Other·June 5, 2024

§ 72541. Unusual Occurrences. Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The following reflects the finding of the California Department of Public Health during the investigation of Facility Reported Incident #: CA00898079 Survey Re-licensing EVENT ID: K9II11 Representing the Department, HFEN #42854 State Citation B was written. The facility failed to report an unusual occurrence incident within 24 hours of an incident to the California Department of Public Health (CDPH) in accordance with the facility’s policy and procedure on “Unusual Occurrence Reporting,” involving an incident from Patient 1 who was not found and eloped the facility on 4/30/2024 and remained missing until 5/1/2024. As a result, California Department of Public Health (CDPH) was not notified timely regarding Patient 1 eloping from the facility on 4/30/24 to 5/1/24. On 5/8/2024 at 10:50 AM, an unannounced visit was conducted at the facility regarding a facility reported incident (FRI) of resident safety. On 5/2/2024 at 4:36 PM, a voicemail was received from the Administrator (ADM) of the facility, reporting Patient 1 elopement from the facility. The ADM stated Patient 1 was missing on 4/30/2024 and was found on 5/1/2024. A review of Patient 1’s Admission Record indicated Patient 1, a 67 year old patient was admitted to the facility on 3/19/2024 with diagnoses that included unspecified psychosis (a persons thoughts are disrupted and they have difficulty recognizing what is real and what is not real), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). A review of Patient 1’s Minimum Data Set (MDS – a standardize assessment and care screening tool) dated 3/25/2024 indicated the patient had severely impaired cognition (the ability or mental action or process of acquiring knowledge and understanding). A review of Patient 1’s History and Physical dated 3/20/2024 indicated that the patient had fluctuating capacity to understand and make decisions. A review of Patient 1’s Elopement Evaluation dated 3/19/2024 indicated the patient was at risk for elopement. A review of Patient 1’s Change in Condition Evaluation (COC) dated 4/30/2024 timed at 4:00 PM indicated Patient 1 left facility without notifying staff. The COC indicated licensed vocational nurse (LVN) 1 reported unable to locate Patient 1’s whereabouts and initiated “code green (response in the event of a missing or eloping resident)” as per facility’s protocol. During an interview on 5/8/2024 at 11:01 AM, the ADM stated not reporting the incident of Patient 1 eloping on 4/30/24 to CDPH, and had not reported the elopement within 24 hours. The ADM stated the incident of Patient 1 eloping from the facility on 4/30/24 was not reported to CDPH until 5/2/24, 48 hours from the date Patient 1 was missing. A review of the facility’s policy and procedure titled “Unusual Occurrence Reporting,” dated 8/1/2012 indicated the facility will follow all applicable state and federal laws and regulations regarding the reporting of unusual occurrences. The policy indicated unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing. The facility failed to report an unusual occurrence incident within 24 hours of an incident to CDPH in accordance with the facility’s policy and procedure on “Unusual Occurrence Reporting,” involving an incident from Patient 1 who was not found and eloped the facility on 4/30/2024 and remained missing until 5/1/2024. As a result, California Department of Public Health (CDPH) was not aware Patient 1 could not be from 4/30/24 to 5/1/24 This violation had a direct relationship to the health, safety, and security of patient 1and and all patients residing in the facility.