Complaint Investigation Report

One night prior to R1’s elopement from the facility, R1 had a fall in the facility causing head trauma and requiring R1 to be observed in the hospital overnight. R1 sustained a hematoma and concussion from the fall. The hospital cleared R1 to leave the next day; and R1 was brought back to the facility the day of the elopement. According to the allegation, the facility was informed of the injury and stated that R1 would be properly supervised, including additional supervision due to the head injury from the fall. However, this supervision did not occur and R1 eloped from the facility due to improper supervision.

On 04/11/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a complaint investigation visit to the facility above. During this visit, the LPA toured the physical plant areas inside and outside that included the observation of the common areas of the facility as well as the individual resident bedroom areas of the facility. LPA observed that most resident bedrooms in the facility contain a front bedroom door as well as a separate door/sliding door to the exterior of the facility. The doors exiting the interior of the facility are monitored by an auditory alarm system in place that alerts Staff members with a loud noise when a door exiting the facility has been opened. These auditory alarm system(s) are located on every door that exits the interior of the facility into the outdoor areas/out of the facility. The auditory alarm system(s) consist of an electronic plastic/metal box and/or device approximately the size of a telephone that are attached to each door at eye level. The auditory alarm system(s) are powered by batteries which need to be changed monthly according to Staff interviews by LPA. This auditory alarm system is in place on the front door of the facility which exits the facility into the front yard and street. The bedroom of Resident #1 (R1) did have an auditory alarm system in place attached to the sliding door exiting R1’s bedroom into the backyard at the time of the allegation.

On 04/11/2024, during the complaint investigation visit, LPA interviewed Staff members about the auditory alarm system(s) in place on doors exiting the facility to outdoor areas, and the monitoring of residents at night in the facility. According to Staff member interviews, the auditory door alarms/alert systems on each exit door out of the facility are battery powered which need monthly maintenance to change the batteries. Without the changing of batteries in the auditory alarm systems monthly, the noise emitted when an exit door is opened could be very faint or potentially nonexistent. Staff members interviewed by LPA stated that the batteries are changed monthly in the actual auditory alert system situated on each doorway out of the facility.