El Rancho Vista Health Care Center
8925 Mines Avenue, Pico Rivera, CA 90660
Citation Number: 940004104
Citation Date: 08/12/2011
Violation Date: 7/7/2007
Class: AA
Penalty: $ 80,000

On 7/07/07, an 80 year old resident who suffered from severe mental illness was struck by a train and died after sustaining multiple traumatic injuries. The resident wandered away from El Rancho Vista Health Care Center that day without being detected despite a recent history of wandering and his doctor's order to use Wanderguard, a device that alerts caregivers when someone exits through a monitored doorway. The investigator found that the resident had eloped from the facility four times earlier in the week of his death and had attempted to elope three other times that week. The nursing assistant assigned to him the day of his death reported she had not been informed about his wandering behavior until after he was missing and that she did not remember seeing him wearing a Wanderguard bracelet. There was also no evidence that the resident was wearing the Wanderguard bracelet during any of the prior elopements that week. The facility was cited because its neglect of the resident led to his death.