Incident investigation·October 25, 2024

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management Visit. The LPA introduced himself and disclosed the purpose of the visit to Executive Director Emily De La Barre. Today's visit was in response to an Unusual Incident Report (LIC 624) submitted to the Department on 10/24/24. It was reported Resident # 1 (R1) had eloped from the facility, police found R1, and escorted R1 back to the facility. During the visit, the LPA reviewed records and conducted interviews. Interviews and a review of R1's Physician Report (LIC 602) revealed R1 was no able to leave the facility unassisted. The LIC 602 also revealed R1 could be confused and was diagnosed with Mild Cognitive Impairment. Interviews with staff revealed R1 had previously attempted to leave the facility by walking out the front door, and without signing out, as indicated in facility's policy. Staff had redirected R1 and advised R1 of the facility's sign out process and to have staff accompany R1. Interviews with staff and an external source confirmed this was the first time R1 had left the facility unassisted. Although R1 had attempted to walk out of the facility previously, there was no clear indication that lack of supervision contributed to R1 leaving the facility. Additionally, interviews confirmed the facility notified R1's family and R1 was transported to the hospital for further assessment. No deficiencies were cited on today's date. An exit interview was conducted with Executive Director De La Barre, to whom a copy of this report, and Licensee/Appeal Rights (LIC 9058), were provided.