Incident investigation·July 18, 2024

Licensing Program Analyst (LPA) Melissa Parks arrived on Thursday July 18, 2024 to follow up on an incident that was received by the Department on 7/14/2024. LPA learned that R1 has a routine of wandering throughout memory care and the memory care courtyard. LPA obtained R1's physicians report, current care plan, and hospital discharge paperwork. They are diagnosed with Dementia. On July 4, 2024, R1 was found in the courtyard, sweating and having labored breathing. LPA interviewed caregivers and med tech who were on duty on the date of the incident. Per staff, R1 is checked on hourly. Staff could not remember the specific time that they last saw R1 however, R1 was observed walking in the courtyard prior to lunch, which is a part of their daily routine. As the food was being served, staff were notified that R1 was in distress. Staff then followed protocol for a medical emergency. Since the incident, the facility has since began to utilize the alarms on the interior courtyard doors to alert staff when a resident goes out to the courtyard. These alarms are to be on when there is excessive heat. No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.