F0689

D

Failure to Adequately Supervise Resident Leading to Elopement

Napa, California Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and monitoring to prevent an elopement for one resident. The resident was admitted with diagnoses including heart disease, aftercare following circulatory surgery, muscle weakness, need for assistance with personal care, and unspecified psychosis. The facility’s front doors opened onto a busy street with consistent traffic. On the date of the incident, the resident left the facility unnoticed by staff and was later found outside the facility by police, who returned him.

The resident’s public guardian reported being informed by facility staff that the resident had eloped over a weekend. According to the guardian, a licensed nurse had believed the resident was in his room with the door shut and did not know he was actually missing. The Infection Preventionist stated she saw a group text message indicating the resident was missing, that staff had looked for him, and that police had been called. Another licensed nurse stated she was at lunch when the resident went missing, confirmed the resident did not have a wander alarm at that time, and stated that if a wander alarm had been recommended on the wandering and elopement assessment, it should have been applied right away and would have prevented the elopement.

The DON stated the resident’s original elopement and wandering assessment score was 8, which the facility considered low risk, and that a score above 10 was considered high risk. The DON also stated that the assessment dated the day of the incident recommended a wander alarm, but she characterized that recommendation as a mistake. She reported that the nurse assigned to the resident had observed him in his room after morning medications and did not notice when he left his room and exited the facility, and acknowledged there was not enough supervision to prevent the elopement. The Administrator similarly stated that staff did not see the resident exit his room and leave the facility and that the facility did not supervise the resident closely enough to prevent him from leaving. The facility’s wandering and elopement policy required that residents identified as at risk have care plan strategies and interventions to maintain safety. The resident’s elopement and wandering risk assessment scored him as low risk but indicated that a wander alarm was indicated, and his care plan included a wander alarm intervention without any specific supervision or monitoring interventions, while a separate falls care plan instructed staff to keep him within supervised view as much as possible.