Follow-up on corrections·August 7, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced, subsequent Case Management visit to cite a deficiency resulting from an investigation conducted on an incident self-reported by the licensee. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Caroline Senteno. On 08/03/2023, the CCLD San Diego Regional Office received an LIC624 Unusual Incident Report from licensee. Per the LIC624: during the evening of 08/01/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of C1.] R1 was returned to the facility unharmed, later that same evening. CCLD’s investigation involved multiple facility tours, testing of delayed-egress exit doors, review of an electronic report showing door alarms/signals, and review of employee time clock records. LPA also reviewed pertinent care and administrative records and interviewed R1, relevant staff, and outside sources. According to R1’s LIC602 Physician’s Report (dated 07/25/2023): R1’s primary diagnosis was Dementia and their doctor determined that they were not able to safely leave the facility unassisted. During the time frame of the incident, R1 resided in the facility’s “Traditions” Memory Care unit, which is a secured area located on the facility’s second floor. In their interview, R1 was articulate and broadly remembered the incident, but due to their baseline short-term memory loss, they were unable to specify the time of elopement that night, or their route of travel used to exit the building. [CONTINUED ON LIC 809-C, 1 of 3] [CONTINUED FROM LIC 809] Interviews of staff and outside sources, corroborated by facility progress notes, revealed: Multiple staff last sighted R1 inside the facility’s memory care unit around 9:57 PM on 08/01/2023. Sometime between 10:15 PM and 10:30 PM, facility staff received a phone call from a third-party, who stated R1 had exited the facility unwitnessed, borrowed a cell phone from a bystander, and called them. Up until this point, staff were unaware that R1 had left the facility, so they began searching for R1. About 15 to 20 minutes later, the bystander walked up to the facility, asked staff if R1 was a resident, stated they first encountered R1 in a commercial plaza across the street from the facility, and then helped coordinate R1’s safe return to the facility. Staff timely notified R1’s responsible person of the incident. During CCLD’s site visit on 08/03/2023, LPA verified that the two (2) delayed-egress exit doors from the facility’s second-floor memory care unit were functioning correctly. Specifically: the doors remained locked. When the egress/panic bars were momentarily depressed, the doors alarmed loudly/audibly, and then unlatched after a 30 second delay. According to a date and time-stamped log generated from the facility’s electronic signals system: On 08/01/2023, there was a perimeter exit door (“Door A”) on the facility’s first floor which was opened at 10:01 PM. [This door creates an audible localized alarm, and also transmits both a visual and audible signal to the pagers which all direct care staff are required to carry.] However, the Door A was not timely addressed or reset by staff, and this signal continued to run for over 45 minutes. Then, at 10:04 PM, a second-floor memory care delayed egress exit-door (“Door B”) was activated. [This door also creates an audible localized alarm, and also transmits both a visual and audible signal to the pagers.] Door B’s alarm was responded to and reset at 10:09 PM (i.e., after 5 minutes.) However, as stated before, and confirmed by LPA testing/observation: Door B’s door-latching mechanism unlocks/disarms itself after a 30-seconds following a push on its panic/egress bar, per design. LPA also observed that Door B led directly to both a stairwell and an elevator going down to Door A, which then led directly outside. [CONTINUED ON LIC 809-C, 2 of 3] [CONTINUED FROM LIC 809-C, 1 of 3] Staff and manager interviews unanimously corroborated: a) on the night of 08/01/2023, no facility staff heard any door alarm go off, b) there were no outside visitors present inside the facility’s second floor memory care around the time of R1’s elopement, and c) only facility staff had the codes to the memory care unit’s doors, and therefore they were the only persons who could unlock or reset door alarms. These interviews also unanimously corroborated: caregivers in the facility’s memory care PM shift are required to stay on duty through 10:00 PM. Their relief counterparts from the NOC/overnight shift are required to start working at 10:00 PM. However, staff interviews, corroborated by employee time clock records, also showed: around the hour of R1's elopement from the facility, the PM shift had four (4) direct care staff who were nearing shift end. The first PM staff clocked out at 9:54 PM (but they also said they had physically departed from the memory care unit about 1 to 2 minutes earlier to reach the time clock at said time). The second and third PM shift staff both clocked at 10:00 PM (but they also said they had had physically departed the memory care unit around 9:57 PM). The first NOC shift employee, Staff #1 (S1), clocked in at 10:00 PM (but they also said they did not physically arrive in the memory care unit until 2 to 3 minutes later). The second NOC shift employee, Staff #2 (S2) said they were late to work; time clock records showed they clocked in at 11:00 PM. Per staff assignments, during the 08/01/2023 NOC shift, R1 was assigned to the personal care of S2 (had S2 been present at work). The fourth PM shift employee remained on duty nearly an hour past end of shift, but they also said: a) the last time they had personally seen R1 was at 9:30 PM, b) they were inside a 2 nd floor office with the door closed during the 10:00 PM shift change, c) they were unaware of when the last two of their PM teammates left the memory care unit, d) they were unaware that one of their NOC shift teammates (S2) was late to work, and e) they stayed on duty longer to respond to R1’s elopement, not because S2 was late to work. When S1 was asked if they were made aware that their teammate, S2, would be late to work that evening, S1 said they could not remember. [CONTINUED ON LIC 809-C, 3 of 3] [CONTINUED FROM LIC 809-C, 2 of 3] A preponderance of evidence exists to show that during the above incident, Licensee’s memory care unit staff did not provide needed observation to R1, which was material to R1’s elopement. One (1) deficiency was cited per California California Code of Regulations, Title 22 (refer to the attached LIC 809-D page). A Plan of Correction was jointly developed with the licensee. LPA also issued Technical Assistance (TA) regarding the staff-alert devices on exit doors. An exit interview was conducted with Senteno, to whom a copy of this report, the LIC809-D, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.