Health inspection·July 22, 2022

F689 - §483.25(d)(1)(2) §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. 22 CCR § 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. On 6/7/22, an unannounced visit was made to the facility to conduct a facility reported incident investigation regarding a patient who wandered out of the facility. The facility failed to provide care and services to prevent accidents to Patient 1 by failing to ensure: 1. All exit doors were locked, and all door alarms were on to keep Patient 1 who had a known history of wandering out of the facility safe. 2. Patient 1’s care plan included strategies and interventions to maintain her safety as indicated in the facility’s policy and procedure. As a result, Patient 1 wandered out of the facility, crossed a busy street, and walked 0.3 miles away from the facility on 5/21/22. A review of Patient 1’s admission record indicated Patient 1 was initially admitted to the facility on 5/25/21 with diagnoses which included dementia (general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Patient 1’s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/30/22, indicated Patient 1's cognitive (ability to think and process information) status was severely impaired. Patient 1 responded adequately to simple, direct communication only and had limited ability to express her needs. The MDS indicated Patient 1 required supervision with most activities of daily living. Patient 1 walked with unsteady gait but was able to stabilize without staff assistance. A review of Patient 1’s Licensed Nurse Progress Note, dated 4/11/22 at 1:40 pm, indicated Patient 1 had an episode of opening the exit door and was found by staff. The Licensed Nurse assessed Patient 1 and found Patient 1 to be confused and disoriented. The Licensed Nurse Progress Note indicated Patient 1 had a wander alarm bracelet (a device worn by a patient which triggers a door alarm to alert staff when the patient gets close to a door) on. A review of Patient 1’s Social Services Progress Note, dated 4/18/22 at 4:11 pm, indicated Patient 1’s family was notified about patient’s episodes of wandering out of the facility and needing a secured/locked facility. The Social Services Progress Note indicated Patient 1 “needed a one-to-one monitoring of her whereabouts at all times.” A review of Patient 1’s Licensed Progress Note, dated 4/18/22 at 10:40 pm, indicated Patient 1 was on observation for wandering in the facility parking lot. The Licensed Progress Note indicated Patient 1 was placed close to the nursing station for close observation. A review of Patient 1’s Elopement/Wandering Risk Care Plan, dated 4/18/22, indicated a goal for Patient 1 to “have no incident of wandering outside of the facility property daily.” The Care Plan interventions indicated to apply a wander alarm bracelet on Patient 1, to check wander alarm bracelet for functioning and placement every shift, encourage family/friends to visit and be involved with patient’s care, encourage group activities and attempt to keep occupied, to encourage patient to be involved with activities of choice, frequent visual checks of patient’s whereabouts, have a current photo of patient in the clinical record, and to provide one-to-one psychosocial support as needed. The Care Plan interventions did not include keeping all exit doors locked and all door alarms on. A review of Patient 1’s Licensed Progress Note, dated 5/21/22 at 10:17 pm, indicated Patient 1 took all her medications and consumed 100% of dinner at 5 pm. The Licensed Progress Note indicated at 6:10 pm staff reported Patient 1 was not in her room and all the staff searched for Patient 1 “all over the facility, room to room, and around the vicinity.” Patient 1 was “found by CNA (Certified Nursing Assistant) across the street and brought back to the facility right away.” The Licensed Progress Note further indicated staff locked all the exit doors. A review of Patient 1’s Elopement Care Plan, dated 5/21/22, indicated Patient 1 eloped from the facility on 5/21/22. The Care Plan interventions included keeping all exit doors locked. A review of the Interdisciplinary Team (IDT, a team of professionals from various disciplines who work in collaboration to address the patient’s care) Review of Patient 1’s 5/21/22 elopement incident, dated 5/23/22 at 9:23 am, indicated, based on root cause of the incident, the IDT recommended to educate staff to make sure all doors are locked. A review of the Facility Investigation Report, dated 5/27/22, indicated the IDT concluded Patient 1 was able to leave the facility through the side door. During an interview with the Administrator on 6/7/22 at 1:15 pm, she stated Patient 1 wandered. The Administrator stated there was a wander alarm (an alarm triggered by a wander alarm bracelet) on the front and back door of the facility. The Administrator said, “We think she (Patient 1) got out through the side door by the smoking area. Sometimes nurses will go out there with patients and forget to lock it.” The Administrator further stated there was no wander alarm on the door to the smoking area. During an interview with CNA 1 on 6/7/22 at 1:30 pm, he stated staff were supposed to keep a close eye on patients who wander and ensure they have a wander alarm bracelet on. CNA 1 stated if not closely monitored Patient 1 will go outside the facility. During an observation on 6/7/22 at 1:37 pm, Patient 1 was observed walking in the hallway with her family. Patient 1 had a wander alarm bracelet on her left wrist. Patient 1 walked with unsteady gait and stabilized herself by holding on to the hallway handrails and/or to family’s arm. Patient 1 walked without any assistive device. During an interview with CNA 2 on 6/7/22 at 1:43 pm, CNA 2 stated Patient 1 wandered and had a wander alarm bracelet on. CNA 2 stated staff kept patients who wander busy with activities and redirected them when they start to wander. During an interview with CNA 4 on 6/7/22 at 1:58 pm, she stated Patient 1 wandered. CNA 4 stated staff were supposed to keep a close eye on patients who wandered and redirect patients who go by the exit doors. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 6/7/22 at 2:06 pm, she stated Patient 1 wandered and had a wander alarm bracelet on. LVN 1 stated Patient 1 was placed on a 30-minute visual check (visually checking patient’s whereabouts) after she wandered out of the facility on 5/21/22. During an interview with LVN 2 on 6/7/22 at 2:13 pm, he stated licensed nurses checked Patient 1’s wander alarm bracelet for placement and function every shift. LVN 2 further stated Patient 1 had a wander alarm bracelet on before she wandered out of the facility on 5/21/22. During a concurrent observation and interview with the Maintenance Supervisor (MS) on 6/7/22 at 2:37 pm, he stated there were two wander alarms in the facility. One wander alarm was by the front lobby door (door from the patient area to the front lobby) and one by the exit door outside the laundry area. The MS stated there were five exit doors in the facility, and all have a door alarm (an alarm that will sound once the door was opened). The MS stated the door to the smoking area did not have a wander alarm, but it had a door alarm. All door alarms were checked with the MS and were all functioning properly. Upon observation of the smoking area with the MS, the smoking area was noted to have easy access to the front parking lot which lead to the street. During an interview with Registered Nurse 2 (RN 2) on 6/7/22 at 3:08 pm, she stated she was busy behind the counter in the front nursing station and had her back turned away from the door when Patient 1 wandered out of the facility on 5/21/22. RN 2 further stated none of the staff on the evening shift (3 pm to 11 pm) heard a door alarm or a wander alarm go off on 5/21/22. RN 2 said, “She (Patient 1) probably went out this side (door to the smoking area) because there is no sensor for [brand name wander alarm bracelet].” RN 2 stated she did not know why the door alarm on the door to the smoking area did not go off. RN 2 stated all staff on the evening shift of 5/21/22 checked all the rooms and checked outside the facility but did not find Patient 1. RN 2 stated all staff checked outside the facility two or three times before they found Patient 1. During an interview with CNA 5 on 6/7/22 at 3:40 pm, CNA 5 stated while he passed out dinner trays on 5/21/22, he could not find Patient 1 and immediately notified all staff. CNA 5 stated he went outside the facility and found Patient 1 walking by the gas station on a big street. CNA 5 stated he crossed the street and talked Patient 1 into going back to the facility with him. CNA 5 said he had to make sure there were no cars before crossing the street with Patient 1. CNA 5 further stated he did not remember hearing any alarms that night. During a phone interview with LVN 4 on 6/7/22 at 3:48 pm, she stated on the evening shift of 5/21/22, CNA 5 reported Patient 1 was not in her room. LVN 4 stated all staff looked all over the facility, out in the parking lot, and on the street, but did not find Patient 1. LVN 4 stated CNA 5 got in his car, saw Patient 1 by the nearest gas station, and brought Patient 1 back to the facility. LVN 4 stated she did not hear any alarms go off that night. LVN 4 further stated patients who smoke ask staff to turn off the alarm to the door to the smoking area so they can go out to smoke on their own. A review of the facility policy titled, “Wandering and Elopements”, dated 3/2019, indicated, “The facility will identify patients who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for patients. If identified as at risk for wandering, elopement, or other safety issues, the patient’s care plan will include strategies and interventions to maintain the patient’s safety.” The facility failed to provide care and services to prevent accidents to Patient 1 by failing to ensure: 1. All exit doors were locked, and all door alarms were on to keep Patient 1 who had a known history of wandering out of the facility safe. 2. Patient 1’s care plan included strategies and interventions to maintain her safety as indicated in the facility’s policy and procedure. As a result, Patient 1 wandered out of the facility, crossed a busy street, and walked 0.3 miles away from the facility on 5/21/22. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1 and other patients who had a known history of wandering out of the facility.