Other·August 14, 2023

The following reflects the findings of the California Department of Public Health during the investigation of complaint. Complaint number CA00850219. Representing the Department, HFEN # 44891 State Citation (A) was written. 42 CFR §483.25(d) Accidents The facility must ensure that - (d)(1) The resident environment remains as free of accident hazards as is possible; and (d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. 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 07/13/2023, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct a complaint investigation regarding Resident 1's elopement. As a result of the investigation, CDPH determined that the facility failed to provide supervision for Resident 1, who was identified as severe cognitively impaired (confusion or memory loss that is happening more often or is getting worse during the past 12 months), a wanderer (a person who had a random or repetitive locomotion), and a high risk for elopement (leaving the facility unsupervised and without staff knowledge) by failing to: 1. Evaluate and analyze hazard and risk of elopement when Resident 1 was observed hanging around and sitting by the front door of the facility. 2. Monitor for effectiveness and modify interventions of Resident 1's at Risk of Elopement plan of care. 3. Implement the "Routine Resident Checks" policy to keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. These deficient practices resulted in Resident 1's elopement from the facility on 7/7/2023. Resident 1 was found by the paramedics unconscious on the ground, in a pool of blood. Paramedics took Resident 1 to the general acute hospital (GACH) on 7/12/2023 and Resident 1 was admitted in the Intensive Care Unit (ICU, a department of a hospital in which patients who are dangerously ill are kept under constant observation). A review of Resident 1's Admission Record indicated the facility admitted Resident 1 on 9/21/2020 with diagnoses including epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing convulsions), encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood) and dementia (loss of cognitive functioning-thinking, remembering, and reasoning). A review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 6/23/2023, indicated Resident 1 had severe cognitive impairment (confusion or memory loss that is happening more often or is getting worse during the past 12 months) and required supervision from staff for dressing, eating, toilet use and personal hygiene. A review of Resident 1's Elopement Risk Assessment dated 1/16/2021, indicated Resident 1 was at risk for elopement. An updated Elopement Risk Assessment after 1/6/21 was requested of the facility but was not provided. A review of Resident 1's At Risk for Wandering/Elopement from the Facility Care Plan with a date initiated on 3/26/2021 and revision date on 10/8/2022 indicated Resident 1 was at risk for wandering/elopement from the facility and indicated intervention includes "Orient resident to key areas in the facility such as dining room, bathroom, business office and kitchen and assist to key areas as needed. Monitor resident's location through visual checks and redirect as needed." A review of Resident 1's Progress Notes dated 7/7/2023, indicated Resident 1 was last seen around 7/7/2023 around 5:45 AM and was not in their bed around 6 AM during medication pass. "Staff stated that he (Resident 1) visits other residents' room." The Progress Notes indicated staff had searched the facility and discovered Resident 1 was not inside the facility. Staff notified the Director of Nursing (DON), Administrator (FA) and police department. A review of Resident 1's Progress Notes dated 7/12/2023, Resident 1 was admitted to a GACH on 7/12/2023, 5 days after elopement from the facility. During an interview on 7/13/2023 at 9:37 AM, FA stated, the last time staff saw Resident 1 was on 7/7/2023 around 5:30 AM-5:45 AM. Around 6 AM, during medication pass, staff could not locate Resident 1. The FA stated Resident 1 usually paces around the facility all day and night. The FA stated the facility has a gate next to the outside patio where staff enters and leaves the facility. The FA stated staff assumed Resident 1 was outside on the patio, near the gate and had waited for the incoming morning shift staff to open the gate and come in the facility. FA stated Resident 1 could have exited the facility without staff knowing. FA stated the resident eloped from the facility on 7/7/2023. FA stated the gate can be opened by a remote control which allowed staff to go in and out of the facility. FA stated the parking lot was also located by the outdoor patio for residents in the facility. FA stated the facility received a phone call from GACH that the GACH admitted Resident 1 on 7/12/2023 for an injury. During an interview on 7/13/2023 at 10:10 AM, the Registered Nurse Supervisor (RNS), stated Resident 1 was confused and walks around the facility. The RNS stated Resident 1 was currently not in the facility because he had eloped and has not returned since. The RNS stated Resident 1 was still in GACH. During a concurrent interview and record review on 7/13/2023 at 10:39 AM with the Social Services Director (SSD), Resident 1's care plan dated 3/26/2021 and Quarterly Risk Data Collection Tool dated 1/16/2021 and 12/27/2020 were reviewed. The SSD stated there were no changes in the interventions of Resident 1's At Risk for Wandering/Elopement from the Facility Care Plan since 3/21/2021. The SSD stated Resident 1 was at risk for elopement because he always walked around the facility and Resident 1's cognitive baseline was confused. The SSD further stated Resident 1 had eloped from the facility on 7/7/2023 in the morning. The SSD stated on 7/7/2023, staff, including herself, walked around the facility area and could not locate Resident 1. The SSD stated she reported Resident 1 missing to the administrative team. Staff notified local enforcement who visited the facility on 7/7/2023. The SSD stated the GACH called the facility on 7/12/2023 stating Resident 1 was found and was in the hospital. During an interview on 7/13/2023 at 11:05 AM, Licensed Vocational Nurse 1 (LVN 1), stated Resident 1 walked around the hallways and mostly hung around with his walker by the front door of the facility. LVN 1 stated Resident 1 was always so close to the front door. During an interview on 7/13/2023 at 11:18 AM, LVN 2 stated Resident 1 sat by the front door of the facility all the time. LVN 2 stated Resident 1 was admitted to the GACH on 7/12/2023 and had bruises to his face from either a fall or an altercation outside the facility. During an interview on 7/13/2023 at 1:27 PM, FA stated Resident 1's care plan with a revised date on 10/8/2022, regarding elopement should have been reviewed at least quarterly and it was not a comprehensive person-centered care plan. The FA stated the facility did not conduct an Interdisciplinary Team (IDT- a group of health care professionals from difference disciplines to help residents receive care needed) meeting regarding updating elopement risks and interventions for Resident 1. The FA stated the facility did not document Resident 1's visual routine checks as indicated in the policy. During an interview on 7/13/2023 at 1:45 PM, Resident 1's Representative (RP 1), RP 1 stated on 7/7/2023 the facility notified her regarding Resident 1's elopement and was admission to the GACH. RP 1 stated that they had notified staff previously that Resident 1 needed to be in a locked facility to prevent Resident 1 from eloping. RP 1 stated he was "absolutely an elopement risk and should not be around open doors." During an interview on 7/13/2023 at 2:55 PM, the Minimum Data Set Nurse (MDSN), MDSN stated Resident 1 paces back and forth in the facility. The MDSN further stated Resident 1 would usually stay outside his room and hung out in the nursing station by the door. The MDSN stated Resident 1 was an elopement risk because of his disease processes (dementia and epilepsy) and forgetfulness. The MDSN further stated elopement risk residents, including Resident 1, should be monitored every shift or hourly to monitor resident whereabouts. The MDSN stated they are a member of the IDT committee. The MDSN stated elopement risk factors include episodes of forgetfulness. The MDSN stated Resident 1 skin was all intact and had no issues prior to his 7/7/2023 elopement. During an interview on 7/13/2023 at 3:09 PM, Resident 1's primary Medical Doctor (MD), the MD stated Resident 1 had eloped from the facility around 5 AM. The MD stated Resident 1 needs to be placed in a "locked facility, that's all that's needed." The MD stated if residents are at risk of elopement, accidents, or at high-risk of harm, "they go in a locked facility." The MD stated he does not know any more details about Resident 1's care, including the elopement. A review of the facility's policy and procedures (P & P) titled, "Emergency Procedure- Missing Resident" dated 8/2018, indicated residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. A review of the facility's P & P titled, "Wandering and Elopements," dated 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 resident. 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. A review of the facility's P & P titled, "Safety and Supervision of Residents," dated 7/2017, indicated "Our 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. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident accident data; and a facility-wide commitment to safety at all levels of the organization. When accident hazards are identified, the QAPI/ safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. The interdisciplinary care team shall analyze information obtain from assessments and observations to identify any specific accident hazards or risks for individual residents." A review of the facility's P & P titled, "Routine Resident Checks" dated 7/2013, indicated "To ensure the safety and well-being of our residents, nursing staff shall make a routine resident check on each unit at least once per each 8 (eight) hour shift. Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met. The nursing supervisor/charge nurse shall keep documentation related to these routine checks, including the time, identify of the person making checks, and any outcomes of each check." The facility failed to provide supervision for Resident 1, who was identified as severe cognitively impaired, wanderer, and high risk for elopement by failing to: 1. Evaluate and analyze hazard and risk of elopement when Resident 1 was observed hanging around and sitting by the front door of the facility. 2. Monitor for effectiveness and modify interventions of Resident 1's at Risk of Elopement plan of care. 3. Implement the "Routine Resident Checks" policy to keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. As a result, Resident 1 eloped from the facility on 7/7/2023 and was found by the paramedics unconscious on the ground in a pool of blood. Paramedics took Resident 1 to the GACH on 7/12/2023 where Resident 1 was admitted in the ICU. 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.