F0689

D

Failure to Develop and Implement Elopement Prevention Care Plan for High-Risk Resident

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent elopement for a resident who had been identified as at risk for elopement. The resident was admitted with diagnoses including paranoid schizophrenia, schizoaffective disorder bipolar type, and a history of stimulant abuse, and was receiving multiple antipsychotic and mood-stabilizing medications. The resident’s BIMS score indicated moderately impaired cognition, and the primary care physician documented that the resident did not have capacity to understand and make healthcare decisions. An elopement evaluation completed on admission produced a score indicating the resident was at risk for elopement.

Despite this identified risk, review of the resident’s records showed no evidence that the facility developed or implemented a person-centered care plan addressing elopement risk, nor any documented interventions or strategies to maintain safety and prevent elopement. Review of all documented care plans revealed no person-centered care plan for elopement risk, and review of nursing notes, physician orders, and the EMAR from admission through the date of elopement showed no documented interventions for monitoring or supervision related to wandering or elopement prevention. Staff interviews, including with the LVN, CNAs, and the DON, confirmed that the resident was known to wander and was considered at risk for elopement, and also confirmed that there were no documented interventions, no continuous or scheduled supervision, and no regular monitoring of the resident’s whereabouts to address this risk.

On the day of the elopement, nursing staff observed the resident walking in the courtyard outside the building in the late afternoon. When a nurse went to administer scheduled medications later that afternoon, the resident was not in the room and could not be located in the facility despite a search. Subsequent nursing alert notes documented that the facility contacted local hospitals and searched surrounding community areas but was unable to locate the resident. Staff interviews indicated that the only likely way the resident could have left the premises was by jumping over a six-foot metal fence in the dark, and staff acknowledged that the lack of supervision and monitoring contributed to the inability to prevent the resident from leaving. The DON confirmed that the resident had been identified as at risk for elopement on admission, that no person-centered care plan or interventions for elopement prevention had been developed or implemented, and that the facility was unable to determine how the resident eloped and had been unable to locate the resident as of the latest interview.

The facility’s physical layout included three separate buildings surrounding a central courtyard, with six-foot metal fences and an eight-foot brick wall with a locked gate, and the maintenance director stated that the front gate was always locked and that only staff with keys could access it. However, staff interviews indicated that the resident, described as tall and thin, was physically capable of jumping the fence, and that it was dark at the time the resident likely left, which staff believed contributed to the elopement going unnoticed. The facility’s own policies on wandering and elopement and on comprehensive person-centered care plans required identification of residents at risk for unsafe wandering or elopement and inclusion of strategies and interventions in the care plan to maintain safety. Despite these policies and the resident’s documented risk factors and behaviors, the facility did not create or implement a person-centered care plan or effective monitoring and supervision interventions to prevent the resident’s elopement.