F0689

D

Failure to Identify and Care Plan Elopement Risk Leading to Unauthorized Exit

San Pablo, California Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The facility failed to identify and care plan an elopement risk for a resident who subsequently left the facility without authorization. The resident was admitted with diagnoses including cellulitis of the left lower limb, unspecified behavioral and emotional disorder, psychoactive substance abuse, schizophrenia, and alcohol dependence. An MDS dated 01/25/2026 showed a BIMS score of 08, indicating moderately impaired cognition. An Elopement Risk Assessment dated 11/13/2025 documented that the resident was ambulatory and had a history of wanting to leave the facility within the last 30 days, yet the assessment indicated the resident did not have substance abuse or psychiatric history and concluded the resident was not at risk for elopement. The facility’s policy stated it would provide a safe environment and preventative measures for elopement, with monitoring and documentation of patients at risk.

On 01/12/2026, after a morning snack, the resident was last seen by LVN 1 heading toward the smoking area between 10:00 a.m. and 10:30 a.m. Lunch trays were passed between 11:30 a.m. and 12:00 p.m., and while LVN 1 was eating lunch between 12:30 p.m. and 1:00 p.m., a CNA reported that the resident was not in her room and had not eaten lunch. LVN 1 then checked the resident’s room, bathrooms, shower rooms, and the smoking area and, when the resident could not be found, notified her supervisor and a Code Yellow for a missing resident was called. A progress note from the morning of 01/12/2026 documented that the resident had asked when she was going home and was told she would not be moving with family that day. A subsequent late-entry progress note recorded that the resident had eloped from the facility and was later located by authorities due to public intoxication and transported to her sister’s home.