Other·June 5, 2024

(Rev. 211; Issued: 02-03-23; Effective: 10-21-22; Implementation: 10-24-22) §483.25(d) Accidents. The facility must ensure that - §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 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: (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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 22 CCR § 72523(a) Patient Care Policies and Procedure. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 4/15/2024, the California Department of Public Health (CDPH) received a Facility Reported Incident (FRI) indicating a resident (Resident 1) eloped (an unauthorized departure of a patient from an around-the-clock care setting without the facility's knowledge and supervision) from the facility on 4/13/2024. On 4/16/2024, the CDPH made an unannounced visit to the facility to investigate the FRI. As a result of the investigation, the CDPH determined the facility failed to provide adequate supervision to prevent Resident 1 from eloping a second time on 4/13/2024. The facility failed to: 1. Ensure Resident 1, with a history of elopement and assessed as high risk for elopement, did not elope from the facility on 4/13/2024. 2. Ensure Resident 1 was not placed in a room with access to an outside patio with a door that opened to an alley. 3. Ensure the patio door alarm, which had a faint sound, could be heard by staff at a distance and not only when in close proximity to it and the alarm would not shut off within five seconds after activation. 4. Ensure the licensed nurses developed and implemented a care plan for Resident 1 when Resident 1 was identified as a risk for elopement on 12/29/2023 that defined "frequent" visual checks and documentation of times when Resident 1 was monitored. 5. Ensure the licensed nurses developed and implemented a care plan when Resident 1 took off and refused to wear his wander guard bracelet (a device placed on a resident that triggers an alarm alerting staff that a resident is close to a door to prevent the resident from leaving unattended). As a result of these deficient practices, Resident 1 eloped from the facility and was missing for 11 hours on 1/19/2024 and eloped from the facility again on 4/13/2024. These failures 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 paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people) schizophrenia (a serious mental disorder in which people interpret reality abnormally) and psychosis (when a person has trouble telling the difference between what's real and what's not) without receiving prescribed medication, 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. Findings: A review of the GACH's Discharge Summary, dated 11/17/2023 and timed at 7:33 p.m., indicated Resident 1's chief complaint was wanting to harm himself. The Discharge Summary indicated Resident 1's baseline level (an initial measurement of a condition taken at an early point in time that is used for comparison over time to look for changes) was disorganized (odd, bizarre behavior such as smiling, laughing, or talking to oneself or being preoccupied/responding to internal stimuli). A review of Resident 1's facility's Admission Record (Face Sheet), indicated Resident 1 a 43-year-old-male, was admitted to the facility on 11/17/2023 with diagnoses including paranoid schizophrenia, psychosis, and absence of his right leg above the knee. A review of Resident 1's Conservatorship documents dated 11/22/2023, indicated Resident 1 was gravely disabled (a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter) as a result of a mental health disorder (a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior). A review of Resident 1's Elopement Evaluation dated 12/29/2023, the Elopement Evaluation indicated Resident 1 scored one (a score of one or higher indicates a risk of elopement). A review of Resident 1's clinical record, the Care Plan section, indicated there was no care plan in place addressing Resident 1's history of elopement or his elopement risk, as assessed on 12/29/2023. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 2/20/2024, indicated Resident 1 was cognitively intact (a person who can follow two simple commands). The MDS indicated Resident 1 received antipsychotic (medication used to treat hallucinations [sights, sounds, smells, tastes, or touches that a person believes to be real but are not real] and delusions [false beliefs]) and antianxiety (medication used to treat symptoms of anxiety [feelings of fear, dread, uneasiness]) medication. A review of Resident 1's Order Summary Report (Physician's Orders), indicated Resident 1 received the following medications as ordered: 1. On 11/17/2023 - Divalproex Sodium 250 milligrams ([mg] a unit of measurement), once a day for seizures. 2. On 11/20/2023 - Risperidone 2 mg, twice a day for psychosis as manifested by visual hallucinations. 3. On 11/29/2024 - Invega 6 mg once a day for psychosis manifested by sudden angry outbursts. A review of the facility's undated floor plan indicated Resident 1's room had access to an outside patio which had direct access to an alley. A review of Resident 1's Situation Background, Assessment, and Recommendation ([SBAR] a communication tool between members of the health care team about a patient's condition) Elopement Report of Incident, dated 1/20/2024 and timed at 12:12 a.m., the SBAR indicated Resident 1 left the building (1/19/2024) without informing the staff. A review of Resident 1's Nurses Notes dated 1/20/2024 and timed at 1:30 a.m., indicated on 1/19/2024 at 10:40 p.m., Resident 1 was seen sitting at the nurses' station. The Nursing Notes indicated at around 11:30 p.m., Resident 1 was not in his room nor in the building. The Nursing Notes indicated the surrounding area was searched and the resident was not located. A review of Resident 1's Nurses Notes dated 1/20/2024 and timed at 11:20 a.m., indicated Resident 1 was accompanied back to the facility on 1/20/2024 around 11 a.m., after being found at a laundromat, 0.4 miles away from the facility (approximately 11.5 hours after Resident 1 went missing). A physician's order was obtained to place a wander guard on Resident 1 for monitoring. A review of Resident 1's Physician's Order dated 1/20/2024 indicated to check placement of the wander guard bracelet every shift and check its function every week. A review of Resident 1's Elopement Evaluation dated 1/20/2024 indicated Resident 1 scored six (a score of 6 indicated Resident 1 was a high elopement risk). A review of Resident 1's Care Plan, dated 1/20/2024, indicated Resident 1 was identified as a high risk for elopement related to a history of elopement and irritable behaviors as evidenced by excessive pacing for no apparent reason. The Care Plan's goal indicated Resident 1 would be safe while at the facility through a review date of 5/14/2024. The Care Plan's interventions included checking Resident 1's wander guard for placement and functioning. A review of Resident 1's Social Service Notes dated 1/26/2024 and timed at 12:53 p.m., indicated Resident 1 verbalized to his Conservator that he had a plan to leave the facility when staff was not around. A review of Resident 1's Social Service Notes dated 1/26/2024 and timed at 3:59 p.m., indicated Resident 1 verbalized he would escape if nobody was looking. A review of Resident 1's Nursing Note dated 1/31/2024 and timed at 6:30 p.m., indicated Resident 1's wander guard was found on Resident 1's dresser. The Nursing Note indicated Resident stated the wander guard drove him crazy when he wore it, especially when the alarm went off when he went outside to smoke. A review of Resident 1's Medication Administration Record (MAR) dated 1/31/2024 and timed at 8:05 p.m., indicated Resident 1 refused to wear the wander guard. A review of the care plan section of Resident 1's clinical record, dated 11/17/2023 thru 4/13/2024, indicated there was no care plan in place addressing Resident 1's behavior of taking his wander guard off or refusing to wear his wander guard. A review of Resident 1's Physician's Order dated 3/30/2024, indicated to administer Ativan 1 mg every 12 hours as needed for irritability as evidenced by excessive pacing for no apparent reason. A review of Resident 1's MAR dated 4/2024, indicated Resident 1 received Ativan for irritability as evidenced by pacing for no apparent reason on the following dates and times: 1. On 4/1/2024, at 2:45 p.m. 2. On 4/2/2024, at 3 a.m. 3. On 4/3/2024, at 4:02 a.m. 4. On 4/5/2024, at 4:06 a.m. 5. On 4/6/2024, at 7:48 p.m. 6. On 4/8/2024, at 7:38 p.m. 7. On 4/9/2024, at 9:50 a.m. 8. On 4/10/2024, at 8:10 a.m. 9. On 4/12/2024, at 7:57 p.m. A review of Resident 1's Progress Notes dated 4/10/2024, indicated at 11:52 a.m., Resident 1 went out on pass for a court appointment. A review of Resident 1's Court Minutes dated 4/10/2024 and timed at 1:30 p.m., indicated Resident 1 remained gravely disabled as a result of a mental disorder and Resident 1's Conservator was reappointed over Resident 1 and his estate. A review of Resident 1's SBAR Elopement Report of Incident, dated 4/13/2024 and timed at 7:45 p.m., indicated Resident was previously seen by staff at approximately 7:25 p.m. A review of Resident 1's Nursing Note dated 4/13/2024 and timed at 7:45 p.m., indicated on 4/13/2024 at around 7:30 p.m., Resident 1 was seen by staff outside of the facility in a wheelchair, wheeling himself across the street. The Nursing Note indicated Resident 1's wander guard was discovered ripped and lying on top of Resident 1's side table. The Nursing Note indicated a search for Resident 1 was initiated outside of the facility and Resident 1 was not found. During a tour of the facility on 4/16/2024 at 3:27 p.m., a total of seven doors were observed. Four of the seven doors were observed with alarms as well as a wander guard system. One door that lead to the rehabilitation patio was observed with an alarm and no wander guard system. One door at the front of the facility, that was used as the primary entrance into the facility and exit out of the facility was observed with a wander guard system but did not have an audible alarm in place. One door was observed in the kitchen that lead to an alley without an alarm or wander guard system. During a concurrent tour of the facility's outside patio and interview with the Maintenance Supervisor (MS) on 4/16/2024 at 3:53 p.m., the facility's outside patio door was observed with access to the alley. The door's alarm, when sounded, was faint and could be heard only when in close proximity to it, and the alarm once activated would shut off within five seconds. The MS stated the alarm was not loud enough to be heard at a distance and didn't stay on long enough for anyone to hear it. During a concurrent observation and interview on 5/17/2024 at 9:45 a.m. with the ADM on the rehabilitation patio, Resident 1's room was observed to have a sliding glass door which lead to the rehabilitation patio that had a door which led to an alley. The ADM confirmed and stated Resident 1's room had direct access to the rehabilitation patio and a door that led to an alley. The ADM stated, he did not think Resident 1 would leave though the rehabilitation patio door because Resident 1 was wheelchair bound. During an interview on 4/16/2024 at 5:32 p.m., Certified Nursing Assistant 1 (CNA 1) stated on 4/13/2024 around 7:30 p.m., she was sitting in her car and saw a man (Resident1) approximately 300 feet away from the facility in a wheelchair crossing the street and blocking oncoming traffic. CNA 1 stated it was difficult to see if it was Resident 1 because it was raining really hard. CNA 1 stated once she realized it was Resident 1 crossing the street, she immediately went inside the facility and notified a Registered Nurse (RN 1) that Resident 1 was outside of the facility crossing the street. CNA 1 stated the facility's front door was locked and she had to ring the doorbell and wait for someone to open the door (not sure of how much time lapsed from identifying Resident 1 outside the facility and obtaining help). CNA 1 stated she did not immediately chase after Resident 1 or yell for him to come back because she was in shock and her first thought was to get help. During an interview on 4/16/2024 at 6:27 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on 1/19/2024 Resident 1 eloped from the facility around 11:30 p.m. LVN 1 stated the facility staff did not know how Resident 1 eloped from the facility. LVN 1 stated on 4/13/2024 around 7:30 p.m., she heard CNA 1 yelling that Resident 1 was outside of the facility crossing the street. LVN 1 stated she did not recall hearing an alarm sound during her shift, but she did see Resident 1's wander guard lying on his bedside table, and it looked as if Resident 1 had ripped it off. During an interview on 4/17/2024 at 10:25 a.m., the MDS Nurse (a nurse who collects and assesses information for the health and well-being of residents), after reviewing Resident 1's Elopement Evaluation dated 12/29/2023 and Nursing Notes dated 1/31/2024, stated a care plan related to Resident 1's elopement risk should have been created as well as a care plan addressing Resident 1's behavior of refusing to wear his wander guard bracelet. During an interview on 4/17/2024 at 12:02 p.m., the DON stated all staff are responsible for the safety of the residents, and anything could happen when a resident elopes from the facility. The DON stated she was aware Resident 1 had a history of elopement. During an interview on 4/18/2024 at 2:28 p.m., Resident 5 stated on 4/10/2024, Resident 1 had a court hearing to determine if he (Resident 1) could leave the facility. Resident 5 stated when Resident 1 returned from his court hearing, he was upset because he wanted to leave the facility and the court would not let him leave. Resident 5 stated Resident 1 carried a backpack which looked full and told him (Resident 5) "I always gotta be ready to leave at any time." During an interview on 4/18/2024 at 4:21 p.m., with the ADM and the DON, the ADM stated, there was a potential for Resident 1 to be injured and/or killed since his whereabouts and health status were unknown. The DON stated, Resident 1 was not taking his psychiatric medications, and there was a potential for him to harm others and/or himself. During a telephone interview on 4/25/2024 at 1:53 p.m., Resident 1's Conservator stated Resident 1 was appointed a psychiatric conservatorship 12/2021 because of Resident 1's mental health disorder and being gravely disabled. The Conservator stated Resident 1 had no plan for self-care and could be a danger to himself and/or other's if he did not continue his medication regimen. The Conservator stated Resident 1 had a history of elopement which was discussed with the facility prior to his admission on 11/17/2023. The