F0689

D

Failure to Supervise High-Risk Wanderer Resulting in Elopement Over Facility Fence

Beaumont, California Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure effective supervision and individualized interventions for a resident assessed as high risk for wandering and elopement. The resident, admitted with dementia and documented moderate cognitive impairment, had an elopement/wandering care plan dated September 6, 2025, that identified risk for elopement/exit seeking/wandering related to agitation and altered cognitive status, and noted the resident voiced a desire to leave. The only intervention listed was to allow wandering in safe areas within the facility, and there were no specific interventions to prevent the resident from exiting the facility grounds. An elopement and wandering risk assessment dated December 19, 2025, scored the resident at 10, indicating risk for wandering or elopement. Staff documentation on an eINTERACT SBAR dated January 15, 2026, recorded that staff saw the resident jump over the fence, that available staff followed and attempted to redirect the resident back inside the facility grounds, and that the resident refused and continued walking along a nearby street.

Interviews with staff further described actions and inactions leading to the elopement. CNA 1, who was assigned to the resident at the time, stated she was informed by CNA 2 that the resident had jumped over the fence, and that staff attempted to redirect the resident but the resident refused, after which law enforcement was contacted. CNA 2 reported being familiar with the resident, noting the resident had verbalized wanting to go home with his brother, had refused meals, and had been observed about a week prior to the incident walking near exit doors and appearing to look for ways to leave the facility. The Activity Assistant stated she knew the resident was at risk for elopement and required close supervision, and that residents at risk for elopement required close supervision when outside. She reported that she observed the resident sitting in the garden while she remained in the lobby, then saw the resident climb over the fence, and acknowledged she should have been outside supervising the resident. The Registered Nurse Supervisor stated that although the facility’s practice was to revise the elopement risk assessment and care plan when exit-seeking was observed, the resident’s care plan was not revised to add new interventions such as 1:1 supervision while outside. The facility’s wandering and elopement policy required that residents identified at risk have care plans including strategies and interventions to maintain safety.