Health inspection·July 1, 2022

F689 § 483.25(d)(2) Accidents. The facility must ensure that each Patient receives adequate supervision and assistance devices to prevent accidents. T22 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. (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. (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 5/19/22, the Department of Public Health conducted a facility reported incident investigation regarding patient care. The facility failed to provide adequate supervision to prevent elopement from the facility for Patient 1. As a result of this violation, on 5/13/22 at 8 PM, Patient 1 was able to walk out of the facility without supervision and was found approximately a mile away from the facility. This deficient practice had the potential to affect Patient 1's safety and placed Patient 1 at an increased risk for fall, injury, and/or death. A review of Patient 1's Admission Record indicated the facility admitted the patient on 11/19/21. The patient was a 47-year-old female with diagnoses including diabetes mellitus (high blood sugar), cellulitis (skin infection caused by bacteria) of right lower limb, schizophrenia (a mental illness that affects how a person thinks, feels, and behaves), depression, anxiety, muscle weakness, and abnormalities of gait and mobility. A review of Patient 1's History and Physical Examination dated 11/20/21, indicated the patient had the capacity to understand and make decisions. A review of Patient 1's care plan dated 11/23/21, indicated the patient was a high risk for falls related to gait/balance problems, psychoactive drug (medication that affects mood, awareness, thoughts, feelings, or behavior) use, and status post (condition after) right foot trans metatarsal amputation (surgery to remove part of the foot). The goal indicated the patient will be free of falls through the review date. The interventions included to anticipate and meet the resident's needs, keep the resident's call light within reach and respond promptly to all requests for assistance, and educate the resident/family about safety reminders. A review of Patient 1's care plan dated 11/29/21, indicated the patient had an activities of daily living (ADL) self-care performance deficit related to disease process. The goal indicated the patient will improve current level of function in ADLs through the review date. The interventions included non-weight bearing status on the right lower extremity, encourage the patient to use the call bell for assistance, and provide assistance with bathing, dressing, personal hygiene, toilet use, and transfer. A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/25/22, indicated the patient was able to communicate and was cognitively intact (able to think, understand, learn, and remember). The MDS indicated the patient was assessed requiring supervision with locomotion on unit, limited assistance (patient highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) and one-person physical assist with bed mobility, transfer, and locomotion off unit, extensive assistance with dressing, toilet use and personal hygiene, and total assistance with bathing. The MDS indicated the patient's balance was not steady during transitions and only able to stabilize with staff assistance. The MDS indicated the patient normally used a wheelchair for mobility. The MDS indicated the patient had no wandering behavior. A review of Patient 1's SBAR/COC (Situation-Background-Assessment-Recommendation/Change of Condition) dated 4/3/22, timed at 10:49 PM, indicated at 4:30 PM, the housekeeper and certified nursing assistant noted the patient trying to walk and go out of the gate. The documentation indicated Patient 1 stated she needed to go to work and aliens were talking to her. Patient 1 was reoriented to place and person and was escorted back into the room. A review of Patient 1's care plan dated 4/3/22, indicated the patient attempted to run out of the building. The care plan goal indicated the patient will remain in the building every shift and will have no running attempts. The interventions included to perform frequent visual checks, reorient the patient to place, person, and time, and monitor frequently for behavior and changes in attitude. A review of Patient 1's SBAR/COC dated 5/13/22, timed at 10:55 PM, indicated the patient had good appetite and ate dinner around 5 PM. At 8 PM, Licensed Vocational Nurse (LVN) 1 was looking for the patient to check her blood sugar but the patient was nowhere to be found. The documentation indicated a thorough check was done from room to room including the restrooms. Facility staff drove around looking for the patient but could not locate the patient. The family was called, and the police was notified. The documentation indicated the facility received a call from Patient 1 stating she was in a street corner near the freeway. LVN 1 went to pick up the patient. The police department and family were updated of the patient's return. The documentation indicated the patient was noted with right plantar (sole of the feet) redness but was in satisfactory condition. A review of Patient 1's Progress Notes dated 5/16/22, timed at 3:35 PM, indicated the interdisciplinary team (IDT, members from different disciplines work collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met regarding the patient's elopement on 5/13/22. The note indicated around 8 PM, the patient was not able to be found when LVN 1 was looking for her for blood sugar check. The patient's restroom, patio, and the rest of the facility were checked. Patient 1 was not found, and Code Green (denotes a missing resident) was initiated. The local police department was notified. The note indicated around 10 PM, the facility received a call from a General Acute Hospital (GACH) stating that Patient 1 was on a cross streets approximately a mile away from the facility. Two staff arrived at the scene and noted the patient standing on the sidewalk with the female GACH. The note indicated Patient 1 was asked how she was doing, and the patient stated "I am fine. I wanted to go to a convenience store but decided to walk a little further." The note indicated the patient walked until she became tired then saw a lady and asked her to call the facility. Patient 1 was returned to the facility with no changes in neurological status, bleeding, skin breaks, range of motion, pain, or distress. The note indicated the patient's physician was notified and the plan of care was updated to redirect the patient as needed, apply wander guard (monitoring device used to ensure safety) as ordered, provide psychiatric follow-up, and put the patient on hourly monitoring. During an interview on 5/19/22 at 12:08 PM, Case Manager (CM) 1 stated she came to the facility on 5/13/22 at 9:44 PM to help locate Patient 1. CM 1 stated Patient 1 asked for assistance from a lady (civilian) to call the facility. CM 1 stated she and LVN 1 picked up the Patient from the corner of cross streets near a dairy store. CM 1 stated the patient used a wheelchair and was able to propel herself, never attempted to leave the facility, and was not an elopement risk. CM 1 stated Patient 1's wheelchair was found in the patio without the resident. CM 1 stated she was surprised that Patient 1 was able to walk. During an interview on 5/19/22 at 12:15 PM, the Director of Nursing (DON) stated the evening shift Registered Nurse (RN) Supervisor would turn on the patio gate alarm at 8 PM. The DON stated the RN Supervisor forgot to turn on the alarm because the facility had a Red Zone in the front entrance and the staff were using the back patio as an entrance to the facility. During an interview on 5/19/22 at 12:21 PM, CM 1 stated the back patio gate had an alarm and the key was in the nursing station. CM 1 stated the RN Supervisor and charge nurse were responsible for alarming the gate at 8 PM. During an interview on 5/19/22 at 4:05 PM, LVN 1 stated according to Patient 1's responsible party, the patient had history of elopement from the previous facility. LVN 1 stated the patient has not eloped since being admitted to the facility. LVN 1 stated the staff monitor Patient 1. LVN 1 stated around 8 PM (on 5/13/22), the patient's wheelchair was in the patio without the resident. LVN 1 stated he informed the RN Supervisor, initiated Code Green, notified the DON, police, and the patient's physician. LVN 1 stated the patio gate alarm was turned off because there was a new admission coming and the gate was being used as an entrance. LVN 1 stated the patio gate alarm should be turned on at all times. During an interview on 5/19/22 at 4:19 PM, Certified Nursing Assistant (CNA) 1 stated she last saw Patient1 around 8 PM in the patio and told the patient to come inside. CNA 1 stated the patient said she wanted to get some fresh air. CNA 1 stated she went back inside the facility to tell the charge nurse and went to help another patient. During an interview and concurrent review of Patient 1's medical record on 5/19/22 at 4:42 PM, the DON stated there was no post elopement assessment done when the patient tried to leave the building on 4/3/22. During an interview on 5/19/22 at 5:12 PM, Patient 1 stated on Friday, 5/13/22, she walked out of the back patio gate around 6 PM because she wanted to go to the store. Patient 1 stated there were no patients or staff in the patio at that time. Patient 1 stated the gate alarm was not turned on. Patient 1 stated she had been sitting in the wheelchair and was not walking in the facility. Patient 1 stated she left her wheelchair in the patio because she did not want to go down the driveway ramp in a wheelchair. Patient 1 stated she walked to the store about half a block and wanted to walk more but her back started to hurt. Patient 1 stated she called the facility around 9 PM. Patient 1 stated last April, she got out of the driveway and was walking to go to the store when the facility staff stopped her. Patient 1 stated she had been asking to go to the store. During an interview and concurrent review of Patient 1's most current MDS on 5/26/22 at 1:47 PM, the DON stated the patient required supervision with locomotion on unit and limited assistance and one-person physical assist with locomotion off unit. The DON stated Patient 1 was wheelchair bound and unable to stabilize herself without staff assistance. The DON stated staff should monitor and supervise Patient 1 while in the patio for safety reasons. The DON stated patients should not be left unattended in the patio. A review of the facility's policy and procedures titled, "Wandering and Elopements," revised in 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 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 policy and procedures titled, "Safety and Supervision of Residents," revised in 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide practices. The policy indicated resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. The facility failed to provide adequate supervision to prevent elopement from the facility for Patient 1. As a result of this violation, on 5/13/22 at 8 PM, Patient 1 was able to walk out of the facility without supervision and was found approximately a mile away from the facility. This deficient practice had the potential to affect Patient 1's safety and placed Patient 1 at an increased risk for fall, injury, and/or death. This violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.