Complaint Investigation Report

Regarding Allegation #1 : Staff allowed resident to wander from facility resulting in a fracture.

This complaint alleges resident R1 left the facility memory care unit and sustained an injury in the facility parking lot. On 11/23/2022 received and reviewed the department’s Investigation Branch (IB) Investigator Edward Hector report. The investigators report states: During the investigation I obtained and reviewed medical records. I interviewed the R1, R1 son and facility administrator and facility staff. All information and interviews confirm that R1 was assigned to the secure and locked memory care unit. R1 absconded from the memory care unit and was later found outside in the parking lot of nearby facility with an ankle injury. R1 did not explain how R1 escaped the memory unit and staff have no information on how R1 got out without any alarms going off. There is sufficient evidence to support the allegation of lack of supervision”.

Based on LPA’s observations and interviews conducted along with records reviewed, there is sufficient evidence that facility “ Staff allowed resident to wander from the facility resulting in a fracture”, therefore this allegation is determined to be “substantiated”.

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Peggy Clark (A1).