Health inspection·January 17, 2024

72541 Unusual Occurrences 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 fire authority or in areas not having an organized fire service, to the State Fire Marshal. On 11/30/2023 the California Department of Public Health (CDPH) received a complaint regarding a resident (Resident 1), who was found next door to the facility at a local business on 11/26/2023 at 8:30 a.m. On 12/1/2023 at 11:05 a.m., the CDPH made an unannounced visit to the facility to investigate the complaint allegation. The CDPH determined that Resident 1 eloped (a form of unsupervised wandering that leads to a resident leaving the facility) from the facility on 11/26/2023 and was later found at a local business next door to the facility but the facility did not report that Resident 1 was missing. The facility failed to: Followed its policy and procedure (P&P), titled, “Unusual Occurrence Reporting” which indicated an unusual occurrence shall be reported within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. As a result of this deficient practice, the CPDP was not allowed the opportunity to investigate the unusual occurrence of Resident 1 eloping from the facility in a timely manner and had the potential for other episodes of elopement to go unreported. A review of Resident 1’s Admission Record (Face Sheet), indicated Resident 1 a 97-year-old female, was initially admitted to the facility on 5/9/2022 and was readmitted on 11/6/2023 with diagnoses including dementia (a progressive loss of memory), unsteadiness on feet, and anxiety (extreme worry). A review of Resident 1’s Minimum Data Set ([MDS]) a standard assessment and care screening tool), dated 11/10/2023, indicated Resident 1’s cognitive (the ability to think, reason, and understood) skills for daily decision-making were severely impaired. The MDS indicated Resident 1 used a walker during ambulation. A review of Resident 1’s Change of Condition (COC) dated 11/26/2023 and timed at 8:30 a.m., indicated Resident 1 was missing, a search for Resident 1 was initiated and Resident 1 was found next door to the facility at a local business at 8:30 a.m. During an interview on 12/4/2023 at 9:50 a.m., Licensed Vocational Nurse 1 (LVN 1) stated he last saw Resident 1 during rounds at 7 a.m., and an unknown Certified Nursing Assistant notified LVN 1 that Resident 1 was last seen between 7:30 a.m., and 8 a.m., when breakfast trays were served. LVN 1 stated at 8:30 a.m., when Resident 1 could not be found an immediate search was initiated. LVN 1 stated Resident 1 was found next door to the facility at a local business unharmed. During an interview with the administrator on 12/5/2023 at 10:23 a.m., the Administrator stated, he did not report Resident 1 was missing from the facility to the CDPH because the Resident 1 was found within minutes after she was discovered missing. The Administrator stated the facility’s protocol was to report the resident missing after 2 hours. A review of the facility's P&P titled, “Unusual Occurrence Reporting” revised 12/2007, indicated as required by federal or state regulations, the facility would report unusual occurrences or reportable events which affect the health, safety or welfare of residents, employees, or visitors. The P&P indicated unusual occurrences shall be reported via telephone to the appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. The facility failed to: Followed its policy and procedure (P&P), titled, “Unusual Occurrence Reporting” which indicated an unusual occurrence shall be reported within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. As a result of this deficient practice, the CPDP was not allowed the opportunity to investigate the unusual occurrence of Resident 1 eloping from the facility in a timely manner and had the potential for other episodes of elopement to go unreported. These violations, jointly, separately or in any combination, had direct or immediate relationship to the health, safety, or security of Resident 1.