complaint·September 23, 2022

A Physician’s Report dated July 13, 2022, indicates R1 has “wandering behavior” and is “not able to leave facility unassisted”. The Preplacement Appraisal LIC 603 dated August 30, 2022, also indicates R1 has wandering behaviors and documents that R1 needs “safety checks”. Interview with Executive Director revealed that it is standard practice to conduct a head count (safety check) on residents every two hours. Records and interviews revealed that on September 6, 2022, R1 was last seen between 6:30 PM and 7:00 PM by R1’s main caregiver (S1). At 6:30 PM, S1 went on a 30-minute break and notified her colleagues via radio that she was going on break. During the interview, Executive Director explained that while S1 was on break the other two caregivers working on the 2nd floor were responsible for the care and supervision of the residents assigned to S1. At 9:30 PM, the facility received a call from a local hospital stating R1 was found at approximately 8:30 PM in the community by a good Samaritan, who then called 9-1-1 to have R1 transported to the emergency room as it appeared R1 had a fall. A review of facility cameras revealed R1 did not exit via the main doors which are equipped with delayed egress. It is suspected that R1 exited via the “back servery doors” that are not equipped with delayed egress or an alarm system. Interviews revealed R1 was not observed by staff for approximately 2.5 to 3 hours and learned of the resident missing when they received notification from the local hospital at 9:30 PM. R1 was admitted to the local hospital at approximately 9:10 PM and was diagnosed with “contusion, forehead; fall; hip pain” and was discharged back to the facility on September 7, 2022, at 1:27 AM. The Department has investigated the complaint alleging lack of supervision resulted in a resident eloping from the facility. Based on evidence obtained, facility staff was not aware of R1’s whereabouts for up to 3 hours, despite R1’s documented wandering behavior and need for safety checks. Accordingly, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted, a plan of correction was jointly developed, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Stefanie Ancheta, Executive Director. Signature on this form confirms receipt of the documents.