F0580

D

Failure to Notify Resident Representative After Elopement Attempt and Change in Condition

Los Angeles, California Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify a resident representative of a significant change in condition and safety risk following an elopement attempt. A resident with a diagnosis of dementia was admitted with documentation listing him as his own responsible party. However, subsequent assessments showed that his cognitive status had declined. An MDS dated 10/6/2025 documented severely impaired cognition for decisions of daily living and noted that he required assistance or supervision with multiple activities of daily living, including oral hygiene, toileting, dressing, transfers, and mobility. A History and Physical dated 11/19/2025 further indicated that the resident did not have the capacity to understand and make decisions.

On 10/5/2025, an SBAR Communication Form documented that the resident had increased confusion and disorientation and attempted to leave the facility, stating that his daughter needed him. There was no documented evidence that staff notified any family member, guardian, or other responsible representative of this attempt to leave or the change in behavior. During interviews, an LVN confirmed that staff failed to notify the resident’s family members about the episode of confusion and elopement, and the DON stated that it is important to notify family and document which family member was notified following such behavioral changes. The facility’s policy titled “Change in a Resident's Condition or Status” stated that the facility will promptly notify the resident representative of changes in the resident’s medical or mental condition or status following a significant change in physical, mental, or psychosocial status, which was not followed in this case.