Health inspection·December 9, 2024

F689 Code of Federal Regulations Title 42 Section 483.25(d) Accidents. The facility must ensure that - (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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 11/4/24, at 7:58 a.m., the California Department of Public Health (CDPH) conducted an unannounced visit at the facility to investigate an entity reported incident of resident elopement. As the result of the investigation, CDPH determined the facility failed to supervise Resident 1, who was at risk for elopement. As the result of this failure, on 10/17/24, Resident 1 left the facility unnoticed, fell outside of the facility, sustained a facial trauma injury with multiple jawbone fractures, and was transported to General Acute Care Hospital (GACH) 1. A review of Resident 1’s Admission Record indicated Resident 1, a 78-year-old male, was admitted to the facility on 10/16/24, with diagnoses that included senile degeneration of brain (gradual decline in cognitive function, such as memory loss, impaired thinking, and difficulty with daily activities), and dementia (a progressive state of decline in mental abilities). A review of Resident 1's Nursing Admission (NA) notes dated 10/16/24, indicated Resident 1's elopement risk factors included 1) mobility: propels self/requires some assistance; 2) two or more medications (psychotropics [a drug or other substance that affects how the brain works and causes changes in mood], Mood Stabilizer [a class of medications used to treat mood disturbances]), 3) conditions (dementia, depression, other type of mental health illness): 2 or more present. The NA notes indicated Resident 1's total score was 10. The NA indicated a total score of 10 or greater was considered an elopement risk. A review of Resident 1's History and Physical (H&P), dated 10/17/24, indicated Resident 1 did not have the capacity to understand and make decisions due to dementia. A review of Resident 1's care plan (CP) titled, "Elopement Care Plan” dated 10/17/24, indicated Resident 1 is at risk for wandering and/or elopement related to disoriented to place, Dx (diagnoses) of dementia, senile degeneration of [the] brain, created prior to Resident 1's elopement on 10/17/24. The CP indicated Resident 1's safety would be maintained through the review date. The CP's interventions indicated for facility staff to distract Resident 1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. The CP indicated for facility staff to identify patterns of wandering, intervene as appropriate, and to monitor Resident 1's location throughout the shifts (shift-based staffing, a method of scheduling employees in shifts, rather than traditional 9 to 5 schedules and to ensure around the clock coverage). A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, structured communication framework that helps teams share information about the condition of a resident) Note, dated 10/17/24, indicated Resident 1 left the facility and fell outside of the facility (exact location was not indicated) on the pavement of the community. A review of Resident 1's Interdisciplinary Team (IDT, a team of health care professions who work together to establish plans of care for residents) Post Accident/Fall Evaluation dated 10/18/24, timed at 10:30 a.m., indicated Resident 1 was at a high risk for falls with a score of 15 (total score of 10 or above represents a high risk for falls). The root cause analysis indicated Resident 1 had a diagnosis of dementia and wandering (alert and with confusion). During an observation on 11/4/24, at 10 a.m., Resident 1's room was located at the end of the hallway next to an exit door. The exit door was unlocked and led to an adjoining connector space (transition area) to the Assisted Living (AL) side of the facility. The connector space had another exit door on the left side that was unlocked and led to the outside of the building. During an interview on 11/4/24, at 10:45 a.m., the Licensed Vocational/Minimum Data Set (MDS - a resident assessment tool) Nurse (MDS 1), stated Resident 1 was taken to the GACH 1 on 10/17/24, by the Fire Department and EMTs (emergency medical technicians) due to a fall with jawbone fractures that occurred after Resident 1 eloped from the facility. MDS 1 stated Resident 1 never returned or readmitted to the facility after 10/17/24. During an interview on 11/4/24, at 11:20 a.m., with Certified Nursing Assistant (CNA) 6, stated, "Resident 1 had a lot of movement; he walked everywhere." During an interview on 11/4/24, at 11:35 a.m., CNA 7 stated, "Resident 1 was ambulatory, very confused, nice man, eager to leave [and] go home to his wife." CNA 7 stated, "We all knew that Resident 1 was at risk [for elopement] and we were told [by licensed nurses] to watch [Resident 1's whereabouts] this resident." During a concurrent observation and interview on 11/5/24, at 10:40 a.m., Maintenance Supervisor (MS) 1 stated, the exit door adjacent to Resident 1's room led to a transition space to the AL side. MS 1 stated within that transition space was another exit door that led to the outside of the building which led to the trash area and the open parking lot. MS 1 stated, the door could be easily pushed open from the inside, but the door is locked from the outside. MS 1 stated the door was used as a service entrance door to deliver food/drinks to the kitchen on the AL side. MS 1 stated the exit door has an alarm, but the alarm was deactivated daily from 8 a.m. to 8 p.m. due to the in and out activities from staff. MS 1 stated housekeeping and laundry staff from the AL side moved freely from the AL facility side to the skilled nursing facility (SNF) side using the transition space. MS 1 stated staff from the SNF must watch the residents and ensure residents from the SNF did not go through the exit door to the outside of the facility unsupervised. During an interview on 11/6/2024, at 8:40 a.m., with CNA 1, who was assigned to care for Resident 1 on 10/17/24, stated Resident 1 had dementia and wandered around [the facility]. CNA 1 stated Resident 1's room was located next to an exit door. CNA 1 stated a huddle meeting (a short, stand-up meeting where a team discusses patient safety and care goals) was conducted every morning. CNA 1 stated there should be a plan [in place] for residents that wandered and had dementia. CNA 1 stated CNA 1 did not know the plan for Resident 1. CNA 1 stated the only intervention for residents that wandered who had dementia was to conduct hourly checks (visual monitoring). CNA 1 stated Resident 1 walked through the door located next to Resident 1's room and went to the local gas station (next to the SNF), and then walked across the street and fell. During an interview on 11/6/24, at 9:36 a.m. Director of Nursing (DON) stated before the DON left to attend a meeting, on 10/17/24 (unable to recall the time), next door at the AL facility, she told all staff to watch/supervise Resident 1. The DON stated when she left the SNF side, Resident 1 was sitting on the sofa in the dining room watching television. The DON stated by the time the DON returned from the meeting, the Fire Department was at the facility and informed the RN Supervisor (RN 1) that Resident 1 fell outside of the facility. During a concurrent observation and interview on 11/6/2024, at 9:47 a.m., with Laundry Attendant (LA ) 1, stated LA 1 transported laundry between AL facility and SNF. LA 1 stated the transition space and the exit door located next to Resident 1's room was used frequently by laundry staff. LA 1 stated the exit door located next to Resident 1's room remained unlocked. LA 1 stated on 10/17/24, (LA 1 could not recall the time the encounter occurred), LA 1 saw Resident 1 standing outside of the storage room door located inside the AL side. LA 1 stated LA 1 did not know who Resident 1 was and LA 1 did not report this incident to any nursing staff because Resident 1 looked like a visitor. LA 1 stated Resident 1 told her, "Have a nice day." LA 1 stated LA 1 found out later that Resident 1 had eloped from the facility. During an interview on 11/6/2024, at 9:56 a.m., with Restorative Nursing Assistant (RNA) 1, stated every staff member was responsible for the whereabouts of residents (in general) that wandered. RNA 1 stated on 10/17/24, RNA 1 was watching Resident 1 while Resident 1 was in the dining room. RNA 1 stated RNA 1 was with Resident 1 until almost 1 p.m. RNA 1 instructed Resident 1 to stay in the dining room because RNA 1 was going to help another resident (unidentified). RNA 1 stated that was the last time RNA 1 saw Resident 1. RNA 1 stated facility staff were looking for Resident 1, but the facility staff did not find Resident 1. Resident 1 was found on a street by an unknown individual and was sent to the GACH 1. RNA 1 stated it was the facility's practice for staff to divert (redirect) residents who wandered in the facility and remind them of their room location. A review of the Los Angeles County Fire Department record dated 10/17/24, indicated the unit was notified by the dispatch staff on 10/17/24, at 1:31 p.m., and the EMT arrived at the scene (on 10/17/24) at 1:36 p.m. where Resident 1 was found sitting on the curb, down the hill from the facility, and complained of face pain (pain rate was not indicated). The record indicated a passerby stated she witnessed Resident 1's fall while Resident 1 was walking down a hill and away from the facility. The record indicated Resident 1 was transported to GACH 1. A review of GACH 1’s Emergency Department (ED) record, admission date 10/17/24, indicated Resident 1 presented to the ED after a fall and on arrival and Resident 1 had notable trauma to the face. The ED record indicated CT (computed tomography scan, medical imaging technique used to obtain detailed internal images of the body) imaging was obtained of Resident 1's head and face. The CT imaging revealed multiple mandibular fractures. The ED record medical decision making indicated Resident 1 had evidence of possible intracranial (within the cranium [bones that form the head]) injury due to the CT of the head showed a left-sided occipital lobe (visual processing area of the brain, located at the back of the head) petechial hemorrhage (tiny round brown, purple spots due to bleeding under the skin). The ED record indicated cardiac (heart) monitoring was initiated due to the potential for rapid decompensation (a system or structure's functional decline after it has been compensating for a defect or stressor) of Resident 1's clinical condition. The ED record indicated Resident 1 was transferred from GACH 1 to GACH 2. A review of GACH 2's Encounter Report dated 10/17/24, indicated Resident 1 fell while leaving Resident 1's care facility. The report indicated Resident 1 struck Resident 1's face on the pavement/ground and Resident 1 sustained multiple mandibular fractures and a chin laceration (cut). The report indicated Resident 1 had a small contrecoup injury (a brain injury that occurs when the brain moves within the skull and hits the opposite side of the head from the initial impact). A review of the facility's P&P titled, "Safety and Supervision of Residents," revised 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible. The P&P indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated systems approach to safety included, resident supervision being a core component of the systems approach to safety. The type of frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P indicated resident risks and environmental hazards included, unsafe wandering. A review of the facility's P&P titled, "Wandering and Elopements," revised 3/2019, indicated, the facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. As the result of the investigation, CDPH determined the facility failed to supervise Resident 1, who was at risk for elopement. As the result of this failure, Resident 1 left the facility unnoticed. Resident 1 fell outside of the facility, sustained a facial trauma injury with multiple jawbone fractures, and was transported to GACH 1. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. 2