Incident investigation·September 3, 2024

Licensing Program Analyst (LPA) Melissa Parks arrived at the facility to conduct a case management visit regarding an incident that occurred on 8/23/2024. LPA met with Administrator Henry Cole and explained the purpose of the visit. LPA learned that R1 was found in the front parking lot on 8/23/2024 at approximately 4:05am. The facility's video surveillance shows R1 leaving the facility at 3:09am. Before R1 was found by staff, they had fallen in the parking lot. Staff found R1 in a seated position. LPA reviewed the 602 and care plan for R1. LPA and Administrator reviewed surveillance footage of R1 leaving the facility and staff responding. R1 was sent to the hospital where they were diagnosed with a rib fracture and UTI. The facility required R1 to have 1:1 supervision from 8pm - 6am. Facility is following up with R1's care team in order to ensure all medical avenues/interventions have been explored. R1 had lived at the facility since April 2021. Their care needs were reassessed on July 8,2024. Per this reassessment, R1 was not a wander risk, was oriented to time, place, and situation, and independent of bathing, dressing, grooming, and toileting. The facility managed R1's medications. LPA reviewed an updated physicians report completed in December 2023. Per the physicians report, R1 is able to communicate needs, and has no wandering behavior. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the facility.