Health inspection·August 31, 2023

F 689 FCR \§ 483.25(d)(2) Accidents. Each resident 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. On 7/27/23 at 8:50 am, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility to investigate a facility reported incident regarding the care of Patient 1. As a result of the investigation, the Department determined the facility failed to ensure Patient 1, who was at risk for elopement (leaving the facility without notice), had sufficient supervision and ensure the Wander Guard alarm [a monitoring device used to help ensure safety] sensor) was working to prevent Patient 1 from eloping from the facility. As a result of this failure, on 7/22/23, Patient 1 eloped from the facility and fell after wandering away from the facility and sustained a head injury after the fall. During a review of Patient 1's Admission Record, indicated Patient 1 was an 88 year-old male and was admitted to the facility on 5/22/23, with multiple diagnoses including Alzheimer's disease (a disease that destroys memory and other important mental functions), hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood), and hypertension (high blood pressure). During a review of Patient 1's, "Elopement Risk Screening," dated 5/23/23, the Elopement Risk Screening indicated Patient 1 should be considered to be at risk for elopement. During a review of Patient 1's Physician Order, dated 5/23/23, the Physician Order indicated Patient 1 had an order for Wander Guard bracelet to ensure patient safety. During a review of Patient 1's "Minimum Data Set" (MDS, a standardized assessment and care screening tool), dated 6/2/23, indicated Patient 1 moderately impaired in cognitive skills (makes poor decisions; cues/supervision required), required assistance from staff for eating, toilet use, and personal hygiene. The MDS indicated Patient 1 had the behavior of wandering which placed the patient at significant risk of getting to a potentially dangerous place (e.g., stairs, outside the facility). During a review of Patient 1's "Emergency Documentation", dated 7/23/23, indicated, Patient 1 was brought to the Emergency Department on 5/22/23. Patient 1 had a head injury after a fall. During an interview on 7/27/23, at 9 a.m., the Assistant Director of Nursing (ADON) stated, Patient 1 was admitted to the facility on 5/20/23 with diagnoses of Alzheimer's Disease and wandering. During an interview on 7/27/23, at 9:21 a.m., Licensed Vocational Nurse 1 (LVN 1) stated, she was working on 7/22/23 as the supervisor. Patient 1 left the facility twice on that day. Patient 1 was confused and had been wandering in the facility looking for the patient’s keys. LVN 1 stated, on 7/22/23, at 7:40 p.m., the hall alarm (Wander Guard) was going off near the back door of the 40's hall. LVN 1 stated, Restorative Nurse Assistant 1 (RNA 1) heard the alarm in the 40's hallway, but the alarm did not sound at the nurse's station. LVN 1 stated, at 9:30 p.m., Patient 1 eloped from the facility again. LVN 1 stated, she had left Patient 1 unsupervised, while he was sitting near the nurse’s station, for 5 minutes. LVN 1 stated, Patient 1 must have left from the back door in the 40's hallway, because he had left his wheelchair outside of the door before walking down the street. LVN 1 stated another nurse (unidentified) found Patient 1 down the street from the facility and that paramedics where already with the patient. LVN 1 stated, a neighbor had witnessed the patient fall and had called 911. LVN 1 stated, the Wander Guard alarm had not worked properly on 7/22/23. LVN 1 stated She had informed the Director of Nursing (DON) right away after the first incident of Patient 1 eloping, and the Wander Guard alarm was not working properly. During an observation on 7/27/23 at 9:34 a.m. in the 40's hallway, there was a Wander Guard sensor on the wall about 25 feet from the exit door at the end of the hallway. During an interview on 7/27/23, at 9:39 a.m., RNA 1 stated, on 7/22/23, at 6 p.m., she was in the 40's hallway and heard the alarm sounding. RNA 1 stated, the alarm was quiet and that she could not hear it at the nurse's station. She ran to the back door and found Patient 1 in the back parking lot. RNA 1 stated, she took Patient 1 back inside to the nurse station. RNA I stated, the alarm should have alarmed at the nurse's station but it did not. During an interview on 7/27/23, at 10:02 a.m., Patient 1 stated, on 7/22/23 while he was walking down the street, he tripped on the sidewalk. Patient 1 stated, an ambulance took him to the hospital. Patient 1 stated, he did not remember what he was doing outside. During an interview on 7/27/23, at 10:34 a.m., the DON stated, LVN 1 told her the Wander Guard alarm had not worked properly. The DON stated, she notified the Administrator (ADM) that the Wander Guard sensor didn’t work properly. During a review of Patient 1's Progress Notes, dated 7/27/23, the notes indicated on 7/22/23, at 3:45 p.m., Patient 1 seemed agitated about, "losing his car keys," and began wandering and searching the facility hallways for his keys. Patient 1's Progress Notes indicated, at 5:45 p.m., Patient 1 began wandering the hallways again, and was frequently reoriented to the unit. Patient 1's Progress Notes indicated, at 7:45 p.m., "Patient 1 was found to have escaped the facility through the door of the 40 hall, where he wandered around the back parking lot to the front of the building and alarm (Wander Guard) did not sound. The Progress Notes indicated, at 9:15 p.m., Patient 1 was not found to be in the facility. Patient 1's Progress Notes indicated, at 9:30 p.m., Patient 1, was picked up by paramedics on a street near the facility. . The notes indicate Patient 1 fell and hit his head, and the neighbor had witnessed the fall and called 911. The notes indicated the Paramedics took Patient 1to a general acute care hospital. During a review of the facility's policy and procedure (P&P) titled, "Resident Elopement," revised August 2016, indicated, the facility was to provide an environment that minimized the risk of elopement. Residents at the facility, who were assessed to be at risk of elopement, were to be provided a Wander Guard bracelet that sounded an alarm upon leaving the facility. As a result of the investigation, the Department determined the facility failed to ensure Patient 1, who was at risk for elopement had sufficient supervision and ensure the Wander Guard alarm was working to prevent Patient 1 from eloping from the facility. As a result of this failure, on 7/22/23, Patient 1 eloped from the facility and fell after wandering away from the facility and sustained a head injury after the fall. The above violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Patient 1.