Incident investigation·September 19, 2024

On 09/19/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA Pascua was met by Facility Designated Administrator (FDA), Alfredo Cruz and explained the purpose of the visit. Current census was 85. A brief interview with FDA Cruz and a tour of the facility was conducted. The purpose of this visit was to follow up on an incident regarding an elopement from the facility on 09/16/2024. On 09/17/2024, LPA Pascua received a phone call from the facility stating that R1 eloped from the facility. It was stated based on interviews of facility staff, R1 was last seen after dinner on 09/16/2024 around 9:00pm in the courtyard smoking. On 09/17/2024, facility staff checked on R1 in their bedroom where they were not found. At approximately 9:30am, staff notified the Facility Designated Administrator who stated that the facility staff conducted a perimeter search by foot. Additionally, the facility conducted a search in the surrounding areas via car and could not find R1. Staff then notified Sacramento Sheriff's office to report the missing resident. On 09/18/2024, LPA Pascua received notification that R1 was found by Sacramento Sheriff's Department approximately 2.8 miles away from the facility. R1 was evaluated by medical personnel to check their vitals and returned back to the facility before 12:00pm. Upon return to the facility, R1 was unaware that they left the facility and repeated stated their feet hurt. Facility staff conducted additional assessments and observed that R1 was unable to walk around by themselves and needed a wheelchair to ambulate to their room and had several blisters on their feet. It was stated by staff that R1 was able to ambulate and walk around themselves and did not have blisters on their feet prior to the elopement. LPA learned that the facility called Emergency Services and R1 was assessed and treated in the Emergency room and discharged with Home Health Services. LPA reviewed R1's physicians report and care plan which states that this resident has a diagnosis of dementia and was not able to leave the facility unattended with safety checks twice a day conducted by facility staff. It was stated by facility staff that safety checks are done during medication pass, incontinence care checks, however it was not clearly stated in the care plan. In addition, LPA reviewed the facilities staffing records for 09/16/2024 and it was learned that there were 3 staff members present during graveyard shift of which 2 staff members who were hired through an outside agency. It was unclear if the staff member assigned to R1's hall conducted health and safety checks during the course of their shift. R1's care plan also indicates that this resident needs consistent assistance due to disorientation and memory loss. An interview conducted with facility staff revealed that R1 had started showing tendencies to leave the facility to purchase additional cigarettes. Staff state that they worked with the responsible party to obtain additional cigarettes and was believed to help mitigate elopement tendencies. Based on the information gathered, the facility did not ensure that R1 was in secured environment based on the resident's LIC602's indication that R1 could not leave the facility and additional care and supervision needs due to their disorientation and memory loss. As a result, an immediate $500.00 civil penalty shall be assessed on September 19,2024 for bodily injury and severe pain, which posed an immediate threat to the Health, Safety, and Personal Rights of R1. Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to facility. An exit interview was held, and a copy of the report was provided.