Other·March 1, 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 1/6/2023, 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 and follow its policy and procedures titled, “Safety and Supervision of Residents,” to ensure Resident 1 would not elope (when a patient who leaves the healthcare facility unnoticed and doing so may present an imminent threat to the patient's health or safety because the patient has been deemed too ill or impaired to make a reasoned decision to leave) from the facility. The facility failed to: 1. Develop and implement a person-centered comprehensive Elopement care plan for Resident 1 upon admission on 10/12/2022. 2. Ensure Resident 1 received care and supervision to prevent accidents and elopement. 3. Ensure the door in Resident 1’s room that led to the outside of the facility had the alarm activated and was in working condition. 4. Implement the facility policy titled, “Audible Battery-Operated Door Alarms,” to alert staff of all persons exiting the facility, and the policy “Safety and Supervision of Residents,” to identify risk factors of accident hazards. As a result, on 1/5/2023, at 4 a.m., Resident 1 eloped and was found by the police the same day, trying to break into a stranger’s house. The police escorted Resident 1 to the general acute hospital (GACH 1) where Resident 1 complained of pain, was given pain medication and had a four centimeters (cm) laceration (deep cut or tear in the skin) on the left thigh requiring stitches. A review of the Admission Record indicated the facility admitted Resident 1 on 10/12/2022 with diagnoses including schizophrenia (a serious mental illness that interferes with a person’s ability to think clearly, manage emotions, make decisions, and relate to others), anxiety disorder, and generalized muscle weakness. A review of the Risk of Elopement Assessment dated 10/13/2022, indicated Resident 1 scored a two and did not have a risk for elopement. A review of the Physician’s Order dated 10/13/2022 indicated Resident 1 received Seroquel (medication used to improve mood, thoughts, and behaviors for people with schizophrenia) 100 milligrams (mg) every 12 hours for schizophrenia, manifested by hearing disturbing voices. A review of the History and Physical dated 10/15/2022 indicated Resident 1 had fluctuating capacity to understand and make decisions. A review of the Minimum Data Set (MDS – a standardized assessment and care screening tool) dated 12/29/2022, indicated Resident 1 was oriented to year, month, and day. The MDS indicated Resident 1 needed supervision with bed mobility, transfer, eating, personal hygiene and limited assistance with dressing, toilet use and bathing. According to a review of the Audible Door Alarm Log dated 1/4/2023 and 1/5/2023, all the facility door alarms were activated and in working condition. A review of the Nursing Note dated 1/5/2023 at 4:50 a.m., indicated at 2 a.m., Resident 1 was in bed sleeping soundly and at 4 a.m., during rounds, Resident 1 was not in her bed and not in the restroom. The Nursing Note indicated the registered nurse supervisor and facility staff searched all rooms, restrooms and facility premises, nearby stores, and gas stations but were unable to locate Resident 1. The Nursing Note indicated at 4:30 a.m., the police, Resident 1’s primary physician, the Director of Nursing (DON) and the Administrator (ADM) were all notified. A review of the Nurses Notes dated 1/5/2023 at 6:34 p.m. indicated Resident 1 was found at GACH 1. During an interview on 1/6/23, at 10:51 a.m., Licensed Vocational Nurse (LVN) 1 stated during Resident 1’s admission, the risk for elopement assessment indicated Resident 1 had a score of two, meaning Resident 1 had no risk for elopement. LVN 1 stated there was no care plan created because Resident 1 was not at risk for elopement. During an interview on 1/6/23 at 11:15 a.m., the Social Service Designee (SSD) stated she called several local hospitals on 1/5/2023 to find Resident 1. The SSD stated she called GACH 1 in the afternoon and was informed that an unidentified female fitting Resident 1’s description had been admitted. The SSD stated she notified the ADM. During an interview on 1/6/2023 at 11:21 a.m., the ADM stated that on 1/5/2023 at 4 a.m., Resident 1 was missing, and the facility searched for Resident 1. The ADM stated the police found Resident 1 breaking into a stranger’s property and took Resident 1 to GACH 1. The ADM stated she went to GACH 1 to identify the resident and Resident 1 would not talk about what happened. On 1/6/2023 at 11:33 a.m., during a telephone interview, the Registered Nurse Supervisor (RNS 1), stated Resident 1’s room had a door with an alarm, the alarm was off, and Resident 1 exited through the door. RNS 1 stated the resident turned off the switch because the alarms used by the facility had on – off switches that were accessible by anyone. RNS 1 stated Resident 1 walked towards the facility gate which led to the parking lot and out to the community. RNS 1 further stated the gate also had an alarm that would emit a sound once opened for 30 seconds and after 30 seconds it automatically turned off. RNS 1 stated no one heard the alarm and Resident 1 was able to leave the facility. A review of GACH 1 Emergency Department (ED) Progress Note dated 1/6/2023 at 4:32 p.m., indicated the police brought Resident 1 to GACH 1 after Resident 1 was found trying to break into a stranger’s house. The ED Note indicated while at the GACH, Resident 1 complained of pain on the left hip and was found to have a four cm laceration on the left thigh. The notes indicated Resident 1 was given lidocaine (local anesthesia [numb a small area of the body]) to the left lateral thigh and sutures were needed to close the laceration. During a telephone interview on 1/20/2023 at 1:30 p.m., the DON stated when Resident 1 eloped on 1/5/2023, it placed the resident at risk for injury. The DON stated the security alarm emitted a sound, but staff did not acknowledge the alarm. The DON stated there was no excuse for the staff not to hear the alarm and respond to it. The DON stated the alarm should be responded to immediately as soon as staff heard the alarm. During a telephone interview on 1/26/2023 at 4:20 p.m., the Risk for Elopement Assessment form dated 10/13/2022 was reviewed with LVN 2. LVN 2 stated the Risk for Elopement Assessment indicated Resident 1 was ambulatory and was resistant to being placed in the long-term care facility. LVN 2 further stated Resident 1 was taking Seroquel (medication used to improve mood, thoughts, and behaviors for people with schizophrenia) 100 milligrams (mg) every 12 hours, and this medication had the potential to cause confusion. LVN 2 stated these factors made Resident 1 a risk for elopement and this should have been care planned upon admission to the facility. LVN 2 stated that the Risk for Elopement Assessment was not accurate. During a telephone interview on 1/27/2023 at 1:50 p.m., the DON stated Resident 1 was not identified as at risk for elopement when admitted on 10/13/2022. The DON stated Resident 1 was ambulatory, was placed in a long-term care facility, and was on psychotropic medications (affecting behavior, mood, thoughts, or perception) that may cause confusion or disorientation. The DON stated and confirmed these factors indicated Resident 1 was indeed a risk for elopement and a care plan should have been created upon facility admission to address the risk of elopement. A review of the facility policy titled, “Audible Battery-Operated Door Alarms dated 8/23/2022 indicated it was the policy of the facility to provide a safe environment for all staff and residents. The policy indicated the facility used six audible battery-operated door alarms to alert staff of all persons entering and exiting the facility. In addition, it alerts staff if a resident wanders. A review of the facility policy titled, “Mini Audible Battery-Operated Door Alarms,” dated 8/23/2022 indicated all residents’ rooms have mini audible battery-operated alarms on the exit doors leading outside to alert staff of all persons entering and exiting from resident rooms. A review of the facility policy titled, “Policy and Procedure Safety and Supervision of Residents,” updated in 2018, indicated resident safety and supervision and assistance to prevent accidents were facility wide priorities. The policy indicated staff shall use various sources to identify risk factors for residents, including information obtained from the medical history, physical examination, observation of the resident and the MDS. The policy further indicated the interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. A review of the facility policy titled, “Elopement Policy and Procedure,” updated on 12/2020 indicated safety of all residents is the primary care standard of the facility. Impaired judgment, perception and thought processes of cognitively impaired make the residents a higher risk for elopement into unsupervised or unsafe areas. Precautions, procedures and staff and visitor education have been put into place to maximize resident safety. The facility failed to provide a safe environment and follow its policy and procedures titled, “Safety and Supervision of Residents,” to ensure Resident 1 would not elope from the facility. The facility failed to: 1. Develop and implement a person-centered comprehensive Elopement care plan for Resident 1 upon admission on 10/12/2022. 2. Ensure Resident 1 received care and supervision to prevent accidents and elopement. 3. Ensure the door in Resident 1’s room that led to the outside of the facility had the alarm activated and in working condition. 4. Implement the facility policy titled, “Audible Battery-Operated Door Alarms,” to alert staff of all persons exiting the facility, and the policy “Safety and Supervision of Residents,” to identify risk factor of accident hazards. As a result, on 1/5/2023, at 4 a.m., Resident 1 eloped and was found by the police the same day, trying to break into a stranger’s house. The police escorted Resident 1 to GACH 1 where Resident 1 complained of pain, was given pain medication and had a four cm laceration on the left thigh requiring stitches. 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.