Health inspection·February 20, 2025

Code of Federal Regulations, Title 42, Section 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. Code of Federal Regulations, Title 42, Section 483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40. California Code of Regulations, Title 22, Section 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: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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. California Code of Regulations, Title 22, Section 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 (b) All policies and procedures required of these regulations shall be in writing, made available upon request to physicians and other involved health professionals, patients or their representatives, employees and the public shall be carried out as written. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 1/22/2025 at 11 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding quality of care of Resident 1. As a result of the investigation, the CDPH determined that the facility failed to provide care and services to prevent elopement for Resident 1 as indicated in the facility's policy and procedure (P&P) titled, "Wandering & Elopement," revised on 1/11/2016.” The facility failed to: 1. Develop and implement a plan of care to address elopement risk for Resident 1, who was assessed as being at risk for elopement on 10/24/2024. 2. Ensure Licensed Vocational Nurse (LVN) 4 and the Social Services Director (SSD) notified all staff caring for Resident 1 of Resident 1's history of elopement. 3. Ensure facility staff provided Resident 1 with a wander guard (monitoring device or system that helps keep residents at risk of wandering safe) as requested by Resident 1's responsible party (RP 1) on 11/8/2024. 4. Ensure LVN 3 accurately assessed Resident 1's elopement risk after Resident 1 eloped from the facility on 1/19/2025. These failures resulted in Resident 1 leaving the facility without supervision on 1/19/2025 at around 7 p.m. These deficient practices had the potential to compromise Resident 1's safety and placed Resident 1 at risk for injuries. A review of Resident 1's "Admission Record (AR)," indicated the facility admitted Resident 1, a 34-year-old male, on 10/24/2024, with diagnoses including paranoid (where a person feels distrustful and suspicious of other people) schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and syphilis (a bacterial infection usually spread by sexual contact). The "AR" indicated Resident 1's responsible party was RP 1. A review of Resident 1's "Elopement Evaluation (EE)," dated 10/24/2024, timed at 9:23 p.m., indicated Resident 1 was at risk for elopement due to Resident 1 wandering aimlessly or non-goal-directed (i.e. confused, moves with purpose, may enter others' rooms and explore others' belongings). A review of Resident 1's "Minimum Data Set (MDS, a resident assessment tool)," dated 10/30/2024, indicated Resident 1 had no impairment in cognitive skills. The "MDS" indicated Resident 1 required supervision or touch assistance from staff for oral, toileting, and personal hygiene and dressing. A review of Resident 1's "Interdisciplinary Team Conference Record (IDT)," dated 11/8/2024, timed at 10:20 a.m., indicated RP 1 informed the facility that Resident 1 had a history of leaving facilities and requested a wander guard for Resident 1. The "IDT" indicated staff would contact Resident 1's physician regarding obtaining an order for a wander guard. The "IDT" indicated LVN 4 and the SSD signed the "IDT." A review of Resident 1's "History and Physical Examination (H&P)," dated 11/23/2024, indicated Resident 1 did not have the capacity to understand and make decisions. The "H&P" indicated Resident 1's surrogate decisionmaker was RP 1. A review of Resident 1's "EE" dated 1/19/2025, timed at 11:11 p.m., completed by LVN 3, indicated Resident 1 was not at risk for elopement. During a concurrent interview and record review on 1/22/2025 at 2:25 p.m., LVN 1 reviewed the facility's Elopement Binder. The Elopement Binder contained pictures of residents with the residents' "AR." LVN 1 stated an Elopement Binder was kept at each nurses’ station and at the receptionist desk. LVN 1 stated the Elopement Binder contained a list of all residents who were at risk for elopement. LVN 1 stated when a resident was assessed to be at risk for elopement, the resident's picture and "AR" were placed in the Elopement Binder. LVN 1 stated Resident 1's picture and AR were not in the Elopement Binder. LVN 1 stated Resident 1 was not at risk for elopement. During an interview on 1/22/2025 at 2:54 p.m., LVN 2 stated on 1/19/2025 at around 6:45 p.m., Resident 1 eloped from the facility. LVN 2 stated LVN 2 attempted to find Resident 1 by driving around the neighborhoods adjacent to the facility. LVN 2 stated Resident 1 was currently still missing from the facility. LVN 2 stated Resident 1 was not wearing a wander guard at the time of Resident 1's elopement. LVN 1 stated LVN 1 had not been aware of Resident 1's history of eloping from other facilities prior to Resident 1's admission to the facility. During a concurrent interview and record review on 1/22/2025 at 3:32 p.m., LVN 3 reviewed Resident 1's "EE," dated 1/19/2025. The "EE" indicated Resident 1 was not at risk for elopement. LVN 3 stated LVN 3 filled out Resident 1's "EE." LVN 3 stated Resident 1's "EE" should have indicated Resident 1 was at risk for elopement because Resident 1 had just eloped from the facility (on 1/19/2025). LVN 3 stated LVN 3 was assigned to care for Resident 1 on the day Resident 1 eloped from the facility. LVN 3 stated Resident 1 was not wearing a wander guard. LVN 3 stated LVN 3 did not know Resident 1 had a history of elopement prior to Resident 1's admission to the facility. During a concurrent interview and record review on 1/22/2025 at 4:14 p.m., LVN 4 reviewed Resident 1's "IDT" Conference dated 11/8/2024, and Resident 1’s physician order summary report dated 1/22/2025. The "IDT" indicated LVN 4 was present during the IDT meeting on 11/8/2024. The "IDT" indicated, "...Spoke with (RP 1) via phone and provided update on resident's condition and current behaviors ... (RP 1) also requested wander guard for (Resident 1), per mom (Resident 1) has history of leaving facilities." The "IDT" indicated a recommendation to contact Resident 1's doctor for an order for a wander guard. LVN 4 stated per RP 1, Resident 1 had a history of elopement from other facilities. LVN 4 stated Resident 1’s physician needed to order a wander guard for Resident 1. LVN 4 stated Resident 1's physician orders indicated there were no orders for Resident 1 to wear a wander guard. LVN 4 stated the facility did not do an IDT meeting to address Resident 1's history of elopement. During an interview on 1/23/2025 at 8:48 a.m., Receptionist (R) 1 stated R 1 was at the front desk when Resident 1 walked out of the facility's front door on 1/19/2025 at around 7 p.m. R 1 stated Resident 1 was not wearing a wander guard. R 1 stated R 1 ran outside after Resident 1. R 1 stated Resident 1 started running down the street and R 1 could not keep up with Resident 1. R 1 stated R 1 had left R 1's cell phone at the facility so R 1 had to return to the facility to inform other staff Resident 1 had left the facility. R 1 stated none of the other facility staff saw Resident 1 leave the facility. R 1 stated if Resident 1 had been wearing a wander guard, facility staff would have been alerted that Resident 1 walked out of the facility’s front door and would have noticed R1 was missing from the front desk. R 1 stated other facility staff could have responded sooner to Resident 1's elopement. During a concurrent interview and record review on 1/23/2025 at 8:58 a.m., the SSD reviewed Resident 1's "IDT," dated 11/8/2024. The "IDT" indicated the SSD was present during the IDT meeting on 11/8/2024. The SSD stated RP 1 informed LVN 4 and the SSD that Resident 1 had a history of eloping from other facilities. The SSD stated based on the information, Resident 1 should have been wearing a wander guard. The SSD stated all facility nurses should have been notified of Resident 1's risk for elopement. The SSD stated nurses should have been made aware (of Resident 1 being at risk for elopement) so they (all nurses) could always keep eyes on Resident 1. The SSD stated Resident 1’s information should have been entered in the Elopement Binder. During a concurrent interview and record review on 1/23/2025 at 9:43 a.m., the Director of Nursing (DON) reviewed Resident 1's "EE," dated 10/24/2024, and Resident 1's "IDT," dated 11/8/2024. The "EE" indicated Resident 1 was at risk for elopement. The DON stated the facility did not implement interventions to address Resident 1's risk for elopement. The DON stated the facility should have called Resident 1's physician to obtain an order for a wander guard. The DON stated if Resident 1 refused the wander guard, facility staff should have documented the refusal in Resident 1's medical record. The DON stated Resident 1’s medical record indicated no documentation of Resident 1’s refusal of the wander guard. The DON stated Resident 1's history of elopement should have been communicated with facility staff to ensure facility staff kept an eye on Resident 1. A review of the facility's P&P titled, "Wandering & Elopement," revised on 1/11/2016, indicated, "The Facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement." The P&P indicated, "The Licensed Nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, quarterly, and upon identification of significant change in condition according to the RAI guidelines to determine their risk of wandering/elopement." The P&P indicated, "The IDT will develop a plan of care considering the individual risk factors of the resident. Specific cues to which the resident may respond to divert wandering behavior will be included on the care plan." The facility failed to provide care and services to prevent elopement for Resident 1 as indicated in the facility's P&P titled, "Wandering & Elopement," revised on 1/11/2016.” The facility failed to: 1. Develop and implement a plan of care to address elopement risk for Resident 1, who was assessed as being at risk for elopement on 10/24/2024. 2. Ensure LVN 4 and the SSD notified all staff caring for Resident 1 of Resident 1's history of elopement. 3. Ensure facility staff provided Resident 1 with a wander guard as requested by Resident 1's responsible party (RP 1) on 11/8/2024. 4. Ensure LVN 3 accurately assessed Resident 1's elopement risk after Resident 1 eloped from the facility on 1/19/2025. These failures resulted in Resident 1 leaving the facility without supervision on 1/19/2025 at around 7 p.m. These deficient practices had the potential to compromise Resident 1's safety and placed Resident 1 at risk for injuries. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.