complaint·January 27, 2023

Regarding Allegation #1 : Facility staff did not adequately supervise resident resulting in resident wandering from the facility on more than one occasion. On 01/23/2023 LPA Calderon interviewed W1 for complaint. W1 states that resident has wandering behaviors and left the facility on 12/17/2022 and was found on Inglewood Blvd by unknown witness who called 911. W1 states that resident was transported to the hospital. W1 states that staff did not properly supervise resident and allowed resident to leave the facility. On 01/27/2023 LPA Calderon interviewed S1 who states she was advised by staff that resident had wandered and left the facility and was found on Inglewood Blvd. On 01/27/2023 LPA Calderon interviewed S2 who states that a guest was visiting the facility and left the front door unlocked. S2 states that staff was aware that resident had wandering behaviors and S2 could not find resident. S2 states that staff searched and 20 to 30 minutes later found resident on Inglewood Blvd, but 911 had been called and fire department took resident to the hospital. On 01/27/2023 LPA Calderon interviewed S3 who states that resident had wandering behavior and had left the facility. S3 states that S3 was told that a guest had left the front door unlocked when they left, and that resident followed the guest out the front door. On 01/27/2023 LPA Calderon reviewed resident facility paperwork to include physician report, needs and service plan and hospital records. Resident was noted to have wandering behavior by staff, but reports do not support this behavior. On 01/27/2023 LPA Calderon attempted to interview R1-R4 but due to communication issues residents were not able to answer any questions. Regarding Allegation #2 : Facility staff did not reset door alarm to prevent residents from leaving without notification on more than one occasion. On 01/23/2023 LPA Calderon interviewed W1 for complaint. W1 states that on two separate occasions resident had left the facility and staff had not secured the front door by locking the door or making sure the door alarm was working. On 01/27/2023 LPA Calderon interviewed S1 who states that a unknow guest left the facility and staff did not lock or alarm the front door one time, but resident who has wandering behaviors left the facility. On 01/27/2023 LPA Calderon interviewed S2 who states that a unknown guest left the front door unlocked and staff did not follow up and make sure the front door was locked and alarmed. On 01/27/2023 LPA Calderon interviewed S3 who states that the responsibility to make sure the front door is locked is the guest. On 01/27/2023 LPA Calderon attempted to interview R1-R4 but due to communication issues residents are not able to answer any questions. Regarding Allegation #3 : Resident sustained a fracture while in care. On 01/23/2023 LPA Calderon interviewed W1 for complaint. W1 states that resident has wandering behavior and had left the facility and was found on Inglewood Blvd by unknown witness who called 911. Resident was transported to the hospital and evaluated with a right fracture ankle due to a unwitnessed fall. On 01/27/2023 LPA Calderon interviewed S1 who states that resident was found on Inglewood Blvd, was transported to the hospital, and evaluated with a right ankle fracture. On 01/27/2023 LPA Calderon interviewed S2 who states that resident was found on Inglewood Blvd and was taken to the hospital with a right ankle fracture. On 01/27/2023 LPA Calderon reviewed hospital records for resident and resident was evaluated with a right ankle fracture. Regarding Allegation #4 : Facility staff are not adequately trained. On 01/23/2023 LPA Calderon interviewed W1 for complaint. W1 states that resident had wandering behaviors and staff had not been trained to deal with a resident with this behavior and had no training as to how to secure the front door to prevent a resident from leaving. On 01/27/2023 LPA Calderon interviewed S1 who states that no formal training had been given for staff to deal with a resident with wandering behaviors. On 01/27/2023 LPA Calderon interviewed S2-S3 who state that they were aware of resident wandering behaviors but were not given formal training. On 01/27/2023 LPA Calderon reviewed dementia training given on 12/19/2022, only 2 staff of 10 signed the sign in sheet and not clear as to what training was given. No training could be found regarding securing the front door or use of alarm. Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations “facility staff did not adequately supervise resident resulting in resident wandering from the facility on more than one occasion” “facility staff did not reset the door alarm to prevent residents from leaving without notification on more than one occasion” “resident sustained a fracture while in care” “facility staff are not adequately trained” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are being cited on the attached LIC 9099D. An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator (S1).