Incident investigation·October 27, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Activities Director Jerome Landers. LPA then met and discussed the purpose of the visit with Executive Director Disha Hall. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 10/26/2023). According to the LIC624: on 10/25/2023, Resident #1 (R1) and Resident #2 (R2) both eloped together from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.] Police located R1 and R2 on 10/26/2023, and they were subsequently returned to the facility. During today’s visit, LPA performed a facility tour and welfare check on R1 and R2. LPA also collected copies of pertinent care and hospital records and interviewed multiple relevant staff. According to their latest LIC602 Physician’s Report (dated 03/01/2023), R1 was diagnosed with Dementia and Cerebral Atherosclerosis, and their doctor determined that they were not able to safely leave the facility unassisted. According to their latest LIC602 Physician’s Report (dated 10/03/2023), R2 was diagnosed with Dementia and Alzheimer’s Disease, and their doctor determined that they were not able to safely leave the facility unassisted. Staff interviews, corroborated by date and time stamped records, showed: Between 11:00 AM and 12:05 PM on 10/25/2023, multiple facility staff saw both R1 and R2 present on the facility premises. Camera footage showed that around 12:08 PM, R1 and R2 exited the facility via a perimeter courtyard gate door. This gate door was unlocked but was alarmed to alert staff whenever it was opened. During today’s visit, LPA observed that the alarm on this gate was working and loudly audible. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] During the incident, multiple staff heard the alarm and responded on foot to the gate, but when they arrived, R1 and R2 were not in sight. Staff reset the gate alarm without looking for the person(s) who set off the alarm and without performing an accounting of residents in care. Around 4:10 PM on 10/25/2023, staff first recognized that R1 and R2 were missing. Facility staff performed an unsuccessful search of the facility and surrounding neighborhood, then notified law enforcement and the residents’ respective responsible persons, consistent with timelines described in the facility’s Elopement Policy (i.e., Absentee Notification Plan). The next day, on 10/26/2023, police located R1 by 9:00 AM and located R2 by 11:53 AM. Both residents were transported to the hospital for evaluation, before being returned to the facility. Staff interviews, corroborated by hospital and facility records, showed: While away from the facility, R1 suffered a left distal radius (i.e., left wrist) fracture of unknown origin, and arrived at the hospital with “dehydration,” a urinary tract infection, and an “acute kidney injury.” Due to language barriers and their baseline memory loss, it could not be determined from R1 how their wrist fracture occurred. LPA observed that R1’s left wrist was indeed wrapped/splinted. While away at the facility, R2 suffered blisters to the bottoms of both of their feet. Due to their baseline memory loss, R2 was not able to be qualified as a reliable historian about the incident, but R2 confirmed they suffered feet blisters during the time that they were away from the facility. A preponderance of evidence exists to show that during the incident in question, Licensee’s staff were not trained to competently respond after the above-mentioned gate alarm had sounded. This resulted in staff not timely recognizing that R1 and R2 had exited the facility premises. A preponderance of evidence also exists to show that four (4) full hours had elapsed without Licensee’s staff visually checking on R1 and R2, despite both residents requiring supervision due to their Dementia diagnoses. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). The incident resulted in serious bodily injury to R1, and non-serious bodily injury to R2. Therefore, an immediate civil penalty of $500.00 was assessed (refer to the LIC 421-IM). Since one of the deficiencies is a repeat violation within a 12-month period of time, a civil penalty of $250.00 was also assessed (refer to the LIC 421-FC). Plans of Correction were jointly developed with the licensee. An exit interview was conducted with Hall, to whom a copy of this report, the LIC809-D, the LIC421-IM, LIC421-FC, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.