Other·December 28, 2022

42 CFR § 483.25(d) Accidents. The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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. 42 CFR § 483.21(b) Comprehensive Care Plans (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. On 3/14/2022, the California Department of Public Health (CDPH) received a facility reported incident (FRI) regarding a resident (Resident A) missing from the facility. On 3/16/2022 at 2:50 p.m., CDPH made an unannounced visit to the facility to investigate the FRI. During the investigation it was determined Resident A, who was diagnosed with dementia (a brain disease marked by memory disorders, personality changes and impaired reasoning) and had a heart pacemaker (a device that generates electrical impulses to the heart to contract), eloped (leaving unnoticed without permission) from the facility on 3/14/2022 at 8:29 p.m. On 3/15/2022, the day after Resident A eloped from the facility, Resident A was found unresponsive in a parking lot approximately 12 miles away from the facility and was transported to a general acute care hospital (GACH) for evaluation, care, and treatment due to the result of a drug overdose. The facility failed to: 1. Ensure Resident A, who was confused, was adequately supervised to prevent the resident from leaving the facility unsupervised. 2. Develop a plan of care with interventions to address Resident A’s need to be closely supervised due to dementia with confusion. 3. Ensure a system was in place to alert staff when the facility’s front door was opened to ensure residents did not leave the facility unnoticed. As a result, Resident A, who was ambulatory, eloped from the facility and was found unresponsive requiring treatment at a GACH for a drug overdose. This deficient practice put Resident A at risk for complications due to missing his insulin and hypertension medications, as well as at risk of Resident A being exposed to environmental conditions, including excessive heat or cold, harm, and could have led to death. During a review of Resident A’s Admission Records (face sheet), the face sheet indicated Resident A, a 82 year-old male, was originally admitted to the facility on 12/10/2020 and last readmitted on 5/27/2021 with diagnoses that included diabetes mellitus (DM, a chronic condition associated with abnormally high levels of sugar in the blood), encephalopathy (brain disease, damage, or malfunction), hypertension (HTN, high blood pressure, a condition in which the force of the blood against the artery walls are high), glaucoma (a group of eye conditions that damage the nerve in the eye often leading to blindness), hearing loss, anxiety disorder (extreme worry or fear), and dementia. The face sheet indicated Resident A’s primary decision maker was a family member. During a review of Resident A’s history and physical (H/P), dated 5/27/2021, the H/P indicated Resident A could make his needs known but could not make medical decisions. During a review of Resident A’s Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/7/2022, the MDS indicated Resident A’s cognitive skills (thought process) for daily decision-making were moderately impaired. According to the MDS, Resident A required an extensive one-person physical assistance to complete his activities of daily living (ADLs, tasks such as eating, bathing, dressing, grooming and toileting) and was occasionally incontinent (involuntary voiding of urine and stool) of bowel and bladder functions. During a review of Resident A’s Physician’s Orders, dated 5/27/2021, the Physician’s Order indicated Resident A did not have the capacity to understand and actively participate in decision making. The physician orders indicated Resident A’s medications included the following: 1. Regular Insulin 2 to 8 units (an indication of measurement [dose] for insulin [a medications that lowers blood sugar]) on a sliding scale (Insulin dose varies based on the resident’s blood glucose level) for diabetes mellitus to cover elevated glucose levels twice a day (glucose levels ranging from 96-141 for the month of 3/2022). 2. Metoprolol 25 milligram ([mg] unit of measurement) every 12 hours for hypertension. 3. Norvasc 5 mg every day for hypertension. During a record review of Resident A’s Medication Administration Record (MAR), dated 3/14/2022 and timed at 9 p.m., until 3/15/2022, (the 24 hours the resident went missing from the facility) Resident A did not receive any of the above ordered medications to control his blood pressure and blood sugar levels. During a review of the facility’s Investigation/Accident Known/Unknown Origin Form, dated 3/14/2022, the form indicated at 9 p.m., on 3/14/2022, Resident A was not in his bed. According to the Investigation Form, the facility’s staff searched inside and outside of the facility for Resident A, which included the staff driving around the vicinity of the facility and contacting local hospitals, but did not find Resident A. During a review of the GACH’s Emergency Department (ED) note, dated 3/15/2022 and timed at 5:06 p.m., the ED notes indicated Resident A presented for evaluation of a suspected drug overdose. Per emergency medical services (ambulance or paramedic services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries), Resident A was found unresponsive in a parking lot and was given Narcan (a medicine that rapidly reverses the effects of an opioid [a substance used to treat moderate to severe pain] overdose in an emergency) prior to arrival to the ED. During a review of Resident A’s GACH laboratory results obtained on 3/15/2022 at 8:39 p.m., the laboratory results indicated Resident A tested positive for opiates in his urine. According to the ED note, Resident A was discharged to another skilled nursing facility on 3/16/2022. During a review of Resident A’s care plans (CPs), there was no indication a plan of care was in place with interventions to address Resident A’s diagnosis of dementia with confusion and forgetfulness, and to ensure Resident A was kept safe and supervised. During an interview on 3/16/2022 at 3 p.m., the Director of Nursing (DON) stated Resident A was alert and oriented to his name, place, and time, but had episodes of forgetfulness due to dementia. The DON stated Resident A could make his needs known but could not make medical decisions. The DON confirmed there was no plan of care developed to address the resident’s dementia with interventions to ensure the resident remained safe and stated there should have been one created. During an interview on 3/16/2022 at 3:14 p.m., the Administrator (ADM) stated on 3/14/2022 at approximately 9 p.m., a certified nursing assistant (CNA 1) was assisting another resident and once she finished with that resident, she went to Resident A’s room but did not find him there. The ADM stated it was reported that Resident A was last seen at the nursing station socializing with other residents at approximately 8 p.m. on 3/14/2022. The ADM stated CNA 1 looked around the facility and when she could not find Resident A she reported it to the charge nurse, Licensed Vocational Nurse 2 (LVN 2). The ADM stated they reviewed the facility’s camera footage and saw Resident A leave the facility through the facility’s front entrance at 8:29 p.m., on 3/14/2022. The ADM stated the receptionist stays at the front desk until 5 p.m. and then locks the front entrance when she leaves. The ADM stated the front door only has a wander guard system (alarm sounds when an at-risk wanderer approaches the monitored door while wearing a wander guard). The ADM stated Resident A was not assessed at risk for wandering so he did not have a wander guard device on. The ADM stated the front door was locked to prevent unauthorized persons from entering the facility after 5 p.m., and there was no alarm on the front door to alert staff the door was being opened from inside of the facility. During an interview on 3/16/2022 at 4:21 p.m., CNA 1 stated Resident A was independent but had some confusion and forgetfulness. CNA 1 stated on the night Resident A eloped from the facility (3/14/2022) she went to Resident A’s room at approximately 8:45 p.m., to check on Resident A’s roommate (Resident B), and Resident A was not there. During an interview on 6/17/2022 at 2:10 p.m., the DON stated the only doors in the facility that alarms when opened from the inside were the facility’s emergency doors. The DON stated the front door has a wander guard alarm on it and would only activate the alarm if a resident with a wander guard device activated it. The DON was asked about the facility’s policy and procedure (P/P) regarding supervision of residents with dementia and forgetfulness, but she was unable to provide a P/P. The facility failed to: 1. Ensure Resident A, who was confused, was adequately supervised to prevent the resident from leaving the facility unsupervised. 2. Develop of a plan of care with interventions to address Resident A’s need to be closely supervised due to dementia with confusion. 3. Ensure a system was in place to alert staff when the facility’s front door was opened to ensure residents did not leave the facility unnoticed. As a result, Resident A eloped from the facility and was found unresponsive and required treatment at a GACH for a drug overdose. This deficient practice put Resident A at risk for complications due to missing his insulin and hypertension medications, as well as at risk of Resident A not being found while being exposed to environmental conditions, including excessive heat or cold, harm, and could have led to death. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.