Health inspection·July 19, 2023

F 689 483.25(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(a) 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. On 5/30/2023, the California Department of Public Health (CDPH), received a facility reported incident (FRI) reporting Resident 1 went missing. A search was conducted, and Resident 1 was not found. On 5/30/2023, at 1 p.m., an unannounced visit was made at the facility to investigate the FRI. Upon investigation, it was determined Resident 1, who was assessed as risk for elopement, eloped (leave without notice) from a door in the facility whose alarm was not triggered and was silent, allowing Resident 1 to exit the building unnoticed by facility staff and leave the facility’s premises through a patio gate that remained unlocked between the hours of 11 p.m. to 7 a.m. The facility failed to: 1. Ensure Resident 1, who was assessed as risk for elopement, was supervised to prevent him from eloping from the facility. 2. Ensure the facility’s exit door’s alarms were activated and working properly. 3. Ensure the facility’s patio gate was locked between the hours of 11 p.m. to 7 a.m., per the practice of the facility. 4. Ensure the facility’s undated policy and procedure (P/P), titled, “Safety and Supervision of Residents” was followed that stipulated, resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 5. Ensure the facility’s undated P&P, titled, "Care Plans, Comprehensive Person-Centered," was followed that stipulated a comprehensive, person-centered care plan is developed and implemented for each resident. As a result, Resident 1 eloped from the facility on 5/26/2023 at 4:25 a.m., unbeknownst to staff, placing Resident 1 and other residents at risk for injury, and/or death. A review Resident 1’s Admission Record (Face Sheet), indicated, Resident 1, an 82 year-old male, was admitted to the facility on 4/7/2023 with diagnoses including unspecified psychosis (a mental disorder that causes abnormal thinking and perceptions), seizures (abnormal electrical brain activity that causes sudden, uncontrollable body movements), chronic kidney disease ([CKD] damage to the kidneys and cannot filter blood as well as it used to), and major depressive disorder disease ([MDD] a mood disorder that causes persistent feeling of sadness and loss of interest). A review of Resident 1’s Minimum Data Set ([MDS] a standard assessment and care screening tool), dated 4/13/2023, indicated, Resident 1’s cognitive (process of thinking) skills for daily decision making were moderately impaired. A review of Resident 1’s History and Physical (H&P), dated 4/12/2023, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Elopement Risk Evaluation (ERE), dated 4/7/2023, indicated a score of 10 (a score of 10 or above is considered at risk for elopement). A review of Resident 1’s Care Plans (CP) indicated there was no CP developed related to Resident 1’s risk for elopement. A review of Resident 1's Social Services Progress Notes (SSPN), dated 5/25/2023 and timed at 11:29 a.m., indicated Resident 1 reported he wanted to go to the hospital (a general acute care hospital [GACH]) where he used to live. A review of Resident 1's Nursing Progress Note (NPN), dated 5/26/2023 and timed at 10:49 a.m., indicated Resident 1 was missing at 7:45 a.m. The staff began a search for Resident 1 and the police were notified at 8:15 a.m. A review of Resident 1's NPN, dated 5/27/2023 and timed at 9:04 a.m., indicated Resident 1 was brought back to the facility on 5/27/2023 at 8:15 a.m., by two Certified Nurse Assistants (CNA 2 and CNA 3) who picked Resident 1 up from the GACH approximately 29 miles away from the facility. During an interview on 5/30/2023, at 1:25 p.m., Resident 1 stated, he left the facility on 5/26/2023 and took the bus and the train to the GACH to visit his friend. Resident 1 stated, the day before he left (5/25/2023), he spoke with the Social Services Director (SSD) about going to the GACH. Resident 1 stated, he saw staff coming in and out of the patio gate and he left when it was not busy and no one was around, when the gate was not locked, and when the alarm was off. During an interview on 5/30/2023, at 1:35 p.m., the Activity Staff (AS) stated the staff on the 3 p.m., to 11 p.m., shift used the patio gate to enter the facility because the front entrance was locked. The AS stated the patio gate was always unlocked at night and not supervised and anyone could walk out of the patio gate. During an interview on 5/30/2023, at 2:29 p.m., Registered Nurse 1 (RN 1) stated on 5/26/2023 when she started her shift at 6 a.m., she was not able to do her rounds and check on her residents because RN 3 needed assistance with another resident. RN 1 stated, at 7:40 a.m., a CNA 4 notified her that Resident 1 could not be found, and she (RN 1) activated code green (code to alert staff within the facility of a missing resident) and began a search of the building for Resident 1. RN 1 stated, Resident 1 was not found, and the police was called. RN 1 stated, Resident 1 did not receive his medications for high blood pressure and seizures the day he left the facility. During an interview on 5/30/2023, at 3:19 p.m., the Maintenance Supervisor (MS) stated, between 8 p.m., to 7 a.m., there were no staff to monitor the front door and the patio gate was unlocked at night and used as an entrance and exit for staff, medication deliveries, and others who came to the facility for services. The MS stated, when the patio gate was unlocked at 8 p.m., the alarm to the exit door to Hallway 8 (that leads to the patio) should be turned on. The MS stated, at 7 a.m., he turns the alarm off on the exit doors and locks the patio gate. During an interview on 5/30/2023, at 3:42 p.m., RN 2 stated she was responsible for turning on the alarm on the exit door in Hallway 8 at 7 p.m. RN 2 stated during the shift change at 11 p.m., the 11 p.m., to 7 a.m., staff uses the patio gate to enter and exit the facility. RN 2 stated, she turns the alarm off to allow staff to enter and exit through the patio gate. RN 2 stated, she was responsible to turn the alarm back on. During a telephone interview on 5/31/2023, at 9:57 a.m., CNA 1 stated, she did not recall hearing any door alarm on 5/26/2023 at 4:25 a.m. (the time Resident 1 was witnessed leaving the facility via the facility’s security surveillance video). CNA 1 stated, she usually enters the facility through the exit door in Hallway 8 and the patio gate was unlocked. CNA 1 stated the exit door was automated and would open when someone approached the door. During an interview and concurrent review of the facility security surveillance video on 5/31/2023 at 10:35 a.m., with the Director of Nursing (DON) the video revealed that on 5/26/2023, at 4:25 a.m., Resident 1 was seen in his wheelchair exiting through the facility’s exit door then leaving the facility’s property through the patio gate. The DON stated, the alarm to the exit door was supposed to be on and if the alarm had gone off when Resident 1 left through the exit door, staff were supposed to see what had happened. The DON stated, after reviewing the facility’s security surveillance video, “the alarm was not on.” During an interview on 5/31/2023, at 11:12 a.m., RN 3 stated, the exit door’s alarm did not go off when Resident 1 eloped from the facility and it should have. RN 3 stated, the patio gate was unlocked from 8 p.m., until 7 a.m., and both the exit door and the patio gate were used by staff. RN 3 stated, unlocking the patio gate from 8 p.m., until 7 a.m., was the practice of the facility’s staff over the last seven that he had been working at the facility. RN 3 stated he did not check to see if the alarm was on during his shift (11 p.m.-7 a.m.) on 5/25/2023 and it was the registered nurse who was on duty, responsibility to lock the patio gate. RN 3 stated, the unarmed (alarm not turned on) door and the unlocked patio gate allowed Resident 1 to exit the facility. During an interview on 5/31/2023, at 11:50 a.m., the DON stated, staff should conduct rounds to check on their residents at the beginning of their shift, during the shift, and when endorsement is made to staff on the incoming shift. The DON stated, CNAs should conduct rounds on their residents every two hours and as needed. The DON stated staff did not check on Resident 1 as required because Resident 1 eloped from the facility at 4:26 a.m., and the staff did not realize until 7:30 a.m., that Resident 1 was gone. During an interview with the MDS Nurse on 6/1/2023 at 9:29 a.m., and concurrent review of Resident 1’s CPs, the MDS Nurse stated Resident 1 was assessed as being at risk for elopement upon admission on 4/7/2023 and a CP should have been developed related to his elopement risk. The MDS Nurse verified there was no CP in Resident 1’s clinical record related to his elopement risk. The MDS Nurse stated the purpose of a CP was to ensure residents get the proper care and necessary interventions. During an interview at 12:18 p.m., the DON stated Resident 1’s elopement score of 10 should have alerted staff to develop a CP and the MDS nurse should have caught that a CP was not developed during the audit for new admissions. During an interview on 6/1/2023, at 11 a.m., the Administrator (ADM) stated, the practice of the facility was to leave the exit door unlocked and to lock the patio gate and the RN supervisor was to ensure the patio gate was locked at night. The ADM stated, the exit door was never locked, and the alarm was never used because it was not a locked facility. The ADM stated the alarm on the exit door was not used because the RN supervisor was supposed to lock the patio gate. During a review of the facility's P&P, titled "Care Plans, Comprehensive Person-Centered," revised 3/2022, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. A review of the facility’s P&P, titled, “Safety and Supervision of Residents,” dated 7/2017, the P&P 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 facility failed to: 1. Ensure Resident 1, who was assessed as risk for elopement, was supervised to prevent him from eloping the facility. 2. Ensure the facility’s exit door’s alarms were activated and working properly. 3. Ensure the facility’s patio gate was locked between the hours of 11 p.m. to 7 a.m., per the practice of the facility. 4. Ensure the facility’s policy and procedure (P/P) titled, “Safety and Supervision of Residents” was followed that stipulated, resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 5. Ensure the facility’s P&P titled, “"Care Plans, Comprehensive Person-Centered," was followed that stipulated a comprehensive, person-centered care plan is developed and implemented for each resident. As a result, Resident 1 eloped from the facility unbeknownst to staff, placing Resident 1 and other residents at risk for injury. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.