Health inspection·June 6, 2024

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 4/21/2024 at 9:30 am., the California Department of Public Health (CDPH, the Department) conducted an unannounced abbreviated standard survey visit regarding quality of care/treatment issues. As a result of the investigation, the Department determined the facility failed to implement measures to ensure Resident 5 received proper supervision to remain inside of a locked facility as indicated in the facility’s protocol, titled, protocol “Community/Recreational Outing Protocol,” and the facility’s policy and procedure (P&P) titled, “Elopement of Resident.” As a result, Resident 5 eloped (leaving the facility without notice) from the facility and ran toward a busy street unsupervised where Resident 5 could have been harmed and sustain serious injuries. A review of Resident 5’s Admission Record (AR), indicated the facility admitted Resident 5, a 31-year-old male to the facility on 7/13/23 with diagnoses that included schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves). A review of Behavioral Specialist 2’s (BS 2) “Employee Orientation IMD Checklist,” dated 12/18/23, indicated BS 2 had one-hour of patient safety elopement precaution training and attended a three-hour mandated training on resident elopement P&P. A review of BS 2’s Programming Orientation Checkoff List, dated 12/19/23, indicated BS 2 was trained on elopement of patient [resident] and monitoring of residents. A review of BS 1’s “Employee Orientation IMD Checklist,” dated 4/9/24, indicated BS 1 had one-hour of patient safety elopement precaution training and BS 1 attended a three-hour mandated training on resident elopement P&P. A review of BS 1’s Programming Orientation Checkoff List, dated 4/10/24, indicated BS 1 was trained on elopement of patient and monitoring of residents. A review of Resident 5's Minimum Data Set (MDS, a resident assessment and care-screening tool), dated 4/15/24, indicated Resident 5 was cognitively (ability to think and process information) intact, was able to understand and be understood by others. The MDS indicated Resident 5 was independent with transfers, eating, and personal hygiene. A review of Resident 5's Order Summary Report (OSR), included active physician orders as of 5/22/24 indicated Resident 5 had an order for Haloperidol (medication used to treat severe behavioral problem such as explosive and aggressive behaviors, affecting mood, thoughts, or perception), started on 1/26/24, 10 milligrams (mg, unit of measurement) by mouth in the morning for manifestations of delusions (a belief or altered reality) related to schizophrenia. During a review of Resident 5’s Change in Condition (COC), dated 5/19/24 timed at 9:58 pm, the COC indicated at approximately 7:17 pm, while on the east unit resident [Resident 5], climbed the fence and eloped. During an investigation of a facility reported incident regarding Resident 5’s elopement and a concurrent observation, on 5/21/24 at 9:20 am, there was one driveway to enter the facility, the driveway was connected to a busy main street that had four lanes (two in each direction). The main street had heavy traffic and multiple cars were traveling in both directions. During an interview with the Program Manager (PM) on 5/21/24 at 12:37 pm, the PM stated Resident 5 had a history of eloping from the previous facility (prior to admission to the current facility). The PM stated, to ensure safety and prevent elopement, the facility protocol was to have no less than four staff members [monitoring residents] when residents were outside in the yard. The PM stated four staff members were necessary because each staff member had a role: 1 staff redirected residents (in general) attempting to elope, the second and third staff members gathered and accounted for all other residents in the courtyard. The fourth staff member calls a code “yellow” to inform the rest of the staff members an elopement was attempted. On 5/19/24 at around 7:15 pm, only two staff members were monitoring the residents that were outside in the courtyard. The PM stated during that time, Resident 5 was able to climb over a 12-foot fence and eloped from the facility. The PM stated there should have been four staff members monitoring the residents in the courtyard because things like escaping (elopement) could happen. The PM stated the facility was adjacent to a main street and [if residents eloped] they could get hit by traffic and this was not safe for the overall health and safety of the resident. During an interview with BS 1, on 5/21/24 at 1:16 pm, BS 1 stated on 5/19/24 around 7:15 pm after dinner, BS 1 stated BS 1 and Behavioral Specialist 2 (BS 2) were the only two staff members monitoring the group of residents that were outside in the courtyard. BS 1 stated BS 1 witnessed Resident 5 climb a 12-foot fence and yelled for Resident 5 to stop and come down the fence. BS 1 stated while BS 2 gathered the rest of the resident in the courtyard, BS 1 walked away from the 12-foot fence to alert the rest of the staff members of the elopement attempt and to call a code “yellow.” BS 1 stated the facility protocol entailed four staff members to monitor residents [in the courtyard] to prevent the danger of resident elopements. During an observation of the facility’s video surveillance recording (VSR), with the Administrator (ADM) and the PM, on 5/21/24 at 2:55 pm, the VSR indicated on 5/19/24 at 7:20 pm, Resident 5 was seen running away from the facility toward the street. Resident 5 was not followed and was alone. During an interview with Resident 6, on 5/21/24 at 3:17 pm, Resident 6 stated on 5/19/24 at around 7:10 pm while in the courtyard, there were two staff members monitoring the residents instead of four. Resident 6 stated Resident 6 witnessed Resident 5 climb the facility fence, jump over, and run away from the facility. During an interview with Resident 7 on 5/21/24 at 3:40 pm, Resident 7 stated on 5/19/24 at around 7:20 pm, in the courtyard, Resident 7 observed Resident 5 climb the fence and Resident 5 jumped over the fence and ran from the facility. Resident 5 stated BS 1 and BS 2 were the only staff members monitoring the residents in the courtyard. During an interview with the Director of Staff Development (DSD) on 5/22/24 at 12:26 pm, the DSD stated for activities in the courtyard, the facility’s protocol was for a minimum of four staff members to monitor the residents. The DSD stated the DSD trained facility staff and taught them the protocol that included four staff members were required to monitor all four corners [of the courtyard] to prevent elopements, ensure safety, and monitoring resident behaviors such as elopement or gestures of elopement. The DSD stated anything less than four staff members in the courtyard [could result in] residents to elope, to be abused, and [result in residents getting] into fights. The DSD stated less than four staff members monitoring [the courtyard] was a liability and jeopardized the safety of the residents. During an interview with the Assistant Director of Nursing (ADON), on 5/22/24 at 1:19 pm, the ADON stated the facility’s population needed to be monitored closely. The ADON stated four staff members needed to be present to cover the four points of the courtyard and to prevent [resident] elopements. During an interview with BS 2 on 5/22/24 at 2 pm, BS 2 stated on 5/19/24 at around 7:05 pm, BS 2 took residents to the courtyard, unscheduled outside activity, and Charge Nurse 1 (CN 1) did not know about the activity. BS 2 stated the outside activity was not a permitted break and two staff [BS 1 and BS 2] were outside in the courtyard with the residents. BS 2 stated there were about 15 to 17 residents in the courtyard. BS 2 stated BS 2 witnessed Resident 5 climb to the top of the facility’s fence. BS 2 stated there were supposed to be four staff monitoring the residents in the courtyard for safety and to prevent elopements. During an interview with the facility’s ADM on 5/22/24 at 2:38 pm, the ADM stated specifically for the facility’s population (with behavior problems), it was very important to have [adequate] supervision twenty-four hours a day, seven days a week. The ADM stated without proper supervision, a lot of things could happen such as resident to resident altercations or elopements. During a review of a facility’s P&P, titled, “Elopement of Resident,” revised 7/12/23, the P&P indicated to provide a process for managing residents at risk for elopement. Elopement occurs with a patient [resident] leaves the premises without authorization (no physician order for discharge or leave of absence) or any necessary supervision to do so. The P&P elopement of a resident: staff witnessing a confused patient or an elopement risk resident attempting to leave the unit (facility) unaccompanied will intervene as appropriate to redirect the resident to a safe area and prevent elopement. If the patient cannot be redirected, alert other staff members to notify the supervisor and stay with the patient until he/she is safely returned to the unit/facility. During a review of the facility’s undated protocol, “Community/Recreational Outing Protocol,” indicated No recreational outings after dinnertime. During a review of the facility’s undated protocol, “Communication, Why Is It Important?” indicated to inform charge nurse when stepping out of the unit and for staff to be monitoring residents at all times in the following areas: TV room (2 staff members), Grooming room (one to two staff members), outdoor recreation (four staff members) and hallway (at all times). As a result of the investigation, the Department determined the facility failed to implement measures to ensure Resident 5 received proper supervision to remain inside of a locked facility as indicated in the facility’s protocol, titled, protocol “Community/Recreational Outing Protocol,” and the facility’s policy and procedure (P&P) titled, “Elopement of Resident.” As a result, Resident 5 eloped from the facility and ran toward a busy street unsupervised where Resident 5 could have been harmed and sustain serious injuries. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 5.