Other·January 24, 2020

California Department of Public Health CA940000046 12/27/2019 PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 PREFIX TAG B000 Initial Comments ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE B000 The following reflects the findings of the Department of Public Health of a Complaint investigation during an Abbreviated Standard Survey. Complaint number: CA00652673 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 37393, RN The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. One deficiency was issued for CA00652673 B4835 T22 DIV5 CH3 ART5-72541 Unusual Occurrences B4835 Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local Licensing and Certification Division STATE FORM 6899 0E0G11 California Department of Public Health CA940000046 12/27/2019 PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE fire authority or in areas not having an organized fire service, to the State Fire Marshal. This Statute is not met as evidenced by: Based on interview and record review the facility failed to implement its policy and procedure for reporting unusual occurrences, which included an elopement (to leave unnoticed by staff)of a resident, to the Department of Public Health (DPH) immediately after the discovery of the incident or within 24 hours for one of three sampled residents (Resident 1). This deficient practice had the potential to jeopardize Resident 1's and other residents' safety within the facility. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on 2/22/19. Resident 1's diagnosis included encephalopathy (disease of the brain that alters brain function or structure), difficulty walking, and hypertension (high blood pressure). A review of Resident 1's admission Minimum Data Set (MDS), a resident assessment and care-screening tool, dated, 3/6/19, indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and understand others. The MDS indicated Resident 1 was assessed as being independent with bed mobility, transferring, locomotion on and off the unit; however required an extensive assistance with dressing and toilet use and limited assistance with personal hygiene. A review of Resident 1's Wander Risk Scale, Licensing and Certification Division STATE FORM 6899 0E0G11 California Department of Public Health CA940000046 12/27/2019 PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE dated 2/22/19 and timed at 7:47 p.m., indicated a score of 15. According to the risk assessment a total score of 11 or greater the resident is considered to be at high risk for wandering. A review of Resident 1's physician's order, dated 3/4/19, indicated for a wander guard to remind patient (Resident 1) not to leave facility unassisted, consent obtained, monitor every shift. A review of Resident 1's care plan titled, "Episode of Unsafe Wandering," initiated on 3/4/19, identified Resident 1 had a problem with wandering. The goal indicated Resident 1 would wear wander guard to remind the resident not to leave the facility unassisted. The staff interventions included to monitor, document pattern and frequency of wandering behavior and notify physician a needed. A review of Resident 1's Licensed Nurses Progress note, dated 3/5/19 and timed at 2:35 p.m., indicated to continue to monitor Resident 1 for wandering. Wander-guard in place and active, pad with tab alarm in place to help remind resident to stay safe in the building. A review of Resident 1's Licensed Nurses Progress note, dated 5/17/19 and timed at 20:30 p.m. (8:30 p.m.), indicated, "Received patient (Resident 1) back to the facility, head to toe assessment done, no noted injury, no bruises or skin tears. Can move all extremities freely with no complaints of pain. Physician notified by the charge nurse. Visual check of Resident 1 every 30 minutes." A review of Resident 1's Interdisciplinary ([IDT] group of different disciplines working together toward a common goal for a resident) Meeting Note, dated 5/23/19 and timed at 1:55 p.m., indicated there was an IDT meeting held regarding Resident 1's incident of leaving the Licensing and Certification Division STATE FORM 6899 0E0G11 California Department of Public Health CA940000046 12/27/2019 PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE facility on 5/17/19, for a couple of hours and was accompanied back to the facility by a Law Enforcement Officer. According to the IDT meeting note, Resident 1 was very alert and oriented, but may appear confused because he speaks broken English. The IDT meeting note indicated Resident 1 placed his wheelchair in a bush, removed his tab alarm and he left to ride a bus to go to the Social Security office to straighten out his finances. The IDT meeting note indicated Resident 1 exited through the window of another resident room out of the facility. On 9/4/19 at 7:49 p.m. during an interview, Registered Nurse 1 (RN 1) stated the wander guard system sometimes does not work. RN 1 stated Resident 1 eloped from the facility and was brought back to the facility by the Police Department. RN 1 acknowledged the responsibility of the staff to monitor Resident 1 for elopement because he tried to leave the facility in the past. On 9/4/19 at 8:17 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 left the facility to go to the Social security office through a window and not the rear door of the facility. The DON stated Resident 1 was safely returned to the facility by the Police Department. According to the DON the elopement was not reported because Resident 1 was physically assessed did not receive any injuries and was alert and oriented. The DON acknowledged he and the facility Administrator (ADM) were notified by the staff of Resident 1's elopement. On 9/6/19 at 10:58 a.m., during a telephone interview, the Administrator (ADM) stated he was informed of Resident 1's elopement. The ADM stated he spoke with the facility's Consultant who deemed the elopement of Resident 1 a non-reportable incident. The ADM acknowledged DPH was not notified of Licensing and Certification Division STATE FORM 6899 0E0G11 California Department of Public Health CA940000046 12/27/2019 PACIFIC PALMS HEALTHCARE 1020 Termino Ave Long Beach, CA 90804 PREFIX TAG ID PREFIX TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE Resident 1's elopement from the facility. On 10/17/19 at 9:07 a.m., during a telephone interview, the ADM acknowledged the elopement of Resident 1 and that it was not reported to DPH. A review of the facility's "Elopement Procedures Checklist" indicated under the notification for the staff to report as an unusual occurrence to the executive director in accordance with state and federal regulations within 24 hours to DPH. A review of the facility's policy titled, "Wandering, Unsafe Resident," indicated the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. A review of the facility's undated policy titled, "Unusual Occurrences," indicated as required by federal or state regulations, the facility reports unusual occurrences or other reportable events which affect the health, safety or welfare of the residents, employees, or visitors. The policy indicated a written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency within 48 hours of reporting the event as required by federal and state regulations Licensing and Certification Division STATE FORM 6899 0E0G11