Complaint Investigation Report

Allegation: Staff did not provide adequate supervision resulting in resident wandering away from facility.

During the interview with S1, S1 stated that they were made aware of the elopement of R1. S1 stated that they were not at the facility when the staff realized that they could not find R1. S1 stated that R1 eloped from the facility on 8/19/2025. S1 stated that they were made aware that R1 was found several blocks from the facility with their walker and had fallen down on the street and a bystander flagged an ambulance which took R1 to the hospital. S1 stated that they received a call from S2 about the situation.

During the interview with S2, S2 stated that they were not at the facility at the time of the situation but was made aware of the situation from a staff member who called them. S2 stated that when they arrived at the facility, the staff at the facility stated that they have been looking for R1 for several hours but could not find R1. S2 stated that R1's responsible party called the facility and let S2 know where R1 was found. S2 stated that the hospital called W1 and let them know how R1 got there. During record review, LPAs observed that R1 is unable to leave the facility unattended. S1 and S2 stated that R1 returned back to the facility the same night. During record review, LPAs observed that R1 was discharged back to the facility the same night and no injuries was noted in the discharge summary.

Allegation: Staff did not inform resident's responsible party of incident.

During interview with S2, S2 stated that they notified S1 while the situation was happening and received a call from R1's responsible party before the facility could call. S2 stated that while they were looking for R1, they were going to call R1's responsible party after they found R1.