Other·March 22, 2023

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: (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 12/6/2022, the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a complaint about Resident 1's quality of care. The facility failed to provide a safe environment, supervision and follow its policy and procedures titled, "Wandering & Elopement," to ensure Resident 1 would not elope (leaving facility without notice or permission) from the facility. The facility failed to: 1. Ensure Resident 1 received an accurate behavioral and mental evaluation after the attempted elopement on 8/1/2022, per the Change in Condition (COC) Evaluation. 2. Develop and implement a person-centered comprehensive elopement care plan for Resident 1, including supervision or a detailed monitoring plan and monitoring placement and functioning of the Wander Guard. 3. Periodically review and revise the care plan by the Interdisciplinary Team (IDT) during the onset of new problems or change of condition per the facility Care Planning policy, to include interventions to supervise or monitor Resident 1. As a result, on 12/2/2022, Resident 1 eloped from the facility and remains missing. A review of Resident 1's admission record indicated the facility readmitted Resident 1 on 6/16/2022 with diagnoses including unspecified encephalopathy (disease of the brain manifested by an altered mental state sometimes accompanied by physical changes), uncomplicated psychoactive substance abuse (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), and hypertension (HTN - elevated blood pressure). A review of Resident 1's Elopement Evaluation, dated 8/1/2022 indicated the resident had a history of attempting to leave the facility without informing staff, was a wanderer, and that Resident 1's wandering behavior was likely to affect the privacy of others. The Elopement Evaluation form indicated Resident 1 scored a 5 and was at risk of elopement, however the evaluation form did not indicate the score key to determine the score range for 'at risk.' A review of Resident 1's COC Evaluation form dated 8/1/2022, indicated Resident 1 had an episode of attempting to leave the facility. The COC form indicated Resident 1 was reoriented multiple times but failed to comprehend. The primary physician recommended applying a Wander Guard (a system to monitor resident safety to protect those at risk of elopement) and closely monitoring the resident. The COC form indicated Resident 1 had an ability to pay attention and had no mental changes compared to baseline. The COC also indicated Resident 1's "behavioral assessment was not relevant to the change in condition" of attempting to elope from the facility and was "not clinically applicable to the change in condition being reported." This indicated a discrepancy in the COC Evaluation for Resident 1. The COC form also indicated a neurological assessment for Resident 1 (including cognition; mood and affect; and thought content), "was not clinically applicable to the in condition being reported." According to a review of the Physician's Orders dated 8/1/2022, Resident 1 received a Wander Guard due to episodes of wandering out of the facility and the order indicated to check the wander guard using the code alert every shift. A review of Resident 1's care plan for elopement and wandering dated 8/1/2022 and updated 9/2/2022 indicated the resident was a risk for wandering and elopement related to the resident being unaware of the resident's safety needs. The care plan interventions included application of a wander guard and assessment of the resident's elopement risk at the following intervals: admission, readmission, quarterly, and identification of significant change of condition. The care plan did not include interventions for Resident 1 to be placed closer to the nursing station or farther from the exit doors, whichever was appropriate or safer, for the resident's needs and did not indicate supervision or a detailed monitoring plan. A review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) Note, dated 9/19/2022 indicated on 8/1/2022 Resident 1 had an episode of attempting to leave facility, and to monitor the resident closely with a Wander Guard to prevent elopement. A review of the Minimum Data set (MDS, an assessment and care screening tool), dated 9/21/2022, indicated Resident 1 was cognitively intact (decisions are consistent and reasonable) and required supervision with set up help only for bed mobility, transfers, and locomotion on and off unit. A review of Resident 1'sChange of Condition form, dated 12/2/2022 indicated the resident was ambulating the hallway in the morning. At 12 pm, Resident 1 was not found in the facility and had eloped. The COC indicated Resident 1 had no mental changes compared to baseline, and "a behavioral assessment was not clinically applicable to Resident 1's change in condition." The COC form also indicated "a neurological assessment (including cognition; mood and affect; and thought content), was not clinically applicable to Resident 1's change in condition." During an interview on 2/1/2023 at 3:24 PM, the Director of Nursing (DON) stated Licensed Vocational Nurse 1 (LVN 1) documented on the COC that Resident 1 was reoriented multiple times but failed to comprehend during the first attempt to elope. The DON stated if Resident 1 did not comprehend or was unable to be reoriented, either the behavioral evaluation section of the COC or mental status evaluation section should have been documented reflecting such. The DON stated the COC Evaluation indicated no changes observed in mental status evaluation and behavioral status evaluation was not clinically applicable to the change in condition being reported. She stated this was not an appropriate assessment of Resident 1 after the attempted elopement on 8/1/2022. The DON stated the recommendation of the primary physician was to monitor closely and apply the Wander Guard. She stated the care plan for elopement risk included to apply the Wander Guard but did not indicate monitoring. The DON stated Resident 1's risk of elopement care plan did not include the monitoring and could potentially increase the elopement risk for Resident 1. The DON stated Resident 1 remains missing. During an interview on 2/1/2023 at 3:45 PM, Registered Nurse 1 (RN 1) stated Licensed Vocational Nurse 1 (LVN 1) documented that Resident 1 was reoriented multiple times but failed to comprehend during the first attempt to elope. RN 1 stated the COC indicated the mental or behavioral evaluation was not conducted and that LVN 1 should have completed a mental or behavioral evaluation after Resident 1's incident on 8/1/22. RN 1 stated the care plan for elopement risk did not include monitoring interventions for Resident 1. On 2/1/2023 at 3:55 PM, during an interview, the Administrator (ADM) stated the elopement care plan for Resident 1 did not indicate visual monitoring for elopement. The Administrator stated it was very unlikely that staff would monitor Resident 1 if not indicated in the care plan causing a potential for Resident 1 to elope from the facility unnoticed. During an interview on 2/2/2023 at 3:47 PM, LVN 1 stated she tried to reorient Resident 1 on 8/1/2022 when the resident tried to ambulate throughout the facility. She stated Resident 1 seemed to not understand and did not want to go back to his room. LVN 1 stated the resident was being difficult. LVN 1 stated there was potentially a change in either his behavior or mental status and that she failed to conduct a behavioral or mental evaluation on 8/1/2022. LVN 1 stated she called the physician who ordered the Wander Guard and to monitor closely, but the care plan for Resident 1's elopement risk did not include monitoring closely. A review of the facility's policy and procedure titled, "Wandering & Elopement," revised 7/2017, indicated the facility will identify residents at risk for elopement and minimize any possible injury as a result of elopement. The Licensed Nurse, in collaboration with the IDT will assess residents upon identification of significant change in condition. The policy indicated the resident's risk for elopement and preventative interventions will be documented in the resident's medical record and would be reviewed and re-evaluated by the IDT upon admission, readmission, quarterly, and upon change in condition. A review of the facility's policy and procedure titled, "Care Planning," revised 11/2018, indicated the care plan will be completed within seven days after completion of the Comprehensive Admission Assessment, and periodically reviewed and revised by IDT at the following intervals: onset of new problems, change of condition, quarterly, annually, and in preparation for discharge. A review of the facility's policy and procedure titled, "Change of Condition Notification," dated 4/1/2015, indicated the licensed nurse would assess the change in condition and determine which nursing interventions were appropriate. The licensed nurse must observe the resident and assess the overall condition utilizing a physical assessment and chart review. The policy indicated the licensed nurse would update the care plan to reflect the resident's current status. The facility failed to provide a safe environment, supervision and follow its policy and procedures titled, "Wandering & Elopement," to ensure Resident 1 would not elope from the facility. The facility failed to: 1. Ensure Resident 1 received an accurate behavioral and mental evaluation after the attempted elopement on 8/1/2022, per the COC Evaluation. 2. Develop and implement a person-centered comprehensive elopement care plan for Resident 1, including supervision or a detailed monitoring plan, and monitoring placement and functioning of the Wander Guard. 3. Periodically review and revise the care plan by the IDT during the onset of new problems or change of condition per the facility Care Planning policy, to include interventions to supervise or monitor Resident 1. As a result, on 12/2/2022, Resident 1 eloped from the facility and remains missing. The above violations 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.