Health inspection·November 21, 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. §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. §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 10/7/2024, the California Department of Public Health (CDPH) received a complaint alleging a resident (Resident 1), eloped (leaving a secured institution without notice or permission) from the facility by climbing over a tall brick wall, walked 23 miles away from the facility, and ended up at a family members home. The complaint alleged when the facility was called for assistance, the facility informed the Complainant that Resident 1 was no longer a resident of theirs, and the facility refused to assist with getting Resident 1's medication as well. On 10/10/2024 the CDPH received a Facility Reported Incident (FRI) to report that Resident 1 was reported missing by facility staff on 10/4/2024 at 9:30 p.m., and on 10/5/2024 they received a call from Resident 1's Responsible Party (RP) that Resident 1 was located at a family members home. The facility indicated they instructed the RP to bring Resident 1 back to the facility, but the RP reported that Resident 1 was resistive and uncooperative and did not want to come back to the facility. On 10/8/2024, the CDPH conducted an unannounced visit to the facility to investigate the complaint and FRI allegations. During the investigation, the CDPH determined that Resident 1 was last seen in the facility on 10/4/2024 at approximately 8:30 p.m., on the facility's patio, smoking. Resident 1 was noted missing on 10/4/2024 at approximately 9 p.m., and was found at his family's residence, 23 miles away on 10/5/2024 at 5:30 a.m. The facility did not report to the CDPH that Resident 1 eloped from the facility until 10-10-2024 (six days after Resident 1 eloped The facility failed to: 1. Ensure Resident 1 was supervised and monitored to prevent him from eloping from the facility in accordance with the facility's P/P titled, "Safety and Supervision of Residents," dated 5/2015 which indicated resident's supervision was a core component of the systems approach to safety. 2. Conduct a thorough and timely investigation following Resident 1's elopement from the facility on 10/4/2024 in accordance with the P/P titled, "Accidents and incidents: Residents investigating and Reporting," dated 1/2017, indicated the nurse in charge shall complete a Report of Incident/Accident form and submit the original to the DON within 24 hours of incident/accident. 3. Report to the CDPH that Resident 1 eloped from the facility on 10/4/2024 within 24 hours of his elopement as indicated in the facility's P/P titled, "Unusual Occurrence Reporting" dated 8/2018. 4. Follow their Policy and Procedure (P/P), titled, "Accidents and Incidents: Residents investigating and Reporting," dated 1/2017, that indicated all accidents and incidents involving residents occurring on facility premises shall be investigated and reported to the administrator. 5. Follow their P/P, titled, "Unusual Occurrence Reporting" dated 8/2018, that indicated unusual occurrences will be reported via telephone to appropriate agencies as required by current law and or regulations within twenty-four hours of such incident or as otherwise required by Federal and State regulations. As a result of these deficient practices Resident 1 eloped from the facility and his whereabouts were unknown to facility staff for over eight hours. When the facility was made aware that Resident 1 eloped from the facility, they did not report Resident 1's elopement to the CDPH within 24 hours, which lead to a delay in the CDPH's investigation. The facility did not conduct a timely or thorough investigation to determine how Resident 1 eloped from the facility to prevent potential elopements in the future. These deficient practices placed Resident 1 at risk of exposure to excessive drops in temperature, motor vehicle accidents, hunger, dehydration, consequences of not taking his regularly scheduled medications related to his diagnoses, and death. A review of Resident 1's Admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on 9/23/2024 with diagnoses including schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and anxiety disorder (a mental illness causing persistent fear and/or worry). A review of Resident 1's History and Physical (H/P), dated 9/23/2024, indicated, Resident 1 did not have the capacity to make medical decisions. A review of Resident 1's Minimum Data Set ([MDS] a federally mandated resident assessment tool) dated 9/29/2024, indicated Resident 1 was admitted from a psychiatric facility. The MDS indicated Resident 1 was able to understand and be understood by others, with moderate cognitive impairment (ability to register and recall information). The MDS indicated Resident 1 had no functional limitations in range of motion ([ROM] the direction a joint can move to its full potential). A review of Resident 1's Nurses Progress Notes, dated 10/4/2024, indicated Resident 1 was noted missing after a head count was conducted (10/4/2024). A review of Resident 1's Nurses Progress Notes, dated 10/5/2024 and timed at 7:50 a.m., indicated Resident 1 arrived at his family's house (located approximately 23 miles away from the facility at 5:30 a.m., (eight hours and 30 minutes after Resident 1 was found missing from the facility). A review of the facility's Patio Monitoring Log, dated 10/4/2024, indicated at 8 p.m. to 8:30 p.m., one staff person was assigned on the patio and from 8:30 p.m. to 9 p.m., the Patio Monitoring Log had no designated staff person assigned to the patio. During an interview on 10/8/2024 at 4:28 p.m., Registered Nurse (RN 1) stated on 10/4/2024 at approximately 9 p.m., she was notified by a staff person (identity unknown), that Resident 1 could not be located during the headcount. RN 1 stated Resident 1 was last seen on the facility's patio during the smoke break at approximately 8 p.m. to 8:30 p.m. RN 1 stated she did not know how Resident 1 eloped from the facility. During a telephone interview on 10/9/2024 at 9 a.m., Resident 1's RP stated Resident 1 arrived at her residence on 10/5/2024 at approximately 5:30 a.m., on foot, he appeared weak and incoherent (not able to express themselves clearly). The RP stated she called the facility and spoke with RN 2, who instructed her to take Resident 1 to a General Acute Care Hospital (GACH) for evaluation and treatment. During an interview on 10/9/2024 at 4:16 p.m., the Administrator (ADM) stated he did not report to the CDPH that Resident 1 eloped from the facility on 10/4/2024 because Resident 1 was not harmed and arrived safely to his family residence on 10/5/2024. The ADM stated he should have reported the incident in order to ensure a timely investigation could be completed by the CDPH. During an interview on 10/10/2024 at 10:42 a.m., the Activity Assistant (AA 1) stated on 10/4/2024 at approximately 8:30 p.m., he saw Resident 1 on the facility's patio during the smoke break after he gave Resident 1 a cigarette. AA 1 stated he was the only staff person on the patio during that time with about 20 residents and he did not see Resident 1 because he (AA 1) was attending to other residents who were waiting to receive and have their cigarettes lit. AA 1 stated it was not sufficient for one staff person to monitor all the residents during smoke breaks. AA 1 stated once Resident 1 received his cigarette he (Resident 1) walked behind him (AA 1) and he (AA 1) lost sight of Resident 1. AA 1 stated he did not know how Resident 1 eloped from the facility but thought he might have climbed over a gate on the smoking patio. During an interview on 10/10/2024, at 2:18 p.m., with the DON, the ADM, the Maintenance Supervisor (MS), and the Director of Staff development (DSD) present, the DON stated it was important for all residents on the patio to be supervised to ensure the residents were safe and secure. The DON, ADM and DSD stated they felt one person monitoring residents on the patio during the smoke break was sufficient to provide adequate supervision to the residents. The DSD stated CNA 1 and a security guard were assigned to make rounds throughout the facility. The DSD stated the nursing staff who work inside the facility were able to see the residents who were on the patio through the windows inside the facility that overlooked the patio and they had never had a problem with that system. The DSD stated if additional staff were designated to supervise the patio, it would decrease the number of staff available to attend to the residents who remained inside the facility. The DON, DSD and the ADM stated they did not know how Resident 1 was able to elope from the facility. During an interview on 10/10/2024 at 3:42 p.m., CNA 1 stated on 10/4/2024 she made rounds and conducted a head count every 30 minutes to ensure all residents were accounted for. CNA 1 stated the last time she saw Resident 1 was at approximately 7:45 p.m. before the 8 p.m., smoke break, and at approximately 8:55 p.m., she inspected Resident 1's room and could not locate him. CNA 1 stated she was assigned to monitor the area near Nursing Station 1, not the patio area, and viewing the residents on the patio from inside the building through the windows that overlooked the patio did not provide adequate supervision for the residents because the patio has blind spots and at night, it was dark. During an interview on 10/10/2024 at 3:45 p.m., RN 3 stated she was assigned to investigate Resident 1's elopement and was to submit the information to the DON within 24 hours after the elopement occurred to ensure a timely investigation was conducted. RN 3 stated she began interviewing witnesses on 10/7/2024 and submitted the incident report to the DON on 10/7/2024. RN 3 stated as of today at 3:45 p.m., six days after Resident 1 eloped, the facility investigation had not been concluded. During an interview on 10/10/2024 at 4:30 p.m., the ADM stated he and the DON did not receive the investigation from RN 3 until 10/7/2024, four days after Resident 1 eloped from the facility. The ADM stated Resident 1 eloped from the facility on Friday 10/4/2024 and the witnesses were not interviewed until Monday, 10/7/2024. The ADM stated it was important to conduct a thorough and prompt investigation of Resident 1's elopement so the facility's current systems and processes could be reviewed and improved as necessary in order to prevent future elopements. The ADM stated it would have been beneficial to the investigation to contact Resident 1's RP to inquire how Resident 1 left the facility. A review of the Facility Assessment (a review of a nursing home's resources and capabilities to care for residents), dated 7/21/2024, indicated the facility maintains adequate staffing necessary to ensure shift to shift coverage was provided for all needs and services. A review of the facility's P&P titled, "Safety and Supervision of Residents," dated 5/2015, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated resident supervision is a core component of the systems approach to safety, the type and frequency of the supervision may vary among residents and over time for the same resident. A review of the facility's P/P titled, "Unusual Occurrence Reporting" dated 8/2018, indicated in accordance with Federal and/or State regulations, unusual occurrences or other reportable events which affect the healthcare, safety and welfare of residents, employees or visitors will be reported. The P/P indicated unusual occurrences will be reported via telephone to 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. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (or appropriate agencies as required by law) within forty-eight (48) of reporting the event or as required by Federal and State regulations. The ADM or designee will keep a copy of any written report on file. A review of the facility's P/P titled, "Accidents and incidents: Residents investigating and Reporting," dated 1/2017, indicated all accidents and incidents involving residents occurring on facility premises shall be investigated and reported to the administrator. The P/P indicated the nurse supervisor/charge nurse or department director shall promptly initiate and document investigation of the accident or incident, the nurse supervisor/charge nurse and or department director shall complete a Report of Incident/Accident form and submit the original to the DON within 24 hours of incident/accident, the DON shall ensure the ADM receives a copy of the "report of incident/accident form for each occurrence. The facility failed to: 1. Ensure Resident 1 was supervised and monitored to prevent him from eloping from the facility in accordance with the facility's P/P titled, "Safety and Supervision of Residents," dated 5/2015 which indicated resident's supervision was a core component of the systems approach to safety. 2. Conduct a thorough and timely investigation following Resident 1's elopement from the facility on 10/4/2024 in accordance with the P/P titled, "Accidents and incidents: Residents investigating and Reporting," dated 1/2017, indicated the nurse in charge shall complete a Report of Incident/Accident form and submit the original to the DON within 24 hours of incident/accident. 3. Report to the CDPH that Resident 1 eloped from the facility on 10/4/2024 within 24 hours of his elopement as indicated in the facility's P/P titled, "Unusual Occurrence Reporting" dated 8/2018. 4. Follow their Policy and Procedure (P/P), titled, "Accidents and Incidents: Residents investigating and Reporting," dated 1/2017, that indicated all accidents and incidents involving residents occurring on facility premises shall be investigated and reported to the administrator. 5. Follow their P/P, titled, "Unusual Occurrence Reporting" dated 8/2018, that indicated unusual occurrences will be reported via telephone to appropriate agencies as required by current law and or regulations within twenty-four hours of such incident or as otherwise required by Federal and State regulations. As a result of these deficient practices Resident 1 eloped from the facility and his whereabouts were unknown to facility staff for over eight hours. When the facility was made aware that Resident 1 eloped from the facility, they did not report Resident 1's elopement to the CDPH within 24 hours, which lead to a delay in the CDPH's investigation. The facility did not conduct a timely or thorough investigation to determine how Resident 1 eloped from the facility to prevent potential elopements in the future. These deficient practices placed Resident 1 at risk of exposure to excessive drops in temperature, motor vehicl