Health inspection·December 24, 2024

§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 11/6/2024 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 11/4/2024. On 11/6/2024, CDPH conducted an unannounced visit to the facility to investigate the FRI. Upon investigation, CDPH determined: The facility failed to: 1. Supervise Resident 1 by conducting observations of Resident 1's whereabouts and monitor the resident every shift for episodes of wandering or attempting to elope from the facility as indicted in the resident's untitled Care Plan dated 8/20/2024. 2. Ensure staff responded to the entrance/exit door alarm at the time Resident 1 was leaving through this door. 3. Ensure staff followed the facility Procedure and Policy (P&P) titled, "Wandering Unsafe Resident" to have a detailed monitoring plan in place to always know Resident 1's whereabouts. These deficient practices resulted in Resident 1 leaving the facility unnoticed and placed Resident 1 at risk for unsafe environmental conditions, including extreme heat and/or cold, possible motor vehicle accident, and medical complications such as stroke (a medical emergency a bleeding in the brain due to uncontrolled high blood pressure [force of blood pushing against the walls of blood vessels]) due to missing her high blood pressure medications from 11/4/2024. Resident 1 was found on 11/15/2024 in the neighborhood where her family lives. Resident 1 refused to come back to the facility and refused to be assessed by the Emergency Medical Transport (EMT). A review of Resident 1's Admission Record, indicated the resident was initially admitted to the facility on 5/22/2024 and re-admitted on 8/19/2024 with diagnoses including schizophrenia (a chronic and severe mental disorder that affects how the person thinks, feels, and behaves) unspecified, psychosis (a condition that affects the way your brain processes information), paraplegia (the inability to voluntary move the lower parts of the body) and hypertension (high blood pressure). A review of Resident 1's history and physical (H&P), dated 8/21/2024, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] resident assessment tool), dated 8/30/2024, indicated Resident 1 required substantial/maximal assistance (helper lifts or hold trunk of limbs and provides more than half the effort) with putting on and taking off footwear and performing personal hygiene. The MDS indicated Resident 1 used a wheelchair for mobility. A review of Resident 1's Initial Wandering Assessment dated 8/19/2024, indicated the resident had a history of wandering and required frequent monitoring. A review of Resident 1's Psychiatric (involving mental illness or its treatment) Follow Up Note dated 10/24/2024, indicated Resident 1 had episodes of auditory hallucinations (hearing sounds that are not based in reality). A review of Resident 1's Physician's Order dated 11/1/2024, indicated the physician's order for Amlodipine Besylate Oral tablet 5 milligrams ([mg] a unit of measurement of mass) one time daily for hypertension ([HTN] high blood pressure). A review of Resident 1's Progress Notes dated 11/5/2024, indicated on 11/4/2024 between 9:30 p.m. and 10:30 p.m., Certified Nursing Assistant (CNA 2) was unable to locate Resident 1 within the facility. On 11/4/2024 at 11:20 p.m., CNA 2 reported to Licensed Vocational Nurse (LVN 2) that Resident 1 was missing. CNA 2 and LVN 2 did not find Resident 1 but found Resident 1's wander guard with the strap broken on her bed side table. The facility staff searched for Resident 1 inside the facility and the surrounding areas outside and did not find Resident 1. During an interview and record review on 11/7/2024 at 10:39 a.m., with LVN 3 and the Director of Nursing (DON), Resident 1's Initial Wandering Assessment dated 8/19/2024 was reviewed. The assessment indicated Resident 1 had a score of three which indicated Resident 1 had a history of wandering and required frequent monitoring. LVN 3 stated he did not know what severity a score of three meant. The DON stated that any score above a one indicated a risk for elopement. The DON stated a score of three meant the resident was at high risk for wandering and elopement. A review of Resident 1's untitled Care Plan dated 8/20/2024, indicated Resident 1 had a potential for injury and or accidents related to wandering or attempting to leave the facility unassisted. The goals set for Resident 1 included the resident's potential for injury and or accidents related to wandering or attempting to leave the facility would be minimized daily, with a target date of 11/30/2024. The Care Plan interventions included constant observations of Resident 1's whereabouts, monitor for episodes of wandering or attempting elopement every shift (tally by episodes), redirection, cueing as appropriate and apply Wander Guard alarm (system to alarm staff of a potential elopement when resident attempts to get out of the facility) device and monitor Wander Guard device every shift for placement. During a tour of the facility on 11/6/2024 at 11:00 a.m., a total of six exit doors were observed of which Doors 1 - 4 were equipped with a wander guard monitor sensor and a code padlock (needs a pass code to open the doors). During an observation on 11/06/2024 at 11:15 a.m., Door 5 was located by Resident 1's room and led to the parking lot. The facility staff use Door 5 to enter and leave the building. Door 5 did not need a pass code to open. To leave through Door 5 one must press the push bar on the door for 15 seconds to unlock the door, and the alarm will sound for 15 seconds then shuts off. On 11/6/2024 at 12:41 p.m., during an interview CNA 2 stated that staff are supposed to do a head count of the residents every two hours. CNA 2 stated that Resident 1 liked to use her wheelchair to wheel herself in the middle and around the building. CNA 2 stated that staff check the exits for wandering residents when they hear the alarms but there are alarms going off all the time in the facility, she was not sure if someone responded when Resident 1 left. On 11/6/2024 at 1:00 p.m., during an interview LVN 2 stated that the Wander Guards are used for residents that attempt to elope. LVN 2 stated that the 3:00 p.m. to 11:00 p.m. shift had checked the Wander Guards for function on 11/4/2024, and they were functional. During a telephone interview on 11/6/2024 at 1:40 p.m., CNA 1 stated she was Resident 1's nurse on 11/4/2024 from 3:00 p.m. to 10:30 p.m. CNA 1 stated she asked Resident 1 at 9:00 p.m., if she was ready for bed and Resident one refused. CNA 1 stated Resident 1 wanted to stay in her wheelchair which was very unusual. CNA 1 stated the last time she saw Resident 1 when she was sitting at the nursing station which is close to the employee entrance /exit. During an interview on 11/7/2024 at 4:58 p.m., the DON stated that the facility relied too much on the Wander Guard system to keep residents from eloping. The DON stated the facility should have also implemented additional interventions such as hourly monitoring of resident's whereabouts, designate staff to monitor the entrance and exits, and designated staff to monitor the hallways. The DON stated there was no documentation to indicate Facility staff were monitoring Resident 1, frequently. During a review of the facility's P/P titled, "Wandering Unsafe Resident" undated, the P/P indicated the facility will identify residents at risk for harm because of unsafe wandering (including elopement) and staff will include a detailed monitoring plan, as indicated for residents who are assessed to have a high risk for elopement. The facility failed to: 1. Supervise Resident 1 by conducting observations of Resident 1's whereabouts and monitor the resident every shift for episodes of wandering or attempting to elope from the facility as indicted in the resident's untitled Care Plan dated 8/20/2024. 2. Ensure staff responded to the entrance/exit door alarm at the time Resident 1 was leaving through this door. 3. Ensure staff followed the facility Procedure and Policy (P&P) titled, "Wandering Unsafe Resident" to have a detailed monitoring plan in place to always know Resident 1's whereabouts. These deficient practices resulted in Resident 1 leaving the facility unnoticed and placed Resident 1 at risk for unsafe environmental conditions, including extreme heat and/or cold, possible motor vehicle accident, and medical complications such as stroke due to missing her high blood pressure medications from 11/4/2024. Resident 1 was found on 11/15/2024 in the neighborhood where her family lives. Resident 1 refused to come back to the facility and refused to be assessed by the EMT. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.