Other·April 10, 2026

California Code of Regulations, Title 22, Section 72523 Patient Care Policies and Procedures (a) Written care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. California Code of Regulations, Title 22, Section 72311 Nursing Service – General (a) Nursing service shall include, but not limited, to the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient’s condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. Code of Federal Regulations, Title 42, Section 483.25 Quality of Care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: Code of Federal Regulations, Title 42, Section 483.25(d) Accidents. The facility must ensure that – (2) Each resident receives adequate supervision and assistance devices to prevent accidents. It was determined that the facility failed to provide adequate supervision or implement necessary interventions for Patient 1, who had been identified to be at high risk for wandering or elopement (a patient leaving a healthcare facility without authorization, supervision, or being formally discharged). This failure resulted in Patient 1 being able to climb over the facility fence and leave the facility premises, placing the patient at risk for serious injury or death. A review of Patient 1’s “Admission Record,” indicated Patient 1 was admitted to the facility on March 13, 2025, with diagnoses which included dementia (memory loss).   A review of Patient 1’s care plan, dated September 6, 2025, indicated, “...Elopement/Wandering: Resident is at risk for elopement/exit seeking/wandering related to agitation, altered cognitive status...voices desired to leave...Interventions...Allow wandering in safe areas within the facility...” A review of Patient 1’s Minimum Data Set (MDS- an assessment tool) dated December 19, 2025, indicated the patient had a Brief Interview for Mental Status (BIMS- a tool to assess cognitive function) score of 11, which meant moderate cognitive impairment. A review of Patient 1's "ELOPEMENT AND WANDERING RISK OBSERVATION/ASSESSMENT," dated December 19, 2025, indicated the patient has a score of 10 (considered at risk for wandering or elopement). A review of Patient 1’s “eINTERACT SBAR [Situation, Background, Assessment, Recommendations- a written communication tool that helps provides essential, concise information during crucial situations] Summary,” dated January 15, 2026, indicated, “...Staff saw the resident [Patient 1] jumped over the fence; available staff followed resident [Patient 1] & (and) redirected the resident [Patient 1] to (sic) back inside the facility grounds but refused and kept on walking along the side of [name of the street]...MD (medical doctor) agreed with Police officer holding him for 51:50 (sic) [a person is temporarily detained for psychiatric evaluation] and brought to nearest hospital...”   During an interview on February 3, 2026, at 11:58 a.m., Certified Nursing Assistant (CNA) 1 stated she was assigned to Patient 1 at the time of the incident (Elopement Incident on January 15, 2026). CNA 1 stated she was informed by CNA 2 that Patient 1 had jumped over the fence, and CNA 1 stated staff attempted to redirect the patient back to the facility, however; the patient refused to return. CNA 1 stated law enforcement was contacted. During an interview on February 3, 2026, at 12:22 p.m., CNA 2 stated that she was familiar with Patient 1, who had verbalized a desire to go home with his (family member) and had refused meals. CNA 2 stated that about a week before the elopement incident, Patient 1 was observed near the exit doors, appearing to be seeking opportunities to leave the facility. A review of Patient 1’s nursing notes did not reflect Patient 1’s behavior observed by CNA 2 about one week prior to the elopement incident on January 15, 2026. During interviews on February 3, 2026, and February 26, 2026, Activity Assistant (AA) 1, made the following statements: a. On February 3, 2026, at 12:56 p.m., she was aware Patient 1 was at risk for elopement and required close supervision. She stated that patients identified as elopement risk required close supervision. AA 1 further stated that when Patient 1 was outside, staff should have been present with the patient at all times to prevent the potential for elopement. AA 1 stated she observed Patient 1 sitting in the garden while she had remained in the lobby, subsequently witnessing the patient climb over the fence. AA 1 stated she should have been outside supervising the patient rather than staying in the lobby; and b. On February 26, 2026, at 3:09 p.m., she stated that activity assistants alternate with nursing staff in monitoring patients considered high risk for elopement. AA 1 confirmed she was in charge of monitoring Patient 1 during the time of the elopement incident on January 15, 2026. During a concurrent interview and record review, on February 26, 2026, at 3:41 p.m., the Registered Nurse Supervisor (RNS) stated that the facility would conduct an elopement risk assessment upon admission and update it if exit-seeking behavior occurs. The RNS stated when Patient 1 showed exit-seeking behavior, the care plan should have been updated to include interventions like 1:1 supervision outdoors. The RNS verified that the care plan for Patient 1 was not updated to include this intervention. On February 26, 2026, at 4:20 p.m., the Director of Nursing (DON) was interviewed. The DON stated that when staff observed exit-seeking behavior, staff were expected to report the behavior to the nurse so the assessment and care plan can be revised, and the patient may be placed on one-to-one monitoring as needed. The DON stated Patient 1's care plan should have been revised and Patient 1 should have been placed on 1:1 supervision. A review of the facility policy and procedure titled, “Wandering and Elopements,” dated March 2019, indicated, “...The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents...If identified at risk for wandering, elopement, or other safety issues, the resident’s care plan will include strategies and interventions to maintain the resident’s safety...” Based on interview and record review, It was determined that the facility failed to provide adequate supervision or implement necessary interventions for Patient 1, who had been identified to be at high risk for wandering or elopement.   This failure resulted in Patient 1 being able to climb over the facility fence and leave the facility premises, placing the resident at risk for serious injury or death. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.