Complaint·January 27, 2024

During today’s visit, LPA Ernand Dabuet conducted a subsequent visit and delivered the findings. LPA/RA Elizabeth Ceniceros reviewed pertinent documents: Facility Staff Roster & Work Schedules and Residents’ Roster (January 2023), Unusual Incident Report (dated 01/16/23), Facility Profile, Personnel Report Summary, Facility Sketch (1 st & 2 nd Floors w/Apartment Numbers); Torrance P.D. Call Detail Report (dated 01/16/23) with photographs; Resident #1’s I.D. Information form (dated 12/21/21), Power of Attorney (dated 06/17/10), Admission Agreement (dated 01/04/21), Physician’s Report (dated 09/20/22), Appraisal Needs & Services Plan (dated 11/24/21), Resident Care Notes (dated 01/13/23), Personal Rights (dated 12/21/21), and Medication Administration Records (December 2022 & January 2023). INVESTIGATION REVEALED THE FOLLOWING: Allegation : Resident wandered away from facility due to lack of supervision resulting in hypothermia. It is alleged Resident #1 wandered away from the facility resulting in hospitalization for Hypothermia. Interviews conducted with facility Staff and residents revealed the following: According to interviews conducted and records reviewed Resident #1 is diagnosed with Dementia and has a history of wandering. According to A1, R1 wears a wander bracelet but it was removed on the day of the incident. On 01/15/23 (approximately 10:00 p.m.), Staff #8 (S8: Christina Guilo, Caregiver) conducted their routine, nightly rounds and had not observed Resident #1 in their room. Staff #8 proceeded with their routine checks and making their rounds and failed to notify Staff #4 (S4: Latasha Ramirez, Med Tech) of Resident #1 missing from their room. Staff #8 didn’t advise Staff #4 until (approximately) 11:00 p.m. on 01/15/23. Staff #4 and Staff #8 began a search for Resident #1 inside the facility; but they failed to look outside the exterior of the facility due to excessive rain. Staff #4 notified Staff #5 (S5: Jacklyn Lefeiloai, Resident Care Coordinator), Executive Director (A1: Julius Osorio), Staff #9 (S9: Courtney Clark, Health Services Specialist), and Resident #1’s Power of Attorney (W1: Family Member) of the missing resident (approximately) 3:30 a.m. on 01/16/23. Once permission was granted by management (A1), Staff #4 called 9-1-1 to make the notification to local law enforcement agency. Within that time, a passerby came to the facility to advise them that there was an elderly person outside in the rain. Resident #1 had been found supine in the bushes (near the sidewalk) in front of the facility (approximately) 4:00 a.m. on 01/16/23. Resident #1 was transported (via ambulance) and admitted to Torrance Memorial Hospital ER for severe hypothermia for which the resident was in ICU. Resident #1 was discharged from the hospital on or about 01/19/23 and did not return to the facility – pending availability in the Memory Care Unit. (Evaluation Report continues LIC 9099-C) Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/ LACK OF SUPERVISION: Resident wandered away from facility due to lack of supervision resulting in hypothermia is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and a citation issued (ref. LIC 9099D) and Civil Penalty assessed for $500 dollars. Allegation #2 : Staff did not notify police of missing resident. Interview and records review conducted revealed the following: this investigation revealed during an interview with Staff #8 (S8: Cristina Guico, Caregiver) admitted not reporting to Staff #4 (S4: Latasha Ramirez, Med Tech) that Resident #1 was missing from their room during their routine round checks (approximately) 10:00 p.m. on 01/15/23. Staff #4 admitted that they began searching for Resident #1 inside the facility (approximately) 11:00 p.m. on 01/15/23 once Staff #8 advised facility staff member; but, they failed to look outside the exterior of the facility due to excessive rain. On 01/16/23, beginning at 3:30 a.m., Staff #4 began notifying (via telephone) Staff #5 (S5: Jacklyn Lefeiloai, Resident Care Coordinator), Executive Director (A1: Julius Osorio), Staff #9 (S9: Courtney Clark, Health Services Specialist), and Resident #1’s Power of Attorney (W1: Family Member) of the missing resident. Once permission was granted by management (A1) to call 9-1-1, Staff #4 made notification of a missing person report to local law enforcement. IB investigator obtained copies of the Torrance Police Department call logs and there is no record of the facility called to report the incident. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of REPORTING REQUIREMENTS: Staff did not notify police of missing resident is found to be SUBSTANTIATED. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to the Activity Director Cortney Holmes.