Complaint Investigation Report

It is alleged a resident in memory care unit went outside the facility while the staff at the desk where on the phone calling for help. Interviews conducted with residents revealed, 6 out of 7 residents did not know if other residents have exited the memory care unit and gone out to the street or lobby. 1 out of 7 residents was unable to answer due to cognitive skills. Interviews conducted with staff revealed, 6 out of 9 staff interviewed stated that residents have exit the memory care unit unattended either reached the lobby or gone outside. 2 out of 9 staff stated residents have not exit the memory care unit and 1 out of 9 staff was not aware of the situation. Administrator and Wellness Director stated that R8 was found in the corner of Lake and Villa by a staff that was leaving her shift for the day on 3/24/23 and brought back into the facility. On 5/13/23 LPA conducted a complaint visit, during that visit LPA observed a resident exit the memory care unit unassisted into the lobby. Receptionist at that time called for assistance. Documents reviewed note the following: Physician’s report dated 8/17/21, note R8 has wandering behaviors and is unable to leave the facility unassisted. Needs and care plan does not note R8’s wandering behaviors and/or a plan to prevent R8 from leaving the memory care or the facility.

Based on LPAs interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED .

Regarding allegation: Staff are blocking the doorway to prevent the residents from coming out. It is alleged there is always a large wood board that staff put to block the door, so the residents don’t come out of memory care unit. Interviews conducted with residents revealed 3 out of 7 residents stated the doors are not block with any items. 2 out of 7 residents stated the doors are block with a wood board, 2 out of 7 residents were either not sure or unable to answer due to cognitive skills. Interviews with staff revealed 5 out of 9 staff stated the doors are not blocked with a wood board. 2 out of 9 staff stated the doors have been blocked with a wood board to prevent residents from leaving memory care unit. 2 out of 9 staff stated either the doors in the memory care unit are not closed correctly to ensure the egress system works or were not sure about if doors were blocked to prevent residents from leaving. During the tour conducted on 4/3/23 LPA Flores observed exit door by room #129 which exits to the parking lot blocked with a sliding wood board, egress system was observed not working for that door, and door was unlock during the visit. Per administrator there was a leak in the wall adjacent to the door and plumbers had to cut the electricity in the door to work on the door. No plumbers were observed working during the visit or staff around the area supervising.