Complaint Investigation Report

The police brought the resident back to the facility and S1 informed the family that R1 needed a higher level of care and the family understood. R1 was able to leave the facility a second time and facility staff were alerted by the sound of the auditory exit alarm and were able to catch up with the resident and redirect R1 back to the facility. At that time S1 called the family and informed them they need to find a new facility for R1. The family called the Psychiatric Evaluation Team (PET) to go check on R1 however, the PET said they could not see R1 at the facility (Senior’s Retreat) the resident could only be evaluated in the emergency room. At that time R1’s family called 911 and had the resident sent to the hospital.

According to S1, after a few days the nurse, discharge planner, and the social worker from the hospital called and asked if R1 could return to the facility. S1 admitting to telling hospital staff, R1 could not return because the resident needed a higher level of care.

Based on the evidence gathered through the interview with Staff 1, and observations the preponderance of evidence standard has been met, therefore, the above allegation is SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22.