Other·June 20, 2024

F689, Code of Federal Regulations, Title 42, Section 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. 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. § 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. On 5/21/2024 10:42 am, the California Department of Public Health (CDPH, the Department) conducted an unannounced visit to the facility to investigate a facility reported incident regarding Resident 1 eloping from the facility. The facility failed to follow its policy and procedure (PP) titled, "Q:15 (every 15) Minute Monitoring," and provide supervision every 15 minutes per the physician's order to prevent elopement from the locked facility for one of four sampled residents (Resident 1) who was assessed as at risk for elopement by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 and CNA 2 monitored and kept Resident 1 in a clear and direct line of sight every 15 minutes. 2. Ensure CNA 1 and CNA 2 accurately monitored and documented Resident 1's whereabouts every 15 minutes. As a result of these failures, on 5/19/2024 at 10:15 am, Resident 1 entered the facility's unlocked Recreation Room without CNA 1 and CNA 2's supervision. On 5/19/2024 at 10:32 am, Resident 1 eloped from the facility through the patio from the Recreation Room. Resident 1 stacked chairs on top of a table in the patio, climbed onto the facility roof, walked to the southwest corner of the front of the facility building, climbed down using facility fencing, and walked southbound on the street and away from the facility. Resident 1 had not been found. These failures had the potential to put Resident 1 at risk for serious injury, harm, and/or death due to not receiving psychotropic medications, not having food and shelter, and being exposed to cold weather at night. A review of Resident 1's Admission Record (AR)indicated the facility readmitted Resident 1, a 44-year-old male, to the facility on 10/26/2023, with diagnoses that included schizoaffective disorder (a mental disorder characterized by abnormal thought processes and an unstable mood), anxiety disorder, and major depressive disorder. A review of Resident 1's Elopement Risk Assessment (ERA), dated 10/26/2023, indicated Resident 1 had a history of elopement from previous placements. The ERA indicated Resident 1 believed he did not need treatment for mental illness and shelter as he had been living in the streets. The ERA indicated staff were aware of Resident 1's wander risk. A review of Resident 1's untitled care plan (CP), initiated on 10/26/2023 indicated Resident 1 had poor impulse control due to absent without official leave (AWOL- also known as elopement) related to schizoaffective disorder. The CP indicated Resident 1 had a history of AWOL from prior facilities. The CP indicated Resident 1 had an attempted AWOL on 1/1/2024 and had one AWOL episode on 1/26/2024. The CP interventions included to assist Resident 1 to identify/discuss feeling associated with impulsive behavior. A review of Resident 1's Physician Order (PO), dated 1/8/2024, indicated an order for staff to monitor Resident 1 Q:15 minutes, every shift related to safety. A review of Resident 1's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 4/23/2024 indicated Resident 1 had moderately impaired cognition. The MDS indicated Resident 1 was independent with eating, oral hygiene, toileting hygiene, and walking 10 to 150 feet (ft). The MDS indicated Resident 1 required supervision or touching assistance with personal hygiene. During a concurrent interview and record review on 5/21/2024 at 10:42 am with the ADM, Resident 1's Location Monitoring Follow Up Question Report (LM Report) dated 5/19/2024 was reviewed. The ADM stated CNA 2 was the primary CNA assigned to monitor Resident 1 every 15 minutes on 5/19/2024. The ADM stated CNA 1 documented on the LM Report that Resident 1 was in Resident 1's room on 5/19/2024 at 10 am. The ADM stated CNA 1 documented on the LM Report that Resident 1 was in the hallway from 10:15 am to 10:30 am. The ADM stated CNA 2 documented on the LM Report that Resident 1 was in the hallway from 11:15 am to 11:45 am. The ADM stated facility staff (CNA 1 and/or CNA 2) did not document Resident 1's whereabouts at 10:45 am and 11 am. The ADM stated per the facility's investigation, Resident 1 entered the facility's Recreation Room at 10:15 am because the Recreation Room door was left unlocked. The ADM stated the Recreation Room's door opened to the patio. The ADM stated residents (all residents) were not allowed to be on the patio without staff supervision. The ADM stated Resident 1 was left unsupervised in the Recreation Room and on the patio (on 5/19/2024) from 10:15 am to 10:32 am. The ADM stated Resident 1 climbed onto the facility's roof from the patio and eloped from the facility. The ADM stated facility staff (CNA 1 and CNA 2) did not realize Resident 1 was missing until after lunch (1 pm), even though CNA 1 and CNA 2 were documenting Resident 1's whereabouts between 10:15 am to 11:45 pm. During a concurrent review of the facility's video surveillance and interview on 5/21/2024 at 11:57 am with the Program Director of Special Treatment Program (PD), the surveyor reviewed the facility's video surveillance, dated 5/19/2024 with the PD. The PD stated, the facility's video surveillance dated 5/19/2024, at 10:10:00 am, Resident 1 was in the hallway, standing adjacent to the facility's Beauty Parlor. The PD stated there were no staff visible in the (video surveillance's) frame. The PD stated at 10:15:22 am, Resident 1 was standing in the hallway across from the Recreation Room. The PD stated no staff were visible in the frame. The PD stated at 10:15:56 am, Resident 1 entered the Recreation Room. The PD stated at 10:30:32 am, Resident 1 climbed onto the roof from the patio using 5 stacked plastic chairs and plastic folding table that Resident 1 obtained from the Recreation Room and placed on the patio. The PD stated at 10:32:36 am, the video surveillance showed Resident 1 was outside of the facility fencing, walking south bound on the street and away from the facility. The PD stated no staff were visible in the frame. The PD stated there were no staff present to monitor and supervise Resident 1 while Resident 1 was in the Recreation Room and the patio. The PD stated the Recreation Room was supposed to remain locked for residents' safety. During a telephone interview on 5/21/2024 at 1:28 pm with CNA 1, CNA 1 stated (in general) when a resident was on Q 15-minute monitoring, CNA 1 was supposed to supervise a resident by checking on him/her. CNA 1 stated (on 5/19/2024) CNA 1 went on break from 10:20 am to 10:30 am. CNA 1 stated CNA 1 documented Resident 1's whereabouts (at 10 am, 10:15 am and 10:30 am) without knowing Resident 1's accurate location because no other staff had documented in Resident 1's record. CNA 1 stated CNA 1 documented the whereabouts of Resident 1 because CNA 1 wanted to ensure the "charting (medical record) was complete." CNA 1 stated CNA 1 changed the documentation to indicate Resident 1 was AWOL once facility staff realized Resident 1 was missing after lunch time. CNA 1 stated it was important to know Resident 1's whereabouts and accurate location for Resident 1's safety. CNA 1 stated when CNA 1 documented she knew Resident 1's location even though she did not, Resident 1 "could get hurt." During a telephone interview on 5/21/2024 at 1:37 pm with CNA 2, CNA 2 stated CNA 2 was the primary CNA assigned to Resident 1 on 5/19/2024. CNA 2 stated Resident 1 was supposed to be monitored every 15 minutes to ensure Resident 1's safety. CNA 2 stated CNA 2 documented Resident 1's whereabouts as being in the hallway at 11:15 am, 11:30 am, and 11:45 am on 5/19/2024 even though CNA 2 did not know Resident 1's accurate location. CNA 2 stated because CNA 2 did not monitor Resident 1's accurate whereabouts as directed; Resident 1 was able to elope from the facility. CNA 2 stated Resident 1 could get really hurt and have an accident being out on the streets. During an interview on 5/21/2024 at 4 pm with the DSD, the DSD stated staff (CNA 1 and CNA 2) completing the Q 15-minute monitoring of Resident 1 must locate and visualize Resident 1's actual whereabouts every 15 minutes for Resident 1's safety. The DSD stated staff blindly documenting Resident 1's whereabouts when Resident 1's actual whereabouts were not visualized put Resident 1 at risk for elopement and serious injury, or even death. The DSD stated Resident 1 should not be out in the community unsupervised because Resident 1 had moderately impaired cognition and Resident 1 was a danger to himself and others. During a concurrent interview and record review on 5/21/2024 at 4:29 pm with the DON, Resident 1's Elopement Risk Assessment (ERA) dated 10/26/2023 was reviewed. The DON stated Resident 1 was at risk for elopement. The DON stated Resident 1 was on monitoring for poor impulse control and for AWOL/elopement risk because Resident 1 had attempted to leave the facility in the past (1/1/2024 and 1/26/2024). The DON stated the facility's protocol for Q 15-minute monitoring was to check a resident's (Resident 1's) location every 15 minutes. The DON stated "that (Q 15-minute monitoring) meant staff needed to visualize Resident 1 every 15 minutes and document Resident 1's accurate location. The DON stated the staff (CNA 1 or CNA 2) who visualized Resident 1 was supposed to document Resident 1's location to ensure Resident 1's location was accurate, and that Resident 1 was being appropriately monitored and supervised. The DON stated (in general) when a resident was not appropriately monitored or supervised like Resident 1, then like Resident 1, that resident could also leave the facility without staff knowing. The DON stated because Resident 1 eloped from the facility, Resident 1 was a danger to himself and others. The DON stated CNA 1 and CNA 2 falsified Resident 1's Q 15-minute monitoring report by documenting they monitored/supervised and knew Resident 1's whereabouts even though they did not visually see Resident 1's whereabouts. The DON stated "this (falsification of record)" prevented staff from knowing Resident 1's accurate location and intervening the moment Resident 1 was missing. The DON stated the consequence of CNA 1 and CNA 2 not monitoring Resident 1's whereabouts accurately was that Resident 1 may not be found. The DON stated Resident 1 could become seriously injured or even die. During a review of the facility's PP titled, "Q:15 Minute Monitoring," dated 4/2024, the PP indicated the facility provided an atmosphere that was safe and secure for all residents and staff. The PP indicated a tool to assist in providing a safe and secure environment was Q:15-minute checks. The PP indicated the CNA assigned to the resident placed on Q:15-minute checks sought, found, and documented location and condition of the resident every 15 minutes during their shift and must be done in a timely manner. The PP indicated staff who implemented the Q:15-minute checks must maintain a clear and direct line of sight at time of documentation of Q:15-minute checks and document their location. The facility failed to follow its PP titled, "Q:15 Minute Monitoring," and provide supervision every 15 minutes per the physician's order to prevent elopement from the locked facility for Resident 1 who was assessed as at risk for elopement by failing to: 1. Ensure CNA 1 and CNA 2 monitored and kept Resident 1 in a clear and direct line of sight (within someone's view) every 15 minutes. 2. Ensure CNA 1 and CNA 2 accurately monitored and documented Resident 1's whereabouts every 15 minutes. As a result of these failures, on 5/19/2024 at 10:15 am, Resident 1 entered the facility's unlocked Recreation Room without CNA 1 and CNA 2's supervision. On 5/19/2024 at 10:32 am, Resident 1 eloped from the facility through the patio from the Recreation Room. Resident 1 stacked chairs on top of a table in the patio, climbed onto the facility roof, walked to the southwest corner of the front of the facility building, climbed down using facility fencing, and walked southbound on the street and away from the facility. Resident 1 had not been found. These failures had the potential to put Resident 1 at risk for serious injury, harm, and/or death due to not receiving psychotropic medications, not having food and shelter, and being exposed to cold weather at night. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.