The resident, identified in inspection records as R1, first left the building through the front door on July 29 at 3:35 p.m. Nursing notes documented the elopement but stated the resident "has had no further behaviors or attempts to exit building."
Three days later, that assessment proved wrong.
On August 1 at 2:54 a.m., a certified nursing assistant spotted R1 walking down the hallway toward the common room. Seconds later, a nurse monitoring security cameras watched R1 attempt to exit the facility. Staff ran to the front door as R1 walked out into the parking lot.
The resident continued walking forward and pushed past staff, heading down the street past a stop sign. R1 became violent and combative, swinging closed fists at nearby staff and repeatedly attempting to physically assault them while yelling throughout the incident.
Staff contacted the facility physician, who ordered R1 sent to the hospital for psychiatric evaluation. Police were called because facility staff could not safely return R1 to the building. The resident was transported to a local hospital.
Despite two elopement attempts in three days, with the second escalating to violence against staff, El Paso Rehabilitation never revised R1's care plan.
The existing plan, last updated May 27, identified R1 as "an elopement risk/wanderer" and included basic interventions dating back months. The April 10 intervention directed staff to "distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book." A May 1 addition instructed staff to "monitor for fatigue and weight loss." The final intervention, added May 27, told staff to "calmly redirect R1 and remind her that this is her home" and "find a task, activity or simply a conversation to engage her in."
No new interventions were developed after either escape attempt.
Federal inspectors arrived August 19 to investigate a complaint about the facility. At 1:10 p.m., they interviewed the Care Plan Coordinator, identified as V10, who confirmed R1's care plan had not been revised after the July 29 or August 1 incidents.
The coordinator acknowledged the facility's failure, stating that "the facility management team should have reviewed R1's plan of care after each elopement attempt and implemented new interventions to reduce the risk of R1 leaving the facility."
Federal regulations require nursing homes to develop complete care plans within seven days of comprehensive assessments and to have them prepared, reviewed, and revised by teams of health professionals. The facility's own policy, dated December 2024, directs staff to address each resident's strengths, weaknesses and care needs, using assessment data to develop comprehensive plans that help residents achieve "the highest practical level of mental functioning, physical functioning and wellbeing as possible."
The policy emphasizes using assessment data to address care needs, yet R1's escalating behavior and successful escapes generated no corresponding updates to prevent future incidents.
R1's case represents a clear breakdown in the care planning process. The resident demonstrated that existing interventions were ineffective by successfully leaving the facility twice. The second incident involved violence against multiple staff members and required police intervention, yet this dramatic escalation triggered no reassessment of safety measures.
The facility's failure violated federal care planning requirements, earning a citation for minimal harm with potential for actual harm affecting few residents. Inspectors found El Paso Rehabilitation failed to update the plan of care despite clear evidence that current interventions were insufficient to prevent a resident identified as an elopement risk from repeatedly leaving the facility unattended.
The August 1 incident particularly highlighted the inadequacy of existing measures. R1's progression from walking down a hallway to becoming violent with staff in the street within minutes demonstrated how quickly situations can escalate when proper safeguards fail.
Federal inspectors concluded their review on August 19, documenting the facility's admission that management should have acted after each elopement attempt. The inspection revealed a 22-day gap between R1's violent escape and any formal acknowledgment that the care plan required updating.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for El Paso Rehabilitation and Health Care Center from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
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