Health inspection·September 21, 2022

42CFR §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR §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. On 8/19/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a facility reported incident about a resident's death. The facility failed to ensure resident safety through effective monitoring, supervision, assessment, and reassessments for three of three sampled residents (Resident 1, Resident 2, and Resident 3), who the facility permitted to go out on pass (OOP) on multiple occasions by failing to: 1.Obtain a Physician's Order for residents to go "Out on Pass" (OOP) under the supervision of a facility staff member. Resident 1 who had moderately impaired cognition (a decline in mental ability to make decisions of daily living), had diagnoses that included psychoactive substance abuse (dependence on substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions), non-pressure chronic ulcer (an open sore caused by poor blood flow) of the left foot and right foot, generalized muscle weakness, and lack of coordination (prevents people from being able to control the position of their arms and legs or their posture), Resident 2 and Resident 3 who had both diagnoses including Type 2 diabetes, muscle weakness, lack of coordination (uncoordinated movement), and unsteadiness on their feet were permitted to leave the facility to go OOP on several occasions without a physician order. 2. Ensure the facility's designee checked/verified if Residents 1, 2, and 3, had physician's order to go OOP prior to the residents signing out and leaving on OOP. 3. Ensure the licensed nurses assessed residents' physical and mental status prior to the residents leaving on OOP and re-assessed residents' physical and mental condition, upon return to the facility according to the facility's policy and procedures titled "Out on Pass." Residents 1, 2, and 3 did not have documented nursing assessments prior to leaving OOP and upon return to the facility. 4. Ensure resident(s) going on OOP, signed out and signed in on the facility's Resident Out on Pass Log in accordance with the facility's policy and procedures. As a result, Resident 1 left the facility on OOP without a physician's order on 8/17/2022 at 3:53 p.m. and was found dead 10.8 miles away from the facility on 8/17/2022 at 6:34 p.m. These deficient practices also had the potential for injuries, accidents, and or death for Residents 2 and 3 and other residents who left the facility on OOP. A review of Resident 1's Admission Records (Face Sheet), indicated the facility admitted Resident 1 on 6/14/2022 with diagnoses including Type 2 diabetes mellitus (impairment in the way the body regulates and uses sugar as a fuel), psychoactive substance abuse, non-pressure chronic ulcer of the left foot and right foot, generalized muscle weakness, and lack of coordination. A review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 6/23/2022, indicated Resident 1 had moderately impaired cognition (mental ability to make decisions of daily living). Resident 1 required one person assist for most activities including: bed mobility, transfer, walking in room, walking in corridor, locomotion on/off unit, dressing, toileting, and personal hygiene. Resident 1 normally used a wheelchair or walker for assistance with mobility. A review of Resident 1's care plan titled "At risk for Decreased ability to perform ADLs (Activities of daily living related to personal care, including bathing, or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating)" dated 6/30/2022, indicated Resident 1 was at risk for decreased ability to perform function mobility tasks including: bathing, grooming/personal hygiene, dressing, bed mobility, transfer, locomotion, and toileting related to impaired balance due to resident's foot ulcer. A review of Resident 1's care plan titled "At risk for Impaired/decline in cognitive function" dated 6/30/2022, indicated Resident 1 was at risk for impaired thought processes, and impaired decision making related to Resident 1's substance use disorder. The goal included Resident 1 would make daily decisions/choices when provided with appropriate level cues and supervision, by the next review date. Interventions included to observe and evaluate changes in cognitive status and notify the physician as needed. A review of Resident 1's care plan titled "At risk for falls" dated 6/30/2022, indicated Resident 1 was at risk for falls due to Resident 1's impaired mobility. The goal included Resident 1 would have no falls with injury times 90 days. Interventions included to provide Resident 1 with opportunities for choice, bed in low position, and provide resident/caregiver education for safe techniques (including when to use call light). On 8/19/2022 at 12:37 p.m., during a concurrent interview and record review, the surveyor and the DON reviewed Resident 1's Physician order Summary Report dated 8/17/2022. The Director of Nursing (DON) verified and stated Resident 1 did not have a physician's order to go OOP. A review of the facility's form titled "Release of Responsibility for Leave of Absence" dated from 8/14/2022 to 8/17/2022, indicated a signing "Out" date, time, signature of person accepting responsibility, anticipated return date and time, signing "In" date, time and signature of person accepting responsibility. Resident 1 had three incomplete entries on two separate forms as follows: a. Sign "out" date, time, anticipated date, and time was blank and Sign "In" on 8/14/2022 at 7:34 p.m. b. Sign out on 8/16/2022 at 3:07 p.m., anticipated date, time and, signing "In" date, time and signature was blank. c. Sign out on 8/17/2022 at 3:53 pm, anticipated date, time and, signing "In" date, time and signature was blank On 8/19/2022 at 12:38 p.m., during a concurrent interview and record review, the surveyor and the DON reviewed Resident 1's Medical chart. The DON stated there was no documentation of Resident 1's communication with nursing prior to Resident 1 leaving OOP on 8/14/2022, 8/16/2022, and 8/17/2022. The DON confirmed and stated, Resident 1 did not have documented nursing assessments prior to leaving on OOP, and reassessments when Resident 1 returned to the facility on: 8/14/2022, 8/16/2022; and 8/17/2022. On 8/19/2022 at 12:39 p.m., during concurrent interview and record review, the surveyor and the DON reviewed the facility's Policy & Procedures (P&P) titled "Out on Pass," dated 8/25/2021. The DON read and stated, "If the resident's attending physician or psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) determine that the resident may participate in activities outside the facility, the Attending Physician will write an order for resident to go out on pass." The DON verified and stated the facility did not comply with its OOP P&P by obtaining a physician's order before Resident 1 left the facility OOP. On 8/19/2022 at 1:16 p.m. during a telephone interview, Staff 1 stated Resident 1 frequently went OOP. Staff 1 stated Resident 1 went OOP almost every day for the week of 8/8/2022 through 8/14/2022: and for the week of 8/15/2022 through 8/17/2022. Staff 1 stated Resident 1 would go OOP at 3:30 p.m. and return at around 9:00 p.m. Staff 1 stated, Resident 1 "signed himself out. Staff 1 stated "the Out on Pass Logbook sits there on the front reception desk and residents can just Sign Out and Sign In themselves." Staff 1 stated the physician's order for OOP was not checked when Resident 1 signed out for OOP. On 8/19/2022 at 1:33 p.m., during concurrent interview and record review, the surveyor and the DON reviewed Resident 1's OOP form entries dated 8/14/2022 and 8/17/2022. The DON visually verified, confirmed, and stated there was no 'Anticipated Return information written by" Resident 1. The DON further confirmed Resident 1 did not document 'Sign Out' information on the OOP form on 8/14/2022 and that the OOP forms were incomplete. On 8/19/2022 at 2:17 p.m., during a concurrent interview and record review, the surveyor and the Administrator reviewed Resident 1's physician's orders dated 6/14/2022. The Administrator verified and stated "there is no out on pass order" for Resident 1. The facility's OOP policy and procedures dated 8/25/2021was also reviewed. The Administrator stated Resident 1 should not have been allowed to leave the facility on OOP. The Administrator stated the facility was not compliant with its OOP policy and procedure by allowing the Resident to go OOP. On 8/23/2022 at 9:15 a.m. during a concurrent interview and internet search, the surveyor and the DON searched Google Maps. The DON calculated the distance from the facility to where Resident 1 was found was 10.8 miles. The DON acknowledged and stated, "That is a far distance given the timeframe. A lengthy period for a resident to be unsupervised walking outside." The DON stated the facility noticed Resident 1 was absent from the facility on 8/17/2022 from 3:53 p.m. to 6:26 p.m. On 8/23/2022 at 4:36 p.m. during a concurrent interview and record review, the surveyor, the DON, and Administrator in Training (AIT) reviewed all of Resident 1's care plans. The DON confirmed and stated Resident 1 did not have Care Plan(s) in place (medical records) for OOP or leave of absence (LOA). On 8/24/2022 at 1:35 p.m., during an interview, Resident 1's primary Physician stated licensed nurses should conduct physical and mental sound (thorough) assessment before residents can go OOP. The primary Physician confirmed and stated Resident 1 must have a verbal or written doctor's order before going OOP. A review of the facility's report incident for "Unusual Occurrence" dated 8/18/2022, indicated Resident 1 signed a Release of Responsibilities for Leave of Absence form to go OOP on 8/17/2022 at 3:53 p.m. However, the Resident did not have a physician's order to go OOP. The report further indicated that at around 6:26 p.m. on 8/17/2022, the DON received a telephone call from an unknown caller who stated that a resident had collapsed on the street and was lifeless. The report further indicated the coroner's (an official who investigates violent, sudden, or suspicious deaths) office called (contacted) the facility and informed the DON that Resident 1 had passed away (died) on 8/17/2022 at 6:34 p.m. A review of Resident 2's Admission Record indicated the facility admitted Resident 2 on 3/16/2022 from a General Acute Care Hospital (GACH), with diagnoses including Type 2 diabetes, muscle weakness, lack of coordination, unsteadiness on feet, peripheral vascular disease (PVD- a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), and non-pressure chronic ulcer (an open sore caused by poor blood flow) of the left foot. A review of Resident 2's MDS dated 6/16/2022, indicated Resident 2 was cognitively intact. Resident 2 required one person assist with dressing, toilet use and personal hygiene, and required a walker to ambulate (walk). A review or Resident 2's Physician order Summary Report dated from 3/16/2022 through 8/31/2022, indicated the OOP order was discontinued (stopped) on 3/19/2022. A review of the facility form titled "Release of Responsibility for Leave of Absence" for Resident 2 dated from 7/4/2022 through 8/18/2022, indicated Resident 2 signed OOP 19 times on: 7/4/2022 at 8:16 a.m. 7/5/2022 at 9:48 a.m. 7/6/2022 at 9:00 a.m. 7/7/2022 at 9:00 a.m. 7/8/2022 at 7:56 a.m. 7/11/2022 at 8:00 a.m. 7/15/2022 at 11:00 a.m. 7/16/2022 at 1:00 p.m. 7/18/2022 at 10:00 a.m. 7/19/2022 at 9:00 a.m. 7/21/2022 at 1:00 p.m. 7/22/2022 at 1:00 p.m. 7/23/2022 at 1:00 p.m. 7/25/2022 at 8:00 a.m. 7/26/2022 at 11:30 a.m. 7/29/2022 at 9:00 a.m. 7/30/2022 at 8:00 a.m. 8/3/2022 at 8:00 a.m. 8/4/2022 at 8:00 a.m. A review of Resident 2's Active Physician Order, dated 8/19/2022, indicated Resident 2 may go out on pass up to four hours as needed for therapeutic purposes. On 8/19/2022 at 12:38 p.m., during concurrent interview and record review, the surveyor and the DON reviewed Resident 2's Medical Records. The DON stated there were no documented communication with nursing prior to Resident 2 leaving on OOP in Resident 2's Medical Records, no nursing assessments prior to Resident 2 leaving on OOP, and no reassessments of Resident 2 upon return to facility from 7/4/2022 through 8/18/2022. A review of Resident 2's care plan titled "At risk for Decreased ability to perform functional mobility tasks" dated 3/17/2022, indicated Resident 2 was a risk for decreased ability to perform function mobility tasks including: bed mobility, transfers, and gait related to recent hospitalization resulting in decreased strength, functional activity tolerance and balance. The goal included Resident 2 would improve current level of function in bed mobility, transfers, and gait ... Interventions included ... physical therapy evaluation, functional mobility training...safety awareness, gait (a person manner of walking) training and wheelchair mobility for Resident 2. On 8/23/2022 at 10:29 a.m., during an interview and concurrent observation, Resident 2 was in the lobby, seated in a chair, and talking with another resident. Resident 2 stated, "when going OOP, I write my "sign out" on the form by the front when leaving. I come back within three to four hours, then write my "Sign in" on the form. The receptionist in the front will help to assist with the log during the day and two other employees will assist during the evening." On 8/23/2022 at 1:30 p.m., during an interview, Certified Nursing Attendant 1 (CNA 1) stated Resident 2 would go OOP to the store every two to three days a week. CNA 1 stated, "because he (Resident 2) will sign out at the front, that is the job of person at the front, and if they let the resident go then it is ok," when CNA 1 was asked if Resident 2 was allowed to go OOP. CNA 1 stated, "No. There's nothing else for me to check, not my job. The person at the front will ask," when asked if CNA 1 was required to check for anything else before Resident 2 went OOP. CNA 1 further stated he would "sign out and then he (Resident 2) can go." CNA 1 stated, "he (Resident 2) does not take long and comes right back, so there is nothing for me to check really," when asked if CNA 1 monitors and or checks on Resident 2 to ensure a safe return to facility. On 8/23/2022 at 1:30 p.m., during a concurrent interview and record review, the surveyor, and Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 2's Physician Order Summary Report dated 7/29/2022 for OOP for Resident 2. Licensed Vocational Nurse 1 (LVN 1) stated she had not seen Resident 2 go OOP "on my shift." LVN 1 stated an active physician's order for Resident 2, dated 8/19/2022, indicated Resident 2 may go out on pass, and that Resident 2 did not have an active OOP order prior to 8/19/2022. c. A review of Resident 3's Admission Record dated 7/13/2022, indicated the facility admitted Resident 3 on 7/13/2022 from GACH with diagnoses including Type 2 diabetes, muscle weakness, unsteadiness on feet, lack of coordination, and osteomyelitis (inflammation or swelling that occurs in the bone) of left foot and ankle. A review of Resident 3's MDS dated 7/12/2022, indicated Resident 3 was cognitively intact. Resident 3 required one person assist with bed mobility, transfer, locomotion on/off unit, dressing, toilet use, and personal hygiene. Resident 3 required wheelchair for mobility. A review of Resident 3's Physician Order Summary Report dated from 7/13/2022 to 8/31/2022, indicated Resident 3 did not have a physician's order to go OOP. However, a physician's