complaint·November 29, 2022

CONTINUED FROM FORM LIC9099 Based on the staff interviews conducted and special incident report provided by the facility, during the night of 10/23/2022 between the hours of 3:00am and 5:00am, resident R1 was able to leave the facility unsupervised and without the knowledge of facility staff present while staff member S1 was attending to another resident. Sound alarms are observed by LPA to be present at the facility during the visit but it is alleged that the volume was insufficient to adequately alert S1 of the resident's exit from the physical plant when it occurred. Resident was then found by first responders and taken to Hoag Hospital before being released back to the facility at approximately 11:30am the same day. Following the incident, a meeting was initiated with R1's Durable Power Of Attorney (DPOA) to update the safety measures in place. A review of staff records confirmed that all facility staff have received appropriate dementia training. The facility has at least one night staff person awake and on duty to tend to residents requiring night supervision, with one additional staff on call and present on the facility's premises. The volume of the auditory alarms has been increased. A neurology appointment was set up for resident R1. Facility staff has additionally requested an updated medical assessment by both the resident's primary care provider and neurologist in order to determine whether the current placement at the facility is still adequate in light of the increased needs of care and supervision displayed by R1. While attempts at ensuring the resident's health and safety are confirmed to have been made by facility staff, these attempts fell short of their intended goal, resulting in R1's leaving the premises unsupervised. Based on the interviews conducted, observations made during the two complaint investigation visits and a review of available staff and resident records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency to the California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached form LIC 9099D and a civil penalty of $500 is being assessed. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights