Health inspection·April 23, 2024

F689 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 - (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. 22 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: (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. 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 3/5/2024, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the investigation of a facility reported incident. The facility failed to provide a safe environment and supervision to ensure Resident 1, who was at risk of elopement (leaving facility without notice or permission, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decision to leave) and had expressed to multiple staff that he wanted to leave, did not elope from the facility. The facility failed to: 1. Assess Resident 1's risk for elopement upon admission. 2. Implement the care plan interventions to check resident's whereabouts. 3. Communicate with the facility staff the planned intervention of every 30 minutes monitoring for Resident 1 who was at risk to leave the facility. 4. Identify Resident 1's risk for elopement behavior of repeatedly asking to leave the facility. 5. Follow their policy and procedure (P&P) titled, Wandering and Elopements, which indicated, if identified as at risk for elopement, or other safety issues, the resident's care plan would include strategies and intervention to maintain the resident's safety. As a result, around 12 AM on 3/3/2024, Resident 1 was found to have eloped from the facility and the staff was unaware of how and when the resident eloped. Resident 1 had an increased risk of decline, serious harm, or death due to not receiving the physician ordered care which included dialysis (a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy) and medications, as Resident 1 remains missing. A review of the general acute care hospital (GACH 1) Medicine Discharge Summary Note, dated 2/29/2024, indicated on 2/5/2024 after being found on a bus incontinent of bowel, Resident 1 was brought to the Emergency Department (ED) in shock (the body's response to a sudden drop in blood pressure) and in renal failure (a condition in which one or both of the kidneys no longer work on their own). Resident 1 was admitted to the hospital and a hemodialysis catheter (a tubular medical device for insertion into canals, vessels, passageways, or body cavities for diagnostic or therapeutic purposes) was placed. Resident 1 was started on continuous renal replacement therapy (a slower dialysis that is 24 hours or longer). The Discharge Summary indicated on 2/13/2024 Resident 1 had an open reduction and internal fixation (ORIF - a surgical procedure for repairing fractured bone using either plates, screws or a rod to stabilize the bone) of his left femur (thigh bone). It also indicated Resident 1 required continued hemodialysis and the resident's discharge diagnoses (active problems) included acute renal failure, septic shock (blood pressure drops to a dangerously low level after an infection), chronic osteomyelitis (a bone infection), altered mental status, severe opioid (class of drug used to reduce moderate to severe pain ) use disorder and severe methamphetamine (a powerful, highly addictive stimulant that affects the central nervous system) use disorder. A review of Resident 1's admission record indicated the facility admitted the resident on 2/29/2024 with the diagnosis of high blood pressure. It also indicated Family Member 1 (FM 1) and Family Member 2 (FM 2) were Resident 1's emergency contacts. A review of Resident 1's History and Physical (H&P) Note, dated 2/29/2024, indicated Resident 1's diagnoses included acute kidney failure, severe sepsis (a life-threatening complication of an infection), altered mental status, hepatitis C, opioid disorder, and methamphetamine use disorder. It further indicated on admission the resident was irritable and uncooperative during examination. It also indicated the resident had fluctuating capacity to understand and make decisions. A review of the physician orders, dated 2/29/2024, indicated Resident 1 was to receive the following medications and care: Valproic acid (treats bipolar disorder) 250 milligrams (mg) - Give two capsules twice a day for mood disorder. Valproic acid 250 mg - Give five capsules with dinner for mood disorder. Olanzapine (Zyprexa - an antipsychotic) five mg as needed for anxiety / agitation. Diazepam two mg (an anti-anxiety medication) twice a day for anxiety manifested by agitation. Eliquis (used to prevent serious blood clots from forming due to a certain irregular heartbeat) five mg twice a day for deep vein thrombosis (DVT - a blood clot in a deep vein of the leg, pelvis and sometimes arm) prophylaxis for 68 days. Sodium Zirconium Cyclosilicate (treats high potassium [salt] in the blood), one time a day for high blood potassium level. Cefazolin (an antibiotic) one gm intravenously (IV - into or within a vein) one time a day every Tuesday, Thursday, Saturday, Sunday for sepsis for 36 days. Cefazolin two gm IV one time in the evening every Monday, Wednesday for sepsis for 37 days. Give after dialysis at the dialysis center. Cefazolin three gm IV one time in the evening every Fri for sepsis for 40 days. Give after dialysis at the dialysis center on Friday. May reinforce dialysis catheter or shunt as needed and every day shift. Monitor dialysis site for tenderness, redness or bleeding every shift. According to a review of Resident 1's Interdisciplinary Team (IDT) Review, dated 3/1/2024, the psychosocial (involving both psychological and social aspects) needs and behaviors were agitation and that the facility explained to the resident the out on pass (OOP) protocol and the risk of safety. A review of Resident 1's Care Plan for Risk for Against Medical Advice (AMA) Identified, initiated 3/1/2024, indicated Resident 1 was identified to be at risk to leave the facility AMA and the facility explained the risk of injury versus the benefits of complying with his stay. The Risk for AMA care plan interventions included to check the resident's whereabouts and redirect as needed. There was no frequency included in the intervention. A review of the Progress Notes, dated 3/1/2024 at 9 AM, indicated Resident 1 was admitted to the facility and had a Perma catheter (a flexible tube inserted into a blood vessel in the neck or upper chest used for dialysis treatment) on the right upper chest and a Heplock (an IV catheter placed in a vein to administer medication or fluid into the bloodstream) on the right hand. A review of the March 2024 Certified Nursing Assistant (CNA) Documentation Survey Report on 3/2/2024 for the 3 PM to 11 PM shift, Certified Nursing Assistant 1 (CNA 1) indicated the resident was not available on the 3 PM to 11 PM shift for personal hygiene, toilet transfer, toileting hygiene and amount [of meal] eaten. A review of Resident 1’s 30 Minute Visual Check forms dated 3/1/2024 and 3/2/2024 indicated assigned staff would document "duty performed" (whereabouts) and initial of the assigned staff every thirty minutes. The 30- Minute Visual Check were pre-printed on the form and start from 6:30 AM to 6 AM the next day. A further review of the 30 Minute Visual Check form dated 3/2/2024 indicated Resident 1's whereabouts was the last identified at 9:30 PM on 3/2/2024 (2.5 hours prior to determining the resident had eloped) that resident was in his room. According to a review of the Situation-Background-Assessment-Recommendation (SBAR - provides a framework for communication between members of the health care team) form, dated 3/3/2024, indicated at 12 AM upon arrival to the facility, Licensed Vocational Nurse 1 (LVN 1) made rounds and noted Resident 1 was not in bed and the resident's dinner tray was at bedside and was untouched. The form further indicated Licensed Vocational Nurse (LVN) 1 called the previous shifts charge nurse LVN 2 and LVN 2 reported he last saw Resident 1 at 5 PM. A review of Resident 1's Elopement Risk Assessment, dated 3/4/2024 (after the resident eloped), indicated Resident 1 was not considered an elopement risk. The Elopement Risk Assessment indicated the resident was not independently mobile and did not perceive that he needed to be doing something other than what he was doing. During an interview on 3/5/2024 at 9:05 AM, the Director of Nursing (DON) stated Resident 1 was determined to be at risk to leave the facility against medical advice (AMA) so, she initiated a monitoring log for the resident in which staff were to monitor the resident's location every 30 minutes. The DON stated she forgot to review and sign the At Risk of Elopement Assessment upon the resident’s admission to indicated it was completed. During a phone interview on 3/5/2024 at 9:22 AM, Registered Nurse 1 (RN 1) stated she completed the At Risk of Elopement Assessment for Resident 1, but further review of the assessment indicated it did not include an assessment of Resident 1’s cognition (the states and processes involved in knowing, which in their completeness include perception and judgment), medications or history of drug use. During a phone interview on 3/5/2024 at 9:23 AM, Registered Nurse 1 (RN 1) stated she worked the 3 PM to 11 PM shift on 3/2/2024. RN 1 stated she last saw Resident 1 sometime between 9 and 10 PM. RN 1 stated Resident 1 inquired about being able to go to a money transfer business that night, to get money and buy clothes. RN 1 stated she told Resident 1 he would have to wait until Monday to speak with social services. RN 1 further stated Resident 1 replied, "Man, that's too late." RN 1 further stated she did not consider Resident 1 an elopement risk and did not check the resident's whereabouts every 30 minutes. RN 1 also stated she was not aware that Resident 1's location was to be monitored every 30 minutes. During a concurrent interview and observation on 3/5/2024 at 10:39 AM, with the Maintenance Director (MTD) a general observation of the facility premises was performed. The MTD stated the facility did not have any working cameras inside or outside the building. During an observation of the smoking area, the MTD stated there was no staff to continuously monitor the electronic parking gate that opened onto the area and the door to the parking area was not alarmed at this time (daytime), but staff were to alarm it at night. During an interview on 3/5/2024 at 10:56 AM, LVN 1 stated he worked the 11 PM to 7 AM shift on 3/2/2024. LVN 1 stated he went to check all of the residents assigned to him and discovered Resident 1 was not in bed, his dinner tray remained at bedside and untouched. LVN 1 stated Resident 1 was known to complete 100% of meals and usually wanted a snack around midnight. LVN 1 stated he assumed the resident returned to the GACH and he completed checking the other residents assigned to him. LVN 1 stated he then started looking on the computer to find out what happened to Resident 1. LVN 1 stated LVN 2 told him he last saw Resident 1 around 5 PM, and the current certified nursing assistant assigned to Resident 1 stated she had not seen the resident at all. LVN 1 stated he then thought Resident 1 had eloped, so he initiated a thorough search for the resident of the facility's premises and after Resident 1 was not found, extended the search to the surrounding area. LVN 1 stated he was very concerned because Resident 1 had intravenous (IV - inside the vein) access and that the resident could give himself IV drugs and overdose. On 3/5/2024 at 12:13 PM, during a phone interview FM 1 stated she was informed by a transportation company that Resident 1 was missing. FM 1 stated the facility never informed her Resident 1 was missing. FM 1 further stated the facility never told her that Resident 1 was at risk for AMA nor did the facility contact her to be part of an IDT meeting. During an interview on 3/5/2024 at 1:58 PM, LVN 2 stated he worked on 3/2/2024 on the 3 PM to 11 PM shift. LVN 2 stated he last saw Resident 1 at 9 PM on 3/2/2024 when he administered Resident 1's medication. LVN 2 stated Resident 1 mentioned he did not want to be in the facility and LVN 2 told Resident 1 he would have to wait until the morning to speak with social services. LVN 2 further stated he was not aware that Resident 1's location was being monitored and he did not monitor or document Resident 1's whereabouts. During a concurrent interview with RN 1 and record review on 3/5/2024 at 3:45 PM, Resident 1's 30 Minute Visual Check forms, dated 3/1/2024 and 3/2/2024 were reviewed. RN 1 stated she had never seen this form. RN 1 stated after Resident 1 stated he wanted to leave the facility; she did not start monitoring his (Resident 1) location or have communicated to the other staff on duty. During a phone interview on 3/6/2024 at 8:04 AM, Certified Nursing Assistant 1 (CNA 1) stated she worked as a registry (staff personnel provided by a placement service on a temporary or on a day-to day basis) CNA at the facility on 3/2/2024 for the 3 PM to 11 PM shift and was assigned to care for Resident 1. CNA 1 stated the last time she saw Resident 1 was around 3:30 PM or 4 PM, when she adjusted Resident 1's clothes in the activities room. CNA 1 stated she placed Resident 1's dinner tray on his bedside table around 5:15 PM and the resident was not present. CNA 1 stated she left his dinner tray at bedside because she thought the resident went to dialysis. CNA 1 stated she was not aware Resident 1 was at risk to leave the facility and she was not instructed to monitor the resident's location. During a phone interview on 3/6/2024 at 9:15 AM, Registered Nurse 2 (RN 2) stated she worked on 3/2/2024 during the 11 PM to 7 AM shift. RN 2 stated she did not observe Resident 1 when she did her rounds at the start of her shift. RN 2 stated LVN 1 arrived around midnight. RN 2 stated LVN 1 informed her Resident 1 was missing and the staff searched the facility and the surrounding neighborhood. Resident 1 was not found. RN 2 stated, she did not know how and when Resident 1 left. Stated she was not informed Resident 1 was at risk to leave the facility and was not informed to monitor Resident 1's location every 30 minutes. RN 2 stated Resident 2's IV access catheter (if he pulled out) was not found in the room, and it was not safe for him to have IV access as he could overdose if he does drugs. On 3/6/2024 at 9:57 AM, during an interview the Director of Staff Development (DSD) stated CNA 1 did not have training on elopement. The DSD stated Resident 1's AMA care plan was not specific enough and the every 30 Minute Visual Check form should have been specified in his care plan. The DSD stated Resident 1's whereabouts should have