Health inspection·January 4, 2024

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. F689 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 (1) Planning of patient care, which shall include at least the following: (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 11/13/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct the investigation of a facility reported incident. The facility failed to provide a safe environment and supervision for Resident 1, who was at risk for elopement (leaving facility without notice or permission, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decision to leave), at risk for wandering (occurs when a person with loss of memory, thinking or reasoning roams around and becomes lost or confused about their location), and had diagnoses of epilepsy (a brain disorder that can cause people to suddenly have a seizure), to address the resident’s attempt of elopement on 11/11/2023 at 1:05 PM. The facility failed to: -Follow its policy and procedure titled, “Elopements, Resident Behavior and Facility Practices,” and promptly report any resident who tried to leave the premises or suspected of being missing to the Charge Nurse or Director of Nursing and the facility policy titled, “Wandering, Behavior, Mood and Cognition,” to develop a care plan including strategies and intervention to maintain the resident’s safety. -Conduct a change of condition (COC) or Situation-Background-Assessment-Recommendation (SBAR - technique provides a framework for communication between members of the health care team and used as a tool to foster patient safety) to alert facility staff of Resident 1’s attempt of elopement on 11/11/2023 at 1:05 PM. - Conduct an Interdisciplinary Team (IDT - a group of health care professionals from different fields who coordinate resident care) meeting to address Resident 1’s attempt of elopement on 11/11/2023 at 1:05 PM. As a result, Resident 1 was at an increased risk of decline in physical, mental and psychosocial needs, and the resident eloped from the facility on 11/11/2023 at 2:20 PM and was missing for over three days. Resident 1 was returned to the facility on 11/15/2023, after police located him over 14 miles away from the facility, with abrasions on his right hand and leg. These negative consequences impacted Resident 1’s quality of care and services received. A review of the General Acute Care Hospital’s (GACH) Psych Emergency Department Progress Note dated 8/31/2023 indicated Resident 1 had limited responses, mostly ‘yes’ or ‘no’ or ‘home / go home.’ The progress note indicated Resident 1 answered yes to being sad, answered no to being happy and wished to go home. The progress note indicated Resident 1 last heard voices approximately two weeks ago and that they were trying to help him. A review of Resident 1’s admission record indicated the facility admitted the resident on 9/6/2023 with diagnoses including epilepsy, unspecified psychosis (abnormal condition of the mind described as involving a loss of contact with reality) not due to substance or known physiological condition, and personal history of traumatic brain injury (TBI -brain dysfunction caused by an outside force, usually a violent blow to the head). A review of Resident 1’s Elopement Risk evaluation dated 9/6/2023 indicated the resident was disoriented / confused and had moderately impaired cognitive skills (decisions poor; cues/supervision required). Under Behavior, the elopement evaluation indicated Resident 1 received medication which may cause confusion, and the resident exhibited anxiety, but had no searching behavior or looking for exits. Under Resident’s Risk Potential, Resident 1 scored two out of three for ‘At Risk’ of Elopement. Further review indicated Resident 1 did not have a care plan with appropriate interventions for Elopement Risk. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated 9/12/2023, indicated Resident 1 entered from an acute hospital and was cognitively moderately impaired. Under Behavior / Potential Indicators of Psychosis indicated none of the above (no hallucinations, no delusions), and the resident had not exhibited behaviors of wandering. The MDS indicated Resident 1 required total dependence with one person assist for transfer, locomotion off unit, and toilet use. The MDS further indicated the resident was not steady, only able to stabilize with staff assistance for walking, turning around, and moving from seated to standing position. According to a review of the Physician’s Order Summary Report for 9/2023, Resident 1 received Lamictal 100 milligram (unit of measure) two times a day for seizures, Olanzapine 10 mg at bedtime for psychosis, Sertraline 100 mg at bedtime for depression, Amantadine Hydrochloride (HCl) 100 mg two times a day for personal history of traumatic brain injury. The Physician’s Order Summary Report for 10/2023 indicated Resident 1 may go out on pass with caregiver. A review of the Progress Notes dated 10/14/2023 indicated Resident 1 was visited by the Psychologist on 10/7/2023. The Psychologist Notes for this visit were requested but not provided from the facility. A review of Resident 1’s Wandering Risk assessment dated 10/26/2023 indicated the resident received antipsychotic medications, antidepressants, and anti-anxiety medications. The risk assessment indicated Resident 1 had a score of four which indicated a low risk for wandering. Further review indicated Resident 1 did not have a care plan with appropriate interventions for Risk of Wandering. A review of the Progress Notes indicated there were no Nursing Notes or Progress Notes documented for Resident 1 on 11/10/2023. A review of the Progress Notes dated 11/11/2023 at 4:57 AM, indicated, “Was a behavior observed? Yes.” The progress notes did not indicate the specific behavior observed. During an observation and review of the facility video surveillance, dated 11/11/2023 at 1:05 PM, Resident 1 was noted attempting to elope out of the facility’s front entrance. The video indicated two facility staff members were present. A review of Resident 1’s medical record indicated there were no COC forms completed, no elopement risk re-evaluation, no wandering risk re-assessment, no physician notification, no IDT meeting, no care plan developed and no responsible party notification for the attempted elopement on 11/11/2023 at 1:05 PM. A review of the Progress Notes dated 11/11/2023 at 1:38 PM, and 1:39 PM indicated, “Was a behavior observed? Yes.” The progress notes did not indicate the specific behavior observed. A review of the Progress Notes dated 11/11/2023 at 6 PM indicated Licensed Vocational Nurse (LVN) 1 documented he was doing rounds at 3:45 PM and noticed Resident 1 was not in his room. LVN 1 then spoke with the charge nurse who indicated Resident 1 was in the patio smoking. LVN 1 documented while he was passing medications around 5:10 PM, he went to Resident 1’s room and the resident was not inside. He then went to the front lobby and the smoking area but the resident was not found. LVN 1 documented the Registered Nurse (RN) supervisor was then notified. A review of the COC, dated 11/11/2023 at 8:55 PM, indicated staff could not find Resident 1 in the dining room or patio. On 11/12/2023 Resident 1 remained missing. On 11/13/2023 Resident 1 remained missing. During an interview on 11/14/2023 at 8:41 AM, Family Member 1 (FM 1) stated the police informed her that the facility’s security video tape showed Resident 1 trying to leave out the front door at around 1 PM and the facility staff brought him back into the facility. FM 1 stated the police informed her the video shows Resident 1 walking out the facility around 2:30 PM and no staff stopped him from leaving. FM 1 stated the facility was aware Resident 1 wanted to go to Hollywood Boulevard on 11/11/2023 instead of waiting to go with her on 11/12/2023. She stated she spoke with a facility staff, about him wanting to go to Hollywood Blvd on 11/11/2023 and they were aware of Resident 1 wanting to go out that day instead of waiting until 11/12/2023. During an interview on 11/14/2023 at 10:28 AM, the facility Receptionist stated she brought Resident 1 back when he tried to leave the facility through the front doors around 1 PM on 11/11/2023. She stated Resident 1 tried to leave the facility multiple times on 11/11/2023 during the morning and she had to stop him from walking out the door. The Receptionist stated the resident would say he wanted to go to Hollywood Blvd. and that he did try to leave the facility before when she was working on the weekend. The Receptionist stated she could not remember exactly what date he tried to leave and that she did not inform a charge nurse when this happened. The Receptionist stated she did not think it was necessary to report since Resident 1 did not actually leave the facility. During an interview with the Maintenance Director on 11/14/2023 at 11:45 AM, in the utility room, the facility’s security footage from 11/11/2023 was reviewed. The Maintenance Director stated the facility video revealed that on 11/11/2023 at 1:05 PM, Resident 1 attempted to elope from the facility by stepping out of the facility front doors and three staff, Receptionist, Minimum Data Set Nurse (MDSN), and Certified Nursing Assistant (CNA 1) were seen on the video bringing the resident back into the facility. The Maintenance Director stated the footage revealed Resident 1 did elope from the facility on 11/11/2023 at 2:22 PM. On 11/14/2023 at 1:05 PM, during an interview, the Minimum Data Set Nurse (MDSN) stated she was working on 11/11/2023, 7 AM to 3 PM shift. The MDSN stated around 1 PM she was making rounds and observed the Receptionist try to redirect Resident 1 to come back into the facility when he attempted to elope through the facility front doors. The MDSN stated Resident 1 mentioned going to see his family, mother and sister out of state. During an interview on 11/15/2023 at 8:23 AM, LVN 1 stated he arrived at the facility late around 3:40 PM on 11/11/2023 and received report from LVN 2. LVN 1 stated he asked LVN 2 where Resident 1 was because he did not see the resident in his room. LVN 1 stated LVN 2 told him Resident 1 was in the patio smoking. LVN 1 stated he did not know if 3:45 PM was the normal smoking time for residents. LVN 1 stated he did not go check if Resident 1 was in fact in the patio or dining room at 3:45 PM. LVN 1 stated around 4 PM, he started doing rounds and medications for the residents. LVN 1 stated he went back to Resident 1’s room around 5:15 PM and noticed Resident 1 was still not in his room. LVN 1 stated he went to the front lobby, dining room, and patio and he did not see the resident. He stated he did a code green for elopement at that time. LVN 1 stated no staff ever informed him Resident 1 tried to leave the facility that day on 11/11/2023 at 1:05 PM. LVN 1 stated if he was informed Resident 1 tried to elope earlier that day he would have been more cautious and conducted close monitoring of Resident 1’s whereabouts when he did not see the resident in his room at 3:45 PM. LVN 1 stated there was no change of condition for the attempted elopement on 11/11/2023 at 1:05 PM and there was no care plan for attempted elopement. During an interview on 11/15/2023 at 11:02 AM, LVN 2 stated she provided change of shift report to LVN 1 around 3:30 PM, LVN 1 asked where Resident 1 was, and she informed LVN 1 the resident was in the dining room. LVN 2 stated she did not actually see or confirm if Resident 1 was in the dining room or patio. LVN 2 stated she did not provide information to LVN 1 that the resident tried to elope on 11/11/2023 at 1:05 PM because she was not made aware of the attempted elopement. LVN 2 stated if she was made aware of Resident 1’s attempted elopement, she would have conducted a change of condition, informed responsible party, notified physician, and started a care plan for resident attempted elopement. She stated she would have also kept closer watch and monitoring of the resident’s whereabouts to ensure he did not try to elope again. During an interview on 11/15/2023 at 11:54 AM, the Minimum Data Set Nurse (MDSN) stated when Resident 1 attempted to elope on 11/11/2023 at 1:05 PM, she did not inform anyone like the charge nurse, Registered Nurse supervisor, or the Director of Nursing. The MDSN stated the protocol when a resident attempted to elope, was to conduct a search, conduct a change of condition or SBAR, notify responsible party, notify physician, conduct IDT, conduct risk for elopement assessment, create a care plan, and follow interventions to ensure resident safety. The MDSN stated the facility failed to follow protocol and the outcome of the failures was the resident eloped on 11/11/2023 at 2:22 PM and had the potential for serious injury, harm, and death. On 11/15/2023 at 1:54 PM, during an interview, the Director of Nursing (DON) stated the facility protocol when a resident attempted elopement was to conduct a change of condition or SBAR, notify physician, notify responsible party, initiate an intervention, re-evaluate and reassessment of the resident, including risk for elopement, conduct a care plan, conduct IDT review, and make recommendations. The DON stated Resident 1 had an attempted elopement on 11/11/2023 at 1:05 PM and the facility staff should have assessed the resident, conducted a change of condition, notified physician and responsible party, conducted an IDT to provide interventions, create a care plan for attempted elopement, and monitored the resident more closely to ensure resident did not elope on 11/11/2023 at 2:22 PM. The DON stated the potential outcome of the failure was the resident could suffer serious injury or even death. During an interview on 11/15/2023 at 2:07 PM, the Administrator (Admin) stated the facility protocol for when a resident attempted to elope was to stop the resident right away, notify nursing so they can do a change of condition, and conduct an assessment, interview resident to discern why they attempted to elope. The Administrator stated the facility staff failed to follow protocol when Resident 1 attempted to elope on 11/11/2023 at 1:05 PM. She stated the facility did not conduct a change of condition, notify physician and responsible party, did not conduct IDT, and no care planning to prevent elopement. She stated the potential outcome of the failures were Resident 1 eloped on 11/11/2023 at 2:22 PM and could potentially suffer serious harm, injury, or death. A review of the facility policy and procedure titled, “Nursing Services, Acute Condition Changes,” revised 2023, indicated nursing assistants w