complaint·January 20, 2023

(Continue from LIC9099) Interviews and facility records revealed that on the afternoon of 07/23/21 R1 and a direct caregiver Staff #1 (S1) were outside smoking cigarettes on the facility front porch. S1 acknowledged during interview statements that they had been advised of R1’s prior elopements and knew R1 was not be left unsupervised. S1 admitted they left the resident alone for 10-15 minutes and went inside to use the bathroom. R1 was alone in an unsecured area of the facility that led directly out to the street. When S1 returned to the porch fifteen minutes later, at approximately 1:00 pm, R1 had left the facility unattended and was not in sight. S1 stated they advised the licensee, Staff #2 (S2) who was present at the facility and searched the immediate vicinity on foot but could not find the resident. When S1’s care shift ended at 6:00 pm in the evening, R1 had still not returned. After the elopement occurred, S2 drove around local streets looking for R1 but acknowledged that they did not call 911 to report the elderly resident as missing. During interview statements, S2 claimed that they attempted to call a non-emergency police number and later went to the local police station that evening but the station was closed. S2 did not leave a voice message or other form of communication to advise law enforcement of the elopement. The next day, 7/24/21, at approximately 8:00 am, the licensee notified R1’s responsible party and other family members of the elopement. A family member then immediately reported R1 as at-risk missing person to local police and advised them R1 had been missing for nearly 24 hours. At approximately 5:45 pm on the evening of 7/24/21, community members found R1 lying injured in a drainage ditch. The open ditch was located down a 20-foot sloped embankment in an empty construction lot several blocks away from the facility. A review of medical and outside source records confirmed that R1 was assessed with serious injuries including a badly fractured ankle, severe dehydration, and a black eye. R1 also had multiple bruises, abrasions and skin tears on their upper and lower extremities from falling into the ditch and a stage 2 pressure injury on their hip. The acute pressure injury was diagnosed as caused by R1 lying immobile for a prolonged period in one position. Medical records noted the resident was “covered in ants and dried feces” and was observed as confused, disoriented and expressing acute pain due to their injuries. R1 required immediate surgery for the ankle fracture and was hospitalized for five days, then discharged to a post-acute care skilled nursing facility. (continue at LIC9099C) (Continue from LIC9099) During investigative interview statements, both S1 and S2 admitted that they knew this resident had a history of previous elopements: R1 had previously gone missing twice from their facility, most recently on 9/7/20 and was brought back by police each time, after neighbors observed the resident wandering away and called local law enforcement. Outside source records revealed that during a subsequent interview, the licensee stated they “did not think it was necessary to call 911” and decided to “wait and see” if the resident would return on their own. Licensee and staff statements also confirmed that they knew the resident had a medical diagnosis of severe cognitive impairment and required close supervision to prevent elopement risk. Based on multiple staff and outside source interviews and review of documentation including medical records, the allegations are substantiated. This Department has investigated the allegations noted above. The Department has found that based upon records review and interviews gathered during the investigation, the preponderance of the evidence standard has been met. Therefore, these allegations are deemed substantiated. An immediate civil penalty in the amount of $500 is being assessed today and per Health and Safety Code Section 1569.49, an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division.