F0689

K

Failure to Assess and Supervise Residents at Risk for Elopement and Misuse of LOA Process

King City, California Survey Completed on 01-30-2026

Penalty

Fine: $414,390

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for residents at risk of elopement, particularly two residents with known risk factors, and the failure to complete required elopement risk assessments for nearly all residents. One resident with alcoholic cirrhosis, alcohol dependence, ascites, and hepatic encephalopathy was cognitively intact per BIMS and independent in transfers and walking, and he frequently went to the facility’s garden. Staff reported that he had previously left the facility in the morning and returned intoxicated in the evening, and that this incident should have been reported to management. Despite a physician’s order for an Elopement Evaluation and an order that he could only leave the SNF/hospital property with a responsible party, no Elopement Evaluation Assessment was completed upon admission, and staff confirmed there was no tool in use to assess elopement risk. The nurse manager stated the assessment was not done because the resident was alert, oriented, and independent.

The same resident’s preference for frequent independent garden time was documented in his activity preferences, but the activity staff did not develop a comprehensive activity care plan that included objectives, interventions, supervision requirements, or monitoring of his whereabouts during garden time. The activities coordinator and nursing staff acknowledged that the existing documentation did not constitute a true care plan and that there was no constant monitoring of the resident while he was in the garden. In addition, the facility did not follow its Leave of Absence (LOA) policy requiring a complete mental, physical, and functional assessment within 30 minutes before leaving and upon return, documented in the nursing progress notes. Multiple LOA forms for this resident showed times out with no times in, missing nurse initials, and incomplete destination information, and the nurse manager confirmed that nurses did not complete or document required assessments on numerous dates. Staff interviews revealed that nurses and CNAs did not routinely check on residents in the garden, did not sign the resident back in when he returned for medications, and believed that the resident’s signature on the LOA form released the facility from responsibility.

On the day of the fatal incident, the resident signed out in the morning to go to the garden, was seen on surveillance video leaving and re-entering the building, and later left again in the early afternoon without signing out. He took his medication early that afternoon, but staff did not verify his whereabouts afterward. Surveillance footage reviewed by the director of quality showed the resident exiting through the lobby doors and heading toward a nearby street, after which he was no longer visible until a truck stopped in front of the hospital later that evening, coinciding with the time of a motor vehicle accident in which he was struck as a pedestrian. He was subsequently admitted to the acute hospital as a trauma patient with extensive injuries and an elevated blood alcohol level and later died; the hospital death summary listed multiple traumatic injuries and alcohol intoxication among the diagnoses and contributing conditions.

A second resident, with diagnoses including alcoholism, diabetes mellitus, hemiplegia due to prior stroke, hypercholesterolemia, hypertension, and wheelchair dependence, had a BIMS score indicating severe cognitive impairment. No Elopement Evaluation Assessment was completed upon his admission. The nurse manager stated that such assessments were only done when residents were “triggered” by an elopement incident or a change in condition, rather than upon admission. This resident routinely signed LOA forms and left the facility or went to the garden unassisted, propelling his wheelchair using his left arm and leg, often in the early morning hours. CNA staff reported that he preferred to go out alone to stores to purchase lottery scratcher tickets and that staff did not take his vital signs each time he returned from LOA. Review of his LOA forms showed numerous entries with times out but no times in, missing nurse initials, missing destinations, and lack of documentation of assessments before leaving or upon return, contrary to facility policy.

Beyond these two residents, the facility failed to complete Elopement Evaluation Assessments upon admission for 39 of 40 residents reviewed. The report states that this failure could result in not identifying residents’ elopement risk levels and not implementing resident-centered plans of care, with the potential to result in harm, injury, or death for residents at high risk of elopement. The cumulative failures to assess elopement risk, to develop and implement individualized care plans for residents with known preferences for independent outdoor time, and to follow the LOA policy for assessment and documentation led to an immediate jeopardy situation, as the noncompliance caused or was likely to cause serious injury, harm, impairment, or death to residents, exemplified by the elopement and subsequent fatal motor vehicle accident involving the first resident.