Health inspection·August 30, 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 7/24/2024 at 7:40 AM to investigate a facility reported incident regarding elopement (instance of running off secretly and when a patient who is not capable of protecting or caring for themselves leaves the facility without authorization). The facility failed to supervise and ensure the safety of Patient 1 in accordance with the facility’s policy and procedure when Patient 1 left the facility through his window. This failure resulted in Patient 1 eloping on 7/23/2024 and is not found as of 8/27/2024 (total of 35 days). A review of Patient 1’s Admission Record, indicated Patient 1 is a 31- year- old- male patient who was initially admitted to the facility on 6/20/2024 with diagnoses of encephalopathy (any damage, disease, or disorder that affects the structure or function of the brain) and schizoaffective disorder (mental illness that occurs when someone experiences both schizophrenia and a mood disorder [a mental health condition that affects a person’s emotional state or mood] at the same time), bipolar type (a serious mental illness that causes unusual shifts in mood ranging from extreme highs [mania] to lows [depression]). A review of Patient 1’s History and Physical Examination (H&P), dated 6/20/2024, H&P indicated the patient has fluctuating capacity to understand and make decision due to being conserved (when a judge appoints another person to act or make decisions for the person who needs help). A review of Patient 1’s Elopement Risk Assessment dated 6/20/2024, the Elopement Risk Assessment indicated Patient 1 was a high risk for elopement with potential interventions including to do frequent monitoring such a checking every hour. A review of Patient 1’s risk for elopement care plan dated 6/20/2024, the risk for elopement care plan indicated Patient 1 was a high risk for elopement. The care plan indicated staff interventions included head count every hour and frequent visual checks. A review of Patient 1’s interdisciplinary team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the patient) conference record dated 6/21/2024, the IDT conference record indicated, Patient 1 is at risk for elopement related to history (hx) of elopement from home and other facility. A review of Patient 1’s Minimum Data Set (MDS – a standardized patient assessment care screening tool), dated 6/27/2024, MDS indicated the patient was moderately impaired with cognitive (ability to think, remember, and reason) skills for daily decision making. Patient 1 was independent (patient completes activity by themselves with no assistance from a helper) with walking 150 feet, transfers (how patient moves to and from bed, chair, wheelchair, standing position), dressing (how patient puts on, fastens, and takes off all items of clothing), personal hygiene and eating. During an interview on 7/24/2024 at 8:20 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated the last time she saw Patient 1 was on 7/23/2024 around 11:00 AM in his room sitting on his bed. CNA 1 stated she then went on her lunch break and when she came back to pass the lunch trays, she noticed the patient was gone and the window in the patient’s room was broken around 12:10 PM. During an observation on 7/24/2024 at 8:25 AM in Patient 1’s room, Patient 1’s bedside window was observed to be missing a window pane (sheets of glass that are housed inside of window frames) and was covered with a large plastic panel that was bolted to the part of the intact window pane and nailed to the window frame. During an observation on 7/24/2024 at 8:27 AM in the back area of the station 2 building (“station 2 back”), Patient 1’s window as observed to be missing a window pane and covered with a large plastic panel. Directly across from the patient’s window is a private residence and facing the patient’s window and to the left was an open area that is not able to be accessed by other patients that stops at a brick wall with a metal fence on top that leads to the street. During an interview on 7/24/2024 at 8:35 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the last time she saw Patient 1 was at 11:30 AM on 7/23/24 in the patient’s room. LVN 1 then stated at approximately 12:15 PM, CNA 1 reported to her that while she was passing lunch trays, LVN 1 went to Patient 1’s room and the patient was missing. LVN 1 stated Patient 1’s window pane was missing and that all staff attempted to look for the patient in the facility and even drove around the area, but the patient was not found. During a concurrent observation and interview on 7/24/2024 at 8:50 AM with Maintenance Supervisor (MS) in “Station 2 back,” Patient 1’s window was observed to be missing a window pane, and covered with hard plastic with a gap at the top between the end of top of the plastic panel and the top of the window. MS stated the window was broken after Patient 1 eloped on 7/23/2024 and they were unable fix it on the same day because the store was closed by the time they got around to trying to fix the window. During an interview on 7/24/2024 at 9:10 AM with the Director of Nursing (DON), the DON stated that CNA 1 was passing lunch trays on 7/23/24 around 12:00 PM when she notified LVN 1 that Patient 1 was missing. The DON stated all room in the facility were searched, and a code yellow (code to alert staff that a patient is missing) was called and that some facility staff went out on foot and drove around the facility within a 5- mile radius and the patient was nowhere to be found. The DON also stated that a head count for all patients is done every hour. During a concurrent observation and interview on 7/24/2024 at 10:20 AM with the DON in Patient 1’s room, Patient 1’s window was observed to be missing a window pane and covered. The DON stated Patient 1’s window is covered with a hard laminate panel that is secured with screws with an approximate five (5) inch gap at the top that is open. The DON stated the window needed to be replaced immediately and that they would have staff monitor the window 1:1 until it is fixed. During an interview on 7/24/2024 at 12:05 PM with SSD, SSD stated Patient 1 was evaluated to be a high risk for elopement since Patient 1’s family representative had informed the facility that Patient 1 had previous eloped from another facility. During a concurrent interview and record review on 7/24/2024 at 12:15 PM with CNA 1 and CNA 2, the facility’s “Head Count and Call Light Check” form dated 7/23/2024 was reviewed. The 7/23/2024 the facility’s “Head Count and Call Light Check” form indicated the last time Patient 1 was seen was at 11:00 AM. CNA 1 and CNA 2 both stated that head counts are done every hour on shift by the CNAs and they make sure to have eyes on the patients and their location. During a concurrent interview and record review on 7/24/2024 at 1:00 PM with the DON, Patient 1’s risk for elopement care plan dated 6/20/2024 was reviewed. The risk for elopement care plan indicated Patient 1 was a high risk for elopement. Staff interventions included head count every hour and frequent visual checks. The DON stated since their facility standard is an hourly head count for all patients, the timing for Patient 1’s head count should have been at least every 30 minutes and should have been more specific for the patient since he was a high risk for elopement. During an interview on 8/2/2024 at 10:31 AM with Administrator (ADM), ADM stated as of today, 8/2/2024, Patient 1 has still not been found. During an interview on 8/27/2024 at 2:05 PM with ADM, ADM stated as of today, 8/27/2024, Patient 1 has still not been found. A review of the facility’s P&P titled “Emergency Procedure – Missing Resident” revised August 2018, indicated “Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety.” A review of the facility’s policy and procedure (P&P) titled “Wandering and Elopements” revised March 2019, indicated, “The facility with identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents,” and “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 facility’s P&P titled “Care Plans, Comprehensive Person-Centered” revised March 2022, indicated: 1. A comprehensive, person-centered care plan that includes measurable, objectives and timetables to meet the resident’s physical, psychosocial ad functional needs is developed and implemented for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The comprehensive, person-centered care plan: describes the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.” The facility failed to supervise and ensure the safety of Patient 1 in accordance with the facility’s policy and procedure when Patient 1 left the facility through his window. This failure resulted in Patient 1 eloping on 7/23/2024 and is not found as of 8/27/2024 (total of 35 days). The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.