Complaint Investigation Report

All staff stated that R1 has history of leaving facility frequently. S1 stated that on 9/9/21, R1 left the facility at 7:00AM and R1 was going to the store. S1 stated that S1 called the day program when they discovered R1 did not return at the usual time and day program staff (W1) stated that R1 was there. At 3 p.m., S1 called the day program again and W1 stated that W1 made an error and R1 was not at the day program. At approximately 7:15 p.m., staff stated that the facility filed a missing persons report with the Pasadena police department since R1 had not come back to the facility. R1 stated that on 09/09/21 R1 forgot to sign out that day and was heading out to go shopping. R1 stated that RI was sent to the hospital because R1 looked disoriented. Per administrator, R1 was admitted to the hospital on 9/12/21 and was discharged from hospital on 9/16/21. Administrator stated that per physician, R1 was admitted due to the hospital because R1 was found unresponsive.

A review of R1's physician's report state that R1 is allowed to leave facility unassisted. Resident sign out sheet showed that R1 did not sign out on 09/09/2021. Incident reports revealed that R1 left facility on 09/09/21 and a missing persons report was filed on the same day. A follow-up incident report stated that UCLA Harbor Medical Center called the facility on 9/13/21 to report that R1 was hospitalized. The discharge papers shows R1 was admitted on 9/12/21 but did not state discharge date. R1-R4 stated that they are allowed to leave the facility unassisted as long as they sign out.

Based upon interviews conducted and records reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated. An exit interview was conducted with Administrator and a hard copy of the report and appeal rights were provided.