complaint·March 15, 2023

CONTINUED... The day of the incident, staff reported attempting to place R1 in bed but reported R1 refused to stay and kept getting out and crawling around on the floor. Staff reported last checking on R1 around 11:30 AM. At approximately 12:15 PM staff reported R1 was found bloodied and wandering the downstairs patio. Per Wellness Director and Memory Care Director, facility staff are to check on residents every two hours. A review of the physical plant confirmed locks were placed on resident windows, however, interviews reported R1 was able to bypass the window lock by lifting the window frame out of the window. Upon entering R1’s room, staff observed R1’s window screen to be off, bent up and setting next to the window. R1 had a known history of depression and generalized anxiety with dementia; however, had no history of suicidal ideation. During an interview with R1, R1 appeared to be alert to time and space and acknowledged jumping out the window due to being in fear of their life as they believed a man and woman were going to torture them for information. R1’s spouse reported believing R1’s hallucinations are a result of medications R1 was placed on. Hospital records obtained confirm upon assessment, hospital staff noted it was difficult to discern at the time of admittance if R1 had any suicidal ideation. R1 was assessed to be able to make their own decisions. Following the incident, the facility has placed an extra lock at the top of all memory care windows to prevent the screens from being removed out. In addition, caregivers and maintenance staff are now expected to check on windows. Based on the investigation, the allegation that Facility did not provide adequate supervision resulting in resident jumping out a window was found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with Administrator Charles Eusey and Health and Wellness Director Laura Sanchez, and a copy of this report, and confidential names list were left at the facility.