Facility Evaluation Report

Licensing Program Analyst (LPA) conducted an unannounced case management visit at the facility regarding incident report submitted to the department on 3/7/24. LPA met wtih Stephanie Funderburg and explained the reason for the visit.

On 3/7/24 facility submitted an incident report to report that on 3/4/24 at 5:30pm staff noticed resident #1 (R1) was not in the community and an exit door was open. R1 was last seen at 5:10pm after finishing dinner.

Interview conducted with administrator and staff revealed after video footage review, R1 used the emergency exit by room #129 in the memory care unit to exit to the parking lot, walked through the parking lot, and jumped over the parking gate to the street. Delay egress system was working, however staff did not hear the device as staff were at the dining room with other residents. Administrator and managers began to search in the area as soon as it was reported R1 was missing and were not able to find R1. Administrator notified Pasadena Police Department and R1's responsible party. Pasadena police department officers found R1 at around 5:48pm and return R1 to the facility. Upon facility's staff physical evaluation, staff noticed a laceration of about 1cm in diameter on the back of R1's head and was send via paramedics to the hospital for further evaluation.

Hospital Discharge dated 3/4/24 notes R1 was seen for an abrasion of scalp and no other head injuries were observed. It is unknown how R1 obtained the abrasion. R1 returned to the facility on the same day. Needs and Care plan dated 3/19/24 was updated with notes of resident has been placed on 24/7 supervision by additional care staff.

LPA observed emergency exit doors with delay egress system in working condition and tested door by #129 which was observed working but with a faint sound. During this visit administrator notified to have communicated the need of a different environment to the family, facility is assisting with seeking better placement for R1. R1 currently has a one-on-one staff to prevent further incidents.