Incident investigation·April 16, 2024

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to a recent AWOL involving resident (R1) on April 6, 2024. LPA met with Editha McCullough, Administrator Designee, and the stated reason for inspection. During today's inspection, LPA and the Administrator Designee observed the exit door and exit Egress gate where (R1) exited on 4/6/24 at approximately 5:10 pm. The door alarm was tested and (2) staff were promptly observed to be responding to the alarm sound. LPA observed a new alarm device to be installed on the top of the door. The Egress exit gate alarm was also tested and sounded for (15) seconds before the gate opened to the parking lot. The AWOL was reported by phone by the Regional Director on 4/10/24. A written incident report was also submitted on 4/10/24. It was determined later on 4/6/24, by a fence company, that resident (R1) was able to leave the facility unnoticed due to the audible sound only being heard in the main lobby area, and not throughout the facility. The egress gate was confirmed to be perfectly functioning. Resident was returned by the police at approximately (20) minutes later, at 5:35 pm, and resident sustained no injuries. Staff received follow up training on 4/8/24 and 4/9/24 relating to resident elopement procedures, delayed egress and re-arming a delayed egress lock after it's used. Additionally, an additional auditory alarm and a strobe system will be installed in another location to help staff hear when an alarm sounds. Resident (R1) is not able to leave the building unassisted due to a diagnosis of Dementia. Per Title 22, Division 6, Chapter, 8, the following (1) citation is issued on the 809-D page. A Technical Advisory Note is also being issued. Exit interview. Copy of report and appeal rights provided.