Complaint Investigation Report

Regarding Allegation: Staff are not properly supervising residents resulting in elopements

It is alleged that a resident has been reported missing four times within the last month and a half. RP was concerned of the facility’s security measures and its ability to provide adequate supervision and staffing for the residents.

The investigation revealed the following:

Based on record reviews, Resident I (R1) was admitted to the facility on March 4, 2025 and was discharged on April 21, 2025. R1 was diagnosed with Dementia and is not able to leave the facility unassisted according to their Physician’s Report dated March 4, 2025. The department received an Incident Reported dated April 20, 2025 indicating that R1 eloped from the facility. R1 was discovered missing again at 7:28 PM on the same day. It was not noted when R1 returned to the facility. Another Incident Report dated March 14, 2025 indicates R1 left the facility again at 12:40 pm. The caregiver (S2) noticed the window was left open. The resident was found at the local Dollar Tree and returned to the facility.

Based on interviews conducted, three out of three staff corroborated to the allegation. One resident could not confirm or deny the allegation. All staff confirmed the resident eloped from the facility on April 20, 2025. All staff stated the resident left the facility in the morning around 11:00 AM and was found at a Ford Dealership near the facility by the police. A staff member arrived at the Ford Dealership where the police was with the resident. The police asked the resident if they wanted to be accompanied by the staff or by the police back to the facility. The resident wanted to return to the facility with staff. The resident and staff were heading towards Dollar tree, where the resident hit the staff in the head twice, then ran away from the staff. Staff called 911. S2 and S3 state police found the resident and returned to the facility around 7:00 PM. Then the resident left the facility again around 7:30 PM. S2 and S3 state the police were notified that the resident was missing again and from orders of hospice, when resident returned that the resident needed to go to the hospital to be evaluated. Resident returned to the facility on April 21, 2025, around 2:30 AM. The police were notified by staff that the resident returned. Per orders of hospice, the Police accompanied the resident to the hospital to be evaluated.