F0689

D

Failure to Care Plan and Supervise High-Risk Wanderer Resulting in Elopement

Los Angeles, California Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement an individualized care plan with specific interventions for a resident who was identified on admission as having a significant actual risk for wandering and elopement. The resident was admitted with diagnoses including encephalopathy, diabetes mellitus, altered mental status, and high blood pressure. The admission nursing assessment documented a recent history of wandering and a significant actual risk for wandering and elopement. The facility’s own policies required that residents at risk for wandering and elopement have preventative interventions documented in the medical record and that a person-centered care plan be developed based on assessed needs, but no such care plan was created for this resident.

The resident’s MDS dated 1/6/2026 indicated that he could make his needs known and understand others, and that he required supervision for transfers and walking 50 feet with two turns, and partial/moderate assistance for walking 10 feet. He did not use a wheelchair. Despite the documented risk for wandering and elopement, interviews and record review confirmed that there were no individualized interventions in the care plan to prevent the resident from leaving the facility unsupervised. The DON later stated that the resident was not considered at risk for elopement before the incident, which conflicted with the admission assessment that identified a significant actual risk.

On the evening of 1/30/2026, staff discovered that the resident was not in his room between approximately 8:30 p.m. and 8:45 p.m. Staff searched rooms, common areas, closets, restrooms, and outside the facility, and also drove along the street and called nearby hospitals but could not locate him. An RN supervisor reported hearing an exit door alarm near the rehab room around 8:00 p.m., checking the parking lot, and not seeing anyone outside; shortly thereafter, a CNA reported that the resident was missing. The facility’s exit doors were not locked but were equipped with alarms, and monitoring of these doors was done only during staff rounds, with no staff assigned to continuously monitor the exit near the rehab room. The resident was later found two days later at a recovering unit in a general acute care hospital and was returned to the facility by the Administrator.