Complaint Investigation Report

9099C(1)... Resident (R1) moved to the facility on/around 7/13/22. Resident’s physician’s report, dated 7/6/22, notes resident has a diagnosis of Dementia, is confused/disoriented, is unable to leave the facility unattended and needs medication management due to Dementia. Pre-appraisal states that resident is ambulatory and is able to walk without any physical assistance and is able to mentally and physically follow signs. Pre-appraisal also notes that resident needs special observation/night supervision due to confusion, forgetfulness or wandering.

Allegation: Staff did not provide adequate supervision resulting in resident wandering away from facility. Complaint alleges that resident was able to leave the facility unattended due to the alarm system not working and/or insufficient staffing.

Staff interviews and resident charting notes document that resident first left the community unattended on 8/28/22 and again on 12/2/22. Charting notes entered on 8/28/22 note that at approximately 1:45 pm , resident left the outside garden area where she was sitting in memory care after eating her lunch. Notes also document that the Assisted Living Med-Tech heard on walkie that Memory Care caregiver announced that the alarm in Memory Care was going off and resident found way out of locked back gate in Memory Care and was walking up the hill. Charting notes entered later in the day on 8/2 8/22 indicate that “patio doors are locked so they will alarm if she goes out the back door…. Resident will need 1:1 care if she continues exit seeking behaviors”. All staff was advised to do frequent checks on resident to include how she is doing and her whereabouts".

Charting notes entered on 12/2/22 document resident's elopement and resident's responsible person was notified by telephone voice mail and a return call was requested. Administrator stated that when resident eloped to the back enclosed parking lot, resident's 1:1 caregiver was talking to another caregiver and staff heard the delayed egress go off. Administrator confirmed there were (3) staff on shift and resident was never out of sight from staff and did not sustain any damage or injuries. Administrator confirmed an incident report (LIC624) was submitted to the Department following each elopement; however, a citation has not been issued.

Based on information obtained, LPA finds the allegation to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. cont on 9099C(2)...