Complaint Investigation Report

Allegation: Staff did not ensure resident ate

During the investigation, LPA conducted interviews with witnesses (W), staff (S), and reviewed resident (R1) documents.

R1 was admitted to the Bridge Program on 09/12/2024. Within two hours of admission, R1 eloped from the facility, requiring further intervention. On 09/17/2024, R1’s case manager notified the facility that R1 had been located following the elopement and was being transported to the Psychiatric Emergency Services (PES) at Contra Costa Regional Medical Center (CCRMC) for evaluation and stabilization. R1 returned to the Bridge Program on 09/20/2024. Program notes indicated that R1 attended dinner service that evening and ate their entire meal. No program notes were documented for 09/21/2024.

Witnesses (W1 and W2) reported that between 09/22/2024 and 09/24/2024, R1 consistently refused to eat. Staff (S3 and S4) corroborated these statements, adding that R1 was prompted at each meal but continued to refuse food.

W1, W2, S3, and S4 all stated that the SC initiated communication with county licensed clinicians due to concerns that R1 was decompensating and required professional evaluation.

On 09/24/2024, the A3 Crisis Team assessed R1 and placed R1 on a 5150 hold. Emergency services (911) were contacted, and R1 was transported to PES for further evaluation. R1 was diagnosed with Schizophrenia [F20.9] with psychosis and admitted to PES under Welfare and Institutions Code (WIC) as “Gravely Disabled.” R1 was discharged back to the Bridge Program on 10/24/2024 and remains under the program’s care.