Health inspection·March 12, 2024

The following reflects the findings of the California Department of Public Health during the investigation of facility reported incident CA00884302. Representing the Department, Health Facility Evaluator Nurse # 43497 A Class B State citation was written. Regulatory Violations: Title 42 Code of Federal Regulations: F689: G Free of Accident Hazards/Supervision/Devices §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. 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: (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. 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 2/9/2024 the California Department of Public Health (CDPH) made an unannounced visit to the facility to investigate a facility reported incident (FRI) regarding Resident 1 eloping (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing) from the facility. The facility failed to supervise and monitor Resident 1 who was admitted to a secured unit (a specific area of the facility that has a restricting device separating the residents in the unit from the residents in the remainder of the facility) located inside the facility due to being a high risk of elopement (identified behaviors of wanting to elope) was not left alone in a room with a door that had a malfunctioning lock. As a result, on 2/4/2024, Resident 1 left the facility through a door inside the dining room which led to an exit door in the facility kitchen. On 2/7/2024. The facility received a call from a security manager of a Department Store, stating that [Resident 1] instructed him (Security Manager) to call the facility as he [Resident 1] wanted to go "home." Resident 1 was placed at risk for dehydration (a condition that occurs when the body loses too much water), malnutrition (not enough nutrition due to not having enough food to eat), hypothermia (abnormally low body temperature), uncontrolled medical and/or mental conditions, and placed the resident at risk for being assaulted, hit by a car, seriously injured resulting in death. A review of Resident 1's Admission Record, indicated Resident 1 a 72 year old male was admitted to the facility on 9/28/2023 with medical history including benign prostatic hyperplasia (enlarged prostate), hypertension (elevated blood pressure), osteoarthritis (joint pain and stiffness), solitary pulmonary nodule (a small single mass in the lungs), altered mental status (a change in mental function), and bipolar disorder (a disorder associated with episodes of mood swings). A review of Resident 1's Minimum Data Set (MDS - standardized assessment and care planning tool), dated 1/2/2024, indicated Resident 1 had moderately impaired cognition (problems with reasoning, memory, knowledge and understanding). The MDS indicated Resident 1 required supervision with oral hygiene, toileting, showering, dressing, and personal hygiene. A review of Resident 1's Admission Elopement Risk Evaluation form dated 9/28/2023, indicated Resident 1 was not at risk for elopement/wandering. A review of Resident 1's Psychosocial Assessment dated 9/29/2023, indicated Resident 1 had bipolar disorder and altered mental status. The assessment indicated Resident 1 required 24- hour skilled nursing care (care provided by trained registered nurses in a medical setting under a doctor's supervision) and assistance with activities of daily living (ADL's: activities related to personal care, which include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) due to generalized weakness and impaired cognition due to bipolar disorder and altered mental status. A review of Resident 1's History and Physical dated 10/1/2023, indicated Resident 1 was unable to care for himself, but had the capacity to understand and make decisions. A review of Resident 1's care plan titled, "Elopement Risk" dated 10/4/2023, indicated the resident was at risk for leaving safe area (areas in the facility which have measures in place to prevent escape and well as staff supervision) without authorization, and leaving premises without authorization secondary to wandering behavior, AWOL [absent without leave: leaving without permission] "Resident 1 will have no elopement until the next assessment date". Interventions included, "monitor at frequent intervals", "elopement risk evaluation", "provide 1:1 [one to one supervision] if indicated to redirect behavior", and "notify physician and responsible party of change of condition". A review of Resident 1's care plan titled, "Secured Unit" dated 10/4/2023, indicated Resident 1 was at risk for "purposeless [no set destination] wandering and potential for self-injury with actual placement in secured unit secondary to wandering behavior, AWOL risk, and cognitive deficits". The goals indicated included safe wandering and no self-injury. Interventions outlined in the care plan included a physician order to admit to the secured unit, psychiatric evaluation, avoidance of antipsychotic drugs as possible, and to notify the physician and responsible party of a change of condition. A review of Resident 1's Change of Condition form dated 2/4/2024 at 7 AM, indicated, "Recap of events: as per interview with 11PM-7AM charge nurse, the resident went to her station at around 3 AM and [Resident 1] was talking to her [charge nurse] about his [Resident 1's] medication and that he [Resident 1] doesn't like and need any medication. Resident [1] was seen walking around the unit at that time as his usual behavior, noted going inside the activity room. 6:30 AM- Charge nurse was doing rounds in the morning and endorsing with outgoing shift nurse. 7 AM charge nurse was assisting in the dining room to assist resident for breakfast. CNA [Certified Nursing Assistant] for the resident called his [charge nurse] attention that resident has not eaten his breakfast. Resident is alert, oriented X3. RN [Registered Nurse] supervisor and CNA checked his room and interviewed roommates, checked the bathroom and rooms adjoining his room, after searching for a few minutes and unable to locate the resident. RN supervisor called "CODE GREEN RM [to Resident 1's room]" to alert the facility staff that we have a missing resident. Head count was done all resident is accounted for at the time except the resident [Resident 1] in question. All staff assisted in looking at all the places including all rooms, dining room, closets, bathrooms, cabinets, garage, basements, and sheds. Several staff drove around the facility to look at the street Some staff are walking around on foot. Resident was unable to be located. 8:30 AM-Administration was informed about the incident. Police department was called. Nearest ER [Emergency Room] was called. MD [medical doctor] and RP [responsible party] sister was informed that the resident was unable to be located at this time inside the facility." A review of Resident 1's Elopement Risk Evaluation form dated 2/4/2024, indicated Resident 1 was at risk for elopement/wandering. The evaluation indicated that the facility had to always monitor Resident 1's whereabouts. A review of a Conclusion Investigation Report provided by the facility on 2/9/2024 for Resident 1, indicated, "through the investigation process, [Resident 1] was discovered to successfully elope from the facility through the kitchen which had direct access to the street. The resident [Resident 1] was able to get inside the kitchen through a door malfunction that did not properly latch. The doorknob and latch were immediately replaced to ensure that it properly closes to prevent reoccurrence. A daily door security check was created to ensure door remained properly closed and latched done every shift. In addition, on February 7, 2024, the facility received a call from a security manager of a Department Store, stating that [Resident 1] instructed him (Security Manager) to call the facility as he wanted to go "home." Facility staff immediately went to pick up the resident. [Resident 1] was readmitted to the facility". During an interview with the Administrator (ADMIN) on 2/9/2024at 2 PM, ADMIN stated, Resident 1 was back in the facility's secured unit. ADMIN stated Resident 1 was found on 2/7/2024 at a Department Store. ADMIN stated, the activities room had a door access to the facility's kitchen which had an exit door to the street. ADMIN stated that on the day (2/4/2024) Resident 1 left the facility, through the door that accessed the kitchen in the activities room and that the door did not properly latch and it did not lock. ADMIN stated, the activity room door must remain locked because the door was inside a secured unit within the facility. ADMIN stated, not locking the activity door which led to the kitchen posed an elopement risk for residents in the facility. ADMIN stated he had in-serviced (training) the staff to make sure the activity room door was always locked. ADMIN state he would speak to maintenance about placing an alarm by the activity room door. During an interview with Licensed Vocational Nurse 1 (LVN1) on 2/9/2024 at 4 PM, LVN1 stated she saw Resident 1 at 3:30 AM walk by the nurse's station. LVN1 stated she asked the resident if he was going to take his morning medication and that was the last time LVN1 saw Resident 1. LVN1 stated she was passing medications at around 6 AM and saw Resident 1's CNA inside the resident's room so LVN1 did not go inside the room. LVN1 stated she did not go inside the room because Resident 1 had refused morning medications. LVN1 stated she did not know Resident 1 was missing. During a telephone interview with Certified Nurse Assistant (CNA 1) on 2/9/2024 at 5 PM, CNA 1 stated CNA 1 worked the 11 PM to 7 AM shift (2/3/2024 to 2/4/2024) and was assigned Resident 1, CNA 1 stated that on the same shift at around 1AM CNA 1 saw Resident 1 leave Resident 1's room. CNA 1 stated Resident 1 enjoyed going to the activities room which was Resident 1's usual behavior. CNA 1 did not remember seeing any staff in the activities room that night (2/3/2024 to 2/4/2024). CNA 1 stated on 2/11/2024 at around 6 AM CNA 1 went inside Resident 1's room to change the bed linen and did not see Resident 1 in bed and figured that Resident 1 was in the activities room. CNA 1 stated CNA 1 did not check the activities room to see if the resident was in there before he clocked out from work. During an interview with Director of Nurses (DON) on 2/9/2024 at 3:24 PM, the DON stated residents in the locked unit were at risk for elopement. The DON stated on 2/4/24 when Resident 1 eloped from the facility the door in the activities room did not latch. The DON stated whenever residents were in the activity room, a staff member had to supervise the residents. The DON stated there was no staff in the activities room supervising Resident 1, that was why Resident 1 eloped from the facility. The DON could not give an exact time frequency of how often residents should be supervised in the secured unit. The DON then stated at least every four hours. The DON stated the exit door in the activities room should always remained locked for the resident's safety. During an interview with the Administrator on 2/9/2024 at 5 PM, ADMIN stated the facility did not have any policy on monitoring the exit doors in their secured unit. A review of the facility's policy and procedures titled, "Policy: Care of Wandering Residents" dated 5/17/2023, indicated "the purpose to protect the wandering resident from injury. Residents who wander shall have their picture taken and placed in the medial record. A plan of care shall address the wandering. Wanderers are to be checked on a regular basis. Nursing and care duties include explaining procedures and their purposes to the resident, continuously reorienting resident to room and belongings, and monitoring the resident's location with visual checks as needed". The facility failed to supervise and monitor Resident 1 who was admitted to a secured unit located inside the facility due to being a high risk of was not left alone in a room with a door that had a malfunctioning lock. As a result, on 2/4/24 Resident 1 left the facility through a door inside the dining room which led to an exit door in the facility kitchen. Resident 1 was not found and returned to the facility until 2/7/2024. Resident 1 was placed at risk for dehydration, malnutrition, hypothermia, uncontrolled medical and/or mental conditions, and placed the resident at risk for being assaulted, hit by a car, seriously injured resulting in death. The above violation had a direct relationship to the health, safety, and security of the residents in the facility.