Health inspection·May 10, 2023

F689 §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 §72311 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. § 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 03/21/2023, an unannounced visit was made to the facility to investigate a complaint received by the California Department of Public Health regarding an accident and injury of unknown origin. The facility failed to ensure Resident 1, a 76-year-old male, who was a high risk for elopement (leaving the facility unsupervised and without staff knowledge) was visually observed frequently, re-oriented to key places such as his room, and monitored at frequent intervals to prevent elopement. As a result Resident 1 eloped and sustained a nasal (nose) bone fracture (is a break, usually in a bone), fracture of the anterior wall of the right maxillary sinus (a hollow space in the bones around the nose), right maxillary sinus hematoma (a solid swelling of clotted blood within the tissues), bruise under his right eye, abrasion (the surface layers of the skin has been broken) on his right knee, and suffered pain to his nose and right knee. A review of Resident 1's Admission Record dated 3/21/2023, indicated Resident 1 was admitted to the facility on 1/3/2023, with diagnoses including dementia (for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), type II diabetes mellitus (a condition were your body has trouble controlling the level of sugar in the blood), lack of coordination, and muscle weakness. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 1/10/2023, indicated Resident 1 had memory problems. The same MDS, indicated, Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one-person physical assist, for walking in room, corridor, and locomotion (the ability to move from one place to another) on and off unit. A review of Resident 1's Fall Risk Assessment, dated 1/3/2023, indicated Resident 1 was a high fall risk. A review of Resident 1's Elopement Risk Evaluation, dated 1/3/2023, indicated Resident 1 was at risk for elopement/wandering. A review of Resident 1's Fall Risk care plan, dated 1/14/2023, indicated Resident 1 was at risk for falls/injury related to dementia, generalized weakness, impaired cognition (ability to remember, understand, make decisions, and learn), poor body balance / control, poor safety awareness/judgement. Intervention includes monitor at frequent intervals. A review of Resident 1's Elopement Risk care plan, dated 2/13/2023, indicated Resident 1 was at risk for wandering and leaving safe area without authorization because of his dementia diagnosis. Intervention includes visually observe resident frequently, re-orient to key places such as his room, and monitor at frequent intervals. A review of Resident 1's Change of Condition (COC) Assessment Form with effective date of 3/18/2023, indicated: 6 pm resident walking around facility talking to everyone, 6:30 pm resident in the doorway of his room, 7 pm resident sitting in from lobby, 8 pm resident last seen sitting in lobby chair, 9:30 pm unable to find resident, looked in surrounding rooms, called a code for missing person, all staff looking for resident, 10:22 pm notified DON [Director of Nursing], Administrator, doctor, and responsible party. 10:45 pm called 911(universal telephone number the gives the public direct access to the Public Safety. Answering point where emergency services such as the fire department, police or paramedics can be dispatched to a location) Police Department (PD) for missing person, PD came to facility to gather information called additional units and helicopter for search. A review of Resident 1's General Acute Care Hospital (GACH) emergency room record dated 3/19/2023, indicated Resident 1 was admitted to the GACH on 3/19/2023 at 1:17 am with a chief complaint of fall, nose pain and right knee pain. A review of Resident 1's GACH Computed Tomography (a medical imaging technique used to obtain detailed internal images of the body) scan report, dated 3/19/23, indicated, acute bilateral (both side) nasal bone fractures, acute fracture of the anterior wall of the right maxillary sinus, and right maxillary sinus hematoma. A review of Resident 1's GACH discharge summary dated 3/19/2023, indicated Resident 1 was discharged with Tylenol (pain medication) 500 milligrams (mg, unit for measurement) two tablets as needed for pain and Amoxicillin Clavulanate (Antibiotics) 875-125 mg oral tablet two times a day for 10 days. A review of Resident 1's Physician Order dated 3/20/2023, indicated to apply ice cold pack to nose for 20 minutes three times a day for five days. Treatment for nose with abrasion: Cleanse with normal saline, pat dry, apply A&D (skin protectant) ointment every day shift for 30 days. A review of Resident 1's Medication Administration Record (MAR)for March 2023 indicated, Resident 1 received two Tylenol (pain medication) 325 mg oral tablets ordered for mild pain on 3/20/23 at 10:07 pm for a pain level of 5/10 (numerical pain assessment whereas zero is no pain and 10 as the worst pain). During an interview with the Receptionist, on 3/21/2023 at 2:15 pm, in the facility' s front entrance lobby, the Receptionist stated she was working on Saturday (3/18/2023) the day Resident 1 eloped. The Receptionist stated she saw Resident 1 came and sat down frequently at the front lobby chairs. The Receptionist further stated when she left at 4:30 pm for the day, the front doors were locked from the outside, so no one comes in. The Receptionist further stated, one can still go out through the doors from inside the facility without a key or alarm. During an interview with the DON on 3/21/2023 at 2:22 pm, the DON stated Resident 1 was known to wander and the day he left the facility, he used the front lobby entrance doors which had no alarm system, around 9:30 pm. During an observation and a concurrent interview on 3/21/2023 at 2:45 pm with Resident 1, a small bruise was observed under his right eye, a minor scratch running down the right side of his nose and healing scabs (a dry, rough protective crust that forms over a cut or wound during healing) on his right knee. Upon Resident 1 touching his nose, he exclaimed "ouch!". Resident 1 stated he was outside by a bus and on the corner where he fell over, started crying and was helped by a man in a passing car. Resident 1 stated, "A man helped him and called an ambulance, there were a lot of sirens, then they took me to the hospital." Resident 1 was not able to remember the name of the facility where he resided. During a telephone interview with Licensed Vocational Nurse 1 (LVN 1), on 3/21/2023 at 3:14 pm, LVN 1 stated Resident 1 usually hangs around the facility's front area by the nursing station (across from the front entrance lobby). LVN 1 further stated she noticed Resident 1 to be missing on 3/18/2023 at around 9:30 pm, and he was found and returned to the facility the next day (3/19/2023) around 3 pm. LVN 1 stated, Resident 1 left the facility from the front doors of the building entrance because they are not alarmed. LVN 1did not respond when asked how often Resident 1 was visually monitored. During an interview and a concurrent review of the facility ' s surveillance camera video footage from 3/18/2023, with the DON on 3/21/2023 at 4:41 pm, Resident 1 was observed sitting in a chair in the front entrance lobby at 7:54 pm. Resident 1 was observed getting up from the chair and leaving through the front entrance lobby doors at 8:08 pm. The DON confirmed and verified Resident 1 left at 8:08 pm on 3/18/2023. A request for the facility's policy and procedures (P &P) for elopement was made to the DON on 3/21/23 at 4:45 pm. The facility failed to provide a policy and procedures for elopement when requested. A second request was made to the DON for the facility ' s P &P for elopement on 4/6/2023 at 11:36 am. The facility was unable to provide the P &P for elopement as requested. A review of the facility's P &P titled "Accident/Incident Prevention" undated, indicated "This facility strives to prevent accidents by providing an environment that is free from accident hazards over which the facility has control, as well as identification of each resident at risk for accidents/incidents". A review of the facility's P &P titled "Care of Wandering Residents" undated, indicated "Wanderers are to be checked on a regular basis." "Monitoring the resident' s locations with visual checks as needed." The facility failed to ensure Resident 1, a 76-year-old male, who was a high risk for elopement was visually observed frequently, re-oriented to key places such as his room, and monitored at frequent intervals to prevent elopement. As a result, Resident 1 eloped and sustained a nasal bone fracture, fracture of the anterior wall of the right maxillary sinus, right maxillary sinus hematoma, bruise under his right eye, abrasion on his right knee, and suffered pain to his nose and right knee. These violations jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result for Resident 1, and other residents.