Complaint Investigation Report

On April 3, 2025, during subsequent visit, LPA Lee obtained a copy of elopement procedure training and sign in sheet. The training was conducted March 17-28, 2025.

During the investigation, LPA conducted 5 additional staff interviews (S8-S12) via telephone and/or obtained written statements due to their shift schedule and availability at the time of LPA’s visit.

The investigation revealed the following:

Resident sustained a serious injury while in care

The detail of the complaint alleges that on February 2, 2024 R1 sustained a fractured hip while eloping from facility. On 1/17/2025 between 8:30am and 9:40am, LPA interviewed Administrator David Cole (A1) who did not deny the allegation and informed LPA that he was aware of the incident and completed an Unusual Incident Report (UIR) when it occurred. A1 stated that all exit doors are delayed egress and equipped with a secondary alarm. Despite the alarms on the exit door, R1 was able to get out of the facility and subsequently found in the rear of building. On 01/17/2025, LPA reviewed ambulance transport document, which revealed that on 2/2/24 at 10:00pm R1 was seen by a passerby laying on ground in alleyway near facility. 911 was called, R1 reportedly complained of hip pain. Emergency services transported R1 to Ronald Reagan Medical Center. The review of R1's Emergency Department to Hospital admission/discharge documentation (MR #6530489) dated 2/2/24 revealed that R1 arrived via ambulance transport to ER and was subsequently admitted to hospital. R1’s diagnosis was Intertrochanteric Fracture, Osteoporotic Hip Fracture. R1 was treated and discharged on 2/10/2024.