Incident investigation·April 16, 2024

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Haley Parker, to conduct a case management visit. The purpose of today's visit is to follow up on an Unusual Incident/Injury Report (SIR) that was received by the Department on 4/8/2024. On 4/1/2024, staff were alerted by the delayed egress alarm at the back of the facility at approximately 2:20 PM. A head count of the community was completed and it was determined that resident (R1) had left the facility. Staff located the resident outside the facility at the adjacent intersection at approximately 2:28 PM. Resident was then redirected back to the facility by staff. No injuries were observed. Interview with Administrator indicated that the gate alarm of the delayed egress notified staff and staff immediately swept the parameter of the care home. Administrator confirmed that resident was found at the intersection adjacent to the facility and took about 8 minutes from the time in which the gate alarm activated and the resident was located. Administrator stated that another assessment of R1 will be conducted to better represent R1's behaviors. Administrator stated that facility will have staff present in the courtyard area with residents. Administrator will also follow-up with fire department regarding suggestions to improve delayed egress process. LPA observed R1's Physician's Report for RCFE LIC 602A dated 6/4/2023, which states that R1 has a diagnosis of dementia and is not able to leave the facility unassisted. Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.