Health inspection·August 27, 2024

California Code of Regulations, Title 22, 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. Code of Federal Regulations, Title 42 F689 Free of Accident Hazards/Supervision/Devices §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. An unannounced visit was made to the facility to investigate a facility reported incident regarding an incident of alleged patient abuse. The facility failed to investigate and attempt to locate Patient 1, who has a history of elopement (a patient who leaves without supervision and without being noticed) when the patient was being transferred to GACH 2 via ambulance. According to the Ambulance Report, Patient 1 jumped out of the ambulance and ran out of GACH 2 parking lot. As a result, Patient 1 had not been located and currently still missing, after eloping from the ambulance transportation on the way to GACH 2 Emergency Room (ER) on 7/11/2024. This deficient practice had the potential to result in Patient 1’s physical injuries and change in condition =that may lead to hospitalization or death. A review of General Acute Care Hospital (GACH 1) records indicated Patient 1, a 39-year-old male was admitted on 6/21/2024 with a diagnosis of Psychosis (mental disorder characterized by a disconnection from reality) and was discharged to Facility on 7/1/2024. A review of GACH 1 records indicated Patient 1 had worsened symptoms of suicidal ideations (thinking about or planning suicide) with a plan to hang himself. The GACH 1 records indicated that Patient 1 verbalized that when he was taking his psychiatric medication (psychoactive drug taken to exert an effect on the chemical makeup of the brain and nervous system) directed by the physician, the medications were effective. A review of Patient 1’s Admission Record indicated a 39 year old, male patient, admitted to the facility on 07/01/2024, with diagnoses that included schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). A review of Patient 1’s History and Physical Assessment dated 7/03/2024, indicated Patient 1 had fluctuating capacity to understand and make decisions. A review of Patient 1’s care plan titled, “Risk for Wandering/Elopement identification” dated 7/02/2024, indicated a goal that Patient 1 would not leave the facility unattended and Patient 1’s safety would be maintained. The care plan interventions indicated the facility would identify if there were triggers for wandering/eloping, identify wandering/elopement and de-escalation behaviors. A review of Patient 1’s care plan titled “Patient alleges that he was abused by staff with complaints of pain” dated 7/11/2024, indicated interventions that included the facility staff would assess for pain, assessed the patient’s skin, the interdisciplinary team would meet with Patient 1 and inform the physician. The care plan indicated a new order to transfer Patient 1 to the GACH 2 for evaluation. A review of Patient 1’s Hospital Transfer Form dated 7/11/2024, indicated Patient 1 was transferred to GACH 2 on 7/11/2024 timed at 2 PM. The Hospital Transfer Form indicated a risk alert for Patient 1 had agitation with risk to harm self or others and may attempt to exit. The Hospital Transfer Form indicated the report was given by the facility’s Registered Nurse (RN1) on 7/11/2024 at 1:15 PM to the GACH 2 Registered Nurse (no name). A review of the Ambulance Record titled “Hospital Care Report” dated 7/11/2024 indicated Patient 1 was transported from the facility to GACH 2. The Ambulance Record indicated “When Ambulance arrived at GACH 2, we opened doors, explained to the patient that report, paperwork needed to be given to [GACH 2] nurse in order to register/admit the patient to GACH 2. [Patient 1] took off seatbelts and jumped out of ambulance and began running out of GACH 2 parking lot.” A review of an electronic communication via mobile device received from GACH 2 to the facility dated 7/13/2024 timed at 10:38 AM, indicated a message from Physician 1 asking, “Where is this patient (Patient 1) now?” The facility Medical Records Director (MRD) response on the same date 7/13/2024 (no time) indicating, “Good morning, he (Patient 1) was sent out to the hospital.” Physician 1 asked, “Which hospital?” MRD responded that Patient 1 was in “GACH 2.” Physician 1 responded and indicated in message “Can’t find,” and indicated in the text message “Please track and let me know.” GACH 2 Liaison responded via electronic communication via mobile indicating “Patient 1 eloped from our emergency room at 5:06 on July 11.” A review of GACH 2 document titled “Certification of No Medical Records” with Patient 1’s name and date of birth, dated 7/16/2024, indicated GACH 2 had no record of Patient 1 was arrived and treated in GACH 2. During an interview on 7/23/2024 at 10:40 AM, with the facility’s Administrator (ADM), the ADM stated Patient 1 was transferred from the facility via ambulance service on 7/11/2024 for medical evaluation due to Patient 1 making claims he was physically abused by 5 people and was in pain. The ADM stated the facility staff conducted a head-to-toe assessment on Patient 1 but did not find any injuries. The ADM stated that Physician 1 was notified, and Physician 1 ordered to transfer the patient to GACH 2 for medical clearance just to “check if everything was okay.” The ADM stated that at first GACH 2 informed the facility that Patient 1 left GACH 2 against medical advice (AMA). The ADM stated that when the ambulance transporters picked up Patient 1 (on 7/11/2024), that was the last time the facility staff saw Patient 1. During the same interview, on 7/23/2024 at 10:40 AM, with the facility’s ADM, the ADM further stated that the facility’s Admission Coordinator (AC) called GACH 2 on 7/15/2024 for a follow up call and was notified by GACH 2 that Patient 1 was not admitted in GACH 2. The ADM stated that the AC requested for any documentation from GACH 2’s Emergency Room (ER) but GACH 2 only sent the “Certification of No Medical Records” indicating that the GACH 2 had no records of Patient 1 being treated or admitted at the GACH. During an interview and concurrent record review on 7/23/2024 at 12:10 PM with the AC, the AC stated as per facility practice, she follows up on patients who have been transferred to GACHs for updates. The AC stated he called GACH 2 to follow up on Patient 1’s status on 7/15/2024, when she was notified by GACH 2 that there was no record indicating Patient 1 had ever been admitted to GACH 2. The AC stated she notified the ADM who instructed AC to follow up with GACH 2’s Medical Records Department and request any documents about Patient 1 from GACH 2. The AC stated when she received GACH 2’s document titled “Certification of No Medical Records” on 7/16/2024, she gave the document to the ADM. During an interview, on 7/23/2024 between the hours of 1 PM to 1:24 PM, the ADM stated she did not follow up with GACH 2 or the Ambulance company, when she was notified by MRD on 7/13/2024, that Patient 1 was not admitted at GACH 2, because it was a Saturday, and the AC would follow up on Monday. The ADM stated that on 7/16/2024, after receiving documentation from GACH 2 indicating there were no records of Patient 1 ever being admitted to GACH 2, the ADM stated she did not follow up or attempt to locate Patient 1 because Patient 1 had been discharged from the facility’s care, so it would have been GACH 2’s responsibility. The ADM stated she did not report to law enforcement because Patient 1 was self responsible. The ADM stated that even if Patient 1 was not self-responsible, Patient 1 would have been GACH 2’s responsibility. During the interview, the ADM called the Ambulance company to verify what happened to the Patient 1 on 7/11/2024 and was informed that Patient 1 took off seatbelts and jumped out of ambulance and began running out of GACH 2 parking lot. Patient 1 was never admitted to the GACH 2. During an interview and concurrent record review on 7/23/2024 at 2:42 PM with the MRD. The MRD, Physician 1, GACH 2 Liaison and Case Manager were part of the electronic communication via mobile. The MRD stated she received a message on 7/13/2024, from Physician 1 asking Patient 1’s whereabouts. The MRD stated she replied to Physician 1 with the location of Patient 1 which was in GACH 2. The MRD stated she saw Physician 1’s response and was notified that Patient 1 was not in GACH 2. The MRD stated that Physician 1 questioned what happened to Patient 1 and GACH 2 Liaison replied that Patient 1 had “Eloped from GACH 2 on 7/11/2024.” The MRD stated that Physician 1 asked Physicians’1’s Case Manager to follow up and locate Patient 1. The MRD stated she notified the facility's ADM on 7/13/2024 that Patient 1 had eloped. The MRD stated she did not document what happened to Patient 1 and notifying the physician and administrator that Patient 1 had eloped. During a follow up interview and record review of the facility’s policy on 7/23/2024 with the ADM, the ADM stated she had reviewed all of the facility’s policies and procedures and could not find a policy that included how the facility would ensure a safe Patient discharge/transfer from the facility to another facility. A review of the facility’s policy and procedures (P&P) titled “Patient Safety” revised on 4/15/2021, indicated “Facility will provide a safe and hazard free environment.” The facility failed to investigate and attempt to locate Patient 1, who was never admitted to the GACH 2 on 7/13/2024. Patient 1 was assessed for at risk of elopement had a history of suicidal ideations, and had fluctuating capacity to understand and make decisions. As a result, Patient 1 had not been located and currently still missing, after eloping from the ambulance transportation on the way to GACH 2 ER on 7/11/2024. This deficient practice had the potential to result in Patient 1’s physical injuries and change in condition that may lead to hospitalization or death. These violations had a direct or immediate relationship to the health, safety, or security of Patient 1.