F0689

D

Failure to Care Plan and Supervise Resident With Drug Use History, Resulting in Elopement

Stockton, California Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident at risk for wandering and elopement received adequate supervision and an appropriate care plan addressing known drug use. The resident was admitted in January 2026 with diagnoses including sepsis, acute osteomyelitis of the right ankle and foot, and type 2 diabetes mellitus, and had a PICC line in place for IV antibiotics. The acute hospital H&P dated 1/15/26 documented a recent history of methamphetamine use. The Social Services Director and the ADON both confirmed that, despite this known history, no care plan was developed to address the resident’s drug use, and no psychiatric consultation was obtained. Facility policies required a baseline care plan within 48 hours of admission and specified that residents identified as at risk for wandering or elopement must have care plan strategies and interventions to maintain safety.

On the early morning of 1/25/26, a licensed nurse reported that the resident requested a lighter to smoke cigarettes during the medication pass. When told a lighter was not available, the resident began packing his belongings while the nurse continued the medication pass. At approximately 5:15 a.m., the nurse returned to the resident’s room and found the resident was no longer there. The nurse searched the building but could not locate the resident and then reported the missing resident to the ADON and another nurse. Subsequent review of facility camera footage by another licensed nurse showed the resident exiting the facility’s outside gate at 4:57 a.m. without staff awareness.

Family later reported that the resident, who was known to be homeless with a long history of drug use, walked a long distance to a family member’s home, complained of foot pain, had scissors and was possibly attempting to remove the PICC line, and had used drugs after leaving the facility. The resident was unaccounted for approximately 27 hours and 30 minutes and was later at a local hospital. The ADON stated that the facility’s elopement process included contacting the Department, police, Ombudsman, and other key personnel, and acknowledged concern for the resident’s safety given the unsafe neighborhood, time of day, weather, PICC line, and drug use history. The Administrator confirmed he did not contact the Department, Ombudsman, or Adult Protective Services after the resident left, despite facility policy requiring reporting of unusual occurrences that affect the health, safety, or welfare of residents to appropriate agencies within specified time frames.