Incident investigation·January 7, 2025

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 02:12PM. The purpose of this visit is to conduct an investigation regarding two self-reported incidents that occurred on 12/05/2024 and 12/22/2024. Upon arrival, the LPA met with staff and Executive Director (ED) Susan Weisbarth. Entrance interview conducted. During today’s visit, LPA Barutyan conducted a brief physical plant tour to ensure there are no health and safety hazards and conducted interviews with five (5) staff members and attempted interviews with two (2) residents. On 12/10/2024, the Department received an incident report stating that on 12/05/2024 around 10PM, Resident 1 (R1) eloped and left the facility unassisted through the back Egress door and had a fall on the sidewalk. Staff heard the alarm ring and noticed that R1’s room was empty. Staff checked inside and outside the facility and found R1 outside being assisted by the Fire Department, which a neighbor called in. R1 was transported to the hospital and was diagnosed with a urinary tract infection (UTI) contributing to R1’s confusion and wandering. Facility management held a meeting with R1’s responsible party to discuss changes in care such as a 1:1 caregiver for nighttime, bed/floor alarms, or relocating R1 to a room in the front of the facility. On 12/27/2024, the Department received an incident report stating that on 12/22/2024 around 2PM, Resident #2 (R2) was spotted by Staff #1 (S1) outside of the community as R2 had eloped unnoticed. S1 recognized R2 and assisted R2 back to the facility. No injuries were noted. Report Continued on LIC 809-C LPA interviewed ED Weisbarth and Health and Services Director (HSD) Tony Nunez on 01/02/2025 who stated that R1 and R2 eloped from the same back Egress door. According to ED and HSD, staff reported that the alarm sounded when R1 eloped on 12/05/2024, which is why staff were able to act quickly and call a code yellow, but did not sound when R2 eloped on 12/22/2024, which is why staff were unaware that R2 had eloped. ED and HSD reviewed the alarm logs and checked the system which showed that the alarm did ring on 12/22/2024. Per HSD, the alarm rings very loud and it is unlikely that staff did not hear the alarm. ED stated they are currently in the process of installing perimeter cameras and a potential gate to secure the grounds. ED also stated that they are looking into changing the delayed egress from 15 seconds to 45 seconds. LPA requested copies of pertinent documents relevant to the investigation on 12/10/2024 and 12/31/2024, documents were received via email on 01/03/2025. On 01/03/2025, LPA reviewed preplacement appraisals and physician’s reports for R1 and R2. R1’s physician’s report dated 11/26/2024 documents that R1 has dementia, mental condition is confused/disoriented, has wandering and sundowning behavior, and is not able to leave the facility unassisted. R2’s physician’s report dated 03/27/2024 documents that R2 has dementia, requires continuous bed care, mental condition is confused/disoriented, has sundowning behavior, is not able to communicate needs or follow instructions, and is not able to leave the facility unassisted. During the visit, LPA interviewed staff who stated that R1 was away from the facility for a period of about 10 minutes. Staff heard the alarm and noticed R1’s empty room, code yellow was immediately called and all staff searched for the resident. For R2’s elopement, staff stated that two (2) door alarms sounded. When staff went to check the doors, they observed Resident #3 (R3) who has a habit of attempting to open the Egress doors and sounding the alarms. Staff assumed that the alarm was sounded by R3 and did not check if other residents were missing. During the visit, LPA observed R3 wandering in the hallways. LPA was unable to interview the residents as R1 moved out of the facility, R2 did not wish to speak to the LPA, and R3 was disoriented and unable to communicate with LPA. During the physical plant tour, LPA asked the maintenance director to demonstrate that the delayed egress door worked. Door was tested twice at 02:34PM and was functioning properly during the visit. The alarm was triggered when the bar was pushed, and each door has three (3) alarms. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.