Other·April 4, 2024

42 CFR 483.21 Comprehensive person-centered care planning. (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[.] 42 CFR 483.25 Quality of care. (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 72311(a)(1)(A)(B) 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 withing 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. 22 CCR 72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient relate goals and facility objective are achieved. On 2/12/2024, the Department of Public Health (CDPH), received a facility reported incident (FRI) indicating a resident (Resident 1) was last seen by staff at the facility on 2/9/2024 at 6 a.m., in bed, but was not found during breakfast (from 7 a.m. - 7:30 a.m.). On 2/12/2024, CDPH conducted an unannounced visit to the facility to investigate the FRI about Resident 1 missing from the facility. Upon investigation, CDPH determined Resident 1 eloped from the facility on 2/9/2024 and as of today (3/12/2024) had not been found. The facility failed to: 1. Ensure the licensed nurses assessed Resident 1 to determine his risk for wandering and elopement upon admission to the facility on 12/28/2023. 2. Ensure a care plan was developed with interventions to prevent Resident 1 from further attempts to leave the facility immediately following Resident 1's attempt to leave the facility on 1/12/2024. 3. Ensure the licensed nurses monitored the placement of Resident 1's wander guard bracelet (a system that helps monitor the movement of patients and prevent them from leaving a facility), following his attempt to leave the facility on 1/12/2024 and after a physician's order for a wander guard bracelet and to monitor its placement each shift. 4. Develop a care plan for Resident 1's use of the wander guard bracelet with interventions including monitoring the wander guard bracelet for its presence every shift, and to address Resident 1's refusal to wear the wander guard bracelet and taking it off. 5. Have a system in place to alert staff when the facility's entrance and exit doors without alarms were opened, to prevent residents from leaving the facility without staff knowledge. These deficient practices resulted in Resident 1's elopement from the facility on 2/9/2024 and placed Resident 1 at risk of exposure to severe weather related conditions (rain and/or cold), hypothermia (a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature), medical complications including malnutrition, dehydration (low fluid levels in the body), stroke (injury to brain tissue caused by hypertension [HTN] high blood pressure) due to missing routine medications and self-inflicted injuries related to Resident 1's documented suicidal ideations of throwing himself into oncoming traffic, and possible death. Resident 1's risk for wandering and elopement was not realized by facility staff when Resident 1 was admitted to the facility on 12/28/2024. Resident 1 attempted to leave the facility on 1/12/2024 and subsequently eloped from the facility on 2/9/2024. A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1, a 49-year-old male was admitted to the facility on 12/28/2023 with diagnoses including hypertension (HTN), major depressive disorder (MDD), anxiety, psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) substance abuse and paranoid schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 1/8/2024 indicated Resident 1 had moderately impaired cognitive skills (process of thinking) for daily decision-making and had a behavior that placed him at significant risk of getting into a potentially dangerous place (e.g., the stairs, outside of the facility). This behavior occurred one to three days per week. A review of Resident 1's of Psychiatric Evaluation from a General Acute Care Hospital (GACH), dated 12/10/2023, prior to Resident 1's transfer to the facility on 12/28/2023, the Psychiatric Evaluation indicated Resident 1 expressed feelings of helplessness, hopelessness, worthlessness and had thoughts of walking into traffic or overdosing. A review of Resident 1's Physician's Order dated 12/28/2023, indicated for Resident 1 to receive the following medications: 1. Lisinopril 40 milligrams (mg), one time daily for hypertension. 2. Escitalopram Oxalate (a mood stabilizer medication) 10 mg, one time a day for depression manifested by verbalization of hopelessness and worthlessness. 3. Aripiprazole 10 mg, one time a day for schizophrenia manifested by hallucination of hearing voices. A review of Resident 1's Admission Wandering and Elopement Assessment dated 1/6/2024, indicated the Wandering Elopement Assessment was left blank. A review Resident 1's medical record, indicated there was no care plan in place addressing Resident 1's wander and elopement risk or addressing Resident 1's behavior of taking his wander guard off. A review of Resident 1's Nurses Notes dated 1/12/2024 and timed at 10:21 p.m., indicated Resident 1 had a schizophrenic crisis, got upset and ran out of the unit toward the exit door but was stopped by staff. A review of Resident 1's Elopement Risk Assessment dated 1/17/2024, indicated Resident 1 scored 2. A score of 2 indicated Resident 1 was at moderate risk for elopement. A review of Resident 1's Physician's Order dated 1/17/2024, indicated to place a wander guard bracelet on Resident 1 and to check placement of the wander guard bracelet every shift. A review of Resident 1's Nurses Notes dated 2/9/2024 and timed at 8:23 a.m., indicated Resident 1's breakfast was not touched, nor did Resident 1 attend the smoke break at 8 a.m. The Nurses Notes indicated a search for Resident 1 was initiated inside and outside of the facility and Resident 1 was not found. During a tour of the facility on 2/12/2024 at 2:12 p.m., a total of four exit doors were observed. All four exit doors had a wander guard alarm installed, however, only two of the four doors, in the front and back of the facility, had regular alarms installed. During an interview on 2/12/2024 at 3:11 p.m., Resident 2 stated he saw Resident 1 gathering his belongings from his closet. Resident 2 stated, Resident 1 told him (Resident 2), "I will see you, when I see you," waved goodbye and left. Resident 2 stated this happened before breakfast trays were handed out. During an interview on 2/12/2024 at 3:42 p.m., the Licensed Vocational Nurse (LVN 1) stated she was Resident 1's nurse the morning of his elopement on 2/9/2024. LVN 1 stated Resident 1 did not have a wander guard bracelet on the morning he left, and she did not recall hearing an alarm sound that day. LVN 1 stated Resident 1 had a routine of walking around the facility, eating breakfast and then waiting in line for the smoke break. LVN 1 stated when she noticed Resident 1's breakfast had not been touched she went to see if Resident 1 was on the smoking patio, but he was not there. LVN 1 stated she reported to Registered Nurse (RN 2) that Resident 1 was missing. LVN 1 stated a search was conducted inside and outside the facility and the local sheriff's department was notified when Resident 1 was not located. As of 3/12/2024 Resident 1 had not been located. During an interview on 2/13/2024 at 10:56 a.m., the Receptionist stationed at the facility's front desk, stated someone was assigned at the front desk from 7 a.m., to 8 p.m., daily. The Receptionist stated the front door did not have a regular alarm; it only had a wander guard alarm. During a concurrent tour of the facility and interview with the Maintenance Supervisor (MS) on 2/13/2024 at 12:08 p.m., staff were observed going in and out of the facility's back door, there was no alarm that sounded. The MS stated, "You see the problem, people go in and out of that door, if someone was to leave, no one would know." During an interview on 2/13/2024 at 12:23 p.m., a Certified Nurse Assistant (CNA 1) stated on 2/8/2024 (the day before Resident 1 eloped) Resident 1 refused to wear his wander guard and gave the wander guard to the DON. CNA 1 stated on the day Resident 1 eloped (2/9/2024), she noticed Resident 1's breakfast had not been touched. CNA 1 stated Resident 1 liked to walk around the facility, so she did not think much about it at the time. CNA 1 stated when Resident 1 was not at the morning smoke break, staff began to search for him. During a concurrent interview and record review with the MDS Nurse (a nurse who collects and assesses information for the health and well-being of residents in a Medicare or Medicaid certified nursing facility) on 2/13/2024 at 1:23 p.m., and a subsequent interview on 2/14/2024 at 12:13 p.m., Section E of Resident 1's MDS dated 1/8/2024 and Resident 1's Admission Wandering Assessment dated 1/6/2024 were reviewed. Resident 1's MDS indicated the resident had wandering behavior. The MDS Nurse stated based on that information, a care plan related to Resident 1's wandering behavior should have been created. The MDS Nurse reviewed Resident 1's Admission Wandering Assessment and confirming it was left blank and stated the Wandering Assessment should have been completed by the nurse who admitted Resident 1. The MDS Nurse stated if Resident 1 refused to wear a wander guard, a change of condition (COC) and care plan should have been created. During a concurrent interview and record review with RN 1 on 2/13/2024 at 1:44 p.m., and a subsequent interview on 2/14/2024 at 1:39 p.m., Resident 1's Medication Administration Record (MAR) dated 1/2024 and 2/2024 was reviewed. The MAR indicated an "X" was documented under the section indicated to check Resident 1's wander guard placement. RN 1 stated Resident 1 had an order to check the placement of his wander guard bracelet every shift and an "X" indicated the order was not carried out and no one checked to see if Resident 1 was wearing his wander guard. During an interview on 2/13/2024 at 2:13 p.m., the DON stated on 2/8/2024, after Resident 1 took off his wander guard bracelet and gave it to her, she (the DON) placed the wander guard bracelet back on Resident 1 on the same day (2/8/2024). The DON stated she was not sure if Resident 1 took the wander guard bracelet off again but stated if Resident 1 had the wander guard bracelet on, staff would have heard the alarm sound when Resident 1 was going out through any of the facility's doors. The DON stated all staff are responsible for the safety of the residents, and anything could happen to a resident when they elope from the facility. During a telephone interview on 2/26/2024 at 9:40 a.m., LVN 2 stated on 1/12/2024 Resident 1 ran toward the exit door located in the lobby of the facility but staff were able to stop him before he got out of the building and redirect him back to his room. During a review of the facility's P/P titled "Wandering and Elopement" dated 10/1/2023, the P/P indicated the facility will identify residents at risk for elopement and minimize any possible injury because of elopement. The P/P indicated the licensed nurse, in collaboration with the Interdisciplinary Team, will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition according to the Resident Assessment Instrument guidelines to determine their risk of wandering/elopement. During a review of the facility's P/P titled "Wandering Bracelet Policy" dated December 2016, the P/P indicated that once wandering potential is established using a wandering and elopement assessment, a wander guard bracelet maybe applied as part of the intervention to keep a resident from wandering away from a safe environment. The P/P also indicated that a daily check of the wander guard bracelet needs to be completed and documented in the resident's medical records. During a review of the facility's P/P titled "Missing Resident Policy" dated December 2016, the P/P indicated that upon admission to the facility, the licensed nurse will complete a wandering and elopement risk assessment. Once the risk has been identified, developed a plan of care for resident at risk for exit seeking behavior, elopement, and post elopement. The facility failed to: 1. Ensure the licensed nurses assessed Resident 1 to determine his risk for wandering and elopement upon admission to the facility on 12/28/2023. 2. Ensure a care plan was developed with interventions to prevent Resident 1 from further attempts to leave the facility immediately following Resident 1's attempt to leave the facility on 1/12/2024. 3. Ensure the licensed nurses monitored the placement of Resident 1's wander guard bracelet (a system that helps monitor the movement of patients and prevent them from leaving a facility), following his attempt to leave the facility on 1/12/2024 and after a physician's order for a wander guard bracelet and to monitor its placement each shift. 4. Develop a care plan for Resident 1's use of the wander guard bracelet with interventions including monitoring the wander guard bracelet for its presence every shift, and to address Resident 1's refusal to wear the wander guard bracelet and taking it off. 5. Have a system in place to alert staff when the facility's entrance and exit doors without alarms were opened, to prevent residents from leaving the facility without staff knowledge. These deficient practices resulted in Resident 1's elopement from the facility on 2/9/2024 and placed Resident 1 at risk of exposure to severe weather related conditions (rain and/or cold), hypothermia (a medical emergency that occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature), medical complications including malnutrition, dehydration (low fluid levels in the body), stroke (injury to brain tissue caused by hypertension [HTN] high blood pressure) due to missing routine medications and self-inflicted injuries related to Resident 1's documented suicidal ideations of throwing himself into oncoming traffic, and possible death. Resident 1's risk for wandering and elopement was not realized by facility staff when Resident 1 was admitted to the facility on 12/28/2024. Resident 1 attempted to leave the facility on 1/12/20