complaint·March 20, 2024

Per the video obtained, R1 can be seen knocking the screen out of the window and climbing halfway out the window. R1 then climbed out onto the small ledge beneath the window and turned around to jump to the ground. At approximately 6:41 PM cameras observed a shadow seen falling out the side of the building. At approximately 6:53 PM a staff member found R1 lying on the sidewalk below their bedroom window. Resident records obtained did not note R1 had a history of suicidal ideation. Interviews with five of seven staff reported R1 had a history of wandering and attempted elopement. Orange County Coroner Report lists R1’s cause of death as Hemopneumothorax, Rib Fracture and Traumatic fall. Per facility policy, windows in the facility memory care are fixed to open no more than eight inches to allow fresh air into the rooms for residents. All exit leading doors are equipped with auditory alarms and delayed egress to alert staff of attempted elopements. Although R1 sustained a traumatic fall resulting in their death, a review of records obtained and interviews conducted determined that R1’s injuries were not sustained as a result of neglect by the facility staff. Evidence obtained indicates more than likely that R1 was unaware of the consequences of their actions and likely fell while attempting to leave the facility. Therefore, based on interviews conducted and documents reviewed, the allegation that staff failed to provide care and supervision which resulted in resident sustaining injuries during elopement is deemed Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted, and a copy of this report and confidential names list was left at the facility.