Incident investigation·February 20, 2024

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management inspection to follow-up on an incident report received by Community Care Licensing on January 30, 2024. LPA spoke to Maria Jimenez, Administrator and explained the reason for the visit. Incident report indicated that on January 27, 2024 at about 6:25am, that while the two caregivers on duty were assisting other resident in the morning routine, it was observed that resident (R1) was not in their bedroom. Administrator immediately notified the responsible party, primary care physician and called local police department. Administrator was informed R1 was found at the near by park at 6:30am and 911 was called for assistance. R1 was transported to the local hospital for evaluation and was picked up by Administrator and brought back to the facility. During today’s visit, LPA interviewed AD who confirmed the details of the incident reported. LPA took a physical tour of the facility and observed residents in dinning table having breakfast and reviewed R1’s records and observed all auditory devices in doors were functioning. R1’s Physicians report indicates R1 has a dementia diagnosis but does not indicate R1 had wandering behavior. Resident appraisal dates May 13, 2023 indicates R1 did not have wandering behavior but likes to explore her environment. Preplacement indicates R1 is active and confused/forgetful due to cognitive impairment. This was the first elopement incident for R1 and first change of condition noticed. R1’s primary care doctor adjusted medication and adjustments were made to routine of care for R1 to avoid this incident from occurring again. R1 has been responding well to adjustments and has not had any other incidents since. R1 remains in the facility with no further issues to report. Due R1’s change of condition/no prior wandering behavior indicated medically and in observation and measures already taken by the facility to ensure the safety of R1 and as well as the other residents in care, LPA is issuing an LIC 9102 (Technical Advisory) in lieu of a citation. This report was reviewed with the facility representative and a copy of this report was provided to the facility.