Complaint Investigation Report

During today’s visit, LPA Ernand Dabuet conducted a subsequent visit and delivered the findings. LPA/RA Elizabeth Ceniceros reviewed pertinent documents: Facility Staff Roster & Work Schedules and Residents’ Roster (January 2023), Unusual Incident Report (dated 01/16/23), Facility Profile, Personnel Report Summary, Facility Sketch (1 st & 2 nd Floors w/Apartment Numbers); Torrance P.D. Call Detail Report (dated 01/16/23) with photographs; Resident #1’s I.D. Information form (dated 12/21/21), Power of Attorney (dated 06/17/10), Admission Agreement (dated 01/04/21), Physician’s Report (dated 09/20/22), Appraisal Needs & Services Plan (dated 11/24/21), Resident Care Notes (dated 01/13/23), Personal Rights (dated 12/21/21), and Medication Administration Records (December 2022 & January 2023).

Allegation : Resident wandered away from facility due to lack of supervision resulting in hypothermia.

It is alleged Resident #1 wandered away from the facility resulting in hospitalization for Hypothermia.

Interviews conducted with facility Staff and residents revealed the following: According to interviews conducted and records reviewed Resident #1 is diagnosed with Dementia and has a history of wandering. According to A1, R1 wears a wander bracelet but it was removed on the day of the incident. On 01/15/23 (approximately 10:00 p.m.), Staff #8 (S8: Christina Guilo, Caregiver) conducted their routine, nightly rounds and had not observed Resident #1 in their room. Staff #8 proceeded with their routine checks and making their rounds and failed to notify Staff #4 (S4: Latasha Ramirez, Med Tech) of Resident #1 missing from their room. Staff #8 didn’t advise Staff #4 until (approximately) 11:00 p.m. on 01/15/23. Staff #4 and Staff #8 began a search for Resident #1 inside the facility; but they failed to look outside the exterior of the facility due to excessive rain. Staff #4 notified Staff #5 (S5: Jacklyn Lefeiloai, Resident Care Coordinator), Executive Director (A1: Julius Osorio), Staff #9 (S9: Courtney Clark, Health Services Specialist), and Resident #1’s Power of Attorney (W1: Family Member) of the missing resident (approximately) 3:30 a.m. on 01/16/23. Once permission was granted by management (A1), Staff #4 called 9-1-1 to make the notification to local law enforcement agency. Within that time, a passerby came to the facility to advise them that there was an elderly person outside in the rain. Resident #1 had been found supine in the bushes (near the sidewalk) in front of the facility (approximately) 4:00 a.m. on 01/16/23. Resident #1 was transported (via ambulance) and admitted to Torrance Memorial Hospital ER for severe hypothermia for which the resident was in ICU. Resident #1 was discharged from the hospital on or about 01/19/23 and did not return to the facility – pending availability in the Memory Care Unit.