Incident investigation·May 7, 2024

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director, Reginald Jones and discussed the purpose of the visit. The facility self-reported an incident that occurred on 04/28/24 involving Resident #1 (R1). R1's Physician's Report dated 05/05/23, indicated R1 is not allowed to leave the facility unassisted. The report stated at 9:20pm staff were unable to locate R1 during routine rounds. A room to room search was initiated but unsuccessful. R1 was last observed by staff at 9pm walking around by the activities room. R1's responsible party was notified, and the La Mesa Police department responded and assisted with the search. At 11:45pm the community received a phone call from someone stating they encountered R1 and R1 stated they lived at the facility. Police and paramedics responded to address given for R1's location. R1 reported they fell and had an abrasion to their forehead. Paramedics transported R1 to the hospital for evaluation. The facility reported at the hospital, there were no significant findings / injury. R1 sustained an abrasion visible to the left side of forehead and left wrist. Resident returned to the facility on 04/29/24. R1 reported they went out front to get some fresh air and then got "turned around". Staff increasing safety checks and monitoring R1. The facility has also provided R1 with a wander guard as a safety precaution. The facility followed their Absentee Notification Protocol. No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights.