Incident investigation·April 10, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Receptionist Rebecca Lane. LPA then met and discussed the purpose of the visit with Resident Services Director River Pagala and Lead Med Tech Marquette Corbett. Today's visit was in response to an LIC624 Incident Report which licensee self-submitted to the CCLD San Diego Regional Office (RO), regarding Resident #1 (R1) being AWOL (absent without leave) from the facility on 03-27-2023. [See LIC811 Confidential Names List for a description of person identifiers used in this report.] According to the LIC624, a nearby business called police after seeing R1 in their own parking lot. R1 was picked up unharmed/uninjured by police and evaluated at a hospital (as a precaution), before being brought back to the facility on 03-28-2023. During today’s visit, LPA briefly toured the facility and performed a welfare check on residents in care. LPA verified that R1 was indeed unharmed/uninured. LPA verified that auditory staff alert devices on the facility’s perimeter exit doors were working. LPA also reviewed pertinent administrative, care, and medical records, and interviewed R1 and relevant staff. Due to R1’s baseline short-term memory loss and disorientation to time (R1 had no recollection of the incident), they were unable to participate as a reliable historian/interviewee. According to R1’s latest LIC602 Physician’s Report, dated 02-23-2023, R1 was diagnosed with “late onset Alzheimer’s dementia” and their doctor determined that they were not able to safely leave the facility unassisted. Per R1’s LIC603A Resident Appraisal, dated 03-11-2023, they exhibited “increased forgetfulness, confusion, and sundowning behavior that gets [worse] at night time,” and had a “history of wandering behavior.” [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Per licensee’s own Care Plan for R1, and corroborated by manager interview, R1 required visual safety checks “every 2 hours” despite needing very little ADL care. Staff progress notes/charting corroborated: from the time of R1’s move-in during mid-March 2023, through the date of their 03-27-2023 AWOL, R1 was often more confused and/or anxious in the evenings. R1 repeatedly wandered hallways to look for their children, and staff frequently redirected them. According to the LIC624, licensee’s own internal investigation, and staff interviews: Staff #1 (S1) was R1’s assigned caregiver for PM shift on 03-27-2023. They were the last person to see R1 inside the facility leading up to the AWOL. Around 8:40 PM, S1 assisted R1 to bed, before their shift ended less than 2 hours later. Staff #2 (S2) was R1’s assigned overnight shift caregiver. S2 told licensee they performed required visual checks and saw R1 in bed at 12:00 AM midnight. However, camera surveillance footage revealed: a) S2 did not visit R1’s room as they stated, and b) R1 instead exited the facility premises around 9:09 PM. It was not until around 6:00 AM on 03-28-2023 that Staff #3 (S3), who was to be R1’s assigned caregiver on AM shift, recognized R1 was missing and alerted coworkers. Consistent with licensee’s own Absentee Notification Plan (Chapter on “Elopement” from their policy manual), staff unsuccessfully searched the facility for 30 minutes, then phoned police and R1’s responsible party. According to licensee, the facts of their internal investigation led them to terminate S2’s employment and to discipline another (separate) staff member from their overnight shift. CCLD’s own investigation concluded that licensee’s staff on 03-27-2023 did not provide R1 needed observation, as was described in R1’s Care Plan. One deficiency is cited per California Code of Regulations (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Corbett. A hard copy of this report, the LIC809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to staff during today’s visit. A copy of these documents was also E-mailed to the facility administrator.