Health inspection·July 14, 2022

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 – §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 3/24/2022, the California Department of Public Health made an unannounced visit to the facility to investigate a complaint about quality of care. The facility failed to ensure care and services were provided in accordance with the comprehensive assessment, plan of care and facility’s policies by not providing supervision and a safe environment for Resident 1 who was at risk of elopement (leaving the facility unsupervised, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decisions) and diagnosed with psychosis (a condition that affects the way the brain processes information, and causes one to lose touch with reality). The facility failed to: 1. Ensure Resident 1 did not wander out of the facility, per the care plan. 2. Monitor the resident’s location through visual checks and redirecting as needed, per the care plan; and 3. Maintain Resident 1’s safety, as the resident was at risk of unsafe wandering, per the facility policy, "Wandering and Elopements.” As a result, on 3/10/2022, Resident 1 eloped from the facility, suffered a fall, and was transferred to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with a finger abrasion (a superficial rub or wearing off the skin) on 3/10/2022 and with a right femoral neck fracture (broken hip) on 3/15/2022. A review of Resident 1’s Admission Record indicated the facility admitted the resident, a 76 year old female, on 8/13/2018, with diagnoses including schizoaffective disorder (a combination of symptoms of schizophrenia [a serious mental disorder in which people interpret reality abnormally] and mood disorder, such as depression [mental health problem that involves a low mood and a loss of interest in activities] or bipolar disorder [a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks]), psychosis, osteoporosis (a condition in which bones become weak and brittle), and unsteadiness on feet (unable to stand or walk easily). A review of Resident 1’s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 3/5/2022, indicated the resident had severely impaired cognition (never/rarely made decisions), was experiencing delusions (false belief or opinion, especially one held in resistance to strong evidence against it), and required supervision (oversight, encouragement, or cueing) and set-up help for walking, transferring, and toilet use. The MDS indicated Resident 1 was not steady with walking or with turning around. A review of Resident 1’s Elopement Risk Assessment dated 3/5/2022, indicated the resident did not have a history of elopement, did not pace, wander or try to get out of the door, but was independently mobile. The assessment indicated Resident 1 was at risk for elopement. A review of the Fall Risk Assessment dated 3/5/2022, indicated Resident 1 did not have a history of fall and for any score more than zero, the resident was considered to be at risk for fall. The assessment indicated Resident 1 due to the medical history of hypertension (a condition in which the force of the blood against the artery walls is too high), osteoporosis, occasional incontinence of both bladder and bowel (unintentional leakage and the inability to control urine or stool), and the inability to always recall that she was in the nursing home, or her room location, Resident 1 was a risk for falls. According to a review of Resident 1’s Elopement Risk Care Plan, dated 3/5/2022, the goal was for the resident to not wander out of the facility. The interventions included monitoring the resident’s location through visual checks and redirecting as needed. A review of Resident 1’s Risk for Falls Care Plan, dated 3/5/2022, indicated a goal to minimize the resident’s falls and injuries from falls. The interventions included monitoring the resident’s location through visual checks. A review of Resident 1’s Medication Administration Record (MAR) dated 3/1 – 3/23/2022 indicated the resident’s location and whereabouts were monitored starting on 3/10/2022. The MAR did not include documentation that the resident’s location and whereabouts were monitored prior to 3/10/2022. According to a review of Resident 1’s Social Service Note, dated 3/10/2022 and timed at 8:02 a.m., the staff could not locate Resident 1 in the facility. Resident 1 was last seen around 6 a.m. The Social Service note indicated the Social Services Director (SSD) took Resident 1’s picture and drove around outside the facility asking vendors and people around the area if they recognized the resident. The note further indicated a vendor recognized Resident 1, stated the resident was wearing black clothes, and was picked up by an ambulance. The SSD received a text from the Admission Coordinator that Resident 1 was at GACH 1. A review of Resident 1’s Situation-Background-Assessment-Recommendation (SBAR - technique provides a framework for communication between members of the health care team about a patient's condition) Communication form dated 3/10/2022, indicated Resident 1 was wandering in and out of her room while Licensed Vocational Nurse 1 (LVN 1) was passing medications. LVN 1 heard the exit alarm, went to the front of the facility, and no one was around. LVN 1 looked for Resident 1 from room to room, and informed the resident’s responsible party of the resident’s elopement on 3/10/2022 at 8:45 a.m. Resident 1’s physician was notified on 3/10/2022 at 9 a.m. A review of GACH 1 Emergency Department (ED) Documentation, dated 3/10/2022 and timed at 6:40 a.m., indicated Resident 1 presented to the ED complaining of left middle finger pain after a trip and fall that occurred that day. Resident 1 had a small abrasion to the left middle finger with no active bleeding and dried blood. A review of GACH 1 Final Report dated 3/10/2022 indicated Resident 1 presented with status post fall and finger laceration. Resident 1 reported she fell with episode of dizziness. Under medical decision making, indicated resident with presyncopal (feeling faint) fall, electrocardiogram (EKG) completed with no abnormalities noted. A review of GACH 1 Social Services form, dated 3/10/2022 and timed at 1:47 p.m., indicated Resident 1 eloped from the facility prior to the ED visit. A review of GACH 1 Discharge Summary dated 3/10/2022 and timed at 9:22 p.m., indicated Resident 1 presented to the hospital after a fall and finger laceration. Resident 1’s finger abrasion was irrigated (applying a continuous flow of water to a wound to cleanse it), and derma bonded (a medical skin adhesive used to glue the sides of a wound closed). According to a review of Resident 1’s Health Status Note dated 3/10/2022 at 10:05 p.m., the resident returned to the facility at 9:40 p.m. via gurney from GACH 1. A review of the Progress Notes dated 3/12/2022 indicated Resident 1 was awake, calm and cooperative with care, denied pain or any distress. Resident 1 remained in her room during the shift. A review of the facility’s letter to the Department dated 3/15/2022 indicated Resident 1 returned from the hospital and hospital documentation suggested the resident incurred a presyncopal (feeling faint) fall, finger laceration, altered mental status and a urinary tract infection (UTI). The facility’s letter indicated during facility assessment Resident 1 denied pain and was able to move all extremities. A review of Resident 1’s SBAR Communication form dated 3/15/2022, indicated Resident 1 complained of pain at a level of 9 of 10 (9/10, pain rating scale from zero to 10, zero indicating no pain and 10 the most excruciating pain possible) to the right leg (hip and thigh), Tylenol (medication to relieve pain) was given but was ineffective. Resident 1’s primary care physician was notified and recommended a STAT (immediately) x-rays of the right hip/pelvis and right femur (thighbone). A review of Resident 1’s Radiology Results Report, dated 3/15/2022 and timed at 10:58 p.m., indicated the resident had a right femoral neck fracture (broken right hip). Resident 1 was transferred to GACH 2 for further evaluation. A review of GACH 2 Medical Record indicated Resident 1 was admitted to GACH 2 on 3/16/2022 for an intertrochanteric fracture of the right femur (a type of hip fracture). During an interview on 3/24/2022 at 6:36 a.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 was very confused and frequently tried to escape. CNA 1 stated if Resident 1 was told she could not get out of the door she would swing and pound things. CNA 1 stated on the day of the resident’s elopement (3/10/2022) Resident 1 left between 4:30 a.m. to 5:30 a.m. "I heard the exit alarm going off but didn’t know what it was. I screamed to the Licensed Vocational Nurse (LVN), and he said alright.” CNA 1 stated he was informed Resident 1 had gone outside. CNA 1 stated at the time, maintenance workers were coming into the facility and probably did not pull the front door closed all the way. During an interview on 3/24/2022 at 7:36 a.m., LVN 1 stated Resident 1 frequently walked up and down the facility asking if she could leave because she wanted to see her family. LVN 1 stated he was attending to another resident when he heard the exit alarm going off and Resident 1 eloped. LVN 1 stated he was the only LVN working that shift, and he could not attend to the exit alarm quick enough. LVN 1 stated when he discovered Resident 1 was missing, he drove his car around the streets surrounding the facility, called hospitals, notified the resident’s physician, family, and the police. On 3/24/2022 at 9:15 a.m., during an interview, the Director of Nursing (DON) stated Resident 1 was a wanderer and during the time of the elopement on 3/10/2022, employees were coming in and out of the facility and staff were working with other residents. The DON stated staff did not respond to the alarm in a timely manner and assumed staff triggered the alarm. The DON stated on 3/15/2022 on the 3 p.m. to 11 p.m. shift Resident 1 started complaining of pain in her right hip and thigh and was currently at GACH 2 for a broken right hip. The DON stated there was no indication Resident 1 had fallen or had any altercation with other residents or staff upon her return to the facility after the elopement. A review of GACH 2 Physician Discharge Summary Noted dated 3/26/2022 indicated Resident 1 underwent an open reduction and internal fixation (ORIF - surgery to stabilize and heal a broken bone) of the intertrochanteric fracture of the right hip. Resident 1 was discharged back to the facility on 3/26/2022. A review of the facility’s policy and procedure titled, "Safety and Supervision of Residents,” revised 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training as necessary; ensuring that the interventions are implemented; and documenting interventions. A review of the facility’s policy and procedure titled, "Wandering and Elopements,” revised 3/2019, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident’s care plan will include strategies and interventions to maintain the resident’s safety. When the resident returns to the facility, the director of nursing services or charge nurse shall examine the resident for injuries. The facility failed to ensure care and services were in accordance with the comprehensive assessment, plan of care and facility’s policies by not providing supervision and a safe environment for Resident 1 who was at risk of elopement) and diagnosed with psychosis. The facility failed to: 1. Ensure Resident 1 did not wander out of the facility, per the care plan; 2. Monitor the resident’s location through visual checks and redirecting as needed; and 3. Maintain Resident 1’s safety, as the resident was at risk of unsafe wandering, per the facility policy, "Wandering and Elopements.” As a result, on 3/10/2022, Resident 1 eloped from the facility, suffered a fall, and was transferred to General Acute Care Hospital 1 (GACH 1) where she was diagnosed with a finger abrasion (a superficial rub or wearing off the skin) on 3/10/2022 and with a right femoral neck fracture (broken hip) on 3/15/2022. The above violations jointly, separately, or in any combination, 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.