Incident investigation·April 30, 2021

Licensing Program Analyst (LPA) Konnor Leitzell arrived at facility to conduct a Case Management Visit regarding a recent AWOL. CCL was notified of R1 leaving the premise without assistance on 4/26/2021, it was stated R1 left the facility twice in 24 hours, both times returning safely. In the incident reports submitted to CCL, it was stated R1 moved into facility very recently and left in search of a comb. Upon residents first returning, a wonder guard wrist monitor was placed on R1’s arm. The monitor did not notify facility of the second elopement. Resident was located by Sheriff's department shortly after and safely returned to facility. During today’s visit LPA conducted interviews and reviewed documents. Through the interviews and documents reviewed, LPA was informed of the following. R1’s 602 stated they did not show signs of wondering; and since the incident Friday R1 has been discharged and moved to Eskaton Lodge Roseville. Eskaton Roseville has a different floor plan, with less accessible exits, and is more conducive for wonder risk residents. When asking why the wonder guard did not work when R1 eloped the second time, ED informed LPA that it was an issue with the system, and they have since fixed the issue. LPA was informed Stanley System (wonder guards) rolled out an update recently, but failed to inform the facility they were required to reset all monitors for the update to be effective. This allowed for a momentary delay of when the exit sensor read the wonder guard. Facility staff have since reset all exit sensors, and tested all wonder guards to ensure they work successfully. Interview with staff reviled that prior to providing R1 with the wonder guard, staff checked to make sure batter was 100%, changed the name to the Resident, and tested the monitor on a side glass door. The monitor worked, but staff believes there was a delay that allowed R1 to leave undetected. Cont LIC 809C LPA was informed upon R1’s return from the first elopement, staff provided R1 with a comb from their in house beauty practitioner. Staff are unsure of the reasoning for the second elopement. LPA was informed facility currently has twelve (12) residents that are not allowed to leave unassisted due to diagnosis of dementia, with three (3) using the wonder guards. No current AWOL issues with other residents. LPA conducted exit interview with Kim Delgado (ED), thanking her for her time and speaking with me. LPA provided ED with a signed copy of the report, and informed ED she is to keep one copy of the report for facility files. No deficiencies cited during visit.