Complaint Investigation Report

Allegation: Staff did not provide adequate supervision resulting in resident eloping from facility

During the investigation, the LPA conducted interviews of facility staff (S), and witnesses (W).

On 11/18/2024 LPA interviewed W1. W1 stated that R1 arrived at Regional Medical Center of San Jose (RMC) on 11/13/2024 at around 3:00 AM. W1 stated that R1 was found in San Jose and that the Emergency Medical Services (EMS) transported R1 to the Emergency Department (RMC) for evaluation. W1 stated that R1 was disoriented and presented with an altered mental status. W1 stated that R1 was hospitalized and was receiving treatment for an infection before they would get discharged. W1 stated that they found out that Opal Care LLC (facility) have gave notice of 30-Day eviction to R1 and that they were not going to accept R1 back after being discharged. W1 stated that they spoke with the Administrator and advised that they have to accept R1 back to the facility. W1 stated that a Missing Persons Report was filed by the family and not the facility.

On 11/20/2024 LPA interviewed S2. S2 stated that on 11/12/2024 the staff did a “roll call” for dinner at around 4:15 PM to 4:30 PM. S2 stated that S2, S4, S5 and S6 noticed that R1 was not in the facility. S2 stated that S2, S4, S5 and S6 searched all the rooms, the neighborhood and S3 drove to MacArthur Bart Station to look for R1. S2 stated that on 11/17/2024, another resident, R2, was admitted to Kaiser Permanente Oakland Emergency Department (ED) after being found. S2 stated that the ED Physician called them and said that they attempted a call to the administrator at the facility but there was no answer. S2 stated that they received the call and that they called the facility to confirm if R2's was missing and staff confirmed that R2 was not at the facility.