Complaint·November 8, 2024

Allegation: Lack of supervision resulting in resident eloping from facility. It was reported that on 10/31/2024, resident (R1) was found wandering the streets in a very confused state and was transported to the hospital at 7:39 PM. According to information obtained, on 10/31/2024 two (2) Skilled Nursing Facility (SNF) escorted resident (R1) to the facility as pre-planned by facility staff and SNF care team, and the resident was received by Wellness Director/staff (S1) at 4:42 PM. Based on staff interviews, resident (R1) was transferred to the facility, and as Assistant Administrator was reviewing admission agreement the resident walked out the door. Wellness Director/staff (S1) attempted to redirect and followed him a short distance, but the resident refused to return to the facility. Staff (S1) is not on shift today and was not interviewed. Three (3) other staff were interviewed. Assistant Administrator/staff (S2) and another Wellness Director/staff (S3) stated that the facility did not consider resident (R1) a resident because the resident refused to sign admission documents. Per Health and Safety code §1569.2 (c) Definitions. “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered....The resident was received by staff (S1) at 4:42 PM. Per record review of SNF discharge documents provided to the facility, R1's Physician's Report states the R1 has Dementia and metabolic encephalopathy. The SNF Admission Record states R1 has difficulty walking and muscle weakness and "does NOT have the capacity to understand and make decisions". LPA interviewed SNF staff, hospital staff, and Downey Police Department personnel. The findings indicate, that facility staff did not call the police department after unsuccessful attempts to redirect the cognitively impaired resident. Downey Police Department received a phone call at 6:15 PM from a passerby stating a male was found wandering the streets off of Lakewood Blvd and Margaret St in a confused state. The passerby reporting party stood by until the Police Department arrived. Therefore, there is sufficient evidence to corroborate the allegation because facility staff neglected responsibility in ensuring the resident's safety. Based on observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to Title 22. See LIC 9099D. An exit interview was conducted with Assistant Administrator Cynthia Flores. A copy of the report and appeal rights were issued.