Health inspection·October 31, 2024

Title 22, California Code of Regulations § 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. § 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. F689 §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. On 9/18/2024 at 11 AM, an unannounced visit was conducted at the facility to investigate two Facility Report Incidents (FRI) regarding patient safety related to wandering behavior (walking or going to places aimlessly) and elopement (the act of leaving a facility premises or a safe area without notifying anyone) that involved Patient 1 and Patient 2. As a result of the investigation the California Department of Public Health (CDPH) determined the facility failed to: 1. Provide adequate monitoring and supervision to ensure Patient 1, who had fluctuating capacity to understand and make decisions, and was assessed at risk for elopement with diagnoses of suicidal ideation (thinking about killing yourself) did not elope from the facility on 9/10/2024 during a change of shift [evening shift and night shift) at 11 PM from Patio I. 2. Provide adequate monitoring and supervision to ensure Patient 2, who had no capacity to understand and make decisions, assessed at risk for elopement and with diagnoses of suicidal ideations, did not elope from the facility, on 9/17/2024, during change of shift [night shift and morning shift] at 7 AM from Patio I. 3. Ensure the facility thoroughly investigated on how Patient 1 eloped from the facility and provided interventions to prevent another resident, Patient 2, eloping from the same location in Patio I. 4. Ensure Patio 1, that is in the front patio, and Patio 2 that is in the back patio, were equally monitored and supervised to prevent residents from elopement. 5. Ensure Certified Nursing Assistant (CNA) 5 immediately informed staff that he saw someone climbing the roof near Patio 1. As a result of these deficiencies Patients 1 & 2 had the potential to sustain fall and injury when climbing the roof and struck by motor vehicles. Patient 1 had the potential to be exposed to extreme weather, malnutrition (lack of proper nutrition) and a psychiatric emergency due to a history of suicidal ideations that could lead to death. Patient 2 missed his daily medications (medications that affects mood and behavior) that were necessary to ensure he was not a danger to self and others. a. A review of Patient 2’s Admission Record indicated that the facility admitted the Patient on 8/1/2024 and readmitted the Patient on 8/14/2024 with diagnoses that included schizophrenia (a serious mental health condition that affects how people think, feel, and behave, with paranoia [mistrust of other people] as one of its most dominant symptoms) and suicidal ideations (thinking of hurting or killing oneself). A review of Patient 2's History and Physical, dated 8/2024 indicated the Patient 2 does not have the capacity to understand and make decisions. A review of Patient 2’s Minimum Data Set (MDS - a standardized assessment and screening tool), dated 5/23/2024, indicated that the patient’s cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was intact. The MDS indicated that Patient 2 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently) when performing activities of daily living (ADL) such as eating, toileting, showering, and when performing oral hygiene. A review of Patient 2’s care plan, initiated on 8/14/2024, indicated Patient 2 was at risk for wandering and elopement, to ensure Patient 2 does not leave the facility unattended, the interventions included identifying triggers for wandering/elopement attempts, identifying patterns and purpose of wandering, and to monitor the resident’s location every hour. A review of Patient 2's Elopement Evaluation (EE) dated 9/11/24 indicated that the Patient 2 was recently readmitted (within the past 30 days). Patient 2 also verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. During a facility tour on 9/18/24 at 11:30 AM, the ADM demonstrated how Patient 2 climbed the roof from the patio to the other side of the building. The building that the residents in the facility occupied had six red doors that led to Patio 1. The patio had a screen fence approximately 12 feet high, with a door equipped with an alarm system, that led to the office of the ADM in another building. During a concurrent interview with the ADM, 9/18/24 at 11:30 AM she stated Patient 2 used the water pipes attached to the wall of the building to climb to the roof and jumped to the other side of the building to escape the facility. The ADM stated that the six red doors that led to Patio 1 remain unlocked 24 hours a day to enable the residents to freely go to the patio whenever they desired. All the doors and leading to the Patio are supposed to be supervised by staff that monitors the Patio 1. During an interview and concurrent record review with Director of Staff Development (DSD) on 9/18/24 at 2:30 PM, she stated on the night shift (11-7 AM), the staff monitoring the breezeway (an architectural feature like a hallway that allows the passage of a breeze) also monitors the patio simultaneously. The ADM stated Patio 1 does not have a dedicated staff to monitor the patio (Patio 1) area between 11 PM and 7AM. A review of the Nursing Staff Assignment dated 9/16/24, 11-7 AM shift, indicated that there was no dedicated staff assigned to monitor Patio 1 during the night shift (11-7 AM). During an interview with CNA 5 on 9/18/2024 at 3 PM, he stated he was assigned to monitor the breezeway on 9/17/24 from 7-3 PM. CNA 5 stated that on 9/17/24 between 7:15 - 7:20 AM, he observed a person from the breezeway climbing the roof in Patio 1 and simultaneously heard a Code Green (an emergency code used by the facility to alert the facility staffs that a patient was missing or eloped using the facility's paging system). CNA 5 stated he immediately stepped out of the building from the breezeway to confirm what he saw, but the person was no longer there. CNA 5 stated he did not report to anyone immediately that he observed someone climbing the roof rather, rather he returned to his post while the rest of the staff looked for Patient 2. CNA 5 stated he learned later from the other staffs that Patient 2 eloped and was missing. During a concurrent interview and observation on 9/18/24 at 3 PM with CNA 5, CNA 5 stated he was assigned to monitor Patio 1 and the breezeway. CNA 5 stated the location from where he stood along the breezeway did not have a full and clear view of Patio 1. During an interview with Licensed Vocational Nurse (LVN) 4 on 9/19/24 at 12:20 PM, LVN 4 stated during breakfast on 9/17/24 at around 7:15 AM, she found a food tray in the food cart that belonged to Patient 2. LVN 4 stated she looked for Patient 2 everywhere in the building and was unable to locate the resident. LVN 4 then stated she immediately paged Code Green on 9/17/24 at around 7:18 AM. During an observation on 9/19/24 at 3:35 PM, the Maintenance Supervisor (MS) measured the distance from the breezeway where the staff stood to monitor Patio 1 simultaneously. The distance from where the staff stood in the Breezeway to the wall where Patient 2 allegedly climbed to the roof was approximately 97 feet away and the height of the wall was approximately 11 feet and 2 inches. A review of the facility investigation report sent to CDPH, dated 9/23/24, indicated on 9/17/24 during a routine hourly head counts in the morning shift change, Resident 2 was not in his room. The staff informed the licensed nurse, and a "Code Green" was immediately called at around 7:18 AM that initiated the search for Resident 2. During the search, a member of the search team saw Resident 2 making his way through the football field at the high school adjacent to the facility. The facility called the police on 9/17/24 at 7:27 AM but the resident was nowhere to be found. A review of the Nursing Staff Assignment dated 9/16/2024, 11-7 AM shift, indicated that there was no dedicated staff assigned to monitor Patio 1 during the night shift (11-7 AM). During an observation of a photo taken at the breeze way from the middle/back position of Patio 1 on 9/19/24 at 12:40 PM indicated the breeze way door frame was blocking full visual view of Patio 1. A review of the facility's closed-circuit television (CCTV, also known as video surveillance, is the use of closed-circuit television cameras to transmit a signal to a specific place, on a limited set of monitors) on 9/19/24 at 12:45 PM showed the camera in Patio 1 only captured one side of the patio. The camera does not show side of the patio where Resident 2 climbed to get to the roof of the building. b. During a review of Patient 1's Admission Record indicated the facility admitted Patient 1 on 9/3/2021 and readmitted on 8/9/202024 with diagnoses that include schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and suicidal ideations. During a review of a Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated 9/4/202024, indicated Patient 1 had intact cognitive (ability to understand and make decisions) skills for daily decision making. The MDS indicated Patient 1 exhibited little interest or pleasure in doing things and trouble concentrating on things, such as reading the newspaper or watching television on half or more of the day. The MDS indicated Patient 1 also exhibited feeling down, depressed, or hopeless and bad about self or being a failure or let self or the family down nearly every day. The MDS indicated Patient 1 was independent with eating, oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, walk 150 feet. During a review of the plan of care, dated 8/9/2024, indicated Patient 1 was at risk for elopement and wandering with the goal to ensure Patient 1 does not leave the facility unattended. The interventions included the facility will monitor patient’s whereabout every hour and will involve Patient in purposeful activity. During an interview on 9/18/2024 at 3:35 PM, with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she worked at the east station on 9/10/2024 from 3 PM to 11 PM. LVN 3 stated she was inside East Nursing Station’s main building around 11 PM on 9/10/2024, when she heard a noise coming from Patio 1, but she did not see anyone on the ground of Patio 1 when she stepped out to the patio. LVN 3 stated she heard a noise coming from the roof on the East wing building, where she saw Patient 1 on top of the roof. During an observation on 9/19/2024 at 12 PM, Certified Nursing Assistant (CNA) 3 was observed standing in the breezeway. In a concurrent interview, CNA 3 stated all the red colored painted doors in the main building opens to Patio 1 that were never locked so that residents have 24 hours access to Patio 1. CNA 3 stated a staff was assigned to monitor only the Breeze way from 7 AM- 11PM, and another staff was assigned to monitor the Patio 1 from 7 AM to 11 PM. CNA 3 stated from 11 PM-7AM only one staff was assigned to monitor the Breeze way, Patio 1 and the Patio 2 (total three areas). CNA 3 stated she does not have a full visual of Patio 1 when standing inside the Breeze way because the walls and the front door of the Breeze way blocks the views in certain areas of Patio 1. CNA 3 stated she had to put her head out or step out of the Breeze way to get a full visual of Patio 1 and Patio 2. During an interview on 9/19/2024 at 1:54 PM, with Registered Nurse (RN) 1, RN 1 stated she worked from 3 PM to 11 PM on 9/10/2024. RN 1 stated at around 11:05 PM, she was in the main building near Patio 1 when LVN 3 from another station notified her she saw someone on the roof near Patio 1. RN 1 stated she activated Code Green through the overhead paging system and when she ran out of the facility, she found Patient 1 on the driveway of the facility. RN 1 stated in the past she has observed Patient always pacing (walk aimlessly) in the hallways and in Patio 1 during the evenings. During an interview on 9/19/2024 at 2:43 PM, CNA 1 stated Resident 1 always walks around in Patio 1. CNA 1 stated he was assigned to monitor Patio 1 from 3 PM to 11 PM on 9/10/2024 and did not see anyone in Patio 1 before he left in the end of his shift. CNA 1 stated he informed the charge nurse that he was leaving the facility and that there was no staff monitoring Patio 1 when he left the facility on 9/10/2024 between 11: 03 PM and 11:04 PM. CNA 1 stated he did not report to an incoming CNAs before he left the facility because he did not know if any staff was assigned to monitor Patio 1. CNA 1 stated he did not witness Resident 1 eloped from the facility on 9/10/2024. During an interview on 9/19/2024 at 3:45 PM, the Assistant Director of Nursing (ADON) stated a facility staff assigned to monitor the breezeway from 11 PM to 7 AM, was supposed to stay inside the breezeway to monitor the patients. In an observation of the breezeway with the surveyor, the ADON explained, the staff monitoring the breezeway does not have a full view of Patio 1 if staff are monitoring the breezeway. During an interview on 9/20/24 at 9:07 AM, LVN 1 stated on 9/10/24 at 11PM until 7 AM on 9/11/24 she was the staff assigned to monitor the Breeze way, Patio 1 and Patio 2. LVN 1 stated the staff monitoring the Breeze way usually stayed inside of the Breeze way, but if there was a resident in Patio 1, the staff goes outside to monitor the resident. LVN 1 stated she did not see anyone in Patio 1 when CNA 1 informed her that he was leaving which was around 11 PM on 9/10/2024. LVN 1 stated she did not see how Resident 1 went on top of the roof of the building. LVN 1 stated Resident 1 eloped because she thought no one would pay attention to her since the staff were busy during the change of the shift at 11 PM on 9/10/2024. LVN 1 stated there were blind spots from the Breeze way to the patio which blocks the view in Patio 1 where Resident 1 eloped from. LVN 1 stated she would not be able to see what was going-on in the patio due to the blind spots to Patio 1. During a concurrent observation and interview on 9/20/2024 at 9:27 AM, Receptionist 1 stated the facility only had one surveillance camera monitoring Patio 1, but the camera could not capture the view of Patio 1 that was close to the main building where Patient 1 and Patient 2 eloped from. Receptionist 1 stated there was no staff assigned to the front office during the night from 11 PM to 7 AM to monitor the patients leaving from the facility in the front lobby or in Patio