Incident investigation·August 21, 2024

08/21/2024 02:00 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Executive Director Sonya Gonzales. LPA interviewed four staff during the visit. Today’s visit is regarding an incident that occurred on 08/16/2024. It was reported that on 08/16/2024 staff were notified that Resident 1 (R1) was in the lobby of Oroville Hospital Post Acute (OPAC), right next door to the facility. R1 had walked out of the garden gate which is normally locked (waiver in place), and walked next door. During the course of the investigation, it was learned that on 08/16/2024 staff had let the gardener in to provide services in the memory care garden. The normal protocol is that the gardener would notify staff when they needed to be let out of the garden area through the secured garden gate. Staff do not recall letting the gardening crew back out of the gate and it is unknown how they left the secured premises. When staff were notified by OPAC staff that R1 was in their lobby staff walked next door and escorted R1 back to the facility. Staff notified the administrator and R1’s responsible party of the incident. R1 was unharmed as a result of the incident and came back willingly to the facility. In order to prevent this from happening again the facility is going to hire a new landscaper that understands the importance of securing the memory care gate. Facility is going to conduct an in-service with all staff on the importance of monitoring the residents, performing resident counts, and when there are outside vendors that need to access the garden staff will be present the entire time until they exit the garden area. No deficiencies are being cited as a result of today’s visit.