Health inspection·August 7, 2024

§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. §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. §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. (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On 6/18/2024, the California Department of Public Health (CDPH) received a facility reported incident (FRI) indicating Resident 1 eloped on 6/16/2024 at approximately 8:50 p.m. On 6/18/2024, at 4:05 p.m., CDPH conducted an unannounced visit to the facility to investigate FRI related to elopement. Upon investigation, it was determined the facility failed to: 1. Ensure Resident 1, who had attempted to elope from the facility by climbing over the patio’s fence on 3/23/2024, was supervised and his whereabouts were monitored to prevent the resident from eloping from the facility on 6/16/2024. 2. Accurately assess Resident 1 for wandering (walk around without any clear purpose or direction) behavior and elopement risk to prevent the resident from leaving the facility unsupervised. Resident 1 attempted to climb over the facility’s patio fence on 3/23/2024 and on 6/16/2024 (2 months and 3 weeks later) he successfully climbed over the patio’s fence. Resident 1 was found on 7/6/2024 and admitted at a psychiatric hospital. 3. Ensure on 6/16/2024 at 8:49 p.m. Resident 1 was supervised while he was on Station A patio to prevent the resident from climbing over the fence and elope from the facility 4. Ensure Resident 1, who had attempted to elope from the facility by climbing over the patio’s fence on 3/23/2024, was supervised and his whereabouts were monitored to prevent the resident from eloping from the facility on 6/16/2024 by climbing over the patio fence. 5. Ensure staff responded to the sound of an alarm when door, leading to Station A patio, was opened on 6/16/2024, at 8:49 p.m., and Resident 1 gained the opportunity to walk through the patio door, climb over the fence, and elope from the facility. As a result of these deficient practices, Resident 1 eloped from the facility on 6/16/2024 at 8:51 p.m. These deficient practices placed Resident 1 at risk for exposure to harsh environmental conditions (rain and/or cold), hypothermia (a dangerously low body temperature), injury from motor vehicle accidents, medical complications related to his diagnosis of schizoaffective disorder (a mental condition characterized by abnormal thought processes and unstable mood) without receiving prescribed medication including Valproic Acid (medication for schizoaffective disorder), Abilify (antipsychotic [treat mental disorder] medication ), and Lithium (medicine used to treat mental illnesses ), lack of food with the risk of malnutrition (health problems that may arise due to lack of nutrients), dehydration (abnormally low fluid levels in the body), and possible death.  A review of Resident 1’s Admission Record indicated Resident 1, a 64-year-old male, was admitted to the facility on 11/21/2023 with diagnoses including schizoaffective disorder, insomnia (sleeplessness), and iron deficiency anemia (a condition in which the body does not have a sufficient amount of iron). A review of Resident 1’s History and Physical (H&P), dated 11/21/2023, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 5/30/2024, the MDS indicated Resident 1 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 1 required with eating, oral hygiene, toileting hygiene, showering/ bathing, and upper and lower body dressing, and required partial to moderate assistance with personal hygiene. The MDS indicated Resident 1 required supervision with walking 10 feet, 50 feet with two (2) turns, and 150 feet. A review of Resident 1’s care plan titled, “Resident 1 had attempted to elope by climbing over the fence,” dated 3/23/2024, indicated there were no documented interventions to prevent Resident 1’s elopement. A review of Resident 1’s Elopement Risk Assessment dated 2/15/2024 and 6/3/2024 indicated Resident 1 was not assessed for the risk of elopement. However, Resident 1’s Elopement Risk Assessment dated 3/23/2024, indicated Resident 1 was assessed as being at risk for elopement. A review of Resident 1’s 72-hour Monitoring Notes, dated 6/16/2024, and timed at 9:20 p.m., indicated an unidentified Certified Nursing Assistant (CNA) has seen Resident 1 last time at 8:40 p.m., on 6/16/2024 in his room. The 72-hour Monitoring Notes indicated that at 9:20 p.m., the facility staff were unable to locate Resident 1 in the facility. The 72-hour Monitoring Notes indicated the facility staff was alerted to look for Resident 1 inside the facility and surrounding area outside the facility. At 10:45 p.m. facility staff called local general acute care hospital (GACH) for Resident 1’s possible admission. At 10:50 p.m., Resident 1’s physician was notified. During a concurrent observation and interview on 6/18/2024, at 5:15 p.m., with the Administrator (ADM), the facility’s recorded video footage for 6/16/2024 was reviewed. The video footage illustrated that on 6/16/2024 at 8:49 p.m., CNA 1 was sitting at the Nursing Station A, diagonally across from the Nursing Station A there was a door leading to the patio surrounded by the ‘chicken wire’ (chain link) fence about 10 feet and 5 inches high. At 8:49 p.m., Resident 1 was seen exiting Station A patio door, located approximately 10-15 feet from Nursing Station A. CNA 1 did not follow Resident 1 outside to the patio area. The recorded video footage illustrated that at 8:51 p.m., Resident 1 was seen climbing over the patio fence and left the facility. The ADM stated the facility was a secured facility (facility secured with locked doors to prevent residents from exiting the premises at will). The ADM stated staff had to check the residents, who were assessed as a high risk for elopement, whereabouts hourly. The ADM stated there were no staff assigned on Station A to monitor patio door as residents were free to walk around and sit in the patio. The ADM stated all residents in the facility were at risk of leaving the facility and had to be monitored hourly to know their whereabouts. During an interview on 6/18/2024, at 6:20 p.m., the Unit Manager (UM 1) stated on 6/16/2024 at 8:20 p.m., Resident 1 approached her on Station C and asked for a gauze dressing for his wound (unspecified location). The UM 1 stated she told Resident 1 she would see him later when she finished with wound care for another resident. The UM 1 stated at 9:20 p.m., she started to look for Resident 1 as the resident had not returned to Station C. The UM 1 stated she checked Resident 1’s room but he was nowhere to be found. The UM 1 stated she directed Licensed Vocational Nurse (LVN 1) to look for Resident 1 in the facility. The UM 1 stated the UM 2 looked for Resident 1 and the Registered Nurse Supervisor (RNS) called the police. The UM 1 stated there should have been staff assigned to Station A patio area when residents go out on the patio, especially at nighttime to ensure residents safety. During an interview on 6/18/2024, at 8:15 p.m., CNA 3 stated she was assigned to care for Resident 1 on 6/16/2024. CNA 3 stated she was working on Station C and saw Resident 1 last time in his room at 8:40 p.m. on 6/16/2024. CNA 3 stated Resident 1 was wandering around the facility and was not staying in one place. CNA 3 stated Resident 1 should have been on 1:1 monitoring (staff provides one to one nursing or observation care to a resident for a period of time) so he would have been watched more closely. During an interview on 6/20/2024, at 10:41 a.m., LVN 1 stated Resident 1 should have been on 1:1 monitoring because Resident 1 walked around the facility a lot and could elope easily. LVN 1 stated there should have been staff to watch the residents when residents were on the patio because the residents could fall or tried to elope like Resident 1. During a concurrent observation and interview on 6/20/2024 at 4:10 p.m., with the Maintenance Supervisor (MS), the MS opened the door leading to Station A’s patio and a sound like a doorbell was heard. The MS stated the sound was to alert staff that a resident was exiting outside to the patio. At the time of observation there were no staff observed coming to the patio area to check if a resident was leaving Station A and was going to the patio area. During an interview on 6/20/2024 at 4:40 pm., CNA 1 stated, on 6/16/2024 at around 8 p.m., she was passing snacks and saw Resident 1 walking between Station A and Station B. CNA 1 stated the facility staff were aware Resident 1 was a high risk for elopement. CNA 1 stated Resident 1 should have been on 1:1 monitoring to closely watch him. CNA 1 stated Resident 1 always was on 1:1 monitoring, but on 6/16/2024 Resident 1 was not on 1:1 monitoring, and she does not know why. During an interview on 6/20/2024, at 4:52 p.m., CNA 2 stated on 3/23/2024, he witnessed Resident 1 tried to leave the facility by attempting to squeeze himself in between the metal pole, where the fence was attached, and the building wall, but could not fit. Resident 1 then started walking around on the patio and then suddenly, Resident 1 walked over to another side of the fence, stood there for a minute, and started to climb over the fence. CNA 2 stated he ran and started to climb the fence to stop Resident 1. CNA 2 stated he redirected Resident 1 back into the patio. CNA 2 stated after this incident on 3/23/2024, Resident 1 should have been supervised and monitored every time he goes to the patio as he was a high risk of elopement and would attempt to elope again. During an interview on 6/20/2024, at 5:17 p.m., RNS stated Resident 1 was a wanderer and was constantly walking around the facility. The RNS stated residents with high risk for elopement should be supervised to know their whereabouts every hour. The RNS stated a resident, who goes to the patio should be supervised to avoid any incident of elopement or fall. The RNS stated there should be staff present on the patio to watch and monitor the residents. The RNS stated a resident, who assessed as high risk for elopement, should have whereabouts checked every hour and that what staff do hourly. During a concurrent interview and record review on 6/20/202F4, at 6:24 p.m., with the UM 1, Resident 1’s Care Plan titled, “At risk for elopement related to medical condition, schizoaffective disorder, and an attempt to elope by climbing the fence on 3/23/2024,” was reviewed. The UM 1 stated Resident 1’s Care Plan indicated there were no selected intervention from pre-determined interventions for the prevention of the elopement for Resident 1, who had a history of climbing over the fence. The UM 1 stated the interventions such as supervise the resident closely (pay special and careful attention to the resident), conduct regular rounds (to do consistent rounds which was hourly), and place Resident 1 on 1:1 monitoring was not selected and not implemented to prevent Resident 1 from elopement. During a concurrent interview and record review on 6/21/2024, at 12 p.m., with the DON, Resident 1 Care Plan titled “Resident 1 had an attempt to elope by climbing over the fence,” dated 3/23/2024 was reviewed. The DON stated the residents who were a high risk for elopement should have been on 1:1 monitoring. The DON stated Resident 1 should been on 1:1 monitoring as he had a history of elopement attempt on 3/23/2024. The DON stated she was not aware Resident 1 was not on 1:1 monitoring. The DON stated if Resident 1 would have been on 1:1 monitoring Resident 1 would not elope. The DON stated the importance of Resident 1 to be on 1:1 monitoring was for his safety. After reviewing Resident 1’s Care Plan and Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) notes, the DON stated there was no documentation indicating IDT meeting was held and an investigation of Resident 1’s elopement attempt on 3/23/2024 was done. The DON stated the Care Plan interventions were not selected to indicate what interventions were in place to prevent Resident 1 from elopement. A review of the facility’s P&P titled, “Elopement Prevention,” ([undated]), indicated it was the facility’s policy to identify residents at risk for elopement and intervene accordingly, and to establish a plan of care when risk factors are present. If a resident is determined to be at risk for elopement, a care plan goal with approaches to ensure a resident’s safety will be implemented as determined by the IDT. The facility failed to: 1. Ensure Resident 1, who had attempted to elope from the facility by climbing over the patio’s fence on 3/23/2024, was supervised and his whereabouts were monitored to prevent the resident from eloping from the facility on 6/16/2024. 2. Accurately assess Resident 1 for wandering behavior and elopement risk to prevent the resident from leaving the facility unsupervised. Resident 1 attempted to climb over the facility’s fence on 3/23/2024 and on 6/16/2024 (2 months and 3 weeks later) he successfully climbed over the patio’s fence. Resident 1 was found on 7/6/2024 and admitted at a psychiatric hospital. 3. Ensure on 6/16/2024 at 8:49 p.m. Resident 1 was supervised while he was on Station A patio to prevent the resident from climbing over the fence and elope from the facility 4. Ensure staff followed facility’s P&P titled, “Elopement Risk Assessment” which indicated residents should be evaluated for the risk of elopement upon admission, quarterly, annually and with any significant change of condition. Resident 1’s Elopement Risk Assessments dated 2/15/2024 and 6/3/2024, indicated Resident 1 was not assessed for the risk of elopement. 5. Ensure staff responded to the sound of an alarm when door, leading to Station A patio, was opened on 6/16/2024, at 8:49 p.m., and Resident 1 gained the opportunity to walk through the patio door, climb over the fence, and elope from the facility. These violations had a direct or immediate relationship to the health, safety, or secu