Health inspection·September 17, 2024

Code of Federal Regulations, Title 42, Section 483.25 (d) Accidents. The facility must ensure that – §483.25(d)(1) The patient environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each patient receives adequate supervision and assistance devices to prevent accidents. California Code of Regulations, Title 22, Section 72311. Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. California Code of Regulations, Title 22, Section 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. On 8/15/2024, the California Department of Public Health (CPDH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding quality of care and resident safety. As a result of the investigation, the CDPH determined the facility failed to provide supervision to prevent elopement for Resident 1 who was assessed as at risk for elopement as indicated in the facility's policy and procedure (P&P) titled, "Elopements and Wandering Residents," by failing to: 1. Ensure Janitor 1 (JAN 1) did not unlock the door of the facility's secured unit to allow Resident 1 to leave the facility without a staff chaperone or helper. 2. Ensure a staff chaperone or helper was present to accompany Resident 1 before allowing Resident 1 to leave the facility with the rideshare driver to go to Resident 1's ophthalmologist's appointment scheduled on 8/13/24 at 8 am. As a result of these failures, on 8/13/24 at 7:07 am, Resident 1 left the facility unsupervised to go to Resident 1's ophthalmologist appointment scheduled on 8/13/24 at 8 am. Resident 1 did not check in at the ophthalmologist's office for Resident 1's scheduled appointment. The facility staff were unable to locate Resident 1 and the facility filed a missing person report with the local police department on 8/13/24 at 11:17 am. As of 9/17/24 at 12:18 pm, Resident 1 had not been found. A review of Resident 1's Face Sheet (FS) indicated the facility admitted Resident 1, a 60-year-old male, on 9/7/22, with diagnoses which included diabetes mellitus and schizophrenia. The FS indicated the responsible party for Resident 1 was the facility's Interdisciplinary Team. A review of Resident 1's Wandering Risk Assessment (WRA) dated 12/16/22, indicated Resident 1 was at risk for wandering outside the facility. The WRA indicated the facility tried multiple alternatives but Resident 1 continued to attempt to wander out of facility premises due to Resident 1's delusional thoughts. A review of Resident 1's Physician Order (PO) dated 12/16/22, indicated an order for the facility to admit Resident 1 to the secured unit after Resident 1 attempted multiple times to wander out of the facility. A review of Resident 1's History and Physical dated 9/12/23, indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of Resident 1's untitled Care Plan (CP) dated 9/13/23, indicated Resident 1 was at risk for elopement due to wandering behavior and confusion. The CP indicated Resident 1 exhibited exit-seeking behavior. The CP interventions indicated for the staff to allow Resident 1 to wander within the secured unit and assure that Resident 1's environment was safe and secured. A review of Resident 1's Minimum Data Set (MDS) dated 6/13/24, indicated Resident 1 communicated verbally and required supervision or touching assistance from staff for oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and walking 150 feet. A review of Resident 1's PO dated 7/12/24, indicated an order for an ophthalmologist appointment scheduled on 8/13/24 at 8 am at ophthalmologist's office address. A review of Resident 1's Licensed Personnel Progress Notes (LPPN) dated 8/13/24, timed at 8 am, indicated Licensed Vocational Nurse (LVN) 1, who worked the night shift (on 8/12/2024 from 11 pm to 7 am), informed LVN 3 that Resident 1 left the facility with the rideshare driver at 7:10 am (on 8/13/24). A review of Resident 1's LPPN dated 8/13/24, timed at 12:30 pm, indicated LVN 3 informed LVN 7 that Resident 1 was not at the ophthalmologist's office. The LPPN indicated Resident 1 was dropped off by the rideshare driver at the ophthalmologist's office at 7:58 am (on 8/13/24). The LPPN indicated LVN 7 called the ophthalmologist's office on 8/13/24 at 8:20 am and was unable to speak with anyone. The LPPN indicated Activities Assistant (AA) 1 and the facility's driver (Van Driver [DRV] 1) followed Resident 1 to the ophthalmologist's office but Resident 1 was not there. The LPPN indicated staff at the ophthalmologist's office told AA 1 and DRV 1 Resident 1 did not check in at the ophthalmologist's office (on 8/13/24 at 8 am). The LPPN indicated the facility filed a missing person report with the local police department on 8/13/24 at 11:17 am. A review of Resident 1's Situation, Background, Appearance, Review Communication Form (SBAR) dated 8/13/24, untimed, indicated (on 8/13/24, at 8 am) Resident 1 did not go to Resident 1's scheduled ophthalmologist appointment. The SBAR indicated facility staff called hospitals, shelters, stores, and nearby areas (to locate Resident 1), and involved the local police department (on 8/13/24 at 11:17 am). During an interview on 8/15/24 at 10:18 am, the ADM stated the rideshare driver picked up Resident 1 on 8/13/24 (at 7:10 am) for an appointment with the eye doctor (ophthalmologist). The ADM stated LVN 1 gave the needed paperwork to the rideshare driver for Resident 1's scheduled eye appointment and told the rideshare driver to wait for the staff helper assigned to accompany Resident 1. The ADM stated after LVN 1 gave the paperwork to the rideshare driver, LVN 1 and another staff in the secured unit could not find the driver and Resident 1 inside the secured unit. The ADM stated DRV 1 and AA 1 drove to Resident 1's ophthalmologist's office (on 8/13/24 at 8:20 am) but did not find Resident 1 there. The ADM stated DRV 1 and AA 1 checked all the offices around Resident 1's ophthalmologist's office and the surrounding areas but were unable to find Resident 1. The ADM stated AA 1 went inside Resident 1's ophthalmologist's office and the ADM called the ophthalmologist's office, and the ophthalmologist's office receptionist told the ADM Resident 1 did not show up for Resident 1's appointment. The ADM stated the facility filed a missing person report with the local police department (on 8/13/24 at 11:17 am). The ADM stated Resident 1 was moved to the secured unit in 2022 because Resident 1 tried to leave the facility without staff supervision. The ADM stated AA 1 needed to accompany Resident 1 to Resident 1's eye appointment. During an interview on 8/15/24 at 10:55 am, the Director of Nursing (DON) stated Resident 1 was admitted to the facility on 9/7/22, and was moved to the secured unit on 12/16/22, because Resident 1 was confused and tried to leave the facility without staff supervision. During a concurrent observation of the facility's secured unit, and interview on 8/15/24 at 11:05 am with the DON, in the facility's secured unit, the DON stated Resident 1 and the rideshare driver exited through the locked door of the secured unit located between the Manor (name of a building in the facility) and the Center (name of secured unit building in the facility). The DON stated the facility did not know who opened the locked door of the secured unit to let Resident 1 and the rideshare driver out. The DON stated all the entrance and exit doors in the secured unit were locked and could only be opened with a passcode. A security camera was observed above the secured unit's locked door. The DON stated AA 1, who was the helper assigned to accompany Resident 1 to Resident 1's appointment, needed to be in the secured unit with Resident 1 before the scheduled pick-up time (on 8/13/24 at 7 am), but AA 1 was not there at that time. During an interview on 8/15/24 at 11:10 am, the Social Services Designee (SSD) stated Resident 1's pick-up time for the ophthalmologist's appointment was scheduled for 8/13/24 at 7 am and AA 1 needed to be in the facility by 7 am. During an interview on 8/15/24 at 11:13 am, LVN 2 stated all residents in the secured unit were at risk for elopement and had to be accompanied by a facility staff for any outside appointment. LVN 2 stated any staff in the secured unit must not unlock the door to let any resident and any rideshare driver out without a staff helper. LVN 2 stated only facility staff knew the passcode to open doors in the secured unit. During an interview on 8/15/24 at 11:36 am, Registered Nurse Supervisor 1 (RNS 1) stated all residents in the secured unit were at risk for elopement and needed a chaperone when a resident goes out for "any appointment." RNS 1 stated staff in the secured unit must not unlock the door until the chaperone or helper was with Resident 1. During an interview on 8/15/24 at 11:52 am with LVN 3, LVN 3 stated all residents in the secured unit needed constant supervision and monitoring because they wandered and at risk for elopement. LVN 3 stated residents in the secured unit were not allowed to go out without a staff helper to ensure residents' safety and to prevent elopement. During a concurrent review of the facility's secured unit's video surveillance and interview on 8/15/24 at 12:05 pm with the Director of Maintenance (DOM) and the DON, the surveyor reviewed the facility's secured unit's video surveillance dated 8/13/24 and timed at 7:07 am to 7:08 am with the DOM and the DON. The video surveillance showed a male staff entering the passcode to unlock the door to allow Resident 1 and the rideshare driver to go outside the secured unit on 8/13/24 at 7:07 am. The DON stated the male staff who unlocked the door was JAN 1. During a concurrent review of the facility's secured unit's video surveillance and interview on 8/15/24 at 12:32 pm with JAN 1, the surveyor reviewed the facility’s secured unit’s video surveillance dated 8/13/24 and timed at 7:07 am to 7:08 am with JAN 1. Jan 1 stated the doors to the secured unit were always locked with a passcode and staff could not let residents out without a staff chaperone/helper. JAN 1 stated the male staff on the video surveillance who let Resident 1 and the rideshare driver leave the secured unit was JAN 1. JAN 1 stated JAN 1 thought the rideshare driver with Resident 1 was a facility staff. During an interview on 8/15/24 at 2:46 pm, LVN 3 stated on 8/13/24 at 7:40 am, the SSD informed LVN 3 that Resident 1 left the facility with the rideshare driver and without a staff chaperone. LVN 3 stated on 8/13/24, unable to recall time, LVN 3 asked LVN 7 to call the ophthalmologist's office to verify if Resident 1 checked in for Resident 1's appointment, but LVN 7 was unable to speak with anyone at the ophthalmologist's office (on 8/13/24 at 8:20 am). LVN 3 stated the ADM informed LVN 3 at 8:51 am (on 8/13/24) that Resident 1 never made it to Resident 1's appointment. During an interview on 8/15/24 at 3:10 pm, the DON stated Resident 1 had an eye appointment on 8/13/24 (at 8 am). The rideshare driver arrived at the facility's secured unit to pick up Resident 1 (on 8/13/24 at 7:07 am) but AA 1, who was the assigned helper to accompany Resident 1, was not in the facility yet. The DON stated LVN 1 told the rideshare driver to wait for AA 1 to arrive, but the rideshare driver did not wait and left the facility with Resident 1. During an interview on 8/15/24 at 3:36 pm, AA 1 stated on 8/13/24 (at 7 am) AA 1 was supposed to go with Resident 1 to the ophthalmologist's office but AA 1 did not wake up on time and was running late. AA 1 stated DRV 1 called AA 1 at 7 am to remind AA 1 of Resident 1's appointment, and AA 1 informed DRV 1 that AA 1 was running late. AA 1 stated as soon as AA 1 arrived at the facility on 8/13/24, unable to recall time, DRV 1 told AA 1 they had to follow Resident 1 to the ophthalmologist's office. AA 1 stated as soon as they (DRV 1 and AA 1) got to the ophthalmologist's office on 8/13/24 at 8:20 am, the receptionist told them Resident 1 did not check in for Resident 1's appointment. AA 1 checked all the offices in the building and DRV 1 drove around the streets near the ophthalmologist office. AA 1 stated when they (DRV 1 and AA 1) could not find Resident 1 they notified the SSD and an LVN. AA 1 stated AA 1 usually accompanied residents to their appointments and that was the first time AA 1 was late. During an interview on 8/15/24 at 4:29 pm, the SSD stated on 8/13/24 at 7:30 am, LVN 3 called the SSD and informed the SSD that Resident 1 left the facility to go to the ophthalmologist's office with the rideshare driver without a staff helper. The SSD stated the SSD called Resident 1's insurance company, on 8/13/24 at 7:35 am, to find out how to get a hold of the rideshare driver because Resident 1's insurance company was the one who arranged the rideshare service. The SSD stated Resident 1's insurance representative informed the SSD that Resident 1 was dropped off by the rideshare driver at the ophthalmologist's office at 7:58 am. The SSD stated the receptionist at the ophthalmologist's office verified Resident 1 had an appointment but Resident 1 never checked in. The SSD stated residents in the secured unit were not allowed to go outside the building without a staff chaperone/helper or a family member. During a phone interview on 8/16/24 at 11:30 am, LVN 1 stated Resident 1 had a doctor's appointment on 8/13/24 (at 8 am) and the rideshare driver arrived to pick up Resident 1 between 7:05 am to 7:10 am. LVN 1 told the rideshare driver to wait inside the secured unit so LVN 1 could find out where AA 1 was. LVN 1 stated Resident 1 and the rideshare driver were standing in the hallway by the secured unit's door between the Manor and the Center, while LVN 1 called the supervisor's office to find out where AA 1 was. LVN 1 stated when LVN 1 hung up the phone, Resident 1 and the rideshare driver were no longer standing in the hallway by the door. LVN 1 stated LVN 1 alerted LVN 3 and LVN 2. LVN 1 stated this happened during shift change, and nurses were coming in and out of the secured unit's door. LVN 1 stated Helper (HLP) 1 looked outside the facility for Resident 1 and the rideshare driver, but HLP 1 did not find Resident 1 and the rideshare driver. LVN 1 stated staff were not supposed to let residents out without staff supervision. LVN 1 stated residents in the secured unit were at risk for elopement and it was important to have a staff helper with them whenever the residents went outside so they would not wander away. A review of the facility’s P&P titled, "Elopements and Wandering Residents," dated 2/2020, indicated "the facility ensured residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk." The P&P indicated "the facility established and utilized a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary." The P&P indicated "adequate supervision would be provided to help prevent accidents or elopement." The facility failed to provide supervision to prevent elopement for Resident 1 who was assessed as at risk for elopement as indicated in the facility's P&P titled, "Elopements and Wandering Residents," by failing to: 1. Ensure JAN 1 did not unlock the door of the facility's secured unit to allow Resident 1 to leave the facility without a staff chaperone or helper. 2. Ensure a staff chaperone or helper was