Health inspection·December 20, 2024

T22 § 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. F689 §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. On 11/20/2024 at 9 AM, an unannounced visit was conducted at the facility to investigate a Facility Report Incident (FRI) regarding patient safety and elopement (the act of leaving a facility premises or a safe area without notifying anyone) that involved Patient 1 who eloped from the facility on 11/18/2024 at 6:27 PM. As a result of the investigation, the Department determined that the facility failed to provide a hazard free environment, monitoring, and supervision to Patient 1 with history of Opiate (a substance used to treat pain or cause sleep), Fentanyl (a powerful synthetic opioid that can be used for surgery or to treat severe pain) and substance abuse (use of illegal drugs or prescription or over-the-counter drugs or alcohol for purposes other than those for which they are meant to be used, or in excessive amounts) in accordance with facility’s policy and procedure titled “Elopement Precautions” by failing to ensure: 1. A facility staff was present outside the facility to monitor and supervise Patient 1 who was heard climbing the roof and jumped over the two fences to reach the street and eloped. 2. There was no opening gap between Building B and the fence on the roof where Patient 1 climbed to and exited to the roof and jumped off the roof, jumped off two fences into the street and eloped. 3. Assess Patient 1’s risk for elopement upon admission to the facility and develop a plan of care to prevent wandering and elopement. After Patient 1 eloped the facility found out Patient 1 had a history of elopement from an assisted living facility (facilities that provide both housing and personal care). These deficient practices resulted as of 11/20/2024, Patient 1 remained missing and exposed environmental hazards and extreme cold weather conditions, which could lead to low body temperature, dehydration (when the body does not have enough water and other fluids to carry out its normal functions), injuries associated to fall from climbing the roof and fences and from motor vehicle accidents, and vulnerability to substance abuse. During a review of Patient 1’s Admission Record, indicated the facility admitted Patient 1, a 20 years old male, on 11/12/2024, with diagnoses including mild intellectual disabilities (condition where a person has an average mental age of between 9 and 12), and attention-deficit hyperactivity disorder (a neurodevelopmental disorder that affects a person's behavior, memory, motor skills, or ability to learn with symptoms that included inattention and hyperactivity). During a review of Patient 1’s “History and Physical” (H&P), dated 11/13/2024 indicated, Patient 1 had a history of Opiate, Fentanyl and substance abuse. During a review of Patient 1's Minimum Data Set (MDS-a federally mandated patient assessment tool), dated 11/17/2024, indicated Patient 1's cognitive (the ability to think and process information) skills for daily decisions making was intact. The MDS indicated Patient 1 was independent with eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, walk 150 feet. A review of the Elopement and Wandering Risk Assessment dated 11/18/2024, with the Administrator (ADM), indicated Patient 1 was not at risk for wandering and elopement. In addition, there was no documented evidence that Patient 1 was assessed for an Elopement and Wandering Risk when Patient 1 was admitted to the facility on 11/12/2024. A review of Patient 1’s clinical record indicated no documented evidence that a plan of care was developed to address elopement risk. During an interview with the ADM on 11/20/2024 at 9:05 AM, the ADM stated it was brought to her attention that after Patient 1's eloped Patient 1 previously eloped from another assisted living facility. The ADM stated, there was no documentation or proof of these tendencies at our facility. The ADM stated Patient 1 was admitted through a court order, and his elopement could result in him being sent back to jail. During a review of the facility’s investigation report conducted with the ADM on 11/20/2024 at 9:20 AM, indicated on 11/18/2024 at 6 PM, during a Core Group Session (a group activity for the patients), Patient 1 approached a facility staff if he was able to participate in the community break (smoke break), the staff informed Patient 1 that he would not be allowed to attend the break. Patient 1 appeared to accept this decision and stated that he would go to bed. On 11/18/2024 at approximately 6:27 PM, Patient 1 stepped out of the group and was heard climbing onto the roof of Building B. a facility staff, a Program Counselor 1 (PC 1) immediately called a "Code Green," (the facility's emergency code to alert staff of a missing or eloping patient) at approximately 6:30 PM on the same date. The report indicated, PC 1 observed Patient 1 running onto the roof and then heard him climbing a fence next to Building B. According to the report, PC 1 heard Patient 1 jump to the ground near the Maintenance Office and proceeded to climb another fence located nearby the side street and when the staff yelled for Patient 1 to stop, the patient was not receptive. The report indicated Patient 1 continued to run, and staff eventually lost sight of the patient, unable to determine which direction the patient escaped to, the police department were contacted, and upon their arrival at the facility. The report indicated Patient 2 approached the staffs and reported that Patient 1 told him earlier that he planned to leave the facility and apologized for not informing staff sooner and stated he did not believe Patient 1 would follow through with his plan to leave. During an interview on 11/20/2024 at 9:05 AM, the ADM stated Patient 1’s incident of elopement was unexpected because the patient had not shown any prior signs of wanting to leave the facility and a care plan was not developed regarding risk for elopement. The ADM explained that Patient 1 appeared to have used a wall to climb onto the roof and exited the premises through an unfenced area on the side of the roof. Following the incident, the ADM stated she assessed the area and identified it as a potential area for patients to leave the facility that were at risk for elopement. The ADM further stated that staff acted according to protocol by initiating a Code Green and attempting to redirect Patient 1. However, Patient 1 was not receptive and continued to elope. The ADM explained that staff are instructed not to chase patients to minimize additional risks, such as the patient running into traffic and potentially being struck by a vehicle. During a facility tour on 11/20/2024 at 10:25 AM, with Program Director 1 (PD1) demonstrated how Patient 1 climbed from the patio to the roof of Building B and although the roof was surrounded by a security fence, one side does not have a gate, and a gap a between the structure and the fence created an opening. In a concurrent interview, PD 1 stated the gap allowed Patient 1 to climb onto the roof and elope. According to PD1, a fence will be added to this area as part of the corrective action plan to prevent future elopements by patients. During an interview on 11/20/2024 at 10:35 AM, PD 1 stated, on 11/18/2024 on the morning before Patient 1 eloped, the patient was calm and participated fully in all scheduled activities and did not show any signs or express any interest in leaving the facility, the patient was moved to a different room for his safety after reports Patient 1 attempting to have sexual contact with another female patient who had no capacity to make decision for herself. PD 1 stated Patient 1 was receptive to the move and continued attending activities throughout the day, showing no signs of distress or elopement risk. Given his calm and respectful demeanor, the elopement came as a complete surprise. We had hoped for more time to work with him and address any potential concerns, but unfortunately, the situation unfolded unexpectedly. Staff observed the During an interview on 11/20/2024 at 12:30 PM, Patient 2 stated, Patient 1 approached him one time and expressed a desire to leave the facility and invited him to join. Patient 2 stated Patient 1 did not provide any specific details or outlined a plan for how he intended to elope, but only stated he wished to leave. Patient 2 stated that he chose not to report this information at the time because he did not perceive it as necessary or urgent. Additionally, Patient 2 explained that he did not want to get involved in the situation. During an interview on 11/20/2024 at 12:55 PM, the ADM stated Patient 1 had not returned to the facility but Patient 1’s family member (FAM 1) informed her that Patient 1 contacted her to inform her that he (Patient 1) was “okay” but did not disclose his location. The ADM stated the police department was informed and will maintain open communication with FAM 1. On 11/20/2024 multiple attempts were conducted by the surveyor and the ADM to contact the staff that witnessed Patient 1 climbing the roof and the fence when Patient 1 eloped, but the calls were not answered by the staff. During an interview with the ADM on 12/11/2024 at 12:24 PM, stated PC 1, who witnessed Patient 1 eloping, voluntarily resigned, and was not answering his calls. The ADM stated, 11/18/2024 at 6:27 PM when Patient 1 eloped, there was no staff in the patio, PC 1 was conducting rounds inside the building when he noticed Patient 1 climbing the roof and PC 1 was the only one who witnessed the entire incident. During a review of the facility's policy and procedure (P&P) titled, “Safety and Supervision”, indicated “Our facility strives to make the environment as free from accident hazards as possible. Patient safety, supervision, and assistance to prevent accidents are facility-wide priorities”. A review of the facility’s policy titled, “Elopement Precautions,” dated 7/19/19, indicated that the “facility grounds are secured with locked fences,” to minimize elopement from the facility. As a result of the investigation, the Department determined that the facility failed to provide a hazard free environment, monitoring, and supervision to Patient 1 with history of Opiate, Fentanyl, and substance abuse in accordance with facility’s policy and procedure titled “Elopement Precautions” by failing to ensure: 1. A facility staff was present outside the facility to monitor and supervise Patient 1 who was heard climbing the roof and jumped over the two fences to reach the street and eloped. 2. There was no opening gap between Building B and the fence on the roof where Patient 1 climbed to and exited to the roof and jumped off the roof, jumped off two fences into the street and eloped. 3. Assess Patient 1’s risk for elopement upon admission to the facility and develop a plan of care to prevent wandering and elopement. After Patient 1 eloped the facility found out Patient 1 had a history of elopement from an assisted living facility. These deficient practices resulted as of 11/20/2024, Patient 1 remained missing and exposed environmental hazards and extreme cold weather conditions, which could lead to low body temperature, dehydration, injuries associated with climbing the roof and from motor vehicle accidents, and vulnerability to substance abuse. These 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 at risk of elopement.