F0689

D

Elopement of Cognitively Impaired Resident Through Unalarmed Laundry Exit

Tracy, California Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and a safe environment to prevent an elopement for a resident with severe cognitive impairment and known wandering risk. The resident was admitted with encephalopathy, delirium, gait and mobility abnormalities, need for assistance with personal care, and dementia. A Brief Interview for Mental Status (BIMS) score of 1 indicated severe impairment in thinking and memory. The resident’s care plan, initiated months earlier, identified risk for wandering or elopement related to exit-seeking behavior, a focus on wanting to go home, dementia, and aimless wandering, with goals to prevent elopement and maintain safety. Interventions included frequent checks of the resident’s whereabouts, redirection when approaching exit doors, assessment for a wander/elopement alarm, and application of a wander guard as ordered. An active order for wander guard placement due to exit-seeking behavior was in place.

On the night of the incident, documentation showed that the resident was last seen by the night shift CNA walking up and down the hallway at approximately 2:35 a.m., and the resident’s roommate later came out to inquire about the resident when she was no longer in the room. Staff then determined the resident was not in the building and began searching the premises. The assigned nurse (LN 3) reported being responsible for 30 residents that shift and stated that around 1:50 a.m. she accompanied an x-ray technician to assist with other residents, leaving the resident under the supervision of the CNA in the activities room because the resident did not want to remain in bed. LN 3 remained with the x-ray technician until about 2:30 a.m. and then took her scheduled lunch break, assuming the resident remained under CNA supervision. LN 3 later became aware the resident was missing when the roommate asked about her whereabouts and initially believed the resident was still in the building because no door alarm had sounded.

Interviews and record review revealed that the resident eloped through a laundry room exit door that was not alarmed and that a second laundry door, which was supposed to be locked from the inside when staff left the area, had been left unlocked. The Administrator stated that prior to the elopement, all exit doors except the laundry door were alarmed, and that staff had forgotten to lock the second laundry door on the night of the incident. The Interdisciplinary Team note documented that the resident, who was alert and ambulatory at the time of exiting, left through a door that did not have an alarm and was outside the patient care area, and that the wander guard did not alarm for this door. Police records indicated that officers responded to a missing person call, searched the surrounding area, and later received a call from a community member reporting an unknown female in her home wearing a yellow gown; officers identified this person as the resident. Due to extreme cold weather, the resident’s age, and health conditions, EMS transported the resident to a hospital, where she was diagnosed with an acute NSTEMI and acute altered mental status, with elevated troponin and treatment including heparin and cardiac monitoring.

Facility policies on wandering, elopement prevention and management, and safety and supervision of residents required identification of residents at risk for unsafe wandering or elopement, inclusion of detailed monitoring plans in the care plan, provision of adequate supervision, and maintenance and utilization of electronic monitoring and door alarm systems when deemed appropriate. Policies also described that a missing resident is considered a facility-wide emergency and outlined notification procedures for the Administrator, DON, legal representative, physician, and law enforcement if a resident is not located. Despite these policies and the resident’s documented risk factors and care plan interventions, the resident was able to leave the building through an unalarmed and unlocked laundry exit without staff knowledge, remained missing for several hours during nighttime and early morning hours, and was ultimately found offsite and transported to the hospital, where an acute cardiac injury (NSTEMI) was diagnosed.