Health inspection·June 16, 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(a)(2) 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 4/4/2022, 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 ensure Resident 1, who was a high fall risk, immunocompromised related to disease, and had activities of daily living (ADL) self-care deficits, was provided a safe environment and supervision, as indicated in the resident's care plans and the facility’s “Missing Resident Policy and Procedures.” As a result, on 9/15/2021, Resident 1 left the facility with a Physician’s Ordered Out on Pass (OOP - temporarily absent from the facility) and did not return. Resident 1 was missing for over seven months with risk of injury or death, as Resident 1 missed an appointment with the physician for continued treatment of artery medication on 9/18/2021 at 1:40 PM., missed his physical therapy and occupational therapy scheduled for five times per week and missed his scheduled daily medications. The facility did not initiate an extensive search of the surrounding areas, call, or report the incident to law enforcement. Resident 1 remains missing. A review of Resident 1's face sheet (admission record) indicated the facility admitted Resident 1 on 6/12/2021 with diagnoses including aphasia (inability to speak), stroke with hemiplegia (weakness, stiffness, spasticity, and lack of control in one side of the body), neuritis (inflammation of a nerve) and was immunocompromised (weak immune system). A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 6/16/2021, indicated Resident 1 had the mental ability to make decisions of daily living, required limited and extensive one-person physical assist with bed mobility, surface transfer, dressing, toileting, and personal hygiene. The MDS indicated Resident 1 used a limb prosthesis (artificial device that replaces a missing body part) for mobility. A review of Resident 1’s Physician’s Telephone Order, dated 6/12/2021, indicated Resident 1 was to receive Biktarvy (medication to treat weak immune system) 50-200-25 milligrams-unit of measurement (mg) one tablet once a day and was to receive Gabapentin capsule (medication for nerve pain) 300 mg orally every eight hours for nerve pain. A review of Resident 1’s undated care plan indicated Resident 1 had ADL self-care performance deficit related disease process, history of stroke, surgical wound repair of brachial artery (main blood vessel of the upper arm and elbow joint), median nerve repair (provides movement to the forearm, wrist, and hand), and ulnar nerve repair (a main nerve in the arm). The interventions indicated to check resident every two hours for soiling and wetness. A review of Resident 1’s undated care plan on risk for hydration or potential for fluid deficits, indicated interventions to monitor and document the intake and output, monitor vital signs (blood pressure, temperature, respirations, and pulse), and monitor for signs and symptoms of dehydration, per facility policy. According to a review of Resident 1’s undated care plan on impaired / weak immune status indicated the resident was at risk of contracting infections. The interventions indicated to keep environment clean, keep people with infection away and monitor abnormal laboratory values. A review of Resident 1’s undated care plan, indicated Resident 1 was at risk for pain related to nerve repair wound trauma. The interventions included to administer analgesia (pain medication) oxycodone HCI/Acetaminophen (strong pain medication) per physician’s orders (30 minutes before treatment care). A review of Resident 1’s undated care plan indicated Resident 1 was on anticoagulation therapy (Aspirin medication for pain, reduce fever, and prevent blood clots) related to cerebral vascular accident / stroke. The interventions indicated to take medication at the same time each day and to wear med alert bracelet indicating resident on anticoagulant medication / therapy. A review of Resident 1’s Case Management Note dated 6/22/2021 timed 3:39 PM, indicated “Spoke with relative of resident,” who enquired regarding resident’s discharge plan, wanting resident be transferred to another facility in a different state. Will continue to communicate with the resident. A review of the undated care plan indicated Resident 1 had adjustment issues to admission and the interventions included to offer resident to communicate feeling to nursing home placement. According to a review of Resident 1’s Physician’s Orders dated 7/16/2021 timed 2:15 PM., Resident 1 had a plastic surgery follow up appointment on 10/15/2021 at 9 AM. A review of Resident 1’s Nursing Admission Assessment document dated 8/11/2021, indicated the wandering and elopement (an unauthorized departure from the facility) risk assessment was incomplete and to monitor Resident 1 frequently. According to a review of Resident 1’s Order Summary Report dated 8/26/2021, Resident 1: -Had appointment with the physician for continual treatment of artery medication on 9/18/2021 at 1:40 PM. -May have psychiatric (a branch of medicine that deals with mental, emotional, or behavioral disorders) and psychology (is the study of the mind and behavior) consult as needed. -Continue skilled occupational therapy (OT) five times a week for four weeks for diagnosis of coordination and treatment may include ADL training, neuromuscular re-education, therapeutic exercises and activities, gait training, and orthotic training. -Continue skilled physical therapy (PT) daily five times a week for four weeks with treatment and diagnosis of muscle weakness, neuro-reeducation, therapeutic exercises, therapeutic activities, gait training, and orthotic training. -Monitor signs and symptoms of bleeding/ gastrointestinal events for aspirin. A review of Resident 1’s Medication Administration Record dated 9/2021, indicated Resident 1 had the following active orders not limited to: -Aspirin EC Tablet delayed release 81 mg one tablet by mouth once a day for prophylaxis cerebral vascular accident. -Atorvastatin Calcium tablet 80 mg one tablet orally at bedtime for hyperlipidemia (high cholesterol). -Check blood pressure weekly. A review of Resident 1’s Fall Risk (Morse) Assessment dated 9/14/2021 timed at 2:10 PM, indicated Resident 1 scored 35 which indicated a moderate risk for fall and had impaired gait (manner of walking). A review of Resident 1’s Social Services note, dated 9/15/2021 timed 11:49 AM, indicated Resident 1 requested to go out on pass with a friend. A review of Resident 1’s Nurses Notes dated 9/15/2021 timed 12 PM, indicated Resident 1 requested to go OOP from facility. The Nurses Note indicated Resident 1 went OOP with a friend and the resident stated he would be gone for four hours. A review of Resident 1’s Physician’s Order dated 9/15/2021 timed 12:11 PM., indicated “PASS: May go out on pass with supervision.” A review of the facility’s undated “Temporary Leave of Absence Out on Pass (OOP), indicated Licensed Vocational Nurse 1 (LVN 1) signed at 1PM when Resident 1 signed and would return in seven hours. The form indicated the resident’s destination was “Out with a friend.” According to a review of Resident 1’s Nurses Notes dated 9/16/2021 timed 12:12 PM, Resident 1 was given an out on pass for four hours and left the facility at 1 PM. The facility attempted to call the resident (24 hours after Resident 1 left) but his phone remained at the facility. The note indicated the friend was contacted who stated, “You have the wrong number … I don’t know him.” A review of Resident 1’s social services progress note, dated 9/16/2021 at 3:41 PM, indicated the Social services worker and the Director of Nursing (DON) spoke to Resident 1’s family member. Resident 1’s family member had questions regarding what happened to Resident 1. The note further indicated that when the staff were attempting to answer the questions, Resident 1’s family member would not allow the staff to finish and hung up the phone. During an interview on 4/4/2022 at 10:22 AM, Family Member 1 (FM 1) stated Resident 1 had a stroke, a speech impediment, was paralyzed, and had a history of “missing several times.” FM 1 stated the facility’s supervisor told FM 1 that Resident 1 “seems competent, knows what’s going on, and didn’t need a chaperone.” FM 1 stated the resident was last seen at the facility on 9/16/2021 and that the facility let Resident 1 go out with a friend but never returned. FM 1 further stated the facility informed FM 1 the next day when the resident did not return, and the facility did not feel there was anything wrong when Resident 1 did not return to the facility. FM 1 stated, “I don’t know what happened to him. At the end of the day, I have to walk around here not knowing if Resident 1 is dead or alive.” During an interview on 4/4/2022 at 3:15 PM, the Director of Nursing (DON) stated residents who were alert and can make their own decisions, can go OOP and that the facility cannot keep them. The DON stated the physician gives an order before a resident can go OOP. The DON stated a friend taking a resident OOP was screened and must sign the resident out. The DON stated the OOP indicated how long the resident would be out for. The DON stated the residents “never take their medications with them” when they go OOP. During an interview with the Receptionist on 4/4/2022 at 3:37 PM., the Receptionist stated, “They don’t tell me who is an elopement risk.” On 4/17/2022 at 1:52 PM., the surveyor attempted to contact Resident 1 using a telephone number on the resident’s face sheet. The person who answered the phone stated Resident 1 “has not been associated this number for about a year.” During an interview with LVN 1 on 4/20/2022 at 11:06 AM, when asked if the facility assessed the person for appropriateness when picking up a resident going OOP, LVN 1 stated, “I don’t believe that happens.” LVN 1 further stated the one physician’s order for out on pass for Resident 1 was dated 9/15/2021, and the order read that he could go out on pass with supervision. During an interview on 4/22/2022 at 1:51 PM, the Social Services Director (SSD) stated Resident 1’s Temporary Leave of Absence form was the OOP log, and that the resident or the person taking a resident OOP must sign the OOP log. The SSD stated, he did not know who signed Resident 1 OOP and could not tell by looking at the log the name of the person who left with Resident 1 on 9/15/2021. The SSD further stated the facility did not conduct a formal assessment for appropriateness when a family member or friend who takes a resident OOP. The SSD stated the facility informed the physician and the next day informed FM 1 that Resident 1 did not return from OOP. The SSD stated, “We did not call the police because the resident is very alert and can make his own decisions.” On 4/22/2022 at 2:57 PM, during a phone interview with the DON, when asked if the facility notified the local law enforcement that Resident 1 did not return to the facility, the DON stated, “If the resident is conserved, I would call the police as a missing person. I don’t believe anyone spoke to Resident 1 after he left the facility.” During an interview on 4/22/2022 at 3:16 PM, the Assistant Administrator (AA) stated the facility did not contact law enforcement regarding Resident 1 missing because the resident was alert and oriented. The AA stated that Resident 1 did not leave with his medications. During an interview on 4/27/2022 at 11:43 AM, the DON stated, she did not know if the Temporary Leave of Absence form was signed correctly for Resident 1 to go OOP. A review of Resident 1’s undated Order Summary Report, indicated Resident 1 had an appointment with an infectious disease doctor on 9/19/2021 at 1:40 PM. A review of the Los Angeles Police Department’s online database of missing person’s (https://www.lapdonline.org/newsroom/missing-32-year-old-man-nr22036dm/) published 2/10/2022, indicated that the family and friends of Resident 1 requested the public’s assistance in locating him and that Resident 1 was last seen on September 2021 near the facility. A review of the facility policy and procedures (P&P) titled, “Resident on Pass,” dated 12/2016, indicated that all residents leaving the facility must be signed out. The policy did not indicate signed out by whom. The policy indicated there must be a physician’s order for the resident to leave the facility, any information pertinent to the resident’s absence from the facility be documented on the progress notes, and an “Out of Facility Release of Responsibility,” should be documented. A review of the facility P&P titled, “Missing Resident Policy,” dated 12/2016, indicated that upon admission to the facility, the licensed nurse will complete a wandering and elopement risk assessment. If a resident was missing from the facility and if the resident was not located, the facility will notify the administration, DON, the attending physician, law enforcement officials, initiate an extensive search of the surrounding areas, call, and report the incident to law enforcement if search party was unable to locate resident and will report the incident to the regulatory agency. The facility failed to ensure Resident 1, who was a high fall risk, immunocompromised related to disease, and had activities of daily living (ADL) self-care deficits, was provided a safe environment and supervision, as indicated in the resident's care plans and the facility’s “Missing Resident Policy and Procedures.” As a result, on 9/15/2021, Resident 1 left the facility with a Physician’s Ordered Out on Pass (OOP) and did not return. Resident 1 was missing for over seven months with risk of injury or death, and the facility did not initiate an extensive search of the surrounding areas, call, or report the incident to law enforcement. Resident 1 remains missing. 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.