Complaint·November 4, 2024

Licensee denied having any knowledge of previous elopement behavior for R1 prior to admission. On December 14, 2022, Department staff observed the facility to be equipped with audible door alarms at the front door, the back French doors leading to the backyard, as well as R1’s bedroom doors leading to the outside. Interview with S1 revealed they did not hear any door alarms on the morning of the incident. A review of Emergency Medical Services (EMS) records revealed they were dispatched at 4:54 AM on August 24, 2022 and responded to the area of 1850 El Norte Parkway in San Marcos, which was one half mile from the facility. EMS observed R1 to have facial trauma, laceration above the left eye, swollen and bloody lip, laceration to the bridge of the nose, and skin tears to both hands and R1 reported to EMS they had too much to drink. R1 was then transported to the hospital. A review of R1’s hospital records dated August 24, 2022 revealed R1 had an odontoid fracture, multiple rib fractures, multiple old fractures of the right clavicle, left scapula, left pubic ramus, and T9 vertebral body, and lacerations to the left hand and face. Although the allegations may have happened or are valid, records reviewed indicated R1 was able to leave the facility unassisted and did not require overnight supervision. Therefore, there is no preponderance of evidence to prove the alleged violations did or did not occur. The allegations are unsubstantiated. An exit interview was conducted, a copy of this report was provided along with Confidential Names list (LIC 811). A review of R1’s Admission Agreement indicated R1 was admitted to the facility April 6, 2022. A review of R1’s Physician’s Report dated January 17, 2022 indicated the categories ‘confused/disoriented’, ‘aggressive behavior’, ‘wandering behavior’, ‘sundowning behavior’, ‘able to follow instructions’, ‘able to leave the facility unassisted’, and ‘able to dress/groom self’ were marked as yes. A review of R1’s Preplacement Appraisal dated March 7, 2022 revealed R1 exhibited short term memory loss, enjoyed smoking outdoors, wandered back and forth in the yard while smoking, avoids front door, did not exhibit exit seeking behavior, can communicate care needs, was aware of surroundings, awake by 9:00 AM, asleep by 10:00 PM, did not have sleep disturbances as long as bedtime medications are taken, and did not require special observation/night supervision due to confusion/forgetfulness/wandering. R1’s Individual Service Plan dated March 3, 2022 revealed R1 was a risk for fall/injury secondary to their diagnosis. The Pre-Placement Appraisal, Physician’s Report, and Individual Service Plan did not indicate R1 had any elopement behavior. Interview with facility Staff #1 (S1) indicated they were sole staff on duty the night of August 23, 2022 into the morning of August 24, 2022. S1 reported their normal routine is to check on the residents twice during the night, once at 1:00 AM and then again sometime between 3:30 AM and 4:30 AM. S1 reported R1 went to bed between 7:00 PM and 8:00 PM on the night of August 23, 2022 after taking their medications and was acting fine and normal. S1 reported they checked on R1 at 4:30 AM on the morning of August 24 th and observed R1 to be sleeping. S1 reported R1 frequently smoked in the backyard but had never left the property before. S1 reported that at 8:00 AM on the morning of August 24 th they went to R1’s room and after discovering R1 was missing they had observed the backyard gate on the north side of the property partially open. Interviews were conducted with separate relevant parties and those parties reported the following timelines obtained by their interviews with S1: one relevant party reported S1 told them S1 had checked on R1 between 4:30 AM and 5:30 AM. Another relevant party reported S1 told them R1 went to bed between 9:00 PM and 10:00 PM and that S1 had checked on R1 at 3:00 AM and again between 4:30 AM and 5:00 AM.