Other·May 15, 2024

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. California Code of Regulations, Title 22, Section 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. (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. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the patient care policy committee. On 4/2/2024, the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate a facility reported incident regarding quality of care and resident safety. As a result of the investigation, the CDPH determined the facility failed to identify and reduce the risk of elopement in the resident's environment for Resident 4 by failing to ensure locked Gates 1 and 2 were opened one at a time. The Director of Staff Development (DSD) unlocked and opened locked Gate 1 to the patio while entering the facility. While, at the same time, Staff Member 5 (SM5) unlocked and opened locked Gate 2 facing the facility's parking lot. Consequently, Resident 4 pushed the DSD and SM 5 and ran away from the facility. This failure resulted on 3/29/2024, Resident 4 eloped from the facility. Resident 4 being missing from the facility and his whereabouts unknown for four days. These effected Resident 4’s health and safety and had the potential to result in injury and harm to Resident 4. A review of Resident 4's Admission Record indicated the facility admitted a 29-year-old male on 3/28/2024 with diagnoses that included anxiety, psychosis, and schizoaffective disorder. A review of Resident 4's History and Physical (H&P) dated 3/28/2024 at 9:49 AM indicated Resident 4 was alert and oriented to time, place, person, and situation. The H&P indicated Resident 4's cognitive abilities were intact. A review of Resident 4's untitled care plan dated 3/28/2024 indicated Resident 4 was on absent without leave precautions. The care plan indicated on 3/30/2024, staff would ensure Resident 4 was not on the patio and would perform one-to-one therapy to monitor AWOL behavior. A review of the facility's Headcount Sheet dated 3/29/2024 indicated Resident 4 was at the patio area at 2 PM and at 2:15 PM, Resident 4 was AWOL. A review of Resident 4's Nursing Note dated 3/29/2024 indicated an employee opened [Gate 1] to go inside the facility and another employee opened [Gate Two] at the same time. The Nursing Note indicated Resident 4 pushed the employees and ran away from the facility. A review of Resident 4's Situation, Background, Assessment and Recommendation (SBAR) dated 3/29/2024 indicated Resident 4's conservator was notified on 3/29/2024 at 3 PM. The SBAR indicated Resident 4's Medical Doctor was notified about Resident 4's elopement on 3/29/2024 at 3:34 PM. During an interview on 4/2/2024 at 9:22 AM with Resident 1, Resident 1 stated he was on the patio and saw Resident 4 run out of the facility. Resident 1 stated as soon as one of the employees opened Gate 1 in the visitor area, Resident 4 ran out. Resident 1 stated Resident 4 was not at the facility for a long time and was recently admitted. During an interview on 4/2/2024 at 10:18 AM with the DSD, the DSD stated when entering and exiting the facility, staff needed to enter and exit through two locked gates (Gate 1 and Gate 2). The DSD stated each gate needed to be locked before opening the next gate. The DSD stated she entered the facility through Gate 1. The DSD stated there was no one in the cage (space between Gate 1 and Gate 2). The DSD stated both she and SM 1 opened the gates (Gates 1 and 2) at the same time and Resident 4 ran out. The DSD stated Resident 4 has not been found. The DSD stated both the DSD and SM 1 did not see each other when they opened the gates. During an interview on 4/2/2024 at 10:32 AM with SM 1, SM 1 stated she thought it was safe to open one of the locked gates and did not see the DSD inside the cage. SM 1 stated if two people are coming in different directions, then one staff needed to communicate to the other staff to wait so the other staff member can enter or exit first. SM 1 stated staff needed to lock one gate first before opening the next gate. SM 1 stated this was not done because SM 1 and DSD did not see each other. During an interview on 4/2/2024 at 10:57 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated one gate needed to be locked before opening the second locked gate. LVN 1 stated staff needed to ensure the environment around Gate 1 was clear with no residents standing close behind staff members or near the gate prior to opening the gate, and to ensure the residents were behind the yellow line. LVN 1 stated residents needed to stay behind the yellow line, a few feet, away from Gate 1. LVN 1 stated the yellow line was to ensure staff can open Gate 1 safely with residents at a safe distance to prevent residents from eloping from the facility. During an interview on 4/2/2024 at 1:39 PM with SM 3, SM 3 stated she saw SM 5 holding Gate 2 open for SM 1 because SM 1 was rolling a barrel of dirty linen. SM 3 stated she saw Resident 4 stood pass the yellow line in the patio area near Gate 1. SM 3 stated she was approaching Resident 4 and told Resident 4 to step back behind the yellow line. SM 3 stated she told the staff members who were opening Gate 1 to close the gate. SM 3 stated SM 1 did not look back prior to opening Gate 1. SM 3 stated SM 1 and DSD did not close Gate 1 while SM 5 had Gate 2 open. SM 3 stated when Resident 4 saw DSD open Gate 1, Resident 4 pushed the staff members away and ran out through both gates (Gate 1 and Gate 2). SM 3 stated Resident 4's elopement was preventable because locked gates needed to be opened one at a time. During an interview on 4/2/2024 at 2 PM with SM 4, SM 4 stated Resident 4's elopement was preventable as Gate 2 was held open. SM 4 stated SM 1 did not look back to check if a resident was behind her as SM 1 and DSD were opening Gate 1. SM 4 stated she saw Resident 4 pass the yellow line and stated Resident 4 ran out before any staff members could stop Resident 4. During an interview on 4/2/2024 at 2:39 PM with the Director of Nursing (DON), the DON stated staff were instructed to open locked gates one at a time when entering or exiting the facility. During an interview on 4/2/2024 at 3:45 PM with SM 1, SM 1 stated she was leaving from inside of the facility and was headed to the parking lot while pushing a container that had dirty linen. SM 1 stated the DSD opened Gate 1 and SM 5 held open Gate 2. SM 1 stated both gates (Gates 1 and 2) were open, and Resident 4 ran out. SM 1 stated Resident 4's elopement was preventable because locked gates needed to be opened one at a time. A review of Resident 4's Social Services Note (SSN) dated 4/1/2024 at 4:41 PM indicated the Social Worker (SW) spoke with the local police department for updates on Resident 4's whereabouts. The SSN indicated no other information was available. During a concurrent interview and record review on 4/2/2024 at 5 PM with the DON, the facility's P&P titled, "Elopement Risk Reduction Approaches," dated 10/2023 was reviewed. The P&P indicated the facility staff need to know the resident's propensity to wander and the triggering conditions. The P&P indicated facility staff need to know the consequences of unsafe wandering and the protocols to follow to minimize successful exiting. The P&P indicated ways to minimize the risk of elopement in the environment were to make exits less obvious by reducing visual cues for exiting. The DON stated staff did not follow the facility's P&P. The DON stated staff should have been aware of their surroundings and doubled check their surroundings to make sure Gate 2 was locked before opening Gate 1. The DON stated Gate 2 should not have been held open because it made an exit obvious to Resident 4. The DON stated Resident 4's elopement was considered avoidable because both locked gates were opened at the same time. The DON stated the risk of not following the facility's P&P would put other residents at risk for eloping. A review of the facility's P&P titled, "Wandering & Elopement," dated 10/1/2023 indicated the facility will identify residents at risk for elopement and minimize any possible injury because of elopement. The facility failed to identify and reduce the risk of elopement in the resident's environment for Resident 4 by failing to ensure locked Gates 1 and 2 were opened one at a time. The DSD unlocked and opened locked Gate 1 to the patio while entering the facility. While, at the same time, SM 5 unlocked and opened locked Gate 2 facing the facility's parking lot. Consequently, Resident 4 pushed away DSD and SM 5 and ran away from the facility. As a result, on 3/29/2024, Resident 4 eloped from the facility. Resident 4 had been missing from the facility and his whereabouts unknown for four days. These effected Resident 4’s health and safety and had the potential to result in injury and harm to Resident 4. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 4.