Health inspection·May 2, 2024

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. 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. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. § 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. An unannounced visit was conducted by California Department of Public Health on 3/12/2024 at 9 AM to investigate a facility reported incident regarding elopement (to go about from place to place usually without a plan or purpose that leads a patient to completely leave the facility, unsupervised and unnoticed) of Patient 1 and 2. The facility failed to ensure Patient 1 and 2 who were assessed as high risk for elopement were supervised when the courtyard gate alarm (a small device mounted next to the door to monitor the movement of the door) was broken. This failure resulted in Patient 1 and 2 having a successful elopement from the facility on 3/10/2024 which had the potential to lead to injury while outside the facility's premises without supervision from staff. Patient 2 was found on 3/12/2024 and Patient 1 was found on 3/19/2024. 1. A review of Patient 1's Admission Record indicated Patient 1 was initially admitted to the facility on 1/25/2023 and readmitted on 3/4/2024 with diagnoses that included unspecified kidney failure, chronic obstructive pulmonary disease (COPD- a lung disease characterized by long term poor airflow), heart failure, and schizophrenia (a mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others). A review of Patient 1's Care Plan, revised on 10/24/2023, indicated Patient 1 was at risk for elopement. The Care Plan interventions indicated to check patients whereabouts frequently, check all exit doors properly alarmed, apply wanderguard (an alarm system used to alert staff if a patient at risk for wandering has left the facility and allows staff to respond quickly and help return them to safety) and monitor presence and function of wanderguard every shift. A review of Patient 1's History and Physical Examination (H&P), dated 3/5/2024, indicated Patient 1 was able to make decisions for activities of daily living. A review of Patient 1's Elopement Risk Assessment, dated 3/5/2024, indicated a total elopement risk score of 11 (a total score of 11 or above indicated high risk to wander). A review of Patient 1's Care Plan, revised on 3/8/2024, indicated patient refused to put on wanderguard stated "I do not want that on me. It is against the law." The Care Plan interventions indicated to ensure that gates (courtyard gate) and doors have a functioning alarm. A review of Patient 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/10/2024, indicated Patient 1 was assessed having moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision making and required partial/moderate assistance (helper does less than half the effort) with shower/bathe self, chair/bed-to-chair transfer, toilet transfer, walking 10 feet (ft- unit of measurement), walking 50 feet with two turns, and walking 10 feet on uneven surfaces. A review of Patient 1's Order Summary Report, dated 3/12/2024, indicated a physician order, with a start date of 3/5/2024, to apply wanderguard on ankle due to dx (diagnosis): attempting to leave the facility. A review of Patient 1's Progress Notes, dated 3/10/2024, at 11:30 PM (late entry), indicated at 5:30 PM patient was called to eat dinner, acknowledged, and went back inside, then at 6 PM to 6:30 PM the patient was seen standing outside the vending machine. The Progress Notes also indicated at 7 PM the patient not found in his room code green (an emergency code for elopement) was initiated. 2. A review of Patient 2's Admission Record indicated Patient 2 was admitted to the facility on 3/3/2024 with diagnoses that included extrapyramidal and movement disorder (involuntary movements that cannot be controlled, caused by taking antipsychotic medications), respiratory conditions due to smoke inhalation, schizophrenia, and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A review of Patient 2's Elopement Risk Assessment, dated 3/3/2024, indicated a total elopement risk score of 11 (a total score of 11 or above indicated high risk to wander). A review of Patient 2's Care Plan, dated 3/7/2024, indicated Patient 2 refused to wear wanderguard. The Care Plan interventions indicated to ensure that gates (courtyard gate) and doors have functioning alarm and redirect patient whenever he attempts to leave the facility. A review of Patient 2's MDS, dated 3/9/2024, indicated Patient 2 was assessed to have moderately impaired cognition for daily decision making. Patient 2 was assessed to have wandering behavior that occurred daily. The MDS also indicated, Patient 2 required supervision or touching assistance with upper and lower body dressing, sit to stand, toilet transfer, walking 10 feet, walking 50 feet with two turns, and walking 10 feet on uneven surfaces. A review of Patient 2's Progress Notes, dated 3/9/2024, indicated Patient 2 attempted to pull alarm off back gate (courtyard gate). A review of Patient 2's Progress Notes, dated 3/11/2024, at 1:32 AM, indicated, at 6:30 PM, Patient 2 started walking and pacing around the hallways and the patio. The progress notes also indicated between 9:30 PM to 9:45 PM the patient was standing at sliding door looking outside and the last time seen in the facility. During a concurrent observation of the courtyard and interview with the Maintenance Supervisor (MS), on 3/12/2024, at 9:23 AM, MS stated Patient 2 broke the courtyard gate alarm numerous times over the weekend. Courtyard gate alarm observed uncovered with one red and black wire exposed. MS opened the courtyard gate and alarm did not sound. During an interview with the Infection Preventionist (IP), on 3/12/2024, at 9:07 AM, the IP stated, IP found Patient 2 in the morning of 3/12/2024. IP stated Patient 2 still had access to the sliding door in his room which leads to the courtyard. During an interview with Patient 2, on 3/12/2024, at 10:07 AM, Patient 2 stated he pulled the red button on the gate because it was too loud on 3/10/2024. Patient 2 stated he left the facility a couple of hours after dinner on 3/10/2024. Patient 2 stated he went to a store to collect cans after he left the facility. During an interview with Certified Nursing Assistant (CNA 1), on 3/12/2024, at 10:29 AM, CNA 1 stated CNA 1 saw Patient 2 standing by the sliding door by the resident's room on 3/10/2024, at approximately 9:30 PM when CNA 1 wheeled the linen hamper to the laundry room. CNA 1 stated the courtyard gate alarm did not sound when he opened the courtyard gate to drop off the linen hamper. CNA 1 stated facility staff knew courtyard gate was broken and CNA 1 was not sure if maintenance staff worked on fixing the courtyard gate alarm on 3/10/2024. CNA stated he did not know when the courtyard gate alarm broke. During the same interview with CNA 1 on 3/12/2024 at 10:29 AM, CNA 1 stated he supervised the patients who smoked on 3/10/2024, at 6:30 PM and did not hear the alarm sound when he opened the courtyard gate to let the patient in and out of the courtyard. CNA 1 stated he did not know who is responsible for checking the alarms in the facility. CNA 1 stated the facility discovered that Patient 1 eloped on 3/10/2024 at around 7 PM after returning from smoking supervision and Patient 2 was discovered missing at around 9:40 PM on 3/10/2024. During an interview with CNA 2, on 3/12/2024, at 11:12 AM, CNA 2 stated Patient 2 kept playing with the courtyard gate alarm on 3/10/2024. CNA 2 stated she did not know when the courtyard gate alarm stopped working. During an interview with Licensed Vocational Nurse (LVN 1), on 3/12/2024, at 11:20 AM, LVN 1 stated, on 3/10/2024, he was informed by another staff that the courtyard gate alarm was not working when his shift started at 7AM. LVN 1 stated facility staff told him Patient 2 broke the courtyard gate alarm. LVN 1 also stated he discovered Patient 1 was missing at around 7 PM to 7:30 PM when he checked his room and did not see Patient 1 there. LVN 1 stated the courtyard area and gate were unsupervised during the time the alarm was broken. During the same interview with LVN 1, on 3/12/2024, at 11:20 AM, LVN 1 stated no one supervised the courtyard gate to make sure patients did not exit the facility and elope. LVN 1 stated the courtyard is where patients can elope. LVN 1 stated the facility knew the alarm was broken because he was told a new alarm had already been ordered but was not fixed. During an interview with MS, on 3/12/2024, at 12:03 PM, MS stated the door alarms including the courtyard gate alarm are checked once a week. MS stated the courtyard door alarm did not work on 3/9/2024 and 3/10/2024. MS stated he did not work on fixing the courtyard alarm on 3/9/2024 and 3/10/2024. During a review of the surveillance video of the camera showing the courtyard with the Administrator (ADM) and the Director of Nursing (DON), on 3/12/2024, at 12:28 PM, the surveillance recording with a view of the courtyard patio showed Patient 2 breaking the courtyard gate alarm on 3/10/2024, at 5:24 AM. The surveillance video also showed at 12:41 PM, Patient 1 exited through the courtyard gate and make a right towards the entrance driveway. The surveillance camera facing the main street showed Patient 1 making a right along the main street with a plastic bag in his hand. During the same review of the surveillance video with the ADM and the DON, on 3/12/2024, at 12:28 PM, the video surveillance recording with a view of the courtyard patio gate showed Patient 2 exiting through the courtyard gate at 9:51 PM. The surveillance video showed Patient 2 made a left turn towards the exit driveway. The surveillance camera facing the main street showed Patient 2 making a right along the main street. During an interview with the ADM on 3/12/2024, at 1:07 PM, the ADM stated facility staff enters the facility through the courtyard gate. The ADM stated the Maintenance Assistant (MA) tried to fix the alarm on 3/10/2024 but it did not work. The ADM stated the facility did not assign staff to supervise the courtyard gate while the alarm was broken. The ADM stated the courtyard gate alarm was only fixed on 3/12/2024. During an interview with MA on 3/12/2024, at 1:19 PM, MA stated Patient 2 started pulling the courtyard gate alarm cover and removing the battery on 3/8/2024. MA stated he fixed the gate alarm on 3/9/2024 and when he returned to work on 3/10/2024 it was already broken. MA stated that on 3/10/2024 he fixed the gate alarm numerous times and Patient 2 pulled out the batteries after he fixed it. MA stated patient got aggressive with facility staff each time he was asked to stop touching the alarm. MA also stated the courtyard gate was not supervised by staff on 3/10/2024. During an interview with the DON, on 3/12/2024, at 3:45 PM, the DON stated Patient 2 did not have a care plan for elopement. The DON stated Patient 2 should have a care plan with interventions to prevent Patient 2 from eloping. The DON stated the care plan should have been specific to Patient 2's needs and should have addressed Patient 2's behavior of removing the battery from the courtyard gate alarm on 3/10/2024. The DON stated it is important for Patient 2 to have a care plan addressing his risk of elopement to properly intervene and monitor Patient 2's behavior and safety. During an interview with the ADM, on 3/12/2024, at 4:06 PM, the ADM stated the facility staff had knowledge of the Patient 2 breaking the courtyard gate alarm since 3/9/2024. The ADM stated Patient1, Patient 2 and the courtyard gate should have been supervised by facility staff when the alarm broke. The ADM stated Patient 1 and 2's elopement could have been prevented if the courtyard gate was supervised. A review of the electronic mail (email) sent by ADM to the surveyor dated 3/19/2024, indicated Patient 1 was found on 3/14/2024 (did not indicate by whom) and was brought to general acute care hospital (GACH) by paramedics. Patient 1 was then admitted back to the facility on 3/15/2024. A review of the "Follow-Up Investigation Report-Facility Reported Incidents," undated, indicated, "Upon review of facility security cameras, Administrator identified CNA 3 as the individual that delivered the resident's dinner (Patient 1) tray and retrieved the dinner tray between 5:15 pm and 6:30 PM. Admin interviewed CNA 3 and denies seeing Patient 1 in the room at the time of delivery and pick-up. He recalls seeing the patient last shortly after lunch." The investigation report further indicated, "LVN 1 and CNA 1 interviewed regarding the incident. Per CNA 1, he states he last saw the patient (Patient 1) when he delivered dinner tray in the room and patient was in the bed. Per CNA 1 and LVN 1, they both last saw the patient in front of the vending machine in the courtyard. Both statements were proven to be incorrect upon review of cameras." A review of the facility's policy and procedure (P&P), titled "Care Planning," revised on 10/24/2022, indicated, "A culturally competent and trauma-informed Comprehensive Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs." A review of the facility's P&P, titled "Wandering & Elopement," revised on 11/1/2017, indicated a purpose to "enhance the safety of patients of the Facility." The policy also indicated, "The Facility will identify patients at risk for elopement and minimize and possible injury because of elopement." The facility failed to ensure Patient 1 and 2 who were assessed as high risk for elopement were provided supervision when the courtyard gate alarm (a small device mounted next to the door to monitor the movement of the door) was broken. This failure resulted in Patient 1 and 2 having a successful elopement which had the potential to lead to injury while outside the facility's premises without supervision from staff. Patient 2 was found on 3/11/2024 and Patient 1 remained missing. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1 and 2.