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F0689
J

Failure to Prevent Resident Elopement Due to Inadequate Supervision and Policy Implementation

Los Angeles, California Survey Completed on 05-31-2025

Penalty

Fine: $9,113
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a diagnosis of nontraumatic intracerebral hemorrhage in the brain stem, severe cognitive impairment, and at risk for elopement was not adequately supervised, resulting in the resident leaving the facility unsupervised. The resident had previously been assessed as low risk for elopement, but on the day of the incident, was observed by a CNA packing belongings and expressing a desire to leave. Despite this, the resident was not immediately reassessed for elopement risk, and no detailed monitoring plan or interventions were implemented in accordance with the facility's elopement policy. Staff, including the DON and Social Services Assistant, were made aware of the resident's intent to leave and were instructed to monitor the resident and ensure the facility doors were supervised. However, the doors were not continuously monitored, as the receptionist responsible for this task was not present and no other staff were specifically assigned to this duty. As a result, the resident was able to exit the facility undetected, travel to a previous residence, and remain away from the facility for over six hours before being returned by an unidentified individual. Interviews and record reviews confirmed that staff failed to follow the facility's policy and procedure for elopement prevention, including reassessment of risk and implementation of appropriate interventions when a resident demonstrates behaviors such as packing belongings and verbalizing a desire to leave. The lack of immediate supervision and failure to monitor facility exits directly led to the resident's elopement.

Removal Plan

  • Resident agreed to be transferred to the acute care hospital for further evaluation. The attending physician issued the order for transfer.
  • Resident will remain on 1 to 1 (1:1) supervision for safety until transportation arrives for pickup. An order was obtained by the physician, and a log was used by the staff to document.
  • The facility will implement 24-hour monitoring of the doors to strive and prevent harm to all our patients.
  • Resident refused to be transferred to the General Acute Care Hospital (GACH) when transport arrived.
  • Received orders from physician to apply a wander guard to Resident.
  • Obtained informed consent from Resident's Responsible Party (RP).
  • Resident continued to refuse the wander guard despite several attempts and education on safety. Physician and Resident's RP made aware.
  • Resident will remain on 1:1 monitoring with a log for staff to document to ensure safety and continuous 24-hour monitoring of doors to prevent another incident reoccurring.
  • Resident's elopement assessment was updated to reflect Resident being at high risk for elopement.
  • Situation, Background, Assessment Recommendation (SBAR) documentation initiated for Resident and 72-hour SBAR documentation initiated.
  • Resident's care plan was updated with interventions implemented to prevent a repeat event.
  • Resident spoke with a psychiatrist via resident's telephone for evaluation for psychological support and emotional distress. The psychiatrist ordered a follow-up with social services for discharge. Resident was placed on psychological monitoring.
  • Resident will be seen by a psychologist for evaluation for psychosocial distress related to the recent event of elopement.
  • All residents have had an elopement risk evaluation assessment. All residents will be assessed upon admission, quarterly and in the event of a significant change with care plans updated.
  • Residents who are at high risk for elopement will be added to the quarterly Quality Assurance and Performance Improvement (QAPI) committee to identify other residents who have the potential to be affected.
  • Care plans will be updated for all residents who are at low, moderate or high risk for elopement and will include strategies and interventions to maintain the residents' safety.
  • The facility has identified only one resident at high risk for elopement which is Resident.
  • The facility will put a system in place for residents who are identified as low to moderate elopement risk for frequent visual monitoring.
  • The facility has put into place 24-hour door monitoring to ensure the deficient practice does not reoccur.
  • The Director of Nursing (DON) and Director of Staff Development (DSD) in-serviced staff members concerning the facility's policy to preserve and maintain resident safety by instituting measures to monitor and prevent resident from opportunities of wandering and eloping away from facility. DSD will in-service all licensed staff and before working assigned shift, staff will be in-serviced. As new hires come in, they will be educated and in-serviced on the elopement policy as well.
  • The facility will place an elopement binder at each nursing station identifying which residents are at low, moderate, and high risk for elopement. Included in the binder will be policy and procedures related to elopement, face sheets with clear picture identifiers of residents at risk and protocols for the event of an elopement.
  • The facility will implement a system that when an employee observes a resident leaving the premises he/she should attempt to prevent the resident from leaving in a courteous manner, get help from staff immediately in the vicinity, instruct the charge nurse and or DON that the resident is attempting to leave or has left the premises.
  • The facility will implement a system that when a resident is missing, the facility will initiate the elopement/missing resident emergency procedure, initiate a search of the building and premises and notify the Administrator (ADM), the DON, the resident's responsible party, physician, law enforcement, ombudsman, and CDPH.
  • The facility will implement a system for when the resident who eloped is found, the DON and or charge nurse will examine the resident for injuries, contact the physician, report findings and conditions of the resident, notify the resident's responsible party, notify local law enforcement that the resident has been located, and initiate 72-hour SBAR documentation.
See complete original report
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