Health inspection·November 22, 2022

F689 CFR §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. T22 CCR §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. T22 CCR §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: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient’s condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. On 10/11/2022 at 12:40 pm, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a Facility Reported Incident regarding quality of care/treatment, patient safety, and death. On 10/7/2022, the Facility submitted a Reported Incident to the CDPH which indicated Patient 1 eloped from the facility without the knowledge of the staff and the patient died on the street. As a result of the investigation, the CDPH determined that the facility failed to: 1. Implement its Policies and Procedures on Safety and Supervision of Residents and Wandering and Elopements for Patient 1 by not conducting an Interdisciplinary team (IDT, a team of professionals from various disciplines who work together to address the patient’s care) analysis of the information about Patient 1’s first elopement (patient leaves the premises or a safe area without authorization) on 5/29/2022, and develop nursing interventions to prevent further elopement. 2. Implement Patient 1’s care plan by placing Patient 1 in a room that would not prevent further elopement. The patient was placed in a room with a large window (49 inches in length by 47 inches in width, and 29 ½ inches from the patient’s floor) that opens to the main street where the patient could exit the facility. 3. Review, evaluate, and update Patient 1’s care plan to specify how often the nursing staff would monitor the patient’s location after Patient 1 eloped on 5/29/2022. As a result of these failures, Patient 1, who had a history of elopement, eloped from the facility unsupervised in the early morning hours of 10/7/22 and died soon thereafter. A review of Patient 1’s Admission Record indicated the facility admitted a sixty-six-year-old-male on 4/28/2022 with diagnoses which included Parkinson’s Disease (a brain disorder that causes uncontrollable movements, such as shaking, stiffness, and difficulty with balance/ coordination) and heart disease (range of conditions that affect the heart). A review of Patient 1’s Situation, Background, Appearance, Review (SBAR) Communication Form, (a form that strengthens communication between nurses and other healthcare professionals), dated 5/29/2022, timed at 6 am, indicated Patient 1 eloped from the facility at 2:10 am unsupervised while in the wheelchair. A review of Patient 1’s care plan for elopement risk, which the facility initiated on 5/29/2022, indicated Patient 1 was at risk for elopement due to “history of attempts to leave facility unattended.” The care plan indicated the goal was for Patient 1 not to leave the facility unattended and for the nursing staff (in general) to monitor Patient 1’s location. The care plan did not specify how often the nursing staff would monitor the patient’s location. A review of Patient 1’s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 8/4/2022, indicated Patient 1’s cognitive (ability to think and process information) status was severely (extremely) impaired. The MDS indicated Patient 1 had limited ability to express ideas and wants, as well as limited ability to respond adequately to simple and direct communication. The MDS indicated Patient 1 required extensive assistance (patient involved in activity; staff provide guided maneuvering) from one person to transfer to and from the bed, chair, wheelchair, and to a standing position. A review of Patient 1’s Physical Therapy (PT, focuses on helping improve your movement, mobility, and function) Treatment Note, dated 10/5/2022, indicated Patient 1 was able to ambulate (walk) using a front wheel walker (a device that gives additional support to maintain balance or stability while walking) for support up to 300 feet. The note indicated Patient 1 required verbal cues for safety and proper speed especially when maneuvering around obstacles and busy hallways. A review of Patient 1’s paramedic (emergency services) report dated 10/7/2022, timed at 4:46 am, indicated a bystander saw Patient 1 collapse. The report indicated the paramedics arrived at the scene at 4:53 am and performed cardiopulmonary resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased) for twenty minutes. The report indicated Patient 1 was pronounced dead at 5:21 am. The report indicated local law enforcement was on the scene A review of Patient 1’s Progress Notes dated 10/7/2022, timed at 5:30 am, indicated on 10/7/2022 at 1:25 am, Licensed Vocational Nurse 1 (LVN 1) saw Patient 1 in his room, lying in bed. The notes indicated on 10/7/2022 at 5:30 am, Police Officer 1 (PO 1) from the local police department called the facility inquiring about Patient 1. The notes indicated the PO 1 stated Patient 1 was found unresponsive on the sidewalk located 0.6 miles from the facility. The notes indicated the paramedics performed CPR on Patient 1, but they were unable to revive the patient. The notes indicated Patient 1’s time of death was 5:21 am. A review of the facility’s Unusual Occurrence Report dated 10/11/2022, untimed, indicated that PO 1 informed the facility at 5:30am on 10/7/2022 that they (the police) responded to a call from a bystander who had seen a man (identified as Patient 1) laying down on the sidewalk 0.6 miles from the facility. The report indicated when the police responded to the scene Patient 1 was unresponsive, the emergency services performed CPR, but the patient was pronounced dead at 5:21 am. The report indicated Patient 1 was identified by his wristband. During a telephone interview on 10/11/2022 at 9:23 am, the Quality Assurance Nurse (QAN) stated there was “a probability” Patient 1 eloped on 10/7/2022 from the patient’s window located inside his room. The QAN stated Patient 1 had a history of eloping from the facility on 5/29/2022. During an observation in Patient 1’s room, on 10/11/2022 at 1:18 pm, there was one window across from the room door with 2 panels (flat rectangular pieces of glass), side-by-side on one wall. The window edge was 29 ½ inches from Patient 1’s floor and 32 inches from the ground outside of the facility. The 2 panels were opened outward, and the hinges (movable joints or mechanisms on which a door or a window swing as it opens and closes) were on the outside. The window was measured 49 inches in length and 47 inches in width. There were no screens on the windows. During a concurrent observation in Patient 1’s room and interview with Maintenance Supervisor 1 (MS 1) on 10/11/2022 at 2:57 pm, MS 1 stated Patient 1’s room was the only patient room in the facility with no sliding windows. MS 1 stated all sliding windows have a stopper and could not open all the way. MS 1 stated there were “no wander alarm system on any windows” in the facility. Upon observation, the windows in Patient 1’s room did not have a stopper and could be opened all the way. In a concurrent observation outside the facility with MS 1, there was a path from Patient 1’s room windows which led to the street. MS 1 stated the facility’s gate, which led to the main street, is always kept open for the ambulance. During an interview on 10/11/2022 at 3:08 pm, the QAN stated Patient 1 eloped on 5/29/2022 at 2:10 am, but the patient’s record did not indicate a detailed description of Patient 1’s elopement except it indicated Patient 1 “eloped from the facility unsupervised while in the wheelchair.” The QAN stated the facility did not have any documented evidence that an IDT meeting was conducted to address the patient’s elopement on 5/29/2022. The QAN stated the facility needed to conduct an IDT meeting after the patient’s elopement on 5/29/2022 to address Patient 1’s elopement and to develop nursing interventions to prevent future elopements. During an interview on 10/11/2022, at 3:10 pm, the DON stated Patient 1 had eloped from the facility on 5/29/2022. The DON stated she was not aware Patient 1’s room had a large window that could be opened all the way. During an interview on 10/11/2022, at 3:25 pm, the ADM stated Patient 1 had eloped from the facility on 5/29/2022. The ADM stated he was not aware Patient 1’s room had a large window that could be opened all the way. During an interview on 10/12/2022 at 11:55 am, Certified Nursing Assistant 1 (CNA 1) stated he last saw Patient 1 sitting on the edge of the patient’s bed on 10/7/2022 at 3:05 am. CNA 1 stated on 10/7/2022 at 5 am, after Registered Nurse Supervisor 1 (RNS 1) told him that Patient 1 was not in the facility, he and the rest of the staff checked on all the other patients. CNA 1 stated he found Patient 1’s wheelchair along with the sweater that Patient 1 often wore next to Patient 1’s bed. CNA 1 stated he did not hear any alarm go off during his shift. During an interview on 10/12/2022 at 12:10 pm, LVN 1 stated she last saw Patient 1 lying in bed on 10/7/2022 at 1:25 am. LVN 1 stated on 10/7/2022 at 5:30 am, LVN 2 informed her a PO 2 called the facility and told LVN 2 they (police) found and performed CPR on Patient 1, but Patient 1 died. LVN 1 stated she notified RNS 1 and she called a “Code Pink,” (facility’s emergency code to alert staff a patient is missing) after she found out Patient 1 was not in the facility. LVN 1 stated all staff checked on the other patients and checked all exit door alarms. LVN 1 stated she found Patient 1’s red sweater on the patient’s bed, Patient 1’s wheelchair was at the bedside, and Patient 1’s room window was cracked open (open a little bit) LVN 1 stated she did not hear any alarm go off during her shift. During an interview on 10/12/2022 at 12:50 pm, RNS 1 stated she last saw Patient 1 sleeping on his bed on 10/7/2022 between 12 am to 2 am. RNS 1 stated on 10/7/2022 after 5 am, the facility phone rang while she was in the medication room. RNS 1 stated when she got out of the medication room, LVN 1 and LVN 2 informed her Patient 1 eloped. RNS 1 stated she called a “Code Pink.” RNS 1 stated all staff started to check on all other patients and outside grounds of the facility. RNS 1 stated the facility windows were always kept closed but LVN 1 told her Patient 1’s room window was opened “a little bit.” RNS 1 stated Patient 1 was at risk for eloping and the patient had a wander alarm bracelet on. During an interview with the DON on 10/12/2022 at 2:52 pm, she stated she reviewed Patient 1’s Clinical Record dated 10/7/2022 and was unable to find documented evidence to indicate that Patient 1’s location was monitored as specified in Patient 1’s elopement risk care plan. The DON stated Patient 1’s elopement risk care plan was not implemented. During an interview with PO 2 on 10/17/2022 at 10:38 pm, he stated he received a call from the local police department’s dispatcher on 10/7/2022 at 4:44 am regarding a man on a sidewalk who was not responding to touch. PO 2 stated a bystander saw the man collapsed. PO 2 stated upon their (police officers) arrival to the scene, the man was not breathing, and they performed CPR. PO 2 stated they found out the man was Patient 1 because the man had mail and paperwork that had Patient 1’s name, date of birth, and the facility name. PO 2 stated the fire department arrived and took over to continue CPR. PO 2 stated CPR was performed for about 25 to 30 minutes and Patient 1 was pronounced deceased (dead) on the scene at 5:21 am. PO 2 stated PO 1 called to inform the facility about Patient 1 was pronounced deceased. A review of the facility’s policy and procedure, titled “Safety and Supervision of Residents,” dated 7/2017, indicated “Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI (Quality Assurance and Performance Improvement, plan of action to improve quality of life, and quality of care and services provided in the facility) reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.” The policy indicated, “When accident hazards are identified, QAPI/Safety Committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.” The policy indicated, “The IDT shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.” A review of the facility’s policy and procedure, titled “Wandering and Elopements,” dated 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 indicated, “If [a resident] is 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.” As a result of the investigation, the CDPH determined the facility failed to: 1. Implement its Policies and Procedures on Safety and Supervision of Residents and Wandering and Elopements for Patient 1 by not conducting an Interdisciplinary team (IDT, a team of professionals from various disciplines who work together to address the patient’s care) analysis of the information about Patient 1’s first elopement (patient leaves the premises or a safe area without authorization) on 5/29/2022, and develop nursing interventions to prevent further elopement. 2. Implement Patient 1’s care plan by placing Patient 1 in a room that would not prevent further elopement. The patient was placed in a room with a large window (49 inches in length by 47 inches in width, and 29 ½ inches from the patient’s floor) that opens to the main street where the patient could exit the facility. 3. Review, evaluate, and update Patient 1’s care plan to specify how often the nursing staff would monitor the patient’s location after Patient 1 eloped on 5/29/2022. As a result of these failures, Patient 1, who had a history of elopement, left the facility unsupervised on 10/27/2022 and died soon thereafter. The above violations jointly, separately, or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Patient 1.