Other·October 14, 2022

42 CFR § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices 42 CFR §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)(2) 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. 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 8/1/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint about quality of care. The facility failed to ensure care and services were provided in accordance with the comprehensive assessment, plan of care and the facility’s policies by not providing supervision and a safe environment for Resident 1, who was at risk of elopement (leaving the facility unsupervised, presenting an imminent threat to the resident's health and safety because the resident was too impaired to make a decision) and diagnosed with opioid abuse and alcohol dependence (addiction that causes excessive drinking of alcohol). The facility failed to: -Conduct a Quarterly Elopement Risk Assessments, as most recent was dated 11/29/2021 (eight months prior to incident). -Develop and implement an individualized care plan with specific interventions regarding non-compliance with facility rules and policies. -Follow Physician’s Orders for Resident 1 to go out on pass with a responsible party. As a result, on 7/28/2022, Resident 1 eloped from the facility, suffered an altered level of consciousness (ALOC-not awake, alert, or able to understand or react as one normally would), low blood pressure, and elevated pulse of 112 (normal pulse is 60 - 100 beats per minute), and an elevated alcohol blood level of 358 mg/dL (normal 0-10 mg/dL). Resident 1 was admitted to General Acute Care Hospital (GACH) 1, where he was diagnosed with alcohol intoxication (occurs when a person drinks an excess of alcohol in a short period of time, can cause alcohol poisoning when severe and can lead to death). A review of the Admission Record (face sheet) indicated the facility admitted Resident 1, a 68-year-old male, to the facility on 11/29/2021, with diagnoses including cognitive communication deficit (difficulty communicating because of an injury to the brain), opioid abuse (use of prescription pain medication illegally), alcohol dependence, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest that can interfere with daily functioning). The Admission Record indicated Resident 1 was homeless and had no responsible party. A review of the Elopement Risk Assessment dated 11/29/2021, indicated Resident 1 was at risk for elopement because he was able to ambulate or self-propel the wheelchair independently. Further review of Resident 1's medical record indicated no further documented Elopement Risk Assessments after 11/29/2021. A review of the Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 6/6/2022, indicated Resident 1 had moderately impaired cognition (decisions poor, cues/supervision required) and required limited assistance and one-person physical assistance for bed mobility, transferring, walking, and personal hygiene. The MDS further indicated Resident 1 did not exhibit wandering behavior and normally used a walker for mobility. A review of Resident 1's Risk for Substance Use of Alcohol and Drugs Care Plan, dated 6/8/2022, indicated a goal that Resident 1 would have decreased episodes of alcohol and drug seeking behaviors. The care plan interventions indicated to monitor Resident 1 for conditions that may contribute to substance abuse. According to a review of Resident 1's Risk for Cardiovascular Symptoms and Respiratory Symptoms Care Plan dated 6/13/2022, Resident 1 had an episode of hypotension (low blood pressure) related to alcohol abuse. The care plan intervention indicated to observe for mental status changes and consult physician as needed. A review of Resident 1's Care Plan for exhibiting behaviors related to non-compliance with rules and policies of the company dated 6/14/2022, indicated the facility staff found a bottle of alcohol in the resident's room. The care plan interventions included the monitoring of medical conditions that may contribute to behaviors. The care plan did not indicate which medical conditions to monitor that contribute to the behavior of non-compliance.  A review of Resident 1's Physician Orders dated 6/29/2022, indicated the resident may go out on pass for four to six hours with a responsible party. A review of Resident 1’s Release of Responsibility for Leave of Absence Form indicated on dates 6/29/2022, 7/10 and 7/23/2022, Resident 1 signed out as the person accepting responsibility for the patient (himself). The form indicated there were no signatures signing Resident 1 back in. A review of Resident 1's Incident Note dated 7/28/2022 at 7:35 p.m., indicated Resident 1 was last seen wheeling around the facility for his usual activity of either smoking on the patio or in front of the facility. Around 5:30 p.m., staff noticed Resident 1 was not in his room and had not eaten his dinner. The incident note indicated all nursing staff searched for Resident 1 throughout the facility and the surrounding neighborhood. The Incident Note further indicated a nurse from GACH 1 called the facility around 8 p.m. and informed the facility that Resident 1 was being admitted to GACH 1. According to a review of the GACH 1 Emergency Department (ED) Summary Report dated 7/28/2022 and timed at 5:45 p.m., Resident 1 was brought in from a public area and was found with an ALOC in front of a liquor store. The ED Summary Report indicated the owner of the liquor store called 911 and stated Resident 1 drank two pints of an alcoholic beverage. The ED Summary Report indicated Resident 1's blood pressure was 82/50 millimeters of mercury (mm Hg, unit of measurement for blood pressure, low blood pressure is considered less than 90/60 mm Hg), pulse 112 (normal pulse is 60 - 100 beats per minute), and alcohol blood level was 358 mg/dL on arrival. A review of the GACH 1 History and Physical (H&P) dated 7/28/2022, indicated Resident 1 looked homeless and was brought in by the paramedics for ALOC and diagnosis of alcohol intoxication. The H&P indicated Resident 1 was prone to alcohol withdrawal and was admitted to a monitored bed (an area of the hospital used to monitor patients at risk for life-threatening heart rhythms and sudden death), started on intravenous (IV) fluids, thiamine (a vitamin supplement given to alcohol users to prevent brain damage), folic acid (a vitamin supplement given to alcohol users to prevent brain damage), Librium (a medication used to manage anxiety levels in alcohol users), and magnesium (a medication used to decrease the intensity of symptoms from alcohol intoxication) were administered. A review of Lexicomp's (an online database that is a collection of content sets and clinical tools that provides users with clinical drug information) titled, "Ethanol (alcohol) Level," dated 6/16/2021, indicated Ethyl (alcohol) is a central nervous system depressant and one of the most common drugs of abuse. Ethanol level is used to diagnose alcohol intoxication and to screen for alcoholism. Normal value is less than 10 mg/dl which indicates a negative test. A critical value is greater than 30 mg/dL which indicates alcohol consumption. A panic value is greater than or equal to 300 mg/dL. A review of Lexicomp's document titled, "Alcohol Intoxication ED," dated 2/23/2022, indicated alcohol intoxication occurs when someone drinks too much in a short amount of time. Alcohol intoxication was the same as being drunk. Severe alcohol intoxication was known as alcohol poisoning. It can make you pass out and can be life threatening if you stop breathing or choke on your own vomit. Alcohol poisoning can also cause seizures or an irregular heartbeat. During an interview on 8/1/2022 at 3:33 p.m., Licensed Vocational Nurse (LVN) 1 stated on 7/28/2022 at around 4:30 p.m. to 5 p.m. Resident 1 was not in his bed and noticed his meal tray was still at bedside. LVN 1 stated, "We called the code for missing resident, and we all went looking for the resident.” LVN 1 stated Resident 1 frequently went in and out of the facility in his wheelchair. During an interview on 8/1/2022 at 4:10 p.m., Resident 2 stated Resident 1 was his roommate and Resident 1 would come in the room and sometimes be drunk. Resident 2 stated once a Certified Nursing Assistant (CNA) found an empty alcohol bottle in Resident 1's closet but could not remember which CNA. During an interview on 8/2/2022 at 1 p.m., with the Liquor store Owner 1 stated on 7/28/2022 a resident was at his liquor store buying alcohol and asked to call a cab. Owner 1 stated the resident was asked to wait for the cab outside of the store. Owner 1 stated he saw the resident slump down in his wheelchair outside, so he called the police. Owner 1 stated the ambulance came to pick up the resident at the front of the store, and when they left, he found an empty bottle of alcohol. Owner 1 stated this resident comes into the liquor store about once or twice a month by himself and buys about half a pint of alcohol. On 8/9/2022 at 4:25 p.m., during an interview, Receptionist 1 stated residents must sign out on the out on pass log indicating when they were leaving, the anticipated time away from facility, and must sign the log when returning back to the facility. Receptionist 1 stated and verified Resident 1 did not sign the out on pass log for 7/28/2022 and that Resident 1 was not allowed to leave the facility unaccompanied because he was not fully alert and oriented. Receptionist 1 stated residents were allowed to leave the facility with supervision or an ‘out on pass order’ from their physician, only if they were fully alert and oriented. During a telephone interview on 8/25/2022 at 4:05 p.m., the Director of Nursing (DON) stated Resident 1 was not supervised when leaving the facility. The DON stated residents who leave the facility must have an out on pass physician order and should be supervised by a responsible party; Resident 1 did not have a responsible party so staff should have supervised the resident when leaving the facility. The DON further stated it was not an acceptable practice for Resident 1 to drink alcohol in the facility. During a telephone interview on 8/25/2022 at 4:10 p.m., the DON stated the risks of drinking alcohol should be explained in the Resident and Elopement Risks Assessments, which must be completed upon admission, quarterly, and as needed. The DON further stated there was no Elopement Risk Assessments documented after 11/29/2021 in Resident 1's medical record. A review of the facility's policy and procedure titled, "Alcoholic Beverages," revised 11/1/19 indicated a physician's order will be obtained for a patient to receive alcoholic beverages at the Center. Alcohol was supplied by the patient or responsible party; however, a Center may offer alcoholic beverages at special events if permitted by state regulation. The policy further indicated Alcohol supplied by the patient or responsible party was labeled with the patient’s name, room number, and date opened and stored in a secure location. A licensed nurse, trained recreation or guest services staff per physician order will dispense alcoholic beverages for each patient. The policy also indicated, if the Medication Administration Record (MAR) or Treatment Administration Record (TAR) indicates ordered for specific time, and if alcohol consumption precipitates unsafe behavior, the Center will contact the physician for recommendations. A review of the facility's policy and procedure titled, "Elopement of Patient," revised 5/1/2022, indicated elopement occurs when a patient leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence -LOA) and/or any necessary supervision to do so. Identify patient's elopement risk by reviewing the following upon admission, re-admission, quarterly, or with a significant change in conditions as defined by Resident Assessment Instrument (RAI) or (MDS) Manual criteria utilizing the nursing assessment, social services assessment, and other disciplinary assessments. The facility failed to ensure care and services were provided in accordance with the comprehensive assessment, plan of care, and facility’s policies by not providing supervision and a safe environment for Resident 1, who was at risk of elopement and diagnosed with opioid abuse and alcohol dependence. The facility failed to: -Conduct a Quarterly Elopement Risk Assessments, as most recent was dated 11/29/2021 (eight months prior to incident). -Develop and implement an individualized care plan with specific interventions regarding non-compliance with facility rules and policies. -Follow Physician’s Orders for Resident 1 to go out on pass with a responsible party. As a result, on 7/28/2022, Resident 1 eloped from the facility, suffered an ALOC, low blood pressure, and elevated pulse of 112, and an elevated alcohol blood level of 358 mg/dL. Resident 1 was admitted to GACH 1, where he was diagnosed with alcohol intoxication. The above 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 harm would result Resident 1.