F0689

D

Failure to Supervise High-Risk Resident Resulting in Elopement

Los Angeles, California Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately supervise, monitor, and implement safety measures for a resident with known elopement risk and cognitive impairment, resulting in an elopement. The resident was admitted with diagnoses including toxic encephalopathy, depression, difficulty walking, and lack of coordination, and had intermittent ability to understand and make decisions. Therapy notes documented that the resident was unsteady when walking and standing, required substantial/maximal assistance to walk ten feet, had a mobility function score of 0, and had impaired safety awareness. The care plan identified the resident as being at risk for decline in functional status and safety concerns during daily care tasks, and also documented a history of elopement at home and prior elopement or attempted leaving the facility without informing staff.

On the day of the incident, the resident’s Change of Condition note indicated an increase in confusion that was a persistent change from usual cognitive function and documented that the resident had attempted to elope multiple times prior to the successful elopement. The resident was last seen in her room at 12:30 PM when lunch was delivered, and at 1:05 PM a CNA noted the resident was not in the room when picking up the lunch tray. By approximately 1:20 PM, staff determined the resident was missing and activated a code yellow. Interviews revealed that earlier that day the RN observed the resident attempting to open the exit door and redirected her back to her room after 12:30 PM, and the RN reported that the resident had tried to elope at least four times prior to successfully leaving. The RN stated a huddle was called to inform staff, including the primary CNA, to be more vigilant in watching the resident, although the primary CNA later reported not recalling this huddle, while another CNA confirmed it occurred.

Staff interviews and policy review showed that the facility did not implement enhanced monitoring or safety devices consistent with the resident’s identified elopement risk and change in condition. The DON acknowledged that if staff knew the resident was attempting to exit through the door, the resident would be at risk for elopement and that the physician should have been notified to obtain an order for a wander guard. The DON also stated the resident should have been closely monitored with staff visually seeing the resident at all times or placing the resident on 1:1 observation, and that these interventions were not implemented. The RN reported that despite multiple elopement attempts, the resident did not have a 1:1 sitter, and staff instead tried to block the exit door with a medication cart. The facility’s wandering and elopement and resident safety policies required assessment of elopement risk, development of a person-centered care plan, and establishment of observation or monitoring systems, including more frequent safety checks when indicated, but the resident was able to leave through the exit door when visitors exited and was not observed by staff as she left.