F0689

J

Failure to Prevent Elopement of Cognitively Impaired Resident

Pomona, California Survey Completed on 05-01-2025

Penalty

Fine: $10,361

Summary

A cognitively impaired resident, who was assessed as being at risk for elopement, was able to leave the facility's secured unit unsupervised. The resident's care plan required staff to conduct visual checks every 15 minutes and to follow specific protocols to prevent elopement. On the day of the incident, a CNA exited the secured unit without ensuring the door was closed and locked behind them, and did not confirm that no residents were following. Surveillance footage showed the resident holding the door open after the CNA exited, then proceeding through the lobby and out the facility's main entrance, which was neither locked nor alarmed at the time. No staff were present in the lobby to monitor the exit.

The resident's whereabouts were not documented in the 15-minute monitoring log for several hours, and the assigned CNA later stated that it was unrealistic to monitor and document all assigned residents every 15 minutes due to workload. The facility's receptionist was not present at the front desk during the time of the elopement, and the main entrance door was not secured or alarmed, allowing the resident to exit undetected. The resident was not discovered missing until later in the evening, after which a search was initiated.

The resident had a history of exit-seeking behaviors, including wandering, expressing a desire to leave, and packing belongings. Medical records indicated diagnoses such as paranoid schizophrenia, anxiety disorder, epilepsy, and diabetes mellitus, and the resident required regular medication and supervision. The facility's policies required regular checks and supervision for residents at risk of wandering or elopement, but these protocols were not followed, resulting in the resident's unsupervised exit from the secured unit and the facility.

Plan Of Correction

F-tag: 689 Free of Accident Hazards/Supervision/Devices

Immediate corrective action:
On 4/28/2025, Resident 3 was found by the local police and dropped off at Clinic 1 at "approximately" 6:30 am. The DON notified Resident 3's Primary Physician / Medical Doctor (MD1) and instructed Resident 3 to come back to the facility.

On 4/28/2025, two CNAs picked up Resident 3 from Clinic 1 and brought Resident 3 back to the facility at 4:35 pm.
On 4/28/2025, RNS 1 conducted a comprehensive assessment of Resident 3 upon return to the facility with vital signs stable. No signs and symptoms of major injury or negative outcome were noted.
On 4/28/2025, Primary MD ordered to transfer Resident 3 to a General Acute Hospital for further evaluation and transferred on 4/29/2025. Resident's 3 Conservator was notified and made aware.

On 4/24/2025, the DON / DSD provided a verbal 1:1 in-service to CNA 6 regarding the elopement policy. Emphasized to ensure the secured unit door is closed and locked when getting out from the secured unit.
On 05/02/25, CNA 6 is no longer in the facility.
On 05/02/25, the Administrator provided 1:1 in-service to Receptionist 1 on policy regarding safety and supervision of residents in the secured unit. To ensure the front door in the front lobby is locked and the alarm is set to enhance resident safety.

From 05/02/25 to 05/10/25, the DON / DSD provided 1:1 in-service to CNA 7 on the policy of elopement and emphasized following the facility's visual check every 15 minutes to monitor residents' whereabouts and safety.
On 4/28/25, the DON posted a visual alert sign at the secured unit exit areas, reminding staff to ensure doors are closed before walking away as part of ongoing safety education.
On 4/28/2025, the facility assigned a staff member to the reception area to assist with visitation and supervise individuals entering and exiting the facility.

On 4/29/2025, the facility installed a new door keypad for safety in the front lobby.
During 4/28/2025 - 4/29/2025, the DON/DSD provided in-services to staff members regarding the elopement policy covering the following topics:
a. Supervise and redirect residents who are close to the exits to mitigate the risk of elopement.
b. While entering or exiting the secured unit, staff members must check/confirm that no resident is exiting before walking away from the door.
c. The importance of conducting rounds every 15 minutes and as needed for adequate supervision.
d. The importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.

The DON conducted rounds on 05/02/25 and 05/20/25 in the secured unit to identify any elopement risk residents. No other residents were affected by this deficient practice.

Process to prevent recurrence:
Effective 4/29/2025, the DON / DSD will repeat the in-service and reinforce the policy of elopement to nursing staff (CNA, LVN, RN) every month for 3 months.

Monitoring process:
The DON / DSD will conduct daily rounds to observe staff entering/exiting the secured unit to ensure compliance and document the findings in the monitoring log.
During the monthly QAPI, the DON will report any deficient findings for follow-up resolution for 3 months.

Completion date: 5/20/25

Removal Plan

• The DON provided a verbal one-on-one in-service via phone regarding the elopement policy to CNA 6, following a disciplinary Performance Correction.
• The Registered Nurse Supervisor contacted nearby hospitals and the local police department to locate Resident 3. The ADM contacted private investigators who were also utilized to find Resident 3. A flyer of the missing resident was also provided by the PI.
• The local police found Resident 3 and dropped Resident 3 off at Clinic 1. The DON communicated with Clinic 1's Nurse who confirmed Resident 3 was currently in Clinic 1 with stable vital signs. The DON notified Resident 3's Primary Physician/Medical Doctor who instructed to transfer Resident 3 back to the facility.
• Two CNAs picked up Resident 3 from Clinic 1 and brought Resident 3 back to the facility.
• The Registered Nurse Supervisor conducted a comprehensive assessment of Resident 3 upon Resident 3's return to the facility. Resident 3's vital signs were stable, no signs or symptoms of major injury were noted. The Medical Doctor ordered to transfer Resident 3 to a General Acute Care Hospital for further evaluation. Facility staff notified Resident 3's conservator regarding Resident 3 was found.
• The DON posted a virtual alert sign at secured unit exit areas, reminding staff to keep doors closed before walking away from all secured exit areas, as ongoing safety education.
• The facility assigned a staff member to the reception area to assist with visitation and supervise individuals entering and exiting the facility.
• The DON and the Director of Staff Development provided in-services to staff members regarding the elopement policy, covering the following topics: supervise and redirect residents who are close to the exits, to mitigate the risk of elopement; while entering or existing the secured unit, staff members must check/confirm that no resident is existing from the secured unit before walking away from the exit doors; the importance of conducting rounds every 15 minutes in the secured unit and as needed for adequate supervision; the importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.
• Elopement Trainings: RNs, LVNs, CNAs, department managers and assistants, activity assistants, housekeeping and laundry employees, and dietary service staff received the in-service training for elopement. Staff need to complete the in-service regarding elopement upon returning to work and prior to providing resident/resident care. Staff not working due to medical, emergency leaves, vacation, and leave of absence will complete their in-services upon their return.
• The ADM notified the Medical Director of the IJ findings in the IJ template. The Medical Director assisted in developing the IJ removal plan.
• The facility also installed a new door keypad for safety in the front lobby.
• There were residents residing in the secured unit.
• The ADM, the DON, and the DSD made rounds, observed staff members entering/exiting the secured unit. No issues were identified.
• The maintenance supervisor inspected all exit doors, gate, and door/gate alarms. No issues were noted.
• The DON would repeat the in-service regarding Elopement policy to staff members every month, for 3 months. The in-services would cover the following topics: supervise and redirect residents who are close to the exits, to mitigate the risk of elopement; while entering or exiting the secured unit, staff members must check/confirm that no residents are exiting the secured unit before walking away from the exit doors; the importance of conducting rounds every 15 minutes and as needed for adequate supervision; the importance of supervision in the front lobby and the activation of the front lobby gate alarm to enhance overall supervision.
• The DON developed an Elopement Monitoring Log, which included supervision and redirection, precautions for entering/exiting the secured unit, and monitoring of the front gate alarm to prevent elopement.
• The facility would conduct a head count at every shift on the secured unit station for 3 months, using the current day's census to enhance supervision.
• The DON, the DSD or the Registered Nurse Supervisor would conduct daily rounds to observe staff entering/exiting the secured unit to ensure compliance and document the monitoring findings/actions in the monitoring log.
• The ADM and the DON developed a Quality Assurance and Performance Improvement for elopement to address the deficient practice in the IJ findings.