Incident investigation·March 4, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit at the facility regarding an incident report submitted to the department on 2/21/24. LPA met with Stephanie Funderburg and explained the reason of the visit. On 2/21/24 incident report was submitted to the department reporting that on 2/21/24 resident #1(R1) was witnessed outside the memory care unit(MCU) on the parking through a window in the parking lot around 9:45am. During today's visit LPA Flores reviewed the following documents; incident report dated 2/21/24, physician's report dated 12/12/23, resident assessment dated 2/21/24, service appraisal for R1 and activity plan for MCU. R1 was admitted to the memory care unit of the facility on 1/20/24. Physician's report notes R1 under dementia. Resident assessment was updated to note elopement on 2/21/24 and enhanced needs to provide ongoing redirection for exit seeking behavior and assistance with wandering device, which is the same as the initial service appraisal. Per activity calendar residents had fitness at 9:30am and Musical performance at 10:00am. LPA conducted a tour of the MCU and observed all emergency exits to have egress system in working condition, passageway leading from the fenced door of the courtyard was observed with pile wood planks against the side of each wall leaving about a foot and a half space of passageway. Video surveillance was reviewed, R1 is observed going into the courtyard at 10:16am, reaches the courtyard emergency exit door at 10:17am and pauses. At 10:18am R1 places the walker against the wall and fenced door, uses the walker to step in it and climbs over to the side wall and over the 7ft fenced door over to the other side, climbs down and walks towards the parking lot by 10:22am staff observed R1 and redirected R1 to the MCU. Interviews with staff revealed there are 3 staff on each shift and 29 residents in the MCU. At the time of the incident one staff was assisting a resident in the wing by the family lounge, the other staff was on break, and the third staff was assisting another resident in the shower room, other residents were with the activity staff in the activity room. (CONTINUED ON LIC 809C) Per administrator the staff were asked to provide supervision for R1, medications were adjusted by physician after notifying physician of incident, and is currently in the process of hiring an additional staff for the MCU. The facility has created a plan of care for R1 and there are no previous records of R1 elopement. However, during this visit LPA noted wood planks in the back passageway leading to the parking lot of the exit door from the MCU courtyard. Therefore, deficiencies are noted on LIC 809D per Title 22 Regulations Division 6 Chapter 8. Exit interview was conducted with Stephanie Funderburg and a copy of this report and LIC 809D was provided.