Complaint Investigation Report

S1 stated they were mopping under the table, medications were already administered, and staff #2 (S2) was on their phone. S1 stated that the front door was open because two (2) residents were sitting outside on the porch, and R1 walked out the door. S1 stated that they let S2 know, and as S1 was about to call 911, S2 went out to look for R1. S1 stated that S2 returned to the facility without R1. Therefore, S1 went looking for R1 in the company van. S1 stated that as they were searching the neighborhood for R1, the police turned on their siren, and ask S1 if they were looking for someone. S1 stated that R1 was in the back seat of the police car.

LPA Nickolas’ interview with S2 confirmed that R1 AWOL’ed from the facility on June 8, 2023. S2 stated that the facility has two (2) caregivers per shift. S2 stated they administered medication while S1 was mopping. S2 stated that S1 informed them that R1 had AWOL’ed. However, S1 could not redirect R1 before R1 left the facility because S1 was mopping. S2 stated that after they put away the medications, they looked for R1. LPA Nickolas’ review of the facility’s shift schedule for the week of June 4, 2023, revealed that the facility had two (2) caregivers working the morning and afternoon shifts.

During today's visit, LPA Nickolas’ did hear the alarms activate when the front door was opened in the facility. However, although the facility is adequately staffed to meet R1's needs, the staff on duty were preoccupied. They were not able to redirect R1 in time or were not able to look for R1 right away.The finding is substantiated.

A finding that the complaint is substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

LPA Nickolas will follow up with R1's placement agency to discuss the reassessment of R1's level of care.

An exit interview was conduct were a copy of this report (LIC 9099), LIC 9099D, and appeal rights were emailed due to technical difficulties.