Health inspection·March 18, 2024

F689 §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. 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 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. An unannounced visit was conducted by California Department of Public Health on 2/1/2024 at 8 AM to investigate a facility reported incident regarding resident’s safety related to patient elopement (leaving the facility without the staff’s knowledge and/ or supervision). The facility failed to supervise and ensure the safety of Patient 1 and 2 in accordance with the facility’s policy and procedure by failing to: 1. Provide a sitter (one staff- to- one resident to provide monitoring) for Patient 1 who is at risk for elopement in accordance with the patient’s care plan. 2. Supervise Patient 2 and ensure the patient signed out and followed the facility’s out on pass (OOP; a non-medical visit outside of the facility mostly used for visits with family or friends) procedure when the patient left the facility on 1/30/2024. These deficient practices resulted in Patient 1 elopement on 1/20/2024 at 5:45 AM and was brought back by the local police department to the facility on 1/20/2024 at 6:20 PM. Patient 2 left the facility on 1/30/2024 and patient’s whereabouts were unknown from 1/30/2024 to 3/2/2024. 1. A review of the admission record indicated Patient 1 is a 84- year- old male who was admitted to the facility on 1/18/2024, with diagnoses that included acute ischemic heart disease (heart weakening caused by reduced blood flow to the heart), unspecific dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), mood disturbance (feelings of distress or sadness, or symptoms of depression and anxiety) and anxiety (feelings of fear, dread and uneasiness). A review of the History and Physical (H&P) report completed on 1/20/2024, indicated Patient 1 did not have the capacity to understand and make decisions. A review of the Minimum Data Set (MDS- a comprehensive assessment tool) dated 1/22/2024, indicated Patient 1 was independent and did not require physical assistance with eating, bed mobility, hygiene, and toilet use. A review of the care plan initiated on 1/18/2024, indicated Patient 1 was at risk for elopement related to dementia episodes and with attempts of elopement on 1/19/2024 and on 1/20/2024. The care plan indicated the following interventions: a. Assign one to one (one person deals directly with only one other person) CNA to take care of him and prevent elopement. b. Visually monitoring the patient every 15 minutes every shift. A review of the facilities Interdisciplinary Team Notes dated 1/19/2024 indicated, “Plan of Care: Frequent visual checks, elopement risk.” During an interview with the Director of Nursing (DON) on 2/2/2024 at 8:05 AM, the DON stated, “On the day he was admitted (1/18/2024) he was ok, at nighttime according to 11PM-7AM shift (night shift), he (Patient 1) tried to get out of the building.” During an interview with Social Service Director (SSD) on 2/2/2024 at 8:27 AM, SSD stated, “that Patient 1 was admitted on Thursday’s night (1/18/2024). On Monday (1/22/2024) when I came in, I heard he eloped on the weekend. I did see him on Friday when I was leaving the facility and Patient 1 did say he wanted to leave and go home.” During an interview with License Vocational Nurse (LVN3) on 2/2/2024 at 8:53 AM, LVN3 stated, “When a patient is assigned a sitter if they are ambulatory, the sitter must go with the patient wherever he goes. For example, if the patient is sleeping, the sitter stays at bedside. If the sitter has to go on a break, we find someone to replace her. The sitter is not supposed to leave at any time away from the patient. The sitter must always ask for someone to cover or charge nurse will do so. In other words, a sitter must remain with the patient at all times. It is for the patient’s safety.” During an interview with Certified Nurse Assistant (CNA3) on 2/2/2024 at 9:22 AM, CNA3 stated, “As a sitter, I have to take the patient to the bathroom, feed him, be with him at bedside, walk with him, stay with the patient at all times. If I need a break, we have to ask another CNA to cover but we know we are never to leave the patient alone, there must always be someone there with the resident at all times. There is no time when you can leave a patient that has a sitter alone, because at that moment they can leave, they can fall, or anything can happen. It is for the resident’s safety.” During an interview with CNA2 on 2/05/2024 at 2:10 PM, CNA2 stated, he was working at the facility on 1/19/2024, 11PM-7AM shift and was assigned to Patient 1. CNA2 also stated he was not a sitter for Patient 1 on 1/19/2024, that night he was assigned as a CNA to other residents and did work with Patient 1 but not as a sitter. CNA2 further stated, around 5 AM (1/20/2024) was the last time CNA2 saw Patient 1. CNA2 also stated, Patient 1 was sleeping most of the night except around 4:30 AM when he got up and went to the nursing station. CNA2 added, he went back to check Patient 1 around 5:45AM and the resident was no longer there in the facility. During an interview with CNA4 on 2/06/2024 at 10:12 AM, CNA4 stated he works the 11PM-7AM shift. CNA4 stated, CNA4 was working the night when Patient 1 went missing. The patient did not have a sitter that night (1/19/2024) when the resident eloped. During a concurrent interview and record review with the DON on 2/06/20204 at 10:33 AM, the DON stated, Patient 1 ’s care plans interventions included a 1:1 sitter and staffing assignment for 1/19/2024 at night shift indicated CNA2 as a CNA for Patient 1 and other residents and not a sitter for Patient 1. During a concurrent interview with Admin on 2/06/2024 at 10:39 AM, Admin stated CNA2 was not a sitter for Patient 1 on 1/19/2024 night shift. During a concurrent interview and record review with the DON on 2/06/20204 at 11:21 AM, the DN stated, CNA 2 was not a sitter for Patient 1 on 1/19/2024 at night shift. The DON stated, a sitter is a dedicated person beside him (Patient 1), at all times.” The DON stated, there should have been a sitter because the resident was not easily redirected, he was just looking for a time to run away, he was so desperate, maybe if it would have been a dedicate sitter, Patient 1 would not have left. The DON also stated, the dedicated sitter to the residents cannot leave the patient’s bedside and even if they go to the bathroom, they must ask for someone to cover them. During a review of the facilities Policy and Procedure titled “Wandering and Elopements”, revised 3/2019 indicated, “the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy also indicated, if identified as at risk for wandering, elopement, or other safety issues, the resident’s care plan will include strategies and interventions to maintain the resident’s safety. A review of the facilities Policy and Procedure titled “Care Plans, Comprehensive Person-Centered” revised 3/2022 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.” 2. During a review of the Admission Record indicated Patient 2 is a 47- year-old- male who was initially admitted to the facility on 5/25/2023 with diagnoses of cord compression (a condition that puts pressure on your spinal cord) and osteomyelitis (swelling of the bone or bone marrow, usually due to infection). During a review of Patient 2’s H&P, dated 5/26/2023, indicated the resident has the capacity to understand and make decisions. During a review of Patient 2’s MDS, dated 12/5/2023, the MDS indicated the resident was cognitively intact (ability to think, remember, and reason) and needed supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with transfers (how resident moves to and from bed, chair, wheelchair, standing position), dressing (how a resident puts on, fastens and takes off all items of clothing) and personal hygiene and was independent with walking and eating. During a review of Patient 2’s Order Summary Report dated January 2024, Order Summary Report indicated Patient 2 may go OOP, a minimum of four hours. During an interview on 2/2/2024 at 9:50 AM with Registered Nurse 1 (RN 1), RN 1 stated that on 1/30/2024 when she came in for work at 3 PM, she was notified by Licensed Vocational Nurse 1 (LVN 1) that Patient 2 left the facility earlier that day, and the patient did not sign OOP and has not been back. RN 1 stated that around 6:30 PM when the patient still has not returned. RN 1 also stated the next day 1/31/2024 Patient 2 still had not returned to the facility and the police authorities were contacted to report him missing. During an interview on 2/2/2024 at 10:21 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that on 1/30/2024 around 2 PM he was approached by Patient 2 in the hallway who told him he was going out. LVN 1 stated he thought Patient 2 was only going to sit outside so he did not ask the patient to sign OOP. During a concurrent interview and record review on 2/2/2024 at 12:55 PM with the Director of Nursing (DON), Patient 2’s Elopement Care Plan, dated 9/17/2023 was reviewed. Patient 2’s Elopement care plan indicated, the patient was at risk for elopement and had documented interventions to, “distract patient from wandering by offering pleasant diversions, and structured activities of choice.” The DON stated the interventions were not applicable for Patient 2 and should have been reassessed and revised. During an interview on 2/2/2024 at 12:55 PM with the DON, the DON stated it is important for patients to follow the facility’s policy and sign OOP before leaving the facility even if it is just to smoke so that the facility staff know where they are and can monitor them if needed. During an interview on 2/2/2024 at 3:09 PM with Administrator (ADM), ADM stated they need to have a more consistent plan and intervention for patients who are at risk for wandering (moving from place to place without a fixed plan) and elopement other than redirection. ADM also stated they need to review their “Wandering and Elopements” policy again and reassess criteria for assessing patients for elopement, how often their interventions are being reevaluated and what additional interventions they need to have in place aside from redirecting the patients if not effective. During an interview on 3/14/2024 at 3:37 PM with ADM, ADM stated Patient 2 showed up at his daughter’s house on 3/2/2024 at 8:21 PM. During a review of the facilities Policy and Procedures titled “Emergency Procedure-Missing Resident” revised 8/2018 indicated, “residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety.” During a review of the facility’s policy and procedure (P&P) titled, “Wandering and Elopements,” revised 3/2019, the P&P indicated: · “If an employee observes a resident leaving the premises, he/she should: o Attempt to prevent the resident from leaving in a courteous manner. o Get help from other staff members in the immediate vicinity, if necessary; and o Instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises.” During a review of the facility’s P&P titled, “Out On Pass (OOP)/Therapeutic Leave,” (undated), the P&P indicated, “Resident/Responsible party to complete sign Out-On pass logbook.” The facility failed to supervise and ensure the safety of Patient 1 and 2 in accordance with the facility’s policy and procedure by failing to: 1. Provide a sitter for Patient 1 who is at risk for elopement in accordance with the patient’s care plan. 2. Supervise Patient 2 and ensure the patient signed out and followed the facility’s out on pass procedure when the patient left the facility on 1/30/2024. These deficient practices resulted in Patient 1 elopement on 1/20/2024 at 5:45 AM and was brought back by the local police department to the facility on 1/20/2024 at 6:20 PM. Patient 2 left the facility on 1/30/2024 and patient’s whereabouts were unknown from 1/30/2024 to 3/2/2024. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1 and 2.