F0689

G

Failure to Supervise Residents and Secure Exits Resulting in Elopement and Unsafe Wandering

San Rafael, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and a safe environment to prevent accidents, resulting in one resident leaving the building unnoticed and being found deceased outside, and another resident wandering unsupervised near unlocked exterior doors. The facility building is three stories high and located on a hillside, with a steep, uneven asphalt driveway and stairs connecting the main entrance to a lower-level parking lot near a busy street. There were no secured gates to prevent residents from leaving the sitting area outside the front doors and attempting to go down the steep driveway in wheelchairs. On one survey date, the reception desk at the main entrance was observed to be empty, and multiple individuals without visible employee identification entered through the front doors.

One resident, admitted with diagnoses including cerebral infarction (stroke), ataxia, dysphagia, major depressive disorder, right above-the-knee amputation, muscle weakness, dysarthria, and anarthria, self-propelled his wheelchair from the second floor via the elevator to the lobby. Video surveillance reviewed by the Administrator and Director of Staff Development showed the resident moving down a long hallway to the front doors, waiting there, and then exiting when visitors opened the unlocked doors. The last video frame showed him leaving the sitting area and heading slowly down the steep driveway. Facility staff were unaware he had left the building until paramedics, called by a passerby who found him slumped over in his wheelchair in the lower parking lot near electric vehicle chargers, arrived around 5 p.m. and requested information. The Administrator acknowledged there was no receptionist at the front desk at the time, despite the usual practice of staffing that area from mid-afternoon to evening, and the Assistant DON confirmed that no one was actively monitoring residents or the front doors.

The resident who eloped had a documented history of suicidal ideation. Progress notes indicated that on a prior date he had stated he wanted to die, attempted to go out a ramp door but was redirected, and later went out to a second-floor balcony and said he wanted to leave and would jump off the balcony. Nursing documentation described him as having suicidal thoughts and verbalizing wanting to die and jump off the balcony, after which he said he did not mean it and was upset about his roommate not receiving help. His care plan included a focus on behavior monitoring due to suicidal ideation, with instructions for continuous monitoring for suicidal thoughts and hourly checks per facility protocol. A physician order from admission stated that he may go out on pass with a responsible party for medical appointments only, with no documented end date. The resident’s physician stated he should only have left with a responsible party and that no one should have been able to leave alone, and the DON stated that residents could not “just walk out,” describing the front desk role as monitoring residents in the lobby and intervening if they attempted to leave.

A second resident, admitted with dementia with behaviors, muscle weakness, abnormal gait and mobility, and glaucoma, was observed on the second floor in an unattended common area adjacent to unlocked sliding doors leading to a wet deck overlooking a steep incline and unlocked double doors leading to a parking lot via a ramp. This resident was awake, non-communicative, and continuously walking around the area and hallway for approximately 40 minutes, turning lights on and off, opening cabinets, and rearranging furniture without apparent reason, with no staff checking on or monitoring her behavior during that time. The Nurse Consultant stated that both the sliding doors to the deck and the doors to the parking lot ramp were supposed to be locked and acknowledged the risk that the resident could have gone onto the deck and slipped and fallen on wet leaves. He also stated that the resident was being monitored remotely by activity staff in the next room and that those staff were supposed to supervise her, but they could not see her from where they were seated. Facility policies on wandering, elopement, and safety and supervision required identification of residents at risk for wandering or elopement, inclusion of safety strategies in the care plan, and targeted interventions such as adequate supervision to address individual hazards, which were not effectively implemented in these instances.

Additional interviews reinforced the lack of effective supervision and control of egress points. The Administrator defined elopement as a resident without capacity leaving without permission and asserted that the eloped resident had capacity, while other staff, including the DON and unlicensed staff, stated that residents could not leave on their own and should only leave with someone for safety. Unlicensed staff reported that the resident left the second floor without being noticed and questioned how he could have navigated the steep, uneven driveway in a wheelchair, describing it as too steep to manage safely. A roommate of the deceased resident described the driveway as steep and dangerous and expressed doubt that the resident could have returned up the hill once he went down. Weather records for the evening of the incident documented cold, rainy, and windy conditions. The facility’s own policies on safety and supervision emphasized an individualized, resident-centered approach, analysis of assessment information to identify accident risks, and targeted interventions including adequate supervision, which contrasted with the observed absence of monitoring at the front entrance and the unlocked access to hazardous exterior areas near wandering residents.