in the lobby or outside. The note indicated a resident head count was completed and Resident 1 was identified as missing During a review of Resident 1's physician’s orders dated 10/10/2022, the orders indicated Resident 1 was receiving the following medications: 1. Atorvastatin (medication used to decrease lipids [fats] in the blood]) 20 milligrams ([mg] unit of measurement) one tablet by mouth at bedtime for antihyperlipidemic (to decrease lipids [fats] in the blood). 2. Benztropine Mesylate (medication used to treat psychosis [severe mental disorder when people loose contact with reality]) 0.5 mg one tablet by mouth two times a day. 3. Chlorpromazine tablet (medication used to treat schizophrenia (schizophrenia (serious mental disorder in which people interpret reality abnormally that impairs daily functioning) manifested by auditory/visual hallucinations [apparent perception of something not present]) 100 mg one tablet by mouth two times a day. 4. Glimepiride tablet (medication used to treat diabetes) 2 mg one (1) tablet by mouth two (2) times a day. 5. Levothyroxine Sodium Tablet (medication used to treat hypothyroidism [when body does not have enough thyroid hormones [hormones that control the way body converts food to energy]) 50 micrograms ([mcg] unit of measurement) one (1) tablet by mouth in the morning. 6. Lithium Carbonate Capsule (for behavior management for restlessness and agitation) 300 mg one capsule by mouth two (2) times a day. 7. Metformin (medication used to manage diabetes) 500 mg one (1) tablet by mouth three times a day. 8. Olanzapine Tablet (medication used to treat schizophrenia manifested by agitation and striking staff) 20 mg one tablet by mouth one (1) time a day. During a concurrent observation and interview with Certified Nurse Assistant (CNA) 1 on 10/13/2022 at 7:16 p.m., during an observation the alarm system in the front lobby was triggered but shut off within five (5) seconds. There were no staff observed in the lobby and adjacent nursing station, the emergency medical services (EMS) personnel and three residents seated on their wheelchairs were observed in the front lobby. At 7:24 p.m. (8 minutes later), CNA 1 entered the lobby area and checked on the residents. CNA 1 stated she did not hear the alarm because she was in a resident room (four rooms down from the lobby and nursing station). CNA 1 stated the staff assignment did not indicate to monitor the lobby area. During an interview with Licensed Vocational Nurse (LVN) 1 on 10/13/ 2022 at 7:30 p.m., LVN 1 stated Resident 1 was last seen on 10/10/2022 at approximately 5:30 p.m. eating dinner in his room. LVN 1 stated from 5:50 p.m. to 6 p.m., she heard the front lobby alarm and immediately went to the front door but did not see anyone inside or outside the facility in close proximity. LVN 1 stated a headcount was completed and at 6 p.m., Resident 1 was identified as missing. According to LVN 1, the Director of Nursing (DON) was notified, and search parties were formed. LVN 1 stated when staff were unable to locate Resident 1, the police was notified, and a missing person report was filed. During a concurrent interview and record review on 10/13/2022 at 8:43 p.m. with LVN 2, Resident 1's Nurses Progress Notes dated 10/2/2022 at 5:34 p.m. was reviewed. LVN 2 stated on 10/2/2022 at 5:34 p.m., Resident 1 was confused and was pacing to and from the patio and lobby. LVN 2 stated Resident 1 then walked briskly towards the door with an intention to exit but LVN 2 stopped the resident. LVN 2 stated an elopement care plan was not created. During a review of Resident 1's Nurses Progress Note dated 10/2/2022 at 5:34 p.m., the note indicated Resident 1 was alert and oriented to self and the resident mostly sat in the lobby throughout the shift and walked "back and forth to the patio." The note indicated Resident 2 attempted to leave the facility and when asked why Resident 1 was trying to leave, the resident made a “nonsense remark." During an interview with the Social Services Assistant (SSA) on 10/14/2022 at 9:44 a.m., the SSA stated the front lobby coverage was seven days a week from 8:30 a.m. until 5 p.m. or 6 p.m. (varies). The SSA stated from 5 p.m. to 8:30 a.m., no one was assigned to monitor the front lobby. During a review of the facility's Front desk Coverage October schedule (handwritten by SSA), the schedule indicated there was no coverage for the lobby after 5:00 p.m. and sometimes 6:00 p.m. until 8:30 a.m. daily. During a review of facility's Staffing Sheet dated 10/10/2022 and 10/13/2022, the sheet indicated there was no specific staff assigned to the front lobby. The assignment sheet did not indicate front lobby monitoring as part of staff duties. During an interview with CNA 2 on 10/14/2022 at 10:35 a.m., CNA 2 stated she was assigned to Resident 1’s care. CNA 2 stated Resident 1 was usually in the lobby or walking around without an assistive device, talking to himself, and “in his own world.” CNA 2 stated Resident 1 could not carry a conversation and he was unable to take care of himself. During a concurrent interview and medical record review of the Elopement Risk Assessments dated 3/14/2022, 10/2/2022 and 10/11/2022, with the MDS Nurse (MDSN) on 10/14/2022 at 11 a.m., the MDSN verified Resident 1 was mostly confused, conserved, and was unable to take care of himself. The MDSN stated Resident 1’s behavior on 10/2/2022 should have been addressed with a care plan and a continuous detailed monitoring plan. The MDSN verified Resident 1’s Elopement Risk Assessments completed on 3/14/2022, and 10/3/2022, were incorrect because it should have identified Resident 1 as at risk for elopement based on the criteria indicated on the elopement tool. During a concurrent interview and record review with the DON on 10/14/2022 at 12:45 p.m., Los Angeles County Superior Court conservatorship dated 8/2/22, indicated Resident 1 was under conservatorship and had a mental disorder and was not able to care for himself. The DON stated Resident 1 was only monitored for three (3) days (from 10/2/2022 to 10/4/2022) after his elopement attempt on 10/2/2022. The DON stated Resident 1’s care plan should have addressed the resident’s elopement risk with a detailed plan to prevent elopement from the facility. The DON stated Resident 1's Elopement Evaluation Risk Tool dated 10/2/2022 and 10/13/2022 should have indicated Resident 1 was high risk for elopement because of the resident’s attempt to leave the facility and/or because Resident 1 displayed wandering behavior in the facility. Resident 1 was found on 10/26/2022 at approximately 2:30 p.m., sixteen days later, by the facility’s PTA 1. According to PTA 1, Resident 1 was located on a sidewalk, 11 miles away from the facility with blood on his shirt and pants due to the resident’s stoma having no colostomy bag pouch. Resident 1 was then transferred to a GACH for evaluation via 911 where he was diagnosed with acute behavioral disorder and acute kidney injury related to dehydration. During a record rev