complaint·March 6, 2023

Regarding allegation: Facility staff did not adequately supervise resident resulting in resident being found outside with a head injury. It is alleged that R1 was found outside of the facility with blunt head injury while it was cold and raining, and is unknown for how long R1 was left outside for. LPA conducted a tour of the facility memory care unit (MCU) with the assistance of Keith and Desiree. LPA observed the MCU to have one central entry point that is locked and could only be opened by entering a code on a keypad, located to the left of the door. R1's room was inspected. The room is a shared bedroom and has a door that leads outdoors to the locked patio area, still located within the MCU. The door was equipped with an auditory device and was operational at the time of the visit. During interviews conducted, (5) of (5) staff confirmed R1 had a fall on 2/28/23, that resulted in a head injury; however, all residents in the MCU receive visual checks every one hour, to ensure they are still within the parameters. S2 and S3 were present when the incident occured. (1) of (2) staff state the auditory device in R1's room was not operating when the incident occurred, while the other staff could not recall if the auditory device was operating. Per S3, at about 2:00AM, R1 was checked on and was in bed. At about 3:00AM, S3 returned to begin checking on the residents and arrived at R1's room at about 3:45AM. Upon arrival at R1's room, S3 noted that R1 was not in bed and informed S2. Both staff searched for R1 throughout the MCU and did not find R1. S3 then walked out of R1's bedroom door toward the MCU patio, about 15 feet away, and found R1 on the floor with bruising and a laceration above the eye - still within the MCU's parameters. R1 never left the MCU. S2 states to have followed behind S3. So, when S3 found R1, S2 assisted S3 to check on R1 and S3 went to go call the facility nurse and proceeded to call 911. (3) of (5) staff stated they did not notice a change in condition or behavior from R1 in the events leading to R1's fall, nor did R1 express a desire to leave the facility at any time. (2) of (5) staff state they were informed at shift change that R1 appeared to be more agitated and confused than usual. After review of R1's Physician's report dated: 08/30/22, R1 is unable to leave the facility unassisted due to cognitive impairment, does not have wandering behavior, and does not have sundowning behavior. Per R1's Pre-Placement appraisal and current appraisal, R1 is able to ambulate independently without assistance of a device.Per hospital discharge documents, R1 was discharged to facility skilled nursing to receive wound treatment on eye laceration. LPA attempted to interview R1 to obtain details of the incident; However, due to R1's cognitive impairment, R1 could not recall the incident occurring. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the complaint investigation of the allegations are Unsubstantiated. Per California Code of Regulations, Title 22 and Health and Safety Code, no deficiencies were cited. An exit interview was conducted and a copy of the report was provided.