Complaint Investigation Report

LPA reviewed R1's physician's report dated September 9, 2024. Physician's report revealed the following; R1 had a primary diagnosis of severe vascular dementia with other behavioral disturbance. R1 was confused, disoriented and had wandering behavior. R1 was not able to leave the facility unassisted. R1's care plan dated March 16, 2022 indicated that elopement was one of R1's "problems." The care plan stated that R1 would be monitored by care staff and personally checked on at least every two hours. LPA searched the CCL incident report database and found three reports were submitted to CCL regarding R1 eloping. The incident reports were dated February 13, 2023, April 13, 2024 and March 22, 2025.

LPA interviewed Staff 1 (S1) who stated that on March 22, 2025 at approximately 4:45PM they were alerted by a resident that their was "somebody in the bushes." S1 stated that they immediately ran towards the front of the facility and found R1 seated in the car of a "good samaritan." S1 stated that they then asked another staff member to assist them in escorting R1 back to the facility. S1 stated that R1 had no visible injuries at the time but was extremely agitated. S1 then asked the front desk to call emergency services as a precaution. S1 stated that R1 had a history of exit seeking and eloped from the facility approximately two to three times. S1 confirmed that in each occasion R1 "completely left the facility" without staff knowledge. S1 stated that the memory care unit was "short staffed" on the day of the incident which resulted in the closure of one of the housing units. S1 stated when one of the housing units is "closed" staff is required to monitor and care for more residents. S1 stated that several of these residents were "total assist" or bedridden which means that they required more time and assistance from the care givers.

LPA interviewed Staff 2 (S2) who stated that their was a lot of "chaos" on the day of the incident. S2 explained that one of the housing units was closed in memory care which resulted in 17 residents being placed in the day room for supervision. S2 stated that throughout most of the morning and afternoon the residents were crying and in need of care. S2 stated that at some point in the afternoon R1 got up from the dayroom area and walked towards their room, which was located in the housing unit that was closed for the day. S2 stated that R1 walked past their housing unit, into the subsequent housing unit, entered room #138, opened the window and escaped. S2 stated that they were not aware that R1 got up and left the television area. S2 stated that R1 had "escaped" the facility four times. S2 stated that on a separate occasion, R1 left the facility and walked into a 7-eleven at the corner. S2 stated that R1 was escorted back to the facility by a passerby who assumed they lived at the facility. S2 stated that they are aware R1's care plan indicated that R1 was to be checked on every two hours but due to the staff shortage it was not realistic.