Health inspection·November 26, 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 10/29/2024 at 8:55 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 Patient1. The facility failed to prevent elopement of Patient 1 when Patient 1 left the facility through the facility's emergency exit door located near the laundry room (Exit Door 1) and the alarm did not go on. This failure resulted in Patient 1 elopement on 10/28/2024 between 1:38 AM to 1:48 AM. Patient 1 was found on 10/29/2024 around 3:40 PM along Street 1 and 2 with unknown individuals. The patient refused to return to the facility. A review of Patient 1’s Admission Record indicated Patient 1 is a 72 year- old- male patient who was admitted to the facility on 10/8/2024 with diagnoses that included hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild loss of strength in a leg, arm, or face) following cerebral infarction (a damage to tissues in the brain due to a loss of oxygen to the area) affecting left nondominant side, alcohol abuse (a pattern of drinking too much alcohol too often), and traumatic pneumothorax (condition that occurs when air builds up in the pleural space, the area between the lungs and chest wall, due to an injury). A review of Patient 1’s History and Physical Examination (H&P), dated 10/9/2024, indicated the patient has the capacity to understand his medical condition or his bill of rights (a patient’s rights and responsibilities). A review of Patient 1's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 10/14/2024, the MDS indicated Patient 1 was able to follow commands, his cognition skills (process of thinking and reasoning) was moderate impaired for decision making. The MDS indicated Patient 1 required helper to do less than half of the effort for patient for the toilet, and personal hygiene. The MDS also indicated Patient 1 required less than half of the effort for change of position and transfer. A review of Patient 1’s risk for elopement care plan dated 10/8/2024, the risk for elopement care plan indicated Patient 1 was a low risk for elopement. During a telephone interview on 10/29/2024 at 12:10 PM with Certified Nursing Assistant 1 (CNA1), CNA1 stated on 10/28/2024 around 4 AM to 5 AM, CNA 1 noticed Patient was not in his bed or in the restroom. CNA1 stated, CNA1 saw the sliding door next to Patient 1’s bed was observed wide open after Patient 1 went missing on 10/28/2024. CNA 1 stated facility staff was unable to locate Patient 1 inside the facility. CNA1 stated he went out of the facility to search for Patient 1 in the facility’s parking lot and he also searched Patient 1 on the nearby streets next to the facility’s parking lot but was unable to find Patient 1. CNA1 also stated Patient 1 can be in danger if the facility is unable to locate the patient. During a telephone interview on 10/29/2024 at 2:10 PM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she got a report from CNA1 on 10/28/2024 between 4 AM to 5 AM that Patient 1 was missing, and the facility staff were not able to find Patient 1 inside the facility nor the facility’s parking lot or the nearby streets. LVN1 stated the sliding door next to Patient 1’s bed was observed to be wide open on 10/28/2024 after Patient 1 went missing. LVN 1 also stated, the sliding door leads to the alleyway that leads to Exit Door 1. LVN 1 stated Exit Door 1 leads to the facility’s back parking lot. LVN1 stated Exit Door 1’s alarm was broken, and it was not alarming when someone opens it. LVN1 stated there was no other guarding tools to prevent Patient 1 from walking away from the facility without notice of the facility staff. LVN1 stated Patient 1 could have walked away through the sliding door next to his bed, then to the alleyway towards Exit Door 1 early morning on 10/28/2024. LVN 1 stated, the Exit Door 1’s alarm not working breached the monitoring system of patients’ safety. The Exit Door 1 alarm is the guarding tool to alert facility staff and prevent patients from eloping from the facility. LVN1 stated Patient 1 can be in danger if the patient is not found. Patient 1 eloping from the facility can increase his risk of injury or accident to the patient. During a concurrent interview and review of facility’s surveillance camera footage on 10/29/2024 at 9:20 AM with Administrator (ADM) and the Director of Nursing (DON), ADM and the DON verified Patient 1 was last seen in the footage time stamped on 10/28/2024 between 1:38 AM to 1:48 AM when Patient 1 was seen in front of the laundry room walking towards Exit Door 1. ADM and the DON confirmed that the patient in the surveillance video who was walking toward Exit Door 1 was Patient 1 and that Patient 1 could have left the facility using Exit Door 1. During a concurrent observation and interview on 10/29/2024 at 10:02 AM with the DON in Patient 1’s room, observed the sliding door in Patient 1’s room was open leading to the alleyway which leads to the facility’s Exit Door 1. The DON confirmed Patient 1’s room sliding door was open to the alleyway and this alleyway leads to Exit Door 1. During an observation on 10/29/2024 at 10:08 AM by the Exit Door 1, observed the Exit Door 1 can be opened from inside of the facility, and did not have a lock. The Exit Door 1 alarm did not turn on when the Exit Door 1 was opened. During a concurrent interview and observation on 10/29/2024 at 10:46 AM with Maintenance Supervisor (MS) in front of Exit Door 1, MS stated the Exit Door 1’s alarm did not turn on then the door was opened, and it was not working since last year (2023) and he was not able to fix the alarm. MS stated he did not notify the administrator about the door alarm malfunction. MS stated patients can walk away from the facility through Exit Door 1 without the facility’s staff’s knowledge and this can create a safety issue to the patient. During a concurrent interview and record review on 10/30/2024 at 9:29 AM with Maintenance Consultant (MC), MC confirmed, Exit Door 1’s alarm was not working since last year, and he did not notify ADM regarding the alarm malfunction. MC also stated the maintenance log did not include checking of the alarm of Exit Door 1 whether it was functioning or not. MC stated patients can use the Exit Door 1 to leave the facility without alarming the facility staff. MC stated this can be a risk to patients’ safety and could cause serious harm to the patients if patients left the facility as a result of no proper monitoring and/ or the Exit Door 1 alarm is not working. During an interview on 10/30/2024 at 11:40 AM with the DON, the DON stated patient’s safety and supervision to prevent accidents are facility-wide priorities. The DON stated patient supervision is a core component of the systems approach to safety and the malfunction of Exit Door 1 alarm can be a breach of the patient’s supervision system. The DON stated, as a result of the Exit Door 1’s alarm not working, Patient 1 was able to elope from the facility without supervision or staff’s knowledge on 10/28/2024. During an interview on 10/30/2024 at 12:10 AM with ADM, ADM stated emergency exit door’s alarm need to be in a good working condition to function as a supervision and monitoring system to prevent Patient 1 and other patient from eloping the facility. A review of the facility’s policy and procedure (P&P) titled, “Safety and Supervision of Residents” revised July 2017, the P&P indicated: • Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. • Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. A review of the facility’s policy and procedure (P&P) titled “Physical Environment Policy” revised October 2021, the P&P indicated, maintain electrical power system for lighting all entrances and exits, fire detection, alarm and extinguishing systems and life support systems in good working condition. i.e. exits, alarm, fire doors and emergency generator. (not all conclusive) A review of the facility’s policy and procedure (P&P) titled “Interior Maintenance Miscellaneous” revised 10/18/2021, the P&P indicated door inspection procedures included check door alarms to ensure they are in good working order. E.g. exit door alarm. The facility failed to prevent elopement of Patient 1 when Patient 1 left the facility through the facility's Exit Door 1 and the alarm did not go on. This failure resulted in Patient 1 elopement on 10/28/2024 between 1:38 AM to 1:48 AM. Patient 1 was found on 10/29/2024 around 3:40 PM along Street 1 and 2 with unknown individuals. The patient refused to return to the facility. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1.