Complaint Investigation Report

According to Unusual Incident Report (LIC 624) submitted to the Department and dated 9/12/2021, on 9/10/2021, resident (R1) was observed to have left the facility unassisted. Facility notified Local Police Department around 9:10 PM. R1 was escorted back to the facility by Local Police at approximately 9:15 PM.

Interview with staff member (S4) indicated that R1 had moved in the Assisted Living Unit (ALU) and was fairly new. The night of the incident, R1 thought the facility was a hotel and wanted to “check out.” R1 initially was in the lobby with no concierge. Staff were checking on R1 every 30 minutes. Staff came around 10 minutes after speaking with R1 and found that R1 was missing.

Interview with ED indicated that Local Police located R1 at Sutter Medical Center (Sutter Medical Center shares parking lot with facility). R1's family was contacted after incident and R1 was moved the same night, 9/10/2021, to the facility's Memory Care Unit (MCU) due to elopement risk.

R1's Physician's Report (LIC 602) dated 8/27/2021 states that R1 is not able to leave the facility unassisted. R1's LIC 602 dated 8/27/2021 also stated that R1 has a primary diagnosis of dementia.

Allegation: Staff do not respond timely to residents' alerts.

Interview with ED indicated that standard response time to residents' call button is 7 minutes, with no more than 15 minutes passing before responding to a resident's call button. LPA reviewed "Questions Related to Alert Pendants at Oakmont," which indicated that "response time is up to 12 minutes, average response time is 4 minutes."

Interviews with staff members S1, S2, S3, S4, S5, and S6 indicated varying times for what would be considered the standard response time to a resident's call button. Interview with S4 indicated that standard response time to residents' call buttons are anywhere between 10 to 15 minutes. Interview with S5 indicated that staff watch pagers and once a call button alert gets "2 tries," staff are alerted to address the call button. The concierge watches a computer in the back and the ED has a pager and can look at response times to monitor staff addressing call buttons. "Try-2" is around 6 minutes. S5 stated that call button alerts may reach "Try-3" if staff need to get from one side of the facility to another. Try-3 is around 10 minutes.