Other·February 16, 2023

F 689 CFR §483.25(d)(2) Accidents. The facility must ensure that each Patient receives adequate supervision and assistance devices to prevent accidents. CCR §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. CCR §72523 (a) (b) 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. On 12/20/2022 at 9:10 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding quality of care for Patient 1. On 12/17/2022, Cook 1 (CK 1) opened the facility's front gate and Patient 1 eloped (leaving the facility without notice) from the facility in front of CK 1. As a result of the investigation, CDPH determined the facility failed to provide adequate supervision for Patient 1 by failing to: 1. Ensure CK 1 intervened or attempted to redirect Patient 1 back to the facility or prevented the elopement as indicated in the facility's policy and procedure titled, “Elopement of Patient.” 2. Develop policy and procedures that included prevention of patient elopement when staff accessed the gate to enter and exit the facility. 3. Train newly hired employees on elopement prevention and interventions. As a result of these failures, Patient 1 eloped from the facility on 12/17/2022 at approximately 6:45 AM and tested positive for amphetamines (an addictive mood-altering drug used illegally as a stimulant and legally children and adults with certain medical condition) at the local hospital’s Emergency Room (ER) on 12/19/2022. These failures had the potential to result in serious injury to Patient 1 and compromise Patient 1’s health and safety. A review of Patient 1's Admission Record indicated the facility admitted a 53-year-old female on 6/02/2022, with diagnoses that included disorganized schizophrenia (mental health condition characterized by loss of contact with the environment and can involve delusions, having strong beliefs that are not true, paranoia, thinking and feeling like they are being threatened in some way). A review of Patient 1's Comprehensive Care Plan, dated 6/18/2022, indicated the patient was at risk for elopement related to being placed in a facility with open placement setting. The care plan interventions included for staff to encourage Patient 1 to engage in the establishment of an appropriate discharge plan and participate in community reintegration focus groups. A review of Patient 1's History and Physical, dated 6/20/2022, indicated the patient did not have the capacity to understand and make decisions. A review of Patient 1's Minimum Data Set (MDS, standardized data collection tool used to assess cognitive and functional status), dated 9/21/2022, indicated the patient had intact cognition (ability to think and process information), was able to understand others, and made herself understood. A review of Patient 1's Comprehensive Care Plan, dated 12/17/2022, indicated the patient was at risk for elopement due to making one or more attempts to leave the facility. The care plan indicated Patient 1 eloped on 12/17/2022, and interventions to prevent elopement included for staff to monitor the patient's location hourly, observe triggers for exit seeking behaviors, and encourage the patient to participate in group activities. A review of Patient 1's Situation Background Assessment and Recommendation (SBAR, communication record between members of the health care team) form, dated 12/17/2022, indicated on 12/17/2022, at approximately 6:45 AM, the Dietary Supervisor (DS) notified the charge nurse that the new employee (CK 1) saw Patient 1 leaving the facility through the (front) gate. The SBAR indicated facility’s staff immediately went searching inside and outside the facility and the patient was nowhere to be found. The SBAR indicated the local police department, the Director of Nursing (DON), the Administrator (ADM), and the patient's conservator (a person appointed by the court to manage and make decisions of another person's personal affairs: medical and financial) were notified. A review of Patient 1's Progress Notes, dated 12/17/2022, timed at 8 AM, indicated the patient eloped at approximately 6:30 AM to 7 AM. The notes indicated the patient had a history of elopement from previous facilities. The notes indicated the charge nurse last saw Patient 1 at 6 AM, during administration of morning medications, when the patient took her medications and returned to her room. The notes indicated CK 1 reported seeing a lady with 2-3 white bags as CK 1 was coming inside the (front) gate at 6:45 AM. The notes indicated CK 1 used his key to close the gate. The notes indicated CK 1 reported that Patient 1 stated, "They said I can go, I can leave," as Patient 1 walked out the gate when CK 1 attempted to close the gate. The notes indicated CK 1 reported the incident to the DS and notified the charge nurse. The notes indicated the charge nurse and staff began a head count to ensure all patients were accounted for and discovered Patient 1 was missing. A review of Patient 1's Progress Notes, dated 12/19/2022, timed at 4 PM, indicated at 2:50 PM, the staff found Patient 1 and brought Patient 1 back to the facility. The notes indicated the facility sent Patient 1 to the local hospital's ER for a full evaluation. A review of Patient 1's Progress Notes, dated 12/19/2022, timed at 5:37 PM, indicated a staff member located Patient 1 on the street (same city as the facility). The notes indicated Patient 1 appeared disheveled (untidy or very messy), malodorous (smelling very unpleasant), with reddened eyes, and pinpoint pupils. The notes indicated Patient 1 was sleeping outside of a smoker's club and admitted to drinking rum and coke on 12/18/2022 in the morning. The notes indicated Patient 1's last meal was on 12/18/2022 when she ate bacon and eggs. A review of Patient 1's ER report, dated 12/19/2022, at 10:01 PM, indicated Patient 1’s urine toxicology (various tests that determine the type and approximate amount of legal and illegal drugs a person has taken) screening results tested positive for amphetamines. The ER report indicated Patient 1 had a urinary tract infection. During an interview on 12/20/2022, at 9:30 AM, the ADM stated on 12/17/2022, CK 1 entered the front gate and exited his vehicle to close the gate and Patient 1 "darted" out of the gate. During an interview on 12/20/2022, at 9:35 AM, the Director of Staff Development (DSD) stated the facility's protocol for entering through the front gate was to press the buzzer located by the front gate which alerted the nursing station. The DSD stated a staff member would be sent out to open the gate, let the person in, and lock the gate. The DSD stated a key was only to be used when it was raining, and no staff member was available to open the gate. The DSD stated CK 1 did not follow the facility’s protocol. During concurrent interviews and observation of the front gate on 12/20/2022, at 9:55 AM, the DSD opened the front gate from inside the facility ground using a key. The key had to remain in a turned position for the gate to fully open. If the key was turned back, the gate would stop moving. The approximate speed to open the gate was 60 to 70 seconds. The DSD stated the gate would not close automatically and if the gate was stopped, the gate would only close once fully opened. The ADM stated the speed of the gate and the fact that the gate had to be fully opened before closing was an issue. The ADM stated Patient 1's elopement could have been prevented if the facility’s protocol was followed. During an interview on 12/20/2022, at 10:10 AM, Patient 1 stated she was allowed to pass and leave the facility by walking out through the front gate when it was opened. Patient 1 stated no staff tried to stop her from leaving the facility. Patient 1 stated she went to the apartments located two buildings away from the facility and slept on the floor. During an interview on 12/20/2022, at 10:15 AM, the DSD stated it was important to prevent elopements because Patient 1 had a form of psychosis (a mental disorder, when a person interprets reality in a very different way than people around them, disconnection from reality). The DSD stated police and other people could be threatened by Patient 1’s behaviors and Patient 1 could get hurt. The DSD stated, "it gets cold out here" and the weather was very dangerous for patients that eloped and did not have proper clothing. During an interview on 12/20/2022, at 10:20 AM, the DS stated on 12/17/2022, CK 1 was scheduled to work at 5:30 AM, but was late to work and arrived at approximately 6:30 AM. The DS stated CK 1 signed in for his shift and then told the DS, "Oh by the way, when I was closing the gate, someone walked out the gate." The DS immediately notified the facility staff. The DS stated protocol for entering the facility was to use the key to open and close the gate. The DS stated dietary staff did not have to push the buzzer to have a staff member open the gate because they each had a key. The DS stated CK 1 was a new employee and had not been trained on any facility’s policies and procedures and did not know what to do if a patient tried to elope. The DS stated CK 1 needed to look around to ensure no patients were by the gate before opening the gate. The DS stated since Patient 1's elopement, the facility assigned a staff member to monitor the gate. The DS stated, "everything and anything could have happened to Patient 1." The DS stated Patient 1 was at risk for "all sorts of hazards," such as cars, the environment (weather), and other people hurting Patient 1. During an interview on 12/20/2022, at 10:36 AM, the ADM stated dietary staff were contracted and employed through an outside company. The ADM stated it was the facility's responsibility to ensure all staff were trained, were aware that it was a locked facility, and aware that elopements had to be prevented. The ADM confirmed CK 1 had not been trained on any of the facility's policies and procedures. The ADM stated elopement prevention training was important because patient elopements could lead to a patient getting hurt, exposure to dangerous substances, cold weather, and worst-case scenario "unfortunately lose their life." During an interview on 12/20/2022, at 1 PM, CK 1 stated he was a new employee. CK 1 stated that other than kitchen training, the facility had not provided him with any training. CK 1 stated on 12/17/2022, he did not see anybody near the (front) gate. CK 1 stated he opened the gate, entered, and exited the vehicle to close the gate. CK 1 stated at that time, he saw a lady, Patient 1, carrying bags and walking out of the gate saying, "They said I could go, they said I could go." CK 1 stated he closed the gate, went to the kitchen, and reported the incident to the DS. CK 1 stated the speed of the gate was very slow and the areas surrounding the gate had areas where patients could hide. CK 1 stated he used the buzzer to enter the facility the first two days of employment but was then told, "Well you have a key to get in so use it." A review of a facility’s policy and procedures titled, "Elopement of Patient," dated 10/24/2022, defined elopement as "Any situation in which a patient leaves the premises or a safe area without the facility's knowledge and supervision, if necessary." The policy indicated staff witnessing a confused patient or an identified elopement risk patient attempting to leave the unit and/or center unaccompanied will intervene as appropriate to redirect the patient to a safe area and prevent elopement. The policy did not indicate elopement preventions measures during opening and closing of the facility's gate. As a result of the investigation, CDPH determined the facility failed to provide adequate supervision for Patient 1 by failing to: 1. Ensure CK 1 intervened or attempted to redirect Patient 1 back to the facility or prevented the elopement as indicated in the facility's policy and procedures titled, “Elopement of Patient.” 2. Develop policy and procedures that included prevention of patient elopement when staff accessed the gate to enter and exit the facility. 3. Train newly hired employees on elopement prevention and interventions. As a result of these failures, Patient 1 eloped from the facility on 12/17/2022 at approximately 6:45 AM and tested positive for amphetamines (an addictive mood-altering drug used illegally as a stimulant and legally children and adults with certain medical condition) at the local hospital’s Emergency Room (ER) on 12/19/2022. These failures had the potential to result in serious injury to Patient 1 and compromise Patient 1’s health and safety. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.