complaint·January 18, 2024

Regarding Allegation #1 : Staff allowed resident to wander from facility resulting in a fracture. This complaint alleges resident R1 left the facility memory care unit and sustained an injury in the facility parking lot. On 11/23/2022 received and reviewed the department’s Investigation Branch (IB) Investigator Edward Hector report. The investigators report states: During the investigation I obtained and reviewed medical records. I interviewed the R1, R1 son and facility administrator and facility staff. All information and interviews confirm that R1 was assigned to the secure and locked memory care unit. R1 absconded from the memory care unit and was later found outside in the parking lot of nearby facility with an ankle injury. R1 did not explain how R1 escaped the memory unit and staff have no information on how R1 got out without any alarms going off. There is sufficient evidence to support the allegation of lack of supervision”. Based on LPA’s observations and interviews conducted along with records reviewed, there is sufficient evidence that facility “ Staff allowed resident to wander from the facility resulting in a fracture”, therefore this allegation is determined to be “substantiated”. An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Peggy Clark (A1). Regarding Allegation #1 : Staff abandoned resident. This complaint alleges that the facility refused to allow R1 to return to the facility after a hospital visit. On 08/17/2023 LPA Calderon interviewed A1(Gomez) for a complaint. A1 (Gomez) expressed that R1 was admitted to the hospital for a left ankle injury sustained during the incident when (R1) wandered off the facility. On 08/23/2023 LPA Calderon interviewed A1 Veronica Gomez and A2 Peggy Clark. A1 claimed that the facility would never abandon a resident in the hospital without evaluating a resident for additional medical care and would take steps to notify the family representatives of R1. A1 and A2 expressed that A1 went to the hospital to evaluate R1. A1 and A2 claimed that R1 had been physically violent with staff and residents while at the facility and continued with violent behavior towards A1 and A2 while at the hospital. Evaluation of (R1) revealed due to (R1’s) violent behaviors, the hospital records confirmed: “Psychiatric based hospitalization is necessary due to patient confusion and easily agitation and disorientation”. Medical records revealed that based on medical assessment, it is recommended to transfer (R1) to a psychiatric unit when medically cleared. Records indicated that medical professionals consulted with family representatives and agreed that (R1) should go to a psychiatric facility to receive treatment before returning to the facility. S1-S4 was interviewed and reported that it is normal for staff to evaluate a resident who is taken to the hospital for further care before the resident is returned to the facility. S1-S4 expressed that they do not know as to why R1 was not returned to the facility. On 02/08/2023 LPA Calderon interviewed R2-R13 for complaint. 12 out of 12 residents expressed that staff would not abandon them at a hospital. On 10/03/2022 LPA Calderon reviewed the South Coast Medical Center report (09/17/2022). “R1 was diagnosed with health issues”. S1-S4 was interviewed and reported that it is normal for staff to evaluate a resident who is taken to the hospital for further care before the resident is returned to the facility. S1-S4 expressed that they do not know as to why R1 was not returned to the facility. On 02/08/2023 LPA Calderon interviewed R2-R13 for complaint. 12 out of 12 residents expressed that staff would not abandon them at a hospital. On 10/03/2022 LPA Calderon reviewed the South Coast Medical Center report (09/17/2022). “R1 was diagnosed with health issues”. Based on LPA’s observations and interviews conducted along with records reviewed, there is insufficient evidence that facility “ Staff abandoned resident”, therefore this allegation is determined to be “unsubstantiated”. An exit interview was conducted, and a copy of the Complaint Report to the Administrator Peggy Clark (A1).