F0689

D

Failure to Supervise Behavioral Activities and Identify Elopement Risk

Tucson, Arizona Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a hazard‑free environment and adequate supervision to prevent accidents during activities and smoking breaks, and to properly identify and plan for elopement risk. One cognitively intact resident with Huntington’s disease and significant behavioral issues was care planned as being at risk for harm to self or others, with interventions including supervision during activities and removal from group activities if behaviors became disruptive. During an observed group activity in the dining room, residents from both long‑term care and behavioral health units participated in a target‑practice game using toy guns and foam darts aimed at balloons, along with karaoke/music. The resident with Huntington’s disease was seated alone at one end of a table, facing other residents across the table, and was allowed to handle a toy gun and foam darts. A foam dart landed on this resident, who then reloaded it into the toy gun. The activity director later stated that residents should have been lined up in front of the balloons, 2–3 feet away, to prevent residents from being hit by darts and to avoid triggering behaviors, and that the aide should have repositioned residents accordingly.

During this same activity session, only one activity aide was present to supervise the group. At one point, the aide left the dining/activity room to wheel a resident out, leaving all remaining residents in the activity room without any staff supervision until he returned about a minute later. The activity aide stated that residents from the behavioral unit are supposed to be 100 percent supervised during activities and acknowledged that he left the room because coworkers were busy. The activity director stated that only one staff member is assigned per activity, that staff must remain in the room at all times while residents are present, and that staff are not permitted to leave residents unattended; if assistance is needed, staff are expected to call her or a CNA. She further stated that if there is no staff with residents during an activity session, residents could have behaviors, wander into the kitchen, or go out into the hall, and that this was not safe.

The deficiency also involves the facility’s failure to adequately identify and plan for elopement risk for a newly admitted, cognitively intact resident with complex psychosocial and substance‑use history. Hospital records prior to admission documented abscess and cellulitis, drug use, amphetamine use, moderate fentanyl dependence, and suicidal ideation, and the resident reported interest in obtaining medical marijuana. A psychosocial evaluation documented self‑reported bipolar disorder, schizophrenia, approximately 20 years of incarceration, and current parole status. A smoking evaluation identified the resident as a smoker who preferred morning and afternoon smoking, was considered a safe smoker, and could access smoking materials with frequent monitoring. A wandering/elopement risk assessment scored the resident as low risk, focusing on mobility, mental status, speech, and history of wandering, but did not address psychosocial, behavioral health, or substance‑use‑related risk factors.

On the evening of the incident, the resident independently showered after staff covered his PICC line and wound dressing. Afterward, staff informed him that the PICC line and dressing needed to be changed, and he requested that this occur after the scheduled smoking break. During the 7:30 p.m. smoking break, the on‑duty receptionist observed the resident get into a black car and leave the facility. The physician and administrator were notified, and 911 was called; an AMA form was later entered into the record documenting that the resident left during the smoking break. The DON stated that narcotic use, homelessness, and suicidal ideation are risk factors for elopement, that the wandering/elopement assessment did not adequately evaluate this resident’s risks or capture his needs and concerns, and that the resident’s departure should have been considered an elopement rather than an AMA discharge. A case manager similarly stated that suicidal ideation, homelessness, and drug use could indicate higher elopement risk and should prompt referral to behavioral health.

Further observations and interviews showed additional supervision lapses related to smoking. A receptionist stated that staff rotate responsibility for monitoring residents in the smoking area and that the receptionist is responsible for monitoring residents during the early morning and evening smoking times. However, an observation on a later morning revealed three residents smoking outside without staff supervision while the receptionist on duty remained seated inside at the reception desk. Facility policy on elopement required that all residents receive adequate supervision to ensure the safest environment possible and that residents be assessed for behaviors or conditions placing them at risk for wandering or elopement. The activities/recreation therapy policy required that programs be provided in coordination with the resident’s comprehensive assessment, but the observed practices during the target‑practice activity and smoking breaks did not align with these requirements.