Incident investigation·May 24, 2024

Licensing Program Analyst (LPA) Rose Ruppert conducted an unannounced case management visit to follow up on an incident report submitted to the department on May 14, 2024 by Assisted Living Director (ALD), Christina Gonzalez. The purpose of this visit is for a case management incident where a client eloped from the facility on May 10, 2024 and was found by Orange Police Department (PD) on a nearby street. LPA requested resident file and evening staffing roster for May 10, 2024. LPA interviewed resident (R1) to ensure she was okay. Resident did not recall PD finding her and stated she, "took off by herself on a long walk." Reviewing R1's file she is unable to leave the facility unassisted but is able to walk around the building. R1 usually has a friend with her or is in an activity walking during the day but the incident took place in the evening around 7:15pm. The concierge did not see R1 leave the facility. ALD took the call from PD and the son happened to be entering facility at the same time. LPA interviewed S1,S2, S3 and ALD. On November 13, 2023 ALD noted a change in condition with R1. On April 10, 2024 NP with Senior Doc stated R1 is, "incapable of making an informed decision..because of the patient's condition, which includes dementia." Prior to the incident R1 did not have exit seeking behavior and checks in with concierge whenever she walks outdoors. Based on LPA observations and interviews there was adequate staffing, with two medical technicians, three aides and the ALD. After the incident ALD spoke with the son and agreed to use a wander guard for R1. ALD is initiating a care plan meeting for R1 to move to Memory Care due to the progression of cognitive decline. Currently they are awaiting urinalysis results to determine if there are other underlying issues. An exit interview was conducted with RRD Debbie Marroquin and a copy of this report was provided at exit.