Incident investigation·September 17, 2024

On 9/17/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with Generations Program Director (GPD), Charles Howard and Regional Clinical Specialist, Yvonne Williams . On 9/16/24, the department received an incident report for R1 leaving the facility unassisted on 9/7/24. The incident report stated that staff was alerted to the back gate alarm. Staff looked inside for R1 while others searched outside. R1 was found unharmed by caregivers, "10 minutes" from the facility. R1 refused to return to return to the community until encouraged by responding local law enforcement. LPA toured the facility with GPD to view where R1 was able to exit the property. Alarms from the exit door from the facility (near Rm 180 of the Lodge memory care) and the exit gate from the adjacent courtyard were operational. Though diagnosed with MCI at the time, R1 is in memory care. Interview with GPD found that R1 is known to have exit seeking behavior and to experience sundowning. R1 was staffed with a 1:1 caregiver from a staffing agency until shortly before the incident at approximately 6:30 PM. In addition to staff monitoring of residents, door alarms are monitored at the front desk for reception to alert caregivers to clear alarms. However, records reviewed found on 9/7/24, the front desk was only monitored until 5 PM. 3 caregivers were scheduled to work at the time. One of the 3 had just left on lunch break. Staff in the community were in the kitchen area opposite where R1 exited the building. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights provided