complaint·July 6, 2023

9099C(1)... RCC, who was not working at 7:30 pm, was contacted by facility staff and she went to the nearby gas station and surrounding area and learned that resident had asked for directions to the bus station. RCC located resident while driving down Antelope Rd and returned resident to the community at around 7:50 pm, uninjured. Resident stated to RCC that he "jumped the fence" in the outside patio area that faces the street. LPA reviewed resident's care plan that was updated on 6/29/2023 with additional notes added regarding wandering and elopement during the evening/sun downing hours. Physician's report, dated 6/26/2023, notes that resident is frequently confused and has increased agitation and confusion at night, due to sun downing, is not able to leave the facility unattended and needs constant medical supervision. Extra staff have been monitoring the resident during evening hours, and the resident has not tried to leave the facility again. Resident's family and physician were notified of the incident with a request that resident's medications be reviewed for a possible adjustment to the evening dosages. LPA observed the outside fence area where resident climbed over and observed an alarm on the patio door to sound when the door is opened. LPA spoke to Maintenance Director who confirmed that the batteries sometimes get low and they were replaced immediately following the incident on the (3) exit doors without a delayed egress alarm. Based on information obtained and reviewed, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) citation is issued on the 9099-D page. Exit interview. Copy of report and appeal rights provided. 9099A-C(1)... LIC624 states that R3 was taken to the ER for further medication evaluation since it was an unwitnessed fall and was prescribed Lidocaine for a scalp laceration. 48 hour alert charting was initiated following the incident for R2 and for R3 upon return from the hospital. LPA interviewed the Ombudsman following her investigation of the incident on 7/3/2023. The Ombudsman discussed the incident with RCC who indicated she had viewed the video surveillance and was informed R3 fell and was not pushed by R2 and R3 did not sustain any substantive injuries. The Administrator and RCC confirmed there were (4) staff working on shift during this incident. Med-Tech was administering night time medications and the (3) care staff were assisting with putting residents to bed. It is common that while staff is helping some residents, there are other residents who are sun downing in the common areas. Based on information obtained, staff responded as quickly as they heard R3 yell, and staff was not able to prevent this isolated incident. LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview. Copy of report to Administrator.