Health inspection·September 7, 2023

F689 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. California Code of Regulations, Title 22, Section 72311. Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (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. The facility failed to provide supervision for Patient 1 who did not have the capacity to make decisions and was at risk for elopement (leaving unnoticed by staff). As a result, Patient 1 eloped from the facility on 7/18/2023, at 10:40 am, wandered outside of the facility without supervision and took a public transportation to go. This failure also had the potential to result in Patient 1 sustaining an injury, dehydration, and abduction (take away by force). A review of Patient 1's Admission Record indicated the facility admitted an 81 years old female on 7/14/2023 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), hypertension (increased blood pressure) and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of the facility's Elopement Risk Assessment, dated 7/14/2023, indicated Patient 1 was at risk for elopement. A review of the physician's initial History and Physical, dated 7/16/2023, indicated Patient 1 did not have the capacity to understand and make decisions. A review of Patient 1’s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 7/16/2023, indicated Patient 1 had clear speech, sometimes understood others, and sometimes made self-understood. The MDS indicated Patient 1 had cognitive impairment (a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Patient 1 required supervision (oversight, encouragement or cueing) with setup help only for walk in room, walk in corridor, locomotion (ability to move from one place to another) on unit and locomotion off unit. A review of the facility's Every 30 Minutes Patient Location Check sheet, dated 7/18/2023, indicated Patient 1 was last seen at 10:30 am in Patient 1's room. A review of the facility's Nurses Notes, dated 7/18/2023, indicated between 10:40 am to12:40 pm, Patient 1 was nowhere to be found inside the facility. The notes indicated at 12:52 pm, Patient 1 was reported to be found at home by local police officer and at 3:45 pm, Patient 1 was sent back to the facility by Family Member (FM 1). During an onsite observation on 7/28/2023, at 10 am, the facility had a locked gate which required a staff member to press the button to unlock the gate for entrance and exit. The facility's locked gate was located a few steps away from the facility's entrance door. The unlock button was under the desktop, inside the facility's nursing station 1, next to the facility's entrance door. During an observation and concurrent interview on 7/28/2023, at 10:45 am, Patient 1 walked out of the activity room with steady steps without difficulties. Patient 1 stated she did not remember that she had ever left the facility and went home. During an interview on 7/28/2023, at 11:01 am, with Screener/Receptionist (Screener 1), Screener 1 stated he was working on 7/18/2023 when Patient 1 eloped from the facility. Screener 1 stated the facility had a locked gate that can only be opened by pressing the button which was located inside nursing station 1 for entrance and exit. Screener 1 stated his job was to screen all visitors, opened gate for them when they in and out the facility. Screener 1 stated he did not know when and how Patient 1 got out of the facility. During an interview on 7/28/2023, at 12:51 pm, Licensed Vocational Nurse 1 (LVN 1) stated the last time she saw Patient 1 was on 7/18/2023, at 10:30 am. LVN 1 stated at 10:40 am, Certified Nursing Assistant 3 (CNA3) reported she could not find Patient 1. LVN 1 stated Patient 1 was at risk for elopement and was place on location check every 30 minutes by CNAs. LVN 1 stated the facility had a locked gate. LVN 1 stated she did not know how and when Patient 1 left the facility. LVN 1 stated it was dangerous that Patient 1 eloped from the facility. LVN 1 stated Patient 1 could get dehydrated in hot weather, hit by a car, abducted and possible death. LVN 1 stated facility staff needed to be careful every time when they open the locked gate to make sure the patient could not leave the facility for the patients' safety. During a telephone interview on 7/18/2023, at 4:30 pm, Patient 1's FM 1 stated Patient 1 went home by a taxi on 7/18/2023 around noon time. FM 1 stated Patient 1 was not able to tell FM 1 how she got out of the locked gate at the facility and what had happened afterwards. FM 1 stated Patient 1 was in "okey" condition when the patient got home. FM 1 stated she called law enforcement and sent Patient 1 back to the facility on 7/18/2023 in the afternoon. During an interview on 8/1/2023, at 10:40 am, CNA 3 stated Patient 1 was on location check for every 30 minutes since admission due to Patient 1 was at risk for elopement. CNA 3 stated on 7/18/2023, at 10:40 am, she could not find Patient 1 during her location check around at 11 am. CNA 3 stated it was important to monitor patients to make sure they were safe. CNA 3 stated Patient 1 could get lost, dehydrated, and injured outside the facility. During an interview on 8/1/2023, at 11:10 am, the facility's Administrator (ADM) stated the facility did not know how Patient 1 eloped. The ADM stated the facility had a locked gate for entrance and exit that could only be opened by the facility staff upon request. The ADM stated supervising and keeping patients safe is the facility's priority. The ADM stated Patient 1 might get dehydrated, sick, or get hit by a car. A review of the facility's policy and procedure titled, "Safety and Supervision of Patients," revised 2/2019, indicated it is the policy of the facility to make the environment as free from accident hazards as possible. Patient safety and supervision and assistance to prevent accidents are facility-wide priorities. The facility-oriented and patient-oriented approaches to safety are utilized together to implement a systems approach to safety, which considers the hazards identified in the environment and individual patient risk factors, and then adjusts interventions accordingly. Patient supervision is a core component of the systems approach to safety. The type and frequency of patient supervision is determined by the individual patient ' s assessed needs and identified hazards in the environment. The facility failed to provide supervision for Patient 1 who did not have the capacity to make decisions and was at risk for elopement (leaving unnoticed by staff). As a result, Patient 1 eloped from the facility on 7/18/2023, at 10:40 am, wandered outside of the facility without supervision and took a public transportation to go. This failure also had the potential to result in Patient 1 sustaining an injury, dehydration, and abduction (take away by force). These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.