Health inspection·February 4, 2022

F689 §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: (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 9/3/2021 the California Department of Public Health made an unannounced visit to the facility to conduct a facility-reported incident investigation regarding quality of care and Resident 1’s record was reviewed. The facility failed to ensure Resident 1, who had dementia (loss of memory, thinking and reasoning), impaired vision, and had expressed a desire to go home, was properly evaluated for his risk of elopement (a resident who leaves the facility when doing so may present an imminent threat to the resident's health and safety because the resident is too impaired to make a reasoned decision to leave), and was provided with a safe environment and supervision to prevent the resident from eloping, per the facility’s policy. As a result, on 8/26/2021, Resident 1 eloped from the facility, sustained multiple injuries and required transfer to a General Acute Care Hospital (GACH 1), where he was diagnosed with a cephalohematoma (accumulation of blood under the scalp), a fracture (break in a bone) of the inferior (below) right pelvic bone (connects the trunk and legs) and severe compression fracture (break in the back bones) of the L4 (4th lumbar-bone of the spine). Resident 1 was admitted to GACH 1 Intensive Care Unit (ICU- a unit in a hospital providing intensive care for critically ill or injured patients) and treated with antibiotics (medication to treat infection). A review of Resident 1’s Admission Record (Face sheet) indicated the facility admitted Resident 1, a 91 year old male, on 10/17/2019, and was readmitted on 7/8/2021, with diagnoses including dementia, atrial fibrillation (an irregular heartbeat), heart failure (the heart muscle does not pump blood), hypertension (a condition when the force of the blood against the artery wall is too high), unspecified glaucoma (a group of eye conditions that cause blindness), and muscle weakness. A review of Resident 1's Care Plan dated 7/8/2021, indicated Resident 1 had impaired vision related to glaucoma. The goal was to minimize the risk of injury related to visual impairment daily by providing a safe environment and free of hazards for Resident 1. The care plan did not indicate how to provide a safe environment free of hazards. A review of Resident 1's Care Plan dated 7/8/2021, indicated Resident 1 was at risk for spontaneous fractures related to osteopenia (a condition that occurs when the body does not make new bone as quickly, as it reabsorbs old bone), chronic compression fracture (loss of bone mass, occurs when the bony block or vertebral body in the spine collapses, which can lead to severe pain, deformity and loss of height). The goal was to reduce the risk of injury daily by providing a safe, hazard free environment, assist with all transfers and ambulation as needed, and a fall risk assessment for Resident 1. A review of Resident 1’s Elopement Risk Evaluation form dated 7/9/2021, indicated Resident 1 had intermittent confusion, did not have any vision or communication problem and had not expressed the desire to go home. The Elopement Risk Evaluation indicated Resident 1 was assessed as no risk of elopement / wandering. No other Elopement Risk Evaluations or updates were documented for Resident 1 reflecting his impaired vision as a result of glaucoma or communication issues related to dementia and not speaking English. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 7/15/2021, indicated Resident 1 needed one-person physical limited assistance with bed mobility, and one-person extensive assistance with transfers, dressing, walking, and toilet use. Resident 1 used a walker and wheelchair for mobility. A review of Resident 1's Change of Condition (COC) Assessment Form dated 8/26/2021, indicated the resident was in his room, seen in wheelchair talking to "a peer" on 8/26/2021 at 8 AM and that Resident 1 did not speak nor understand English. At 9:45 AM, the facility staff were not able to locate Resident 1 during rounds. The COC indicated the facility staff located and brought back Resident 1 to the facility on 8/26/2021 at 10:30 AM and Resident 1 was noted with multiple skin abrasions and dried blood to the right side of Resident 1's forehead. The right foreside abrasion measured 4.5 cm (centimeters, unit of measurement) in length by (x) 4.5 cm in width, the left small finger abrasion measured 0.5 cm x 0.5 cm and left fourth finger abrasion measured 0.2 cm x 0.2 cm. The COC indicated Resident 1 stated that while he was out on the street, he tried to propel self in wheelchair with both feet off the ground, but he fell face down when he leaned forward. Resident 1 denied pain. A review of Resident 1’s COC Assessment form dated 8/28/2021, indicated Resident 1 had a right shin excoriation, and another excoriation was noted on Resident 1's left lateral knee. A review of the Physician's Order, dated 8/31/2021 timed at 4:20 PM, (five days after the elopement), indicated to transfer Resident 1 to the GACH due to right front leg wound infection. A review of Resident 1's Discharge Summary Report dated 8/31/2021 at 9:40 PM, indicated transfer to the GACH was necessary, as Resident 1 had a right front leg wound infection. A review of GACH 1’s History and Physical exam for Resident 1, dated 9/2/2021, indicated a computed tomography scan (CT scan - a series of images taken from different angles around the body) of the abdomen and pelvis indicated fracture of the inferior right pubic ramus (pelvic fracture) with an uncertain age, acute and severe compression fracture of the L4 vertebral body involving the superior and inferior end plates. CT of the head indicated a small cephalohematoma on the right frontal scalp. A review of GACH 1’s Physician Daily Progress Note for Resident 1, dated 9/3/2021, indicated the resident was transferred to the ICU per cardiologist (a doctor who specializes in the study or treatment of heart diseases and heart abnormalities). Resident 1 had cellulitis of right lower extremity with possible sepsis (severe infection) and was started on intravenous (IV) antibiotics. The orthopedic (medical specialty concerned with diagnosis and treatment of disorders of bones) recommendations included no surgery, non-weight bearing (not putting weight on the legs/feet) and administration pain medications as needed. During an interview, on 9/3/2021 at 2:50 PM, the Treatment Nurse stated the resident always said he wanted to go home. During an interview, on 9/3/2021 at 3 PM, Director of Nursing (DON) stated she did not know how Resident 1 left the facility. The DON stated, "We are always monitoring all the residents, we looked everywhere, we eventually found him on the street and brought him back to the facility." The DON stated, "Someone is supposed to always monitor the front door, but I am not sure what happened on this day." During an interview, on 10/12/2021 at 11:30 AM, the Facility Receptionist stated she monitors the front entrance of the facility to make sure the residents stay inside the facility. The Receptionist stated she would call someone to monitor the facility's front entrance if she needed to step away but did not remember what happened the day Resident 1 left the facility. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 10/13/2021 at 2 PM., LVN 1 stated someone (did not identify the person), informed LVN 1, that Resident 1 was missing. LVN 1 further stated he located Resident 1 a couple blocks away from the facility. LVN 1 stated, "No one was monitoring the main entrance at the time" Resident 1 left the facility. A review of the facility's document titled, "Job Description for Receptionist/Office Assistant," dated 10/1/2011, indicated the facility observes safety and security procedures; reports potentially unsafe conditions and ensures residents or responsible parties sign residents in and out appropriate sheet when leaving or returning to the community. A review of the facility's policy and procedures (P&P) titled, "Monitoring Exit Door Alarm," dated 3/4/2019, indicated the facility has installed alarms on all main exit doors (front/back station). The P&P further indicated the facility will ensure safety of residents who attempt to elope from facility premises, maintenance staff to check all exit doors twice a week on Mondays and Fridays to ensure function of door alarms, and any malfunction identified will be reported to administration immediately. A review of the facility's undated policy and procedures titled, "Care of Wandering Residents," indicated the facility would protect the wandering resident from injury, residents who wander shall have their picture taken and places in the medical record. Wanderers are to be checked on a regular basis. Nursing staff to monitor the resident's location with visual checks as needed, continuously reorienting the resident to their room and belongings. The facility failed to ensure Resident 1, who had dementia, impaired vision, and had expressed a desire to go home, was properly evaluated for elopement risk and was provided with a safe environment and supervision to prevent the resident from eloping, per the facility’s policies. As a result, on 8/26/2021, Resident 1 eloped from the facility, sustained multiple injuries, and required transfer to GACH 1, where he was diagnosed with a cephalohematoma, and a fracture of the inferior right pelvic bone of the L4. Resident 1 was admitted to GACH 1 ICU and treated with antibiotics. The above violations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1.